Hilltop Center
152 Saddleshop Road, Hilltop, WV 25855 · For profit - Corporation · 120 certified beds · (304) 469-2966 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- a middle-of-the-pack inspection score (3/5)
- lower-than-typical staff turnover (32% vs 45% nationally) — better care continuity
- it has an abuse, neglect, or exploitation citation (F0600), cited May 2025
- it has 2 actual-harm citations
- a high number of inspection citations overall (30) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $22,562 in federal fines (most recent 2025-05-13)
- its facility-reported quality-measure score sits well above its independent inspection score
- its payroll-based staffing rating is low (2/5)
- about 45% of its spending goes to commonly-owned related companies
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 3 of 5 |
| StaffingFrom payroll records (PBJ) | 2 of 5 |
| Quality measuresSelf-reported by the facility | 5 of 5 |
Worth a closer look. This home's quality-measure rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 5 of 5 |
| Long-stay residentspeople who live here | 5 of 5 |
| Short-stay residentsrehab / post-hospital | 5 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 2 to 5 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 5.3% | 14.7% | 15.4% | better |
| Long-stay residents who lose too much weight | 0.5% | 6.3% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.0% | 0.4% | 0.9% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 0.8% | 1.6% | 2.0% | better |
| Long-stay residents with depressive symptoms | 1.3% | 7.6% | 6.5% | better |
| Long-stay residents who were physically restrained | 0.0% | 0.2% | 0.1% | better |
| Long-stay residents with falls causing major injury | 3.4% | 4.4% | 3.3% | typical |
| Long-stay residents whose ability to walk worsened | 3.1% | 15.9% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 30.0% | 27.0% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 99.1% | 97.6% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 3.7% | 4.2% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 27.0% | 22.1% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 1.1% | 13.4% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 0.0% | 1.0% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 94.8% | 79.4% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 16.9% | 22.5% | 22.6% | better |
| Short-stay residents with an outpatient ER visit | 7.8% | 11.3% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 1.01 | 1.80 | 1.67 | better |
| Long-stay outpatient ER visits per 1,000 resident days | 1.03 | 1.84 | 1.80 | better |
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
47.6% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 124 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 63.4% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 101 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.
Therapy staffing: this home’s payroll records show 0.57 therapist hours per resident per day in 2026Q1 — more than 87% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 15% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 47.6%CMS range 37.1–56.1 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 13.3%CMS range 9.3–17.4 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 63.4% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 60.4% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 57.4% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 96.7% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 96.9% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 3.9% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 0.7% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 7.2%CMS range 4.7–11.1 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.18 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 120 beds and averages 117.3 residents a day — about 98% occupied, or roughly 3 beds typically open. It runs essentially full — expect a waiting list. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.24 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.66 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.65 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 2.61 hrs/resident/day on weekends vs 3.50 on weekdays — 25% thinner on weekends — a notable drop. RN hours go from 0.81 to 0.29 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 32% is below the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
30 citations, most serious first. The 12 most serious are shown; the remaining 18 are one tap away and print in full.
