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Logan Center

Po Box 540, Logan, WV 25601 · For profit - Partnership · 66 certified beds · (304) 752-2273 Medicare & Medicaid certified

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Abuse-prevention, restraint, or reporting citation — no harm found (F0609) — cited Jun 20251 immediate-jeopardy citation1 immediate-jeopardy citation CMS recorded as corrected before the inspection ended (past non-compliance)$16,981 in federal fines
Insights

This home has serious findings on its record. Read them closely before you consider it.

In its favor
  • a middle-of-the-pack inspection score (3/5)
Worth asking about
  • it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • inspectors cited 1 immediate-jeopardy problem — the most serious level
  • inspectors recorded 1 serious finding as past non-compliance — the problem was found, fixed, and verified before the survey closed, so it is history rather than a current condition, but it is still worth asking what changed
  • a high number of inspection citations overall (31) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $16,981 in federal fines (most recent 2025-06-11)
  • its payroll-based staffing rating is low (2/5)
  • its last standard health inspection was over 3 years ago — the star rating may not reflect current conditions

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.

3/5
CMS overall
3 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 3 of 5
StaffingFrom payroll records (PBJ) 2 of 5
Quality measuresSelf-reported by the facility 4 of 5

Location & what’s nearby

Hospital
★★ 2/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
1115 2nd Ave · (304) 831-0085 · Call to confirm hours
Pharmacy
1036 Old Logan Rd · (304) 896-2127 · Call to confirm hours
Grocery
776 Mud Fork Rd · (304) 752-4850 · Call to confirm hours
Park
Typically dawn to dusk
Place of worship

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 4 of 5
Long-stay residentspeople who live here 5 of 5
Short-stay residentsrehab / post-hospital 3 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 held steady at 3 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.

Overall rating3★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased5.6%14.7%15.4%better
Long-stay residents who lose too much weight4.2%6.3%5.4%better
Long-stay residents with a catheter left in their bladder0.0%0.4%0.9%better than state — see note marked double-dagger below the table
Long-stay residents with a urinary tract infection0.4%1.6%2.0%better
Long-stay residents with depressive symptoms5.8%7.6%6.5%better
Long-stay residents who were physically restrained2.5%0.2%0.1%worse
Long-stay residents with falls causing major injury1.2%4.4%3.3%better
Long-stay residents whose ability to walk worsened5.2%15.9%16.1%better
Long-stay residents on antianxiety or hypnotic medication29.2%27.0%18.9%worse
Long-stay residents given the seasonal flu vaccine100.0%97.6%95.3%typical
Long-stay residents with pressure ulcers7.0%4.2%4.7%worse
Long-stay residents with worsening bladder/bowel control16.6%22.1%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table18.2%13.4%17.1%typical
Short-stay residents who newly got an antipsychotic medication2.4%1.0%1.4%worse
Short-stay residents given the seasonal flu vaccine90.4%79.4%79.4%better
Short-stay residents rehospitalized after admission31.0%22.5%22.6%worse
Short-stay residents with an outpatient ER visit8.9%11.3%12.0%better
Long-stay hospitalizations per 1,000 resident days1.811.801.67typical
Long-stay outpatient ER visits per 1,000 resident days0.981.841.80better

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.

49.3% 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 42 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

49.3%U.S. median 51.5%
Got home and stayed home
10.2%U.S. median 10.7%
Went back to hospital
52.5%U.S. median 56.6%
Met the expected recovery
0.35U.S. median 0.31
Therapy hours / resident / day
0.16hours / resident / day
Physical therapy
0.12hours / resident / day
Occupational therapy
0.08hours / resident / day
Speech therapy

Met the expected recovery: 52.5% 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 40 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 0.35 therapist hours per resident per day in 2026Q1 — more than 60% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 10% 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
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF49.3%CMS range 32.6–64.951.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF10.2%CMS range 6.8–13.910.7%Oct 2022–Sep 2024no 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 discharge52.5%56.6%Oct 2024–Sep 2025CMS 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 discharge50.0%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge50.0%50.0%Oct 2024–Sep 2025CMS 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 identified97.3%98.7%Oct 2024–Sep 2025CMS 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 setting97.1%100.0%Oct 2024–Sep 2025CMS 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 dischargenot 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 stay0.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened0.0%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization5.8%CMS range 3.0–9.97.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.401.02Oct 2022–Sep 2024CMS 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

0.68
RN hours/ resident / day
0.85
LPN hours/ resident / day
1.77
Aide hours/ resident / day
3.31
Total nurse hours/ resident / day
0.33
RN hoursweekends
36.8%
Total nursing turnover
30.0%
RN turnover

How full it usually is: this home is certified for 66 beds and averages 65.2 residents a day — about 99% occupied, or roughly 1 bed 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 3.31 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.68 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.77 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 2.97 hrs/resident/day on weekends vs 3.44 on weekdays — 14% thinner on weekends. RN hours go from 0.82 to 0.33 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 37% is about the same as 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

10
deficiencies at the latest standard inspection (2023-08-09)
8
at the previous standard inspection (2022-04-06)

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.

