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Care Haven Center

2720 Charles Town Road, Martinsburg, WV 25401 · For profit - Corporation · 68 certified beds · (304) 263-0933 Medicare & Medicaid certified

Call the home — (304) 263-0933 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse-prevention, restraint, or reporting citation — no harm found (F0609) — cited Sep 2024
Insights

This home’s record is mixed — some reassuring signs, some worth asking about.

In its favor
  • a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
  • no federal fines or payment denials on record
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
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
  • a high number of inspection citations overall (28) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its payroll-based staffing rating is low (2/5)

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.

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

Location & what’s nearby

Hospital
★★★★ 4/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
510 Butler Ave · (304) 263-0811 · Call to confirm hours
Pharmacy
510 Butler Ave · (304) 263-0811 · Call to confirm hours
Grocery
50 Coast Guard Dr · (304) 267-3827 · Call to confirm hours
Park
WV-9 · 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 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.

Overall rating5★
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 increased19.6%14.7%15.4%worse
Long-stay residents who lose too much weight2.6%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 infection0.5%1.6%2.0%better
Long-stay residents with depressive symptoms0.5%7.6%6.5%better
Long-stay residents who were physically restrained0.0%0.2%0.1%better
Long-stay residents with falls causing major injury2.0%4.4%3.3%better
Long-stay residents whose ability to walk worsened36.6%15.9%16.1%worse
Long-stay residents on antianxiety or hypnotic medication26.0%27.0%18.9%worse
Long-stay residents given the seasonal flu vaccine100.0%97.6%95.3%typical
Long-stay residents with pressure ulcers1.6%4.2%4.7%better
Long-stay residents with worsening bladder/bowel control21.7%22.1%21.2%typical
Long-stay residents who got an antipsychotic medication — see the note below the table4.0%13.4%17.1%better
Short-stay residents who newly got an antipsychotic medication0.0%1.0%1.4%better
Short-stay residents given the seasonal flu vaccine96.6%79.4%79.4%better
Short-stay residents rehospitalized after admission14.5%22.5%22.6%better
Short-stay residents with an outpatient ER visit6.2%11.3%12.0%better
Long-stay hospitalizations per 1,000 resident days1.091.801.67better
Long-stay outpatient ER visits per 1,000 resident days0.221.841.80better

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.

58.7% 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 127 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

58.7%U.S. median 51.5%
Got home and stayed home
9.6%U.S. median 10.7%
Went back to hospital
58.1%U.S. median 56.6%
Met the expected recovery
0.34U.S. median 0.31
Therapy hours / resident / day
0.17hours / resident / day
Physical therapy
0.10hours / resident / day
Occupational therapy
0.07hours / resident / day
Speech therapy

Met the expected recovery: 58.1% 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 86 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 0.34 therapist hours per resident per day in 2026Q1 — more than 58% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 14% 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 SNF58.7%CMS range 50.4–65.451.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF9.6%CMS range 6.3–13.010.7%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 discharge58.1%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 discharge40.7%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 discharge48.8%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 identified100.0%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 setting99.0%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 stay0.8%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 worsened2.6%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 hospitalization7.2%CMS range 3.9–11.17.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.851.02Oct 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

0.80
RN hours/ resident / day
0.49
LPN hours/ resident / day
1.78
Aide hours/ resident / day
3.07
Total nurse hours/ resident / day
0.41
RN hoursweekends
42.9%
Total nursing turnover
41.7%
RN turnover

How full it usually is: this home is certified for 68 beds and averages 66.8 residents a day — about 98% 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 3.07 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.80 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.78 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 2.73 hrs/resident/day on weekends vs 3.22 on weekdays — 15% thinner on weekends. RN hours go from 0.95 to 0.41 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 43% 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

6
deficiencies at the latest standard inspection (2026-01-21)
12
at the previous standard inspection (2024-09-06)

Deficiencies are fewer than at the previous inspection — improving. 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.

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.

28 citations, most serious first. The 10 most serious are shown; the remaining 18 are one tap away and print in full.