- Actual harm · G2025-05-13 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview the facility failed to ensure one (1) of two (2) residents reivewed for pressure ulcers were not neglected. Resident #1 entered the facility without a pressure ulcer. He was discharged to another facility (nursing home). An assessment completed within 40 minutes after his discharge from the facility revealed a deep foul smelling wound to the coccyx. Resident #1 sustained actual harm. Resident identifier: #1. Facility Census: 118 Findings Include: a) Resident #1 Resident #1 was admitted to the facility on [DATE] from a critical illness recovery hospital. He had been at that facility from 01/22/25 - 02/18/25. He had previously been at another acute care hospital from [DATE] - 01/22/25. He was sent to the acute care hospital on [DATE] after his percutaneous endoscopic gastrostomy tube malfunctioned. While hospitalized he had two (2) surgeries and left the hospital on [DATE] with a surgical wound to the left and right abdomen. Due to postoperative complications a wound vac…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Actual harm · G2025-05-13 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview the facility failed to ensure one (1) of two (2) residents reivewed for pressure ulcers received the apprpirate care to treat a wound to the coccyx. Resident #1 entered the facility without a pressure ulcer to the coccyx . He was discharged to another facility (nursing home). An assessment completed within 40 minutes after his discharge from the facility revealed a deep foul smelling wound to the coccyx. Resident #1 sustained actual harm. Resident identifier: #1. Facility Census: 118 Findings Include: a) Resident #1 Resident #1 was admitted to the facility on [DATE] from a critical illness recovery hospital. He had been at that facility from 01/22/25 - 02/18/25. He had previously been at another acute care hospital from [DATE] - 01/22/25. He was sent to the acute care hospital on [DATE] after his percutaneous endoscopic gastrostomy tube malfunctioned. While hospitalized he had two (2) surgeries and left the hospital on [DATE] with a surgical wound to the left and right…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-05-12 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interview, resident interview, and observation, the facility failed to ensure physician orders were followed for residents receiving oxygen therapy. This failed practice had the potential to affect a limited number of residents. Resident Identifiers: #54 and #87. Facility Census: 117. Findings included:a) Resident #54 On 05/11/26 at 12:45 PM, Resident #54's oxygen concentrator was set on 1.5 liters and the resident reported he felt he was short of breath. The resident reported he was supposed to be on two (2) liters of oxygen. Review of Resident #54's electronic medical record revealed:-The resident's physician order stated, Oxygen at 2L/min via Nasal Cannula continuously every day and night shift. -The resident's care plan stated, Oxygen per order. On 05/11/25 at 2:26 PM, the resident's care plan was updated following surveyor intervention to include: Resident is non-compliant with use of oxygen since admission on [DATE]. Resident will at times refuse to wear oxygen, throw tubing…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-05-12 · tag F0807 — failed to offer suitable drinks — isolatedEnsure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, resident interview, and staff interview, the facility failed to provide adequate hydration for Residents #55, #107, and #68. These were random opportunities for discovery. Resident Identifiers: #55, #107 and #68. Facility Census: 117.Findings Included:a) Resident #55On 05/11/26 at 12:25 PM, an initial interview was held with Resident #55. The resident stated, I would like some ice water. The resident was asked, Did you get any fresh ice water today? Resident #55 stated, No, I haven't. An observation was made at this time of a 12-ounce Styrofoam cup, which was undated, that had a small amount of water and no ice inside the cup.On 05/11/26 at 12:30 PM, Activities Director #55 was asked to come into the resident's room. The Activities Director confirmed the cup was not dated and there was a small amount of water and no ice inside the cup.b) Resident #107On 05/11/26 at 12:35, an initial interview was held with Resident #107. Resident #107 is roommates with Resident #68. The resident was asked, Did you receive fresh ice water today? The resident stated, No, we…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-05-12 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and staff interview, the facility failed to maintain an effective infection control program related to the placement of urinary catheter drainage bags for Resident #72 and #78, and storage of a granulated cylinder for Resident #54. These were random opportunities for discovery. Resident Identifiers: #72, #78 and #54. Facility Census: 117. Findings Included:a) Resident #72On 05/11/26 at 12:19 PM, an initial interview was held with Resident #72. The urinary catheter drainage bag was observed behind the wheelchair hanging and touching the floor. On 05/11/26 at 12:23 PM, the Activities Director #55 was asked to come to the resident's room. The Activities Director #55 confirmed the urinary catheter drainage bag should not be touching the floor. The Activities Director #55 raised the bag and the urinary catheter drainage bag was not touching the floor.On 05/11/26 at approximately 12:40 PM, the Administrator was notified and confirmed the urinary catheter drainage bag should not be touching the floor. The Administrator stated, We will talk to the staff.b) Resident…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-05-12 · tag F0919 — failed to provide a working call system — isolatedMake sure that a working call system is available in each resident's bathroom and bathing area.