This trend is not current. The most recent of these two inspections was over 3 years ago; the arrow describes what inspectors found then, not what the home is like now.

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.

ABCDEFGHIJKL

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.

31 citations, most serious first. The 13 most serious are shown; the remaining 18 are one tap away and print in full.

  • Immediate jeopardy · J2025-06-11 · tag F0805 — failed to prepare food in a form residents can eat — isolated
    Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
    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 interviews, the facility failed to provide food in the correct consistency per physician orders and resident's individual needs for Resident # 168 resulting in a choking incident requiring emergency response and hospitalization. This created an immediate jeopardy situation. This failed practice had the potential to affect more than a limited number of residents. The facility had corrected this situation that began on 12/04/24 on 12/09/24. This issue is cited at past noncompliance. Resident identifiers: #168, #33, #51, #22, #25, #47, #39, #35, and #59. Facility Census: 63. Findings included: a) Resident #168 Review of a Facility Reported Incident (FRI) documentation revealed Resident #168 had a choking episode on 12/04/24. The resident was transferred to an acute care facility and admitted . The resident was hospitalized from [DATE] to 12/11/24. It was reported that the resident was served broccoli that was not chopped. According to the FRI, the resident indicated and gestured he…

    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.

    Nutrition and Dietary Deficiencies · Past Non-Compliance
  • Immediate jeopardy · Kcited before2019-09-26 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    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, Center for Disease Control and Prevention (CDC), Facility Policy, and observation,` the facility has failed to ensure and establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. The facility failed to store clean linens in a safe, clean and sanitary manner. Furthermore, the facility failed to appropriately place Residents #59 and #28, diagnosed with Multiple Drug Resistant Organisms (MDRO), in contact precautions, and they also failed to use proper Personal Protection Equipment (PPE) while providing care. In addition, the facility failed to have PPE equipment readily available for staff. Resident #59 currently has a active diagnosis of Carbapenem-resistant Enterobactiaceae (CRE) in his urine. There were not any signs on the door to alert staff or visitors of the type of precautions to use. Resident #28…

    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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Actual harm · G2023-09-26 · tag F0697 — failed to manage pain — isolated
    Provide safe, appropriate pain management for a resident who requires such services.
    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 resident interview, record review and staff interview the facility failed to ensure a resident received treatment and care in accordance with professional standards of practice and the resident's choices, related to pain management. Resident #12 complained his medication was administered late frequently which caused him to suffer unnecessarily. This demonstrates actual physical harm for Resident #12. This was true for one (1) of three (3) reviewed for the care area of Pain. Resident identifier: Resident #12. Facility Census: 65. Findings included: a) Resident #12 During an interview on 9/25/23 at 12:09 PM, Resident #12 stated, I can't get my medications when needed. I am supposed to take my medicine before bedtime, but it is closer to midnight before I receive them. During an interview, on 09/25/23 at 2:31 PM, the Director of Nursing (DON) stated, (Resident #12's name) has been on comfort measures since admission on [DATE]. During a record review on 09/25/23 at 3:00 PM, Resident #12's medical records…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-06-11 · tag F0908 — failed to keep essential equipment working — pattern
    Keep all essential equipment working safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review and staff interviews, the facility failed to ensure safe operating essential equipment for the facility's ice machine and Resident 21's bed. Resident identifier: #21. Facility census: 63. Findings: a) On 06/08/25 at approximately 3:48 p.m., an observation of the ice machine located in the dining area revealed the drainage line coming from the ice machine goes directly into the floor drain. On 06/08/25 at approximately 3:53 p.m., an interview with the facility's Maintenance Director and Regional Maintenance Director verified this finding. This finding was also acknowledged with the facility Administrator upon exit on 06/11/25 at approximately 1:00 p.m. b) Resident #21 On 06/09/25 at approximately 3:29 p.m., a record review of Resident #21 revealed a progress note dated 02/27/24 by Employee #21. The note revealed that the resident's bed had been dysfunctional for 3 days after witnessing Resident #21 fall on 02/27/24. On 06/09/25 at approximately 4:09 p.m., an interview with the facility Administrator verified that Resident #21's bed 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.