  • Potential for harm · Ecited before2026-01-21 · tag F0656 — failed to write and follow a full care plan — pattern
    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

    Based on record review and staff interview, the facility failed to develop and/or implement care plans related to Hospice services and meal intake percentages. This failed practice was found true for (3) three of 23 residents reviewed for care plan accuracy during the Long-Term Care Survey Process. Resident identifiers #65, #5, #12. Facility Census 65.Findings included: a) Resident #5 On 01/20/26 at 8:16 AM, a review of physician orders and Resident #5's care plan was completed as it related to nutrition. The care plan in part stated,monitor intake all meals. A review of meal percentage documentation (which outlines how much a resident consumed at each meal) revealed 15 out of 30 days reviewed where not all meals were entered: -12/20/25, only one (1) meal was recorded. -12/22/25, only two (2) meals were recorded. -12/23/25, only two (2) meals were recorded. -12/26/25, only one (1) meal was recorded. -12/28/25 only one (1) meal was recorded. -12/30/25, only two (2) meals were recorded. -12/31/25, only one (1) meal was recorded. -01/01/26, only two (2) meals were recorded. -01/03/26,…

    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 · E2026-01-21 · tag F0804 — failed to serve food at safe, palatable temperature — pattern
    Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on resident interview, staff interview, and food tray temperatures, the facility failed to serve food that was palatable and at an appetizing temperature. The facility failed to ensure hot foods were served hot and cold foods were served cold. This practice was true for three (3) of the four (4) hallways tested for milk on the beverage carts and food tray temperatures for two (2) of two (2) meal trays tested throughout the survey process. Facility census 65 Findings included a) Policy Review Review of the facility's policy read in part, all foods will be held at appropriate temperatures, greater than 135 degrees (or as state regulation requires) for hot foods and less than 41 degrees for cold food b) Palatable and Food Temperatures Interviews with 18 of 23 sampled residents revealed consistent complaints of the meals not being palatable because hot foods were being served cold. A test tray, on 01/19/26 at 2:00 PM, was served to surveyors to test the palatability of the food. The meal palatability tray revealed the Salisbury steak tasted bland and the scallop potatoes had…

    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 · Ecited before2026-01-21 · tag F0812 — failed to store, cook, and serve food safely — pattern
    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, record review and staff interview, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food safety. This practice had the potential to affect more than a limited number of residents receiving nourishment from the kitchen. Facility census: 65.Findings include: a) Policy Review of the facility's policy for food storage reads in part, Food is to be stored, prepared, distributed and served in accordance with professional standards. Ensuring food service safety, sanitary condition and the prevention of foodborne illnesses. b) Kitchen Tour On 01/19/2026 at 8:00 AM during an initial walk through, [NAME] #82 was observed without a hairnet and had a cap on with dread unrestrained.Additionally, the following items were verified by [NAME] #82:-There was a dried sticky substance on top of the ice maker.-Food debris was found in a container holding lids.-A dried, red sticky residue was in the two (2) bowl sink.-A case of bananas with received date 12/23/25 were dark brown in color and very soft in the walk in…

    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 · Ecited before2026-01-21 · tag F0842 — failed to keep accurate, complete medical records — pattern
    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 — the official record, unedited, may be distressing

    Based on record review and staff interview, the facility failed to ensure a complete and accurate medical record related to resident meal percentages. This failed practice was a random opportunity for discovery and had the potential to affect more than a limited number of residents during the Long-Term Care Survey Process. Resident identifier #14. Facility census: 65.Findings include: a) Resident #14 A review of meal documentation (how much a resident ate during each meal) on 01/20/26 at 10:59 AM, for Resident #14 from 12/22/25 to 01/14/26, revealed that out of 23 days, only six (6) days had all three (3) meals documented. During an interview on 01/20/26 at 10:59 AM, the Director of Nursing (DON) confirmed they should be documenting for each meal that a resident receives.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-01-21 · 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 — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and staff interview, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice. The resident's Peripherally Inserted Central Catheter (PICC line) dressing was not changed in accordance with professional standards of practice. This was true for one (1) of one (1) residents with PICC lines reviewed. Resident Identifier: #30. Facility Census: 65. Findings included: a) Resident #30 The facility's policy titled Dressing Change for Vascular Access Devices dated 2011 stated Peripherally Inserted Central Catheter (PICC line) dressings were to be changed every seven (7) days. On 01/19/26 at 9:10 AM, Resident #30 was noted to have a right arm peripheral catheter. The resident stated he was receiving intravenous antibiotics through the catheter. The catheter had a date of 01/07/26 written on the dressing to indicate when the dressing had last been changed. Review of Resident #30's medical records showed his right arm…