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, staff interview, and record review, the facility failed to ensure call systems were within the resident's reach. This failed practice had the potential to affect a limited number of residents. Resident Identifiers: #69 and #85. Facility Census: 117.Findings included:a) Resident #69On 05/11/26 at 12:30 PM, Resident #69's call light was attached to her nightstand. The resident was sitting in her wheelchair near the bottom of her bed. The resident stated, I want it close as I can. The resident's call light was not within reach.On 05/11/26, Activity Director #140 confirmed the call light was out of reach. The activity director attached the call light to the resident's blanket on the bed within the resident's reach.b) Resident #85 On 05/11/26 at 12:29 PM, Resident #85's call light was observed on the floor behind the resident's wheelchair. The resident was sitting in his wheelchair at the time. On 05/12/26, Activity Director #140 confirmed the resident's call light was in the floor and placed the call light within the resident's reach.c) Policy for Call LightsThe…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2026-01-21 · tag F0656 — failed to write and follow a full care plan — patternDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and staff interview, the facility failed to ensure the resident's care plans were comprehensive, patent-centered and individualized for transfers. This was found true for five(5) of 31 care plans reviewed during the Long Term Care Survey process. Resident Identifiers: #2, #9, #84, #85, and #105. Facility Census: 117.Findings included: a) The facility's policy and procedure stated, the Center must develop and implement a person-centered care plan for each patient/resident (hereinafter patient) consistent with patient rights measurable objectives and timeframes to meet a patient's medical, nursing and mental and psychosocial needs and all services that meet professional standards of quality. b) On 01/20/2026 at 3:53 PM , the following resident's records were reviewed: Residents #2, #9, #84, #85 and #105. All five (5) care plans reviewed listed the intervention for transfers as Lift per assessment. The care plans were not individualized for each resident. On 01/20/2026 at 04:36 PM, the Minimum Data Set (MDS) Coordinator confirmed the care plans were the same for…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-01-21 · tag F0558 — failed to accommodate residents' needs and preferences — isolatedReasonably accommodate the needs and preferences of each resident.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review, observation, staff interview and resident interview, the facility failed to ensure a resident's call light was adapted to a resident's individual physical needs. This failed practice was a random opportunity for discovery and had the potential to affect a limited number of residents. Resident identifier: #84. Facility census: 117. Findings included: a) Resident #84 On 01/19/2026 at 10:10 AM, Resident #84's call light was out of reach and attached to the bed. Registered Nurse (RN) #78 confirmed the call light was out of reach and stated, it was hooked around the bed. RN # 78 re-attached the call light in reach of the resident. The resident reported they could reach it and the resident stated, but no one answers it. RN #78 requested the resident to push the call light. The resident attempted to push the call light, but it did not come on. The resident was physically unable to activate the regular, standard call light button on the call light device. The state surveyor pushed the call light button, and it came on immediately. After surveyor intervention, an…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-01-21 · tag F0636 — isolatedAssess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and staff interview, the facility failed to ensure a comprehensive assessment of resident preferences for customary routine and activities was completed and documented in the annual Minimum Data Set (MDS) for one (1) of two (2) residents. This was true for Resident #15. Resident identifier: #15. Facility census: 117.Findings include:a) Resident #15On 01/20/25, a review of Resident #15's annual Minimum Data Set (MDS) completed on 07/06/25 revealed that Section F (Preferences for Customary Routine and Activities) was not completed. The MDS reflected Not assessed for all required items, including:F0300 - Should the resident be interviewed regarding daily and activity preferencesF0400 - Interview for daily preferencesF0500 - Interview for activity preferencesF0600 - Primary respondent for daily and activity preferencesF0700 - Should a staff assessment be conductedF0800 - Staff assessment of daily and activity preferencesThis demonstrated that the facility failed to conduct and document an assessment of Resident #15's customary routine and activity preferences as…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-01-21 · tag F0645 — isolatedPASARR screening for Mental disorders or Intellectual Disabilities
What the surveyor found here — the official record, unedited, may be distressing
Based upon record review and staff interview, the facility failed to coordinate assessments with the pre-admission screening and resident review (PASARR) program when a new mental health diagnosis or change in condition is presented. This was found to be true for one (1) of six (6) residents during the long term care survey process. Resident identifier #87. Facility census: 117. Resident #87 a) On 01/20/26 reviewed Resident #87 PASARR dated 09/17/24. It was observed that the only diagnosis on the form was Delusional Disorder. According to the medical diagnosis listed for Resident #87 was diagnosed with conversion disorder with seizures or convulsions and anxiety disorder unspecified on 02/05/25. On 01/21/26 at approximately 9:00 a.m., interview with the facility's Social Worker verified the missed diagnosis and that a new PASARR should have been completed (Social Worker did submit a new PASARR on 01/21/26).