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-06-11 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    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 report alleged physical abuse to the proper state agencies within the required two (2) hour timeframe. This is true for one (1) of seven (7) residents reviewed under the care area of abuse. Resident identifier: #32. Facility Census: 63. Findings include: a) Resident #32 On 06/09/25 at 1:00 PM, a review of the facility policy entitled, Abuse Prohibition was completed. The review found in section 7.2 of the facility policy states, Report allegations involving abuse (physical, verbal, sexual, mental) not later than 2 hours after the allegation is made. On 06/09/25 at 11:21 AM, a facility-reported incident (FRI) dated 03/05/25 regarding an allegation of physical abuse on 03/04/25 was reviewed. The review found the alleged physical abuse was not reported to the proper state agencies within the required two (2) hour time frame. The alleged incident took place on 03/04/25 at 10:45 PM; and was not reported until 03/05/25 at 9:15 AM. The timeframe from the alleged event to the time of reporting was 10 and 1/2 hours. 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-06-11 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, the facility failed to develop a care plan in the area of fall prevention for Resident #42. Resident identifier: #42 Facility census: 63. Findings include: a) Resident #42 Resident #42 had a fall on 04/17/25. Resident #42 was assessed with bruising to forehead, ankle and knee. X-rays were ordered for the ankle and knee and neuro checks were ordered. Resident was sent to the local ER on [DATE] and was diagnosed with cerebral infarction due to unspecified occlusion or stenosis of right middle cerebral artery. Resident #42's medical record revealed a fall risk evaluation was performed on 03/12/25 and a care plan review started on 03/7/25. Fall risks were identified as a focus area, goals were to have no falls with major injury and minor injury. However, the Interventions were Encourage resident to consume all fluids during meals. Observe for and report signs and symptoms of nausea/vomiting, and observe for changes in medical status, pain status, mental status and…

    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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-06-11 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on record review and staff interview, the facility failed to be free from accidents/hazards by leaving Resident #21 in a broken bed. Resident identifier #21. Facility census 63. Findings include: a) On 06/09/25 at approximately 3:29 p.m., a record review for Resident #21 revealed a progress note dated 02/27/24 by Employee #21. The note reflected that the resident's bed had been dysfunctional for 3 days after witnessing Resident #21 fall on 02/27/24. On 06/09/25 at approximately 4:09 p.m., an interview with the facility Administrator verified that Resident # 21 bed was malfunctioning and employee #21 did not remove the malfunctioning bed out of service on 02/24/24. This finding was also acknowledged by the Administrator upon exit on 06/11/25 at approximately 1:00 p.m.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2023-08-09 · tag F0880 — failed to prevent and control infections — widespread
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations and staff interview, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections with regards to Resident handwashing and to maintain a separation between the clean and soiled area of the laundry room to prevent contamination by airflow. This practice had the potential to affect more than an isolated number of residents. Facility census: 64. Findings included: a) Dining Room An observation during dining, on 08/07/23 at 12:44 PM, revealed the residents in the dining room, did not receive hand hygiene prior to or during the lunch meal tray pass. A second observation on 08/08/23 at 11:40 AM through 12:30 PM found no hand hygiene was offered prior to the noon meal. During an interview, on 08/08/23 at 12:18, with Nurse Aide (NA) #29 verified no hand hygiene was completed prior to the meal service. She stated that they usually use hand wipes for the residents. She stated that she…

    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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-08-09 · tag F0679 — failed to provide activities — pattern
    Provide activities to meet all resident's needs.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on observation and staff interview, the facility failed to implement an ongoing activity program designed to meet the interests of and support the well-being of each resident specifically premeal activities not being provided. This was a random opportunity for discovery. Facility census: 64. Findings included: a) Dining observations An observation of Dining Room meal service on 08/07/23 from 11:42 AM to 12:15 PM, found 25 residents sitting with dining room waiting for their noon meal, six (6) residents appear to be sleeping . No Pre meal activities were provided. A second observation of the dining room on 08/08/23 from 11:35 AM to 12:30 PM, found 27 Resident's sitting around the room with no premeal activities being provided. During an interview on 08/08/23 at 1:27 PM with the Administrator confirmed staff should be present in the dining room providing premeal activities, such as soft music, television, or socialization.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-08-09 · tag F0868 — pattern
    Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
    What the surveyor found here — the official record, unedited, may be distressing