    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 · D2026-01-21 · tag F0808 — failed to follow doctor-ordered diets — isolated
    Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
    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 follow resident's therapeutic diet for fortified foods. This failed practice was a random opportunity for discovery during the Long-Term Care Survey Process. Resident identifiers: #14, and #1. Facility census: 65.Findings included: a) Resident #1 Resident #1 had the following diet order written on 12/08/25, Regular/Liberalized diet, Regular texture, Standard Thin Liquids consistency, fortified food with all meals: oatmeal with breakfast, mashed potatoes with lunch and pudding with dinner. Resident #1, who was eating in her room, was served her lunch tray on 01/21/26 at 1:14 PM. Her lunch tray was served by the Kitchen Account Manager. The surveyor noted the resident didn't have mashed potatoes on her tray and fortified food was not noted on the resident's meal tray ticket. The Kitchen Account Manager stated, She's not on fortified food. On 01/21/2026 at 1:30 PM, the Administrator confirmed Resident #1 had an order for fortified food at each meal, but this was not noted on 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-09-06 · tag F0809 — failed to serve meals on a reasonable schedule — pattern
    Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on observations, record review, resident interview, and staff interview, the facility failed to maintain regularly scheduled mealtimes. This had the potential to affect all residents that get their nutrition from the kitchen. Facility census: 64. Findings Included: a) Dining Observation An observation on 09/03/24 at 12:30 PM revealed the lunch meal had not been served. 16 residents were in the dining room waiting for their meal. A review of the posted mealtimes found that the lunch meal was scheduled to start at 12:15 PM daily. An interview with Nurse Aide #29 on 09/03/24 at 12:44 PM revealed the lunch meal was late most days. During an interview, on 09/03/24 at 12:56 PM, Certified Dietary Manager (CDM) verified the noon meal was not served on time. She stated breakfast was late so they could not start on time for the lunch meal. Continued observation on 09/03/24 found drinks were not served until 1:05 PM, upon inquiry by the surveyor. Observation continued to find the first tray was served in the dining room at 1:20 PM.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-09-06 · tag F0812 — failed to store, cook, and serve food safely — pattern
    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 — the official record, unedited, may be distressing

    Based on observation and staff interview the facility failed to serve food in accordance with professional standards for food serve safety. This had the ability to effect more than a limited number of residents. Facility census: 64. Findings included: a) Initial Kitchen Tour During the initial kitchen tour on 09/03/24 at 1:20 PM an observation of tray service found the Dietary Manager (DM) dipping food with gloved hands, touching and opening hamburger buns, touching serving scoops, the plate warming cart, the counter, bowls, bowl rack, and the environment around the service area. Continued observation found The DM using the plate lifter to get the plates from the warmer and when not in use, suction the plate lifter to the countertop. During an interview at 09/03/24 1:35 PM the DM stated that she only cleans the top counter after breakfast, lunch and dinner. The DM confirmed that suctioning the plate lifter to the countertop could cause germs to be spread. She also verified that she was touching the surrounding environment and the resident's hamburger buns without changing her gloves.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-09-06 · 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. Resident identifier: #119. Facility census: 64. Findings included: b) Resident #119 An observation on 09/03/24 at 2:26 PM of Resident #119 lying in bed with her noon meal tray sitting on bed side table not opened. During a second observation of the meal service on 09/03/24 at 2:43 PM revealed Nurse Aide (NA) #12 was standing over Resident #119 feeding her in bed. During an interview on 09/03/24 at 2:45 PM the Director of Nursing confirmed NA #12 was standing over Resident #119 feeding her at this time. The DON corrected NA #12 at this time.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-09-06 · tag F0582 — isolated
    Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
    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 the required Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage (SNF ABN) form to one (1) of three (3) residents reviewed for the facility's beneficiary protection notification practice during an annual survey. This failure placed the resident at risk of not being informed of her rights prior to the end of Medicare Part A covered services. Resident identifier: #25. Facility census: 64. Findings included: a) Resident #25 On 09/06/24 at 8:36 AM, a review was completed regarding the beneficiary protection notification liability notices given for Resident #25 who remained at the facility following her last covered day of Medicare Part A services: Resident #25 began Medicare Part A skilled services on 08/15/24. The last covered day of Part A service was 08/28/24. Notice of Medicare Non-Coverage (NOMNC) was signed and dated on 06/26/24. No SNF ABN form was provided. Review of Form Instructions Skilled Nursing Facility Advanced Beneficiary Notice on Non-coverage (SNF ABN) Form CMS-10055 (2018)…