- Potential for harm · D2026-01-21 · tag F0806 — failed to honor food preferences — isolatedEnsure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review , observation, staff interview and resident interview, the facility failed to ensure a resident received food that accommodated the resident's intolerances and preferencesfor one (1) of two (2) residents reviewed for choices. Resident Identifier: #84. Facility Census: 17. Findings included: a) The facility's policy and procedure for Person-Centered Choices stated, Patients/Residents (hereinafter resident) are offered a choice of nourishing, palatable, well-balanced food and beverage options that meet their daily nutritional needs, taking into consideration the preferences of each resident. b) On 01/20/2026, Resident #84's tray card was reviewed by the state surveyor. The resident received the following items on her tray: Fish on a bun, Potato Wedges and Sliced Peaches. Resident #84 reported they had told staff they did not like fish. The DON asked the resident if she wanted the rice or an alternate from the always available menu. The resident declined the rice and alternates from the always available menu. According to Resident #84's food preference list,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-01-21 · tag F0810 — isolatedProvide special eating equipment and utensils for residents who need them and appropriate assistance.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation and staff interview, the facility failed to ensure a resident was provided a physician ordered assistive device during mealtime in the dining room. This failed practice was a random opportunity for discovery, and had the potential to affect a limited number of residents residing in the long term care facility. Resident Identifier: #6. Facility Census: 117. Findings included:a) Resident #6The facility's policy and procedure for Activities of Daily Living (ADL's) stated, Assistive devices and adaptive equipment are provided, as needed. The facility's policy and procedure for Dining Service Standards 6.6 Assistance - adaptive devices are provided, as indicated on the resident plan of care. The resident 's diet order stated, Regular Liberalized diet Regular Texture, Standard Thin Liquids consistency, Scoop plate with meals, large portions, [NAME] Cup. The resident's care plan interventions stated, Scoop plate with all meals, large portions, Kennedy cup. The resident's tray card…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 18 citations
- Potential for harm · Dcited before2026-01-21 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
What the surveyor found here — the official record, unedited, may be distressing
Based on records review and staff interviews, the facility failed to ensure a complete and accurate medical records. This failed practice was found true for one (1) out of (31) residents reviewed. Resident identifier: #61. Facility Census: 117 a) Resident #61 Documentation review of the medical record revealed a note by a medical provider reflected that resident has capacity and the assessment sheet scanned into the medical record demonstrated resident lacks capacity. Interview with the facility's Assistant Administrator on 01/18/26 at approximately 3:08 p.m., verified the inaccuracy of Resident #61's medical record.
- Potential for harm · Dcited before2026-01-21 · tag F0919 — failed to provide a working call system — isolatedMake sure that a working call system is available in each resident's bathroom and bathing area.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review, staff interview, resident interview and observation, the facility failed to ensure call lights were operational and within the resident's reach. This failed practice had the potential to affect a limited number of residents. Resident identifiers: #9 and #84. Facility Census: 117.Findings included: a) Resident #9 On 01/18/2026, during the initial interview process, Resident #9 was observed requesting to lay down. The resident's call light was behind him on his bed. The resident was unable to reach his call light upon two observed attempts. Assistance was obtained by the state surveyors. Nursing Assistant (NA) #25 confirmed the call light was out of reach. The NA reported the resident was care planned to be out of bed for meals. The patient's call light did not turn on when activated by the surveyor. At 11:20 AM, NA # 25 confirmed the call light did not turn on and stated, Maybe it got unplugged a little bit. On 01/18/2026 at11:40 AM, the Administrator reported the broken call light was put into the TELS system to be repaired and maintenance was coming in to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-10-23 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — the official record, unedited, may be distressing
Based on record review and staff interview, the facility failed to revise the care plan with a correct diagnosis for Resident #118. This was true for one (1) of 20 residents reviewed during the survey process. Resident Identifier: #118. Facility Census: 116.Findings Include: a) Resident #118On 10/21/25 at 10:00 AM, a record review was completed for Resident #118. The review found the care plan had not been revised with the correct diagnosis of restless leg syndrome. Under the focus area of Resident exhibits or is at risk for alterations in comfort related to chronic pain, neuropathy, left knee pain, bilateral calf pain, bladder spasms, Parkinsons disease, fibromyalgia, ganglion right wrist, spondylosis, osteroarthritis., the resident did not have a diagnosis of Parkinson's disease but did have a diagnosis of restless leg syndrome. On 10/21/25 at 11:45 AM, the Administrator #22 confirmed the care plan was incorrect. The Administrator #22 confirmed the diagnosis of Parkinson's disease was incorrect and should have been restless leg syndrome.