    Based on Quality Assurance Performance Improvement (QAPI) attendance sheets and staff interview, it was determined that the facility failed to ensure the required QAPI meetings were held, and all required QAPI committee members were in attendance. This deficient practice had the potential to affect more than an isolated number of residents in the facility. Facility census: 64. Findings included: Review of the QAPI attendance sheets found no evidence meetings were held the last two (2) quarters of 2022 (July, August, September-3rd quarter and October, November, and December 2022- 4th quarter) found no sign in sheets and/or minutes. Additionally, the Infection Preventionist (IP) failed to attend the QAPI meetings on 02/23/23 and 03/23/23. On 08/08/23 at 2:55 PM in an interview the administrator confirmed the QAPI meetings and minutes had disappeared, and there was no evidence of meetings held in 2022. She also confirmed the IP had not attended the meeting on the above-mentioned dates.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-08-09 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on observation, and staff interview the facility failed to treat each resident with respect and dignity regarding meal service. This was a random opportunity for discovery. Facility census: 64. Findings included: a) Dining Room During an observation of meal services on 08/07/23 from 12:01 PM through tray pass revealed Resident's in the dining room seated together did not received their trays at the same time. A second dining observation of meal services on 08/08/23 from 12:01 PM through tray pass revealed Resident's in the dining room seated together did not received their trays at the same time. During an interview on 08/08/23 at 12:25PM the Dietary Account Manager #83 verified that the Residents seated together should be served at the same time.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-08-09 · tag F0623 — isolated
    Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
    What the surveyor found here — the official record, unedited, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, the facility failed to notify the Ombudsman of a resident's transfer to the hospital. This deficient practice had the potential to affect one (1) of two (2) residents reviewed for the care area of hospitalization. Resident identifier: #33. Facility census: 64. Findings included: a) Resident #33 Review of Resident #33's medical records showed in the last 120 days the resident was transferred to the hospital on [DATE] and 04/24/23. On 08/08/23 at 11:12 AM, the Administrator provided a report of discharges from the facility for the dates 03/16/23 to 06/11/23 and provided evidence the information was provided to the Ombudsman on 06/12/23. Resident #33's transfers to the hospital on [DATE] and 04/23/23 were not on the report. The Administrator confirmed the Ombudsman was not notified regarding Resident #33's transfers to the hospital on [DATE] and 04/23/23. No further information was provided through the completion of the survey.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-08-09 · tag F0641 — isolated
    Ensure each resident receives an accurate assessment.
    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 have a complete and accurate Minimum Data Set (MDS) in the care area of restraints and antipsychotic medication. Resident identifier: Resident # 24, and #50. Facility census 64. Findings included: a) Resident #24 A review of the medical record for Resident #24 discovered there was an order for a Merry [NAME] to be used, dated 06/26/23. A review of the MDS found nothing was marked for Restraints. During an interview on 08/08/23 at 2:29 PM, with Clinical Care Reimbursement (CCR) #1 agreed the use of a Merry walker was not on the MDS and should have been added. On 08/09/23 at 8:45 AM the Administrator made aware of the information above. b) Resident #50 Review of Resident #50's medical records showed the resident had been receiving the antipsychotic medication aripiprazole (Abilify) since returning to the facility from the hospital on [DATE]. Resident #50's Minimum Data Set (MDS) assessment with Assessment Reference Date (ARD) 07/24/23 showed 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
Show the remaining 18 citations
  • Potential for harm · Dcited before2023-08-09 · tag F0657 — failed to keep the care plan current — isolated
    Develop 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 — an excerpt from the official record, may be distressing

    Based on record review and staff interview, the facility failed to ensure a resident's comprehensive care plan was revised when there was a change in the resident's plan of care. This deficient practice had the potential to affect one (1) of one (1) residents reviewed for the care area of transmission-based precautions. Resident identifier: #33. Facility census: 64. Findings included: a) Resident #33 Upon observation on 08/07/23 at 11:30 AM, Resident #33 had a sign on the room of his door for Enhanced Barrier Precautions. Review of Resident #33's medical records showed the resident had a history of Methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant enterococci (VRE) infections. Review of Resident #33's comprehensive care plan showed a focus related to the resident's history multi-drug resistance organism infections VRE and MRSA. However, an intervention for Enhanced Barrier Precautions was not included on the care plan. On 08/08/23 at 12:32 PM, the Assistant Director of Nursing confirmed Resident #33 was not care planned for Enhanced Barrier Precautions. 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-08-09 · tag F0698 — failed to provide proper dialysis care — isolated
    Provide safe, appropriate dialysis care/services for a resident who requires such services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, staff interview and resident interview, the facility failed to provide dialysis services consistent with professional standards of care. This was true for one (1) of one (1) resident reviewed under the care area of dialysis. Resident identifier: #35. Facility census: 64. Findings included: a) Resident #35 1. Hemostats On 08/07/23 at 12:40 PM, a record review was completed for Resident #35. The review found a physician's order stating, keep hemostats to head of bed and chair at all times d/t (due to) dialysis port. (Typed as written.) The resident has a right upper chest port implanted for hemodialysis. The hemostats are kept close to the resident in case of any bleeding from the dialysis port. On 08/08/23 at 1:38 PM, an interview with Resident #35 was completed regarding the hemostats' location. Resident #35 stated, they keep them on the cart .they aren't normally in here. On 08/08/23 at 1:44 PM, Registered Nurse (RN) #9 stated, We keep them on the wall above his bed. Upon entering Resident #35's room, RN #9 stated, Where are they? I keep them…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-08-09 · tag F0770 — failed to provide lab services — isolated
    Provide timely, quality laboratory services/tests to meet the needs of residents.
    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 residents received treatment and care in accordance with professional standards of practice. The facility failed to obtain laboratory testing in accordance with physician's orders for one (1) of five (5) residents reviewed for the care area of unnecessary medications. Resident identifier: #50. Facility census: 64. Findings included: a) Resident #50 Review of Resident #50's physician's orders showed an order written on 07/18/23 to obtain complete blood cell (CBC) laboratory testing every seven (7) days for four (4) weeks from 07/19/23 to 08/16/23. Review of Resident #50's laboratory results showed CBC results for 07/19/23 and 08/07/23. Further review of Resident #50's medical records showed an order written on 07/18/23 to obtain magnesium level laboratory testing every week, beginning 07/26/23. Review of Resident #50's laboratory results showed the resident's last magnesium level testing was on 07/19/23. During an interview on 08/09/23 at 8:00 AM, the Administrator confirmed Resident #50's CBC and magnesium…