    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
Show the remaining 18 citations
  • Potential for harm · Dcited before2024-09-06 · tag F0583 — failed to protect personal privacy — isolated
    Keep residents' personal and medical records private and confidential.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on record review and staff interview, the facility failed to protect the personal privacy and confidentiality of residents ' medical records. This was true for two (2) residents as a random opportunity for discovery. Resident identifiers: #47 and #59. Facility census: 64. Findings included: a) At 2:30 PM on 9/4/24, the surveyor discovered that pharmacist medication regimen review paperwork dated 8/28/24 (entitled PharMerica Recommendation maintain current dose Citalopram .pdf) containing Resident #59's name and medication information was scanned into Resident #47's medical record. Further record review revealed that the same document had been scanned into resident #59's record. The two residents' respective medication reviews were included on a single printed sheet, and medical records did not redact the name before the document was scanned in. On 09/04/24 at 2:50 PM, the surveyor informed the Director of Nursing (DON) who reviewed the record and confirmed that the record, as present, contained the combined personal health information of Resident #47 and #59.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-09-06 · 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 — the official record, unedited, may be distressing

    Based on record review and staff interview, the facility failed to report alleged violation related to, neglect, or abuse, and report the results of all investigation to the proper authorities within prescribe time-frames. This was a random opportunity for discovery. Resident identifier: #8. Facility census: 64. Findings include: a) Resident #8 An investigation of a Facility Reported Incident of abuse that accrued on 03/23/24 revealed that the Incident was not reported to appropriate agencies until 04/05/24. Continued record review found multiple statements from Registered Nurses #47 and #39 and Nurse aide #13 stating they witnessed Nurse Aide # 74 clap her hands and yell at Resident #8 on 03/23/24. During an interview with the Administrator and Director of Nursing on 09/05/24 at 2:32 PM they verified the incident on 03/23/24 for Resident #8 was not reported within prescribe time-frames. It was also verified that all employees at the facility were mandatory reporters.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-09-06 · 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 and implement a comprehensive person-centered care plan for Resident #15 that was trauma-informed and would allow Resident #15 to attain or maintain his highest practicable physical, mental, and psychosocial well-being. This was true for one (1) of three (3) residents reviewed for the diagnosis of Post Traumatic Stress Disorder (PTSD). Resident identifier: #15. Facility census: 64. Findings included: a) Resident #15 A record review, completed on 09/04/24 at 2:52 PM, revealed Resident #15 was admitted to the facility on [DATE] with a PTSD diagnosis. Review of Resident #15's Care Plan revealed the following: Focus: [Resident #15] has the potential to exhibit signs or symptoms of anxiety or depression r/t (related to) a dx (diagnosis) of Post Traumatic Stress Disorder. Goal: [Resident #15] will be free of signs or symptoms of depression or anxiety throughout next review. Interventions: -Provide a calm, quiet, well-lit environment -Explain…

    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 · D2024-09-06 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on staff interview and medical record review the facility failed to ensure Resident #92 received assistance with meals. This was true for one (1) of (1) residents reviewed for nutrition. Resident identifier #119. Facility census: 64. Findings included: a) Resident #119 An observation on 09/03/24 at 2:26 PM the lunch tray was sitting in front of resident, she was not eating, no assistance was offered. An bservation of the meal service on 09/04/24 at 1:24 PM revealed a tray set up in front of Resident #119 with food spillage all over her. She was trying to drink her sherbet. She had her phone receiver laying in the middle of her tray. During an interview with the Director of Nursing (DON) on 09/04/24 at 1:28 PM she verified Resident #119 was an assist with meals. At this time the DON went to get Resident #119 assistance.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-09-06 · 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 — an excerpt from the official record, may be distressing