- Potential for harm · Dcited before2025-10-23 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and staff interview, the facility failed to provide an accurate and complete record for Resident #118's discharge and diagnosis for a medication. This was true for for one (1) of two (2) residents reviewed during the survey process. Resident Identifier: #118. Facility Census: 116.Findings Include: a1) Resident #118On 10/21/25 at 9:00 AM, a record review was completed for Resident #118. The review found the discharge plan documentation dated 07/09/25 was incorrect. Under section C entitled Recreation, a physician's order for treatment was listed as: Cleanse right 2nd toe amputation site with wound cleanser, pat dry, cover with betadine soaked gauze calcium alginate, wrap with kerlix. Upon further review, the resident did not have an amputation of the second toe.On 10/21/25 at 10:00 AM, the Administrator #22 confirmed this information listed on the discharge plan documentation was incorrect. a2) Resident #118On 10/21/25 at 9:00 AM, a record review was completed for Resident #118. The review found a physician's order for the medication Ropinirole (Requip) was…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-05-13 · tag F0628 — isolatedProvide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, and staff interview the facility failed to provide accurate information to the receiving facility regarding skin condition. This failed practice was found true for (1) one of (3) three residents reviewed for transfer/discharge during the complaint survey. Resident identifier #1. Facility census: 118. Findings Include: a) Resident #1 A record review on 05/12/25 at 9:55 AM, revealed that Resident #1 was transferred from this facility to a different nursing home on [DATE] at approximately 5:20 PM. Further record review revealed the following general note dated 04/10/25 at 5:20 PM, that read as follows: Resident discharging from the facility at this time via ambulance transport to (Local State Nursing Home Named). Vital signs obtained and within normal limits. Skin check completed and no new issues identified. All discharge paperwork reviewed with MPOA (via phone) and with the Nurse during the report called to (Local State Nursing Home Named). Medication list reviewed and sent with the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-12-05 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
What the surveyor found here — the official record, unedited, may be distressing
Based on observation, staff interview and record review, the facility failed to complete an accurate Minimum Data Set (MDS) related to dental status. This failed practice was found true for (1) one of (3) three residents reviewed for dental during the Long- Term Care Survey Process. Resident identifier #55. Facility Census: 112. Findings included: a) Resident #55 The initial observation on 12/02/24 at 12:02 PM, revealed that Resident #55 has no upper teeth. She has several teeth on the bottom that appeared to be broken off at the gums. A record review on 12/03/24 at 12:49 PM, revealed an MDS with an Assessment Reference Date (ARD) of 07/29/24, section L, question B, indicated Yes for being edentulous. Question D, indicated No for obvious broken natural teeth. During an interview and observation, on 12/03/24 at 12:49 PM, Licensed Practical Nurse (LPN) #37 confirmed that Resident #55 had bottom teeth that were broken off at the gums and black in color.