    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.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-08-09 · tag F0883 — failed to offer flu and pneumonia vaccines — isolated
    Develop and implement policies and procedures for flu and pneumonia vaccinations.
    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 review of the Centers for Disease Control (CDC) Adult Immunization Schedule, record review, and staff interview, the facility failed to ensure all eligible residents were offered and/or given the Pneumonia vaccine. This was true for one (1) of five (5) residents reviewed for immunizations. Resident identifier: #15. Facility census: 64. Findings included: CDC Adult Immunization Schedule review revealed the following: Previously received both PCV13 and PPSV23 but NO PPSV23 was received at age [AGE] years or older: 1 dose PCV20 at least 5 years after their last pneumococcal vaccine dose OR complete the recommended PPSV23 series as described here: Previously received both PCV13 and PPSV23, AND PPSV23 was received at age [AGE] years or older: Based on shared clinical decision-making, 1 dose of PCV20 at least 5 years after the last pneumococcal vaccine dose. a) Resident #15 During a medical record review found Resident #15 was (age) at the time of this survey. Resident #15's immunization record revealed 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-04-06 · tag F0578 — failed to honor advance directives / code status — isolated
    Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on medical record review and staff interview, the facility failed to ensure resident's Physician's Order for Scope of Treatment (POST) forms conveying end-of-life wishes were complete. This deficient practice was found for two (2) of 20 POST forms reviewed for the area of advanced directives during the Long-Term Care Survey Process. The POST forms for Resident #13 and #1 did not specify how long intravenous fluids were to be administered. Resident identifier: #13 and #1. Facility census: 66 Findings included: a) Resident #13 A medical record review of Resident #13's record on 04/04/22, revealed Section C of the POST completed on 06/05/20 did not specify how long intravenous fluids were to be administered. In an interview with the Social Service Director on 04/04/20 at 2:10 PM, they verified Section C did not specify how long intravenous fluids were to be administered. b) Resident #1 On 04/04/22 at 2:03 PM a record review for Resident #1 found the Physician Order for Scope of Treatment (POST) form dated 02/16/17 directed use of Intravenous (IV) fluids for a trial period of 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2022-04-06 · tag F0657 — failed to keep the care plan current — isolated
    Develop 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 — an excerpt from the official record, may be distressing

    Based on observation, record review, and staff interview, the facility failed to revise the comprehensive care plan when a change occurred. This deficient practice was true for one (1) of 20 residents reviewed during the long-term care survey process. Resident identifier: #23. Facility census: 66. Findings included: a) Resident #23 On 04/04/22 at 12:15 PM, Resident #23 was noted to be ambulating with a Merry [NAME] assistive device. Review of Resident #23's medical records showed an order written on 6/23/21 stating, May be up in Merry [NAME] when out of bed as tolerated, release every 2 hours for skin care/toileting. Review of Resident #23's comprehensive care plan showed the following focus, [Resident's name redacted] is unable to ambulate safely without support. He attempts to ambulate unassisted, is unable to maintain his balance and had several falls. He exhibits impaired mobility, impaired cognition. He is now up in Merry [NAME] when out of bed, released every 2 hours for skin care/toileting. The care plan contained the following intervention initiated on 07/06/21, Observe 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-04-06 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on medical record review and staff interview, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice. The physician's orders for Resident #40 were not followed for monitoring blood glucose levels . This failed practice had the potential to affect one (1) of five (5) residents reviewed for the care area of unnecessary medications during the Long Term Care Survey Process. Resident identifier: #40 Facility census: 66 Findings included: a) Resident #40 A medical record review on 04/05/22, revealed orders for blood glucose levels by fingerstick two (2) times a day for diabetes. A review of the medication administration record (MAR) from 03/24/22 to 04/05/22 found seven (7) missed fingersticks. On 03/24/22, 04/03/22, 04/04/22 and 04/05/22 had no morning (AM) fingerstick and on 04/02/22, 04/03/22, and 04/04/22 had no evening (PM) for monitoring blood glucose levels. In an interview with the Director of Nursing (DON) on 04/05/22 at 1:22 PM, verified there were seven (7) missed fingersticks from 03/24/22 to 04/05/22. .