    Based on medical record review, observation, and staff interview, the facility failed to ensure one (1) residents received treatment and care in accordance with professional standards of practice. Resident identifier: #30. Facility census: 64. Findings included: a) Resident #30 A record review on 09/05/24 at approximately 8:00 AM, revealed nurses documenting Blood pressure (BP) being taken in the right arm. Further record review revealed the resident had a Physician order which stated, Do not take B/P in the right arm, with an order date of 08/14/24. Continued record review on 09/05/24 shows resident having orders - Dialysis port location: right upper chest. - Monitor hemodialysis catheter site 2 lumens, right upper chest for signs and symptoms infection, edema, bleeding, and upon return from dialysis. Notify primary care physician and dialysis unit if there are signs and symptoms of infection. If catheter site is bleeding apply pressure for 15 minutes and notify MD/physician if bleeding does not stop, every shift and as needed. Do Not Change End Caps. On 09/05/24 at 9:52 AM a call…

    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 · D2024-09-06 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
    Provide enough food/fluids to maintain a resident's health.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on staff interview and medical record review the facility failed to ensure Resident #92 received assistance with meals. This was true for one (1) of (1) residents reviewed for nutrition. Resident identifier #119. Facility census: 64. Findings included: a) Resident #119 An observation on 09/03/24 at 2:26 PM the lunch tray was sitting in front of resident, she was not eating, no assistance was offered. An bservation of the meal service on 09/04/24 at 1:24 PM revealed a tray set up in front of Resident #119 with food spillage all over her. She was trying to drink her sherbet. She had her phone receiver laying in the middle of her tray. During an interview with the Director of Nursing (DON) on 09/04/24 at 1:28 PM she verified Resident #119 was an assist with meals. At this time the DON went to get Resident #119 assistance.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-09-06 · 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 — the official record, unedited, may be distressing

    Based on medical record review and staff interview the facility failed to ensure one (1) of one (1) residents reviewed for nutrition received the correct therapeutic diet. Resident #119. Facility census: 64. Findings included: a) Resident #119 A record review on 09/04/24 at 11:45 AM found, two (2) conflicting orders for a diet: --2 gm Sodium (2g Na) diet, Dysphagia Advanced texture, Standard Thin Liquids consistency diet. Order date 09/02/24. --2 gm Sodium (2g Na) diet, Regular Texture, Standard Thin Liquids consistency diet. Order date 8/26/2024. An interview 09/04/24 at 1:28 PM the Director of Nursing (DON) verified Resident #119 had two (2) different diet orders on her active chart. The DON stated that they should have discontinued the regular texture diet out of the active orders.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-09-06 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, the facility failed to maintain accurate records on two (2) out of 22 sampled residents in the Long-Term Care Survey Process. Resident identifiers: #64 and #119. Facility census: 64. Findings included: a) Resident #64 A record review, completed on 09/05/24 at 7:30 PM, revealed resident had been hospitalized on [DATE] and had not returned to the facility. There was also a nurse practitioner (NP) note, dated on 6/25/2024 at 10:52 PM, that listed the date of service (date of NP visit at the facility) as 06/25/24. Details of the note were, She is seen resting to bed with no grimaces or s/s (signs and symptoms of) pain. She was recommended hospice by oncology however declined. Labs and meds reviewed. She continues rehab for weakness. This shift increased weakness reported with general declines. The note indicated the NP had spent 46 minutes total meeting with resident and reviewing resident's chart. During an interview, on 09/06/24 at 10:05 AM, the Director of Nursing (DON)…

    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 · Ecited before2023-03-01 · tag F0656 — failed to write and follow a full care plan — pattern
    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

    Based on record review and staff interview, the facility failed to address resident preference and potential for future discharge within resident care plans. This was true for Residents #55, #46, and #12. The facility also failed to develop a care plan for non-pharmacological interventions for pain. This was true for Residents #164 and #42. The facility's failure to ensure accurate comprehensive care plans was true for five (5) of 21 sampled residents in the long-term care survey process. Resident identifiers: #55, #46, #12, #164, and #42. Facility census: 67. a) Resident #12 A record review, completed on 02/27/23 at 9:04 PM, revealed the care plan did not address Resident #12's preference and potential for future discharge. During an interview on 02/28/23 at 8:34 AM, the Acting Interim Director / Director of Nursing (DON) acknowledged the care plan was lacking resident's potential for discharge. The the Acting Interim Director / DON stated she would need to follow-up with the facility's Social Worker to determine why it had not been included. b) Resident #46 A record review,…