- Potential for harm · Dcited before2024-12-05 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review, staff interview, observation and resident interview, the facility failed to develop and implement a comprehensive care plan for one (1) of two (2) resident's revieed for vision/hearing. Resident #62 had a hearing deficit/use of hearing aids. Resident identifier #62. Facility Census: 112. Findings included: a) Resident #62 During an interview with Resident #62 on 12/02/24 at 1:11 PM, Resident #62 reported that she was hard of hearing, that she wore hearing aids and asked that I speak loudly. She was observed to be wearing said hearing aids at this time. A review of resident's care plan showed no mention of resident's hearing aids or hearing deficit at the time of review in the chart on 12/02/24. A copy of resident's care plan was printed and given to the surveyor on 12/03/24 and was noted in the electronic chart to have hearing deficit and hearing aids added to the care plan on this date. During an interview, on 12/04/2024 9:00 AM, with the Director of Nursing (DON) the DON reported that when asked for information yesterday, she realized the hearing deficit…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-12-05 · tag F0679 — failed to provide activities — isolatedProvide activities to meet all resident's needs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and staff interview, the facility failed to provide an activity program to meet the needs and interest of the residents. This failed practice was found true for (1) one of (2) two residents reviewed for activities during the Long-Term Care Survey Process. Resident identifier: #52. Facility Census 112. Findings Included: a) Resident #52 During the initial interview on 12/02/24 at 11:59 AM, Resident #52 stated, I would go to activities if I knew what was going on. I have no idea. A record review on 12/04/24 at 1:06 PM, of Resident #52's activity participation for the months of 09/2024, 10/2024, and 11/2024 revealed that Resident #52 only participated in (2) two group activities for the (3) month period. During an interview on 12/04/24 at 1:07 PM, The Activity Director stated, We offer her to come but she refuses. No, I do not have the refusals documented. A record review on 12/04/24 at 1:30 PM, revealed a Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/06/24, Section F, Question E is marked to indicate that it is Somewhat important for…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-12-05 · tag F0685 — isolatedAssist a resident in gaining access to vision and hearing services.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review, resident interview and staff interview, the facility failed to ensure that one (1) of two (2) residents reviewed for vision/hearing received proper assuasive devices to maintain hearing abilities. Resident identifier #12. Facility census: 112. Findings included: a) Resident #12 During an interview with Resident #12 on 12/02/24 at 3:20 PM, Resident #12 reported that her hearing aids were missing. A review of resident's records revealed that the resident had an audiologist evaluation completed on 01/25/24 and the physician gave resident an order for hearing aids. Upon further review of the records, there was no mention of hearing aids in the care plan or any other assessments. On 12/04/24 at 8:50 AM an interview with Social Services Worker #45 who reported that residents have never had hearing aids. When I asked about the order for hearing aids in January of 2024, she reported she did not know why she has not gotten them and reported that she would find out. On 12/04/24 9:00 AM an interview with Director of Nursing (DON), who reported that she was not sure why…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-12-05 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, the facility failed to ensure complete and accurate medical records for 2 of 27 residents reviewed. Resident identifiers: #8 and #55. Facility census: 112. Findings included: a) Resident #8 A review of the medical record on 12/03/24 at 3:24 PM found the Fall Risk Evaluations dated 12/01/24 and 08/30/24 for Resident #8 were marked 1-2 falls in the past 3 months. No falls were logged on the residents e-interact or reported on the reviewed Incident Report Log from 07/24 to 12/24. The DON was asked for the falls documented on the Fall Risk Evaluations and the DON reported the patient hasn't had any falls the past year. DON completed a Fall Risk Evaluation on 12/03/24 to correct the history of falls. A review on 12/04/24 at 3:35 PM of Progress Note: 12/01/24- documented 1-2 falls in the past 3 months. A corrected progress note dated 12/03/24 with no falls in the past 3 months. b) Resident #55 The initial observation on 12/02/24 at 12:02 PM, revealed that Resident #55 has no…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-12-05 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, and staff interview, the facility failed to establish and maintain an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infections. The facility failed to initiate enhanced barrier precautions for a resident with reoccurring open wounds. This was a random opportunity for discovery that had the potential to affect a limited number of residents. Resident identifier: 67. Facility census: 112. Findings included: a) Resident #67 The facility's procedure titled Enhanced Barrier Precautions with effective date 08/01/23 and revision date of 05/01/24 stated enhanced barrier precautions would be applied to residents with chronic wounds. Review of Resident #67's physicians' orders showed the following orders: - Cleanse open lesion to left knee with wound cleanser, pat dry, apply wound prep. This order was written on 08/19/24. - Cleanse open lesions to right knee with