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2022-04-06 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    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 complete quarterly smoking evaluations for one (1) of one (1) residents reviewed for the care area of smoking. Resident identifier: #30. Facility census: 66. Findings included: a) Resident #30 The facility's policy and procedure titled Smoking with effective date 06/01/96 and review date 11/04/19 stated the admitting nurse would perform a smoking evaluation on each resident who chooses to smoke and re-evaluations would be performed quarterly and with a change in condition. The facility provided a list of residents who smoked and included Resident #30 as a resident who was permitted to smoke independently. Review of Resident #30's medical records showed the resident was admitted to the facility on [DATE]. On 06/27/21, a smoking evaluation was performed for Resident #30 and assessed the resident as being safe to smoke independently. No further smoking evaluations were located in the resident's medical records. During an interview on 04/05/22 at…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-04-06 · tag F0693 — failed to provide proper feeding-tube care — isolated
    Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on medical record review, observations and staff interview the facility failed to prevent complications for a resident who receives enteral feeding. It was discovered the head of the bed had not been elevated to the correct position. This was true for one (1) of two (2) residents reviewed for the care area of tube feeding during the Long Term Care Survey Process. Resident identifier: #13 Facility census: 66 Findings included: a) Resident #13 A medical record review on 04/06/22, revealed a physician's order for Resident #13's head of the bed to be elevated 30 to 45 degrees while in bed every shift with a start date of 11/19/21. During an observation on 04/06/22 at 8:10 AM, it was discovered the head of the bed had not been elevated to the 30 to 45 degree angle. In an interview on 04/06/22 at 8:12 AM with Licensed Practical Nurse (LPN) #65, verified the bed was in the flat position and not at the 30 to 45 degree angle. .

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-04-06 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on observation, medical record review and staff interview, the facility failed to deliver respiratory care services consistent with professional standards of practice. This was true for one (1) of two (2) residents reviewed in the care area of respiratory care during the long term care survey process. Resident identifier: #216. Facility census: 66 Findings included: a) Resident #216 On 04/04/22 at 11:40 AM an observation found Resident #216's oxygen tubing for the nasal canula was not dated with a change out date. This was confirmed with Licensed Practical Nurse (LPN) #56 on 04/04/22 at 11:43 AM. The oxygen was running on 2 Liters, however upon verification of the order, there was not an order for the oxygen. This was confirmed with the Director of Nursing (DON) on 04/05/22 at 12:43 PM who stated there should be a physicians order for the oxygen. The Policy and Procedure states the oxygen tubing and storage containers for all respiratory supplies are to be changed weekly and dated on the change out date. .

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-04-06 · tag F0756 — failed to review each resident's drug regimen — isolated
    Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on record review and staff interview, the facility failed to ensure documentation of the pharmacist's recommendations and the response by the physician. This deficient practice had the potential to affect one (1) of five (5) residents reviewed for the care area of unnecessary medications. Resident identifier: #30. Facility census: 66. Findings included: a) Resident #30 Review of Resident #30's medical records showed monthly pharmacist medication regimen reviews had been performed. On 08/30/21, the pharmacist medication regimen review states, Comments/Recommendations noted - see report. No pharmacy report for 08/30/21 was located in Resident #30's medical records. During an interview on 04/05/22 at 2:25 PM, the Director of Nursing (DON) confirmed no pharmacy report for 08/30/21 could be located. The DON was unable to provide information regarding what comments or recommendations were made by the pharmacist or how the physician responded. No further information was provided through the completion of the survey. .

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-04-06 · tag F0810 — isolated
    Provide special eating equipment and utensils for residents who need them and appropriate assistance.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on observation, record review and staff interview, the facility failed to provide appropriate assistive devices to Resident #10 to maintain their current ability to drink independently This was a random opportunity for discovery. Resident Identifier: #10. Facility Census: 66. a) Resident #10 On 04/04/22 at 12:00PM , the resident was observed during lunch. The dietary ticket for Resident #10 indicated they were to have cup with handles .lid. The resident did not have a cup with handles and lid. The only cup on the lunch tray was a plastic coffee cup. On 04/04/22 at 12:05 PM, Nurse Aide (NA) #37 confirmed the cup with handles and lid was not on the lunch tray. NA #37 stated, she (Resident #10) can put her thumb around the coffee cup handle and hold it. On 04/05/22 at 12:15 PM, a review of the care plan meeting note dated 01/19/22 found, current physician's orders and care plan are noted with two (2) handled cup with lid for all meals. On 04/05/22 at 12:35 PM, the Director of Nursing (DON) was notified and confirmed the two handled cup with lid should be used for all meals. .

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2019-09-26 · tag F0623 — isolated
    Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . c) Resident # 28 A review of Resident #28's medical record found the resident was discharged to the hospital on [DATE]. The record did not have any evidence to show they notified the Ombudsman of this discharge. On 09/25/19 at 4:02 PM, an interview with the Social Worker revealed she did not send a copy of the discharge notice to the Ombudsman. She stated, she did not know that she had to notify the Ombudsman when the resident was going to the hospital. Based on record review and staff interview, facility failed to notify the State Long-Term Care Ombudsman of resident discharges as required. This was true for three (3) of four (4) resident discharges. Resident identifiers: #64, #56 and #28. Facility census: 64. Findings included: a) Resident #64 A review of Resident #64's medical record, at 11:41 a.m. on 09/25/19, found the resident was discharged from the facility to the hospital on the following dates: 06/03/19, 0612/19, 06/21/19, 07/05/19, 07/29/19, 08/29/19, 09/13/19, and 09/23/19. The record did not have…