wound cleanser, pat dry, cover with dry dressing. This order was written on 11/25/24. - Cleanse open lesions to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-10-18 · tag F0561 — failed to honor residents' choices — patternHonor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, resident interview and staff interview, the facility failed to promote self-determination through supporting the resident in choices that were significant to them. This deficient practice was true for three (3) of four (4) residents reviewed who did not receive care based on the resident's individual preference for care. Resident #93 did not receive grooming in accordance with requests made and/or customary routines for hair care, Resident #89 did not receive food preferences and Resident #77 did not receive shower preferences. Resident identifiers: Resident #93, #77 and #89. Census: 117. Findings included: a) Resident #93 An interview, with Resident #93, on 10/16/23 at 12:11 PM, revealed the resident had requested to receive a haircut over three (3) months ago and to date had not received one. Resident #93 stated further, he had questioned staff about the need for a haircut and had been told he had been placed on a list. An observation of Resident #93, during the interview on 10/16/23 at 12:11 PM, revealed the resident's hair was unkempt. A…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2023-10-18 · tag F0636 — patternAssess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on record review, observation, individual and staff interview, the facility failed to analyze or obtain supplemental information based on the comprehensive assessment to assist the resident in receiving dental services. This was true for one (1) of two (2) sampled residents reviewed for the care area of dental care. Resident identifier: Resident #93. Census: 117. Findings included: a) Resident #93 An interview with Resident #93, on 10/16/23 at 12:13 PM, revealed the resident complained dental services had been requested and stated he had been placed on a list, however, was still waiting for care. Resident #93 stated it had been over three (3) months and he wanted to have dentures because he did not like receiving chopped up foods to eat. Observation of Resident #93 on 10/16/23 at 12:13 PM, revealed the resident did not have any teeth or dentures present. Record review showed Resident #93 was admitted to the facility on [DATE]. A Minimum Data Set (MDS), completed 04/26/23, identified the resident as…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-10-18 · tag F0800 — patternProvide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and interview the facility failed provide an adequate amount of nutrition during a dinner meal on unit one and Resident #73. This was a random opportunity for discovery. Resident #73. Facility Census: 117. Findings included: a) Hall One During observation of the dinner meal on the last unit served on 10/15/23 at 5:26 PM found multiple residents not receiving enough tomato soup to meet the dietary needs of the residents. On 10/15/23 at around 5:41 PM an interview and observation in the kitchen with the Dietary Manager and Administrator found the soup bowls were not being adequately filled for a serving size. The Administrator advised the dietary staff to make more soup for unit one and re-serve all residents more soup. b) Resident #73 During an interview on 10/15/23 at 5:16 PM, Resident #73 stated that she never gets what's listed on the tray card. Observation of tray revealed mechanically altered chicken tenders, potato wedges and a brownie. Review of Resident #73's tray card revealed mechanical chicken tenders on bun, potato wedges, tomato soup, and pears. On…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-10-18 · tag F0644 — isolatedCoordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on record reviews and staff interviews, the facility failed to ensure the completion of a new Preadmission Screening and Resident Review (PASARR) for residents with a newly added psychiatric diagnosis. This deficient practice had the potential to affect two (2) of three (3) residents reviewed for the PASAAR care area. Resident identifier: #13 and #75. Facility census: 117. Findings included: a) Resident #13 Review of Resident #13's medical records showed the resident's most recent Preadmission Screening and Resident Review (PASARR) was performed on 06/28/22. The mental illness and intellectual disability assessment in the PASARR had no diagnosis of schizophrenia disorder. The Level II evaluation was determined to not be required. A review of Resident #13's diagnoses report showed the diagnosis of schizophrenic disorder was added to the resident's diagnoses list on 02/15/22. During an interview on 10/16/23 at 2:09, the Social Worker confirmed Resident #13 did not have a new PASARR completed when the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-10-18 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on resident interview, observation, and staff interview the facility failed to provide the necessary services to maintain good incontinence care. This was true for one (1) of three (3) residents reviewed for activities of daily living. It was discovered Resident #91 was wearing the wrong size incontinence brief. Resident identifier: #91. Facility census: 117. Findings included: a) Resident #91 During an interview on 10/15/23 at 1:15 PM, Resident #91 reported she was wearing the wrong size incontinence brief. She explained the nurse aide (no name provided) put on the wrong size brief twice last night and also this morning. She further reported the nurse aide (NA) did not know how to get into the supply room to get the correct size briefs. Resident also said the brief she was wearing was too tight and was rubbing her inner thighs. In an interview with the Nursing Home Administrator (NHA) on 10/15/23 at 2:00 PM, verified the code to the supply room was written on the door frame and any needed supplies were easily accessible to staff. He also reported the correct size briefs were…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-10-18 · tag F0679 — failed to provide activities — isolatedProvide activities to meet all resident's needs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review and staff interview the facility failed to implement an ongoing resident centered activities program designed to meet the interest of and support the physical, mental and psychosocial well-being for resident #99 This practice was found true for one (1) of three (3) residents reviewed for the care area of activities during the Long Term Care Survey Process. Resident identifier # 99. Facility census 117 Finding Included: a) Resident #99 During the initial tour of the facility on 10/15/23 at 12:30 PM, Resident #99 was observed laying in the bed, the bed was against the wall. Resident was facing the wall and a window. There was a TV in the room turned toward the roommate; which was not turned on. The tv was not in a location where Resident #99 could see it. During another observation on 10/15/23 at 3:30 PM Resident #99 continued to lay in the bed, facing the wall. Resident #99 was observed rubbing on his sheets with his hand. During an observation on 10/16/23 at 10:00 AM Resident #99 was observed laying in the bed. There was no stimulation in the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-10-18 · tag F0692 — failed to prevent malnutrition and dehydration — isolatedProvide enough food/fluids to maintain a resident's health.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on staff interview, record review and observation the facility failed to provide a therapeutic diet which takes into account the resident's clinical condition, and preferences, when there is a nutritional indication. Resident #108 did not receive the correct diet of regular/liberalized diet for no oranges, orange juice, bananas, or tomatoes. This failed practice is true for one (1) of one (7) residents reviewed for nutrition. Resident identifier #108. Facility Census 117. Findings included: a) Resident #108 Record review on 10/17/23 Resident #108's medical record found a diet order which read, Regular texture for no oranges, orange juice, bananas, or tomatoes. During an observation on 10/17/23 of the lunch time meal Resident #108 received a meal that included a meatball sub covered in marinara sauce and ketchup packets for his french fries. During an observation on 10/17/23 of the lunch time meal Resident #108's tray ticket read regular diet and had no mention of the no oranges, orange juice, bananas or tomatoes, which did not match the order from 9/14/23 that read regular…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
$22,562 in federal fines across 1 penalty.
- $22,562 — penalty dated 2025-05-13
Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.
Part of a chain
This home belongs to GENESIS HEALTHCARE — 184 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 4 of 5 | 2.4 | +1.6 vs chain |
| Health inspection | 3 of 5 | 2.3 | +0.7 vs chain |
| Staffing | 2 of 5 | 2.5 | -0.5 vs chain |
| Quality measures | 5 of 5 | 3.5 | +1.5 vs chain |
The other 183 homes this chain runs (chain average 2.4★, per CMS)
Showing 40 of 183; lowest-rated first.
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| SADDLE SHOP ROAD OPERATIONS LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 04/20/2007 |
| FC-GEN OPERATIONS INVESTMENT LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 12/01/2012 |
| GEN OPERATIONS I LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 12/01/2012 |
| GEN OPERATIONS II LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 12/01/2012 |
| GENESIS HEALTHCARE INC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 02/02/2015 |
| GENESIS HOLDINGS LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 02/02/2015 |
| GENESIS OPERATIONS LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 09/07/2007 |
| GENESIS WV HOLDINGS LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 09/07/2007 |
| GHC HOLDINGS LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 09/07/2007 |
| SUN HEALTHCARE GROUP INC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 02/02/2015 |
| WHITMAN, ARNOLD | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 02/02/2015 |
| BERG, MICHAEL | Individual | CORPORATE OFFICER | — | since 12/01/2012 |
| BRIDGEFORD, LAURA | Individual | CORPORATE OFFICER | — | since 06/01/2024 |
| MENDELSON, AVI | Individual | CORPORATE OFFICER | — | since 06/01/2024 |
| ANTOLINI, MICHAEL | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 02/09/2025 |
| CHAPMAN, BRIAN | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 02/09/2025 |
CMS files one row per role, so the 18 rows in the source record cover these 16 parties — each is shown once here with every role it holds. Nothing is omitted.
10 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
About 82% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $8.0M paid to related parties — landlords or management companies under common ownership — equal to about 45% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2024. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2024). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in WV
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the West Virginia Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 515061. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-01-21, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →
Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →
Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.