    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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2019-09-26 · tag F0641 — isolated
    Ensure each resident receives an accurate assessment.
    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 accurately complete the minimum data set (MDS) assessment when they entered inaccurate weight measurements into the nutritional section of the assessment. This deficient practice was found for one (1) of 20 sampled residents reviewed during the survey. Resident identifier: #50. Facility census: 64. Findings included: a) Resident #50 On 09/24/19 at 9:41 AM Resident #50's quarterly minimum data set (MDS) assessment with an assessment reference date (ARD) of 08/22/19 was reviewed. Resident #50's weight in section K, the nutritional section of the MDS, was coded as 290 pounds. At the same time Resident #50's significant change in status assessment with an ARD of 05/27/19 was reviewed. Resident #50's weight in section K was coded as 295 pounds. Per MDS section K instructions, weight should be based on the most recent measurement in the last 30 days. A review of Resident #50's weight measurements during the survey found that Resident #50 weighed 300 pounds on both 05/27/19 and 08/20/19. These dates were the most recent…

    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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2019-09-26 · tag F0657 — failed to keep the care plan current — isolated
    Develop 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 — an excerpt from the official record, may be distressing

    Based on record review, staff interview, and resident interview the facility failed to ensure the comprehensive care plan was appropriately reviewed and revised on a quarterly basis. This was true for one (1) of two (2) Residents reviewed in the care area of interdisciplinary care plan meetings. Resident identifier: #45. Facility census: 64. Findings included: a) Resident #45 During an interview on 09/23/19 at 11:22 a.m., Resident #45 stated she has never heard of a care plan meeting and hasn't been to any kind of meeting for quite some time. Record review on 09/24/19 at 12:30 p.m. indicated revealed written invitation was extended to Resident's family for dates of 2/06/19 and 05/08/19 to attend the care plan conference. Sign in sheet for the care plan meeting held on 02/06/19 was provided, with no record of the care plan meeting held on 05/08/19. Review of progress notes in the Residents electronic medical record revealed no data or record of a care plan meeting held on the date of 05/08/19. During an interview on 09/24/19 at 1:00 p.m., Director of Social Services (DSS) was asked…

    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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2019-09-26 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — the official record, unedited, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observations and staff interview, the facility failed to maintain safe water temperatures. This failed practice had the potential to affect more than an isolated number of residents. Facility census: 64. a) Water Temperatures During observations of rooms [ROOM NUMBERS], on 09/23/19 at 11:30 a.m., the water felt too hot to the touch and was too hot to comfortably hold your hand under for a prolonged period of time. At 11:38 p.m. on 09/23/19, the Maintenance Director (MD) came to the 300 hall and obtained the water temperature in the hand sinks in rooms [ROOM NUMBERS]. The water temperature was 118. 6 degrees Fahrenheit (F) in room [ROOM NUMBER], and was 126 degrees F in room [ROOM NUMBER]. The maintenance director when asked when the last time he obtained a water temperature he stated, I checked them this morning and they were 126 I believe so I made some adjustments. State licensure regulations water temperatures to not exceed 100 degrees F. The water tested in both rooms exceeded this requirement. .

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2019-09-26 · tag F0812 — failed to store, cook, and serve food safely — isolated
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, staff interview, and review of the 2017 Food Code, the facility failed to ensure ready-to-eat food served to a resident was free from contamination when an employee touched a resident's sandwich with bare hands. This deficient practice was found during a random opportunity for discovery and affected an isolated number of residents. Facility census: 64. Findings included: a) Dining Observation During an observation of the noon meal in the facility's dining room on 09/23/19 at 12:03 PM Nurse Aide (NA) #40 was observed touching a resident's sandwich with bare hands. When asked about touching the sandwich at the time of the finding, NA #40 covered her mouth with her hands and said, I'm sorry. I'll get her another one. According to the Food and Drug Administration (FDA) 2017 Food Code, FOOD EMPLOYEES may not contact exposed, READY-TO-EAT FOOD with their bare hands and shall use suitable UTENSILS such as deli tissue, spatulas, tongs, single-use gloves, or dispensing EQUIPMENT. On 09/23/19 at 12:32 PM the above observation was discussed with the facility's…

    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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2019-09-26 · tag F0842 — failed to keep accurate, complete medical records — isolated
    Safeguard 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 maintain medical records that were accurately documented. This was true for two (2) of two (2) Residents reviewed for documentation of personal hygiene care. Resident identifiers: #45, #39. Facility census: 64 Findings included: a) Resident #45 Review of the Resident's weekly bath and skin report found the resident received a shower on the following dates during the month of September 2019: 09/03/19, 09/06/19, 09/09/19, 09/12/19, 09/14/19, 09/18/19, 09/21/19, 09/24/19. However, review of the Resident's Activity of Daily Living flow sheet found the resident was only documented as having a shower on the following dates for September 2019: 09/03/19, 09/04/19, 09/06/19, 09/09/19, 09/15/19, 09/16/19, 09/18/19. Review of the Resident's weekly bath and skin report found the resident received a shower on the following dates during the month of August 2019: 08/01/19. 08/04/19 08/07/19 08/10/19 08/12/19 08/16/19 08/18/19, 08/22/19, 08/25/19, 08/28/19, 08/31/19. However, review of the Resident's Activity of Daily Living flow…

    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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction

“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.

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • 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.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

Fines & penalties

$16,981 in federal fines across 1 penalty.

  • $16,981 — penalty dated 2025-06-11

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 →

RatingThis homeChain avg
Overall 3 of 52.4+0.6 vs chain
Health inspection 3 of 52.3+0.7 vs chain
Staffing 2 of 52.5-0.5 vs chain
Quality measures 4 of 53.5+0.5 vs chain
The other 183 homes this chain runs (chain average 2.4★, per CMS)
1 of 5Alexandria Care CenterLos Angeles, CA 1 of 5Bay Crest Care CenterTorrance, CA 1 of 5Bethlehem North Skilled Nursing And RehabilitationBethlehem, PA 1 of 5Bethlehem South Skilled Nursing And RehabilitationBethlehem, PA 1 of 5Bridgeville Rehabilitation & Care CenterBridgeville, PA 1 of 5Brightwood CenterFollansbee, WV 1 of 5Carlisle Skilled Nursing And Rehabilitation CenterCarlisle, PA 1 of 5Casa De Oro CenterLas Cruces, NM 1 of 5Devonshire Care CenterHemet, CA 1 of 5Gettysburg CenterGettysburg, PA 1 of 5Glenwood CenterFlorence, AL 1 of 5Heritage CenterHuntington, WV 1 of 5Hidden Valley CenterOak Hill, WV 1 of 5Inners Creek Skilled Nursing And Rehabilitation CeDallastown, PA 1 of 5Jersey Shore Skilled Nursing And Rehabilitation CeJersey Shore, PA 1 of 5Kingston Court Skilled Nursing And RehabilitationYork, PA 1 of 5Las Palomas CenterAlbuquerque, NM 1 of 5Lebanon Center, Genesis HealthCareLebanon, NH 1 of 5Lebanon Skilled Nursing And Rehabilitation CenterLebanon, PA 1 of 5Linden Grove Health Care CenterPuyallup, WA 1 of 5Magnolia RidgeGardendale, AL 1 of 5Marmet CenterMarmet, WV 1 of 5Meridian CenterHigh Point, NC 1 of 5Merry Wood LodgeElmore, AL 1 of 5Mount Olive CenterMount Olive, NC 1 of 5Mountain Ridge Center, Genesis HealthCareFranklin, NH 1 of 5Oak Grove CenterWaterville, ME 1 of 5Oceanside Skilled Nursing And RehabilitationHampton, NH 1 of 5Orchard Park Health Care & Rehab CenterTacoma, WA 1 of 5Parkersburg CenterParkersburg, WV 1 of 5Pembroke CenterPembroke, NC 1 of 5Pine LodgeBeckley, WV 1 of 5Playa Del Rey CenterPlaya del Rey, CA 1 of 5Pocahontas CenterMarlinton, WV 1 of 5Pottstown Skilled Nursing and Rehabilitation CentePottstown, PA 1 of 5Putnam CenterHurricane, WV 1 of 5Ridgewood CenterRidgewood, NJ 1 of 5Rio Rancho CenterRio Rancho, NM 1 of 5River City CenterDecatur, AL 1 of 5River Ridge CenterKennebunk, ME

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 / managerTypeRoleShareSince
GENESIS OPERATIONS V LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST100%since 12/31/2011
FC-GEN OPERATIONS INVESTMENT LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 02/02/2015
GEN OPERATIONS I LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 02/02/2015
GEN OPERATIONS II LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 02/02/2015
GENESIS HEALTHCARE INCOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 02/02/2015
GENESIS HEALTHCARE LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 02/02/2015
GENESIS HOLDINGS LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 02/02/2015
GHC HOLDINGS LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 02/02/2015
SUN HEALTHCARE GROUP INCOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 02/02/2015
WHITMAN, ARNOLDIndividual5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 02/02/2015
BERG, MICHAELIndividualCORPORATE OFFICERsince 12/01/2012
BRIDGEFORD, LAURAIndividualCORPORATE OFFICERsince 06/01/2024
MENDELSON, AVIIndividualCORPORATE OFFICERsince 06/01/2024
FRAZIER, DOROTHYIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/15/2024
TOOTHMAN, JAMESIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 02/25/2023

CMS files one row per role, so the 17 rows in the source record cover these 15 parties — each is shown once here with every role it holds. Nothing is omitted.

9 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.

$9.0M
Net patient revenuemost recent cost report
+1.6%
Operating marginrevenue minus expenses
$609K
Related-party expense7% of expenses
Who pays — share of resident-days
Medicaid 87%Medicare 11%Other / private 2%

About 87% 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 $609K paid to related parties (affiliated landlords or management companies) in its most recent cost report.

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

$378per resident / day
operating cost
$11,493per month
≈ monthly operating cost
$384per day
avg. revenue, all payers

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

Paying with Medicaid

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.

Typical monthly cost in West Virginia
$12,836/mo
Nursing home (semi-private)
$13,262/mo
Nursing home (private)
$6,340/mo
Assisted living

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 515175. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2023-08-09, 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.

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