    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 · E2023-03-01 · tag F0697 — failed to manage pain — pattern
    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

    Based on observation, interview and record review, the facility failed to ensure that a resident received the treatment and care in accordance with professional standards of practice regarding parameters for pain medications. This was true for four (4) of four (4) residents reviewed for pain. Resident identifiers: #28, #164, #56, #42. Facility census: 66. Findings included: a) Resident #28 Medical record review for Resident # 28 found a physician's order: --Acetaminophen Extra Strength Tablet 500 MG (Acetaminophen) Give two (2) tablets by mouth every six (6) hours as needed for mild pain, with a start date 04/07/22. A continued review of Medication Administration Record (MAR) revealed: --02/20/23 at 7:41 PM pain level 7 -Acetaminophen tablet given. --02/24/23 at 5:00 PM pain level 4 -Acetaminophen tablet given. --02/26/23 at 5:40 PM pain level 4 -Acetaminophen tablet given. During an interview on 2/28/23 9:34 AM the Director of Nursing, verified Resident #28 had no physician prescribed parameters for pain medications. She stated that pain medications should be given for pain levels…

    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 · Ecited before2023-03-01 · tag F0842 — failed to keep accurate, complete medical records — pattern
    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 an accurate medical record for four (4) of nine (9) sampled residents reviewed in the Long-Term Care Survey process. Resident identifiers: #16, #34, #55, and #45. Facility census: 67. Findings included: a) Resident #16 A brief record review, completed on 02/21/23 at 7:29 PM, identified resident had a Physician Orders for Scope of Treatment (POST) form on file. The facility had obtained verbal consent from Resident #16's Health Care Surrogate (HCS) on 01/26/22. The facility failed to follow-up with the HCS to obtain an original signature. The 2021 POST Form Guidance instructs, If the incapacitated patient's MPOA representative or Health Care Surrogate is unavailable at the time of form completion, this section can be signed by two witnesses for verbal confirmation of agreement from the patient's MPOA representative or health care surrogate. The form should be signed at the earliest available opportunity. During an interview on 02/28/23 at 8:30 AM, the Acting Interim Director / Director of Nursing (DON)…

    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 · E2023-03-01 · 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

    Based on observations, policy review 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 including Covid-19 and infections with regards to Resident handwashing, Resident Covid -19 screening not completed accurately (Vital Signs) and storing a used bed pan on the bathroom floor. This has the potential to affect more than a limited number of residents in the facility. Resident identifiers: #28, #56 and #146. Facility census: 66. Findings included: a) Hallway meal pass 02/22/23 03:23 PM Interview with Interim Adm she stated that she will have a in-service. An observation on 02/21/23 12:18 PM revealed, the Resident's on the B hall, did not receive hand hygiene prior to or during the noon meal tray pass. During a second observation on 02/22/23 at 12:00 PM, no hand hygiene was provide to the residents on the A hall or the B hall prior to the noon meal On 02/22/23 at 12:25 AM during 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-03-01 · 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 — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation and staff interview, the facility failed to treat one (1) of the 21 sampled residents in the long-term care survey process with dignity and respect. The facility failed to honor Resident #46's right to a dignified existence prior to beginning an activity in a public area. Resident Identifier: #46. Facility Census: 67. Findings included: a) Resident #46 Observation on 02/21/23 at 2:18 PM, revealed multiple residents in the dining room being greeted by activity staff. As residents entered the dining room, [NAME] Gras beads were being placed around their necks in preparation for the [NAME] Gras party that was scheduled at 2:30 PM. Further observation found Resident #46 sitting in the dining room with what appeared to be flaking skin covering the top part of Resident #46's maroon long-sleeved shirt. The white particles were in the front of the maroon long-sleeved shirt from shoulder to shoulder and easy visible to any passerby. Staff had already greeted resident and had placed [NAME] Gras…

    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 · D2023-03-01 · tag F0552 — isolated
    Ensure that residents are fully informed and understand their health status, care and treatments.
    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 medical record review and staff interview, the facility failed to honor Resident #56's right to direct her own medical care. This was true for one (1) of nine (9) residents reviewed for Advance Directives. Resident identifier #56. Facility census: 66. Findings included: a) Resident #56 A medical record review for Resident #54 revealed, the Maryland Medical Order for Life-Sustaining Treatment (MOLST) completed [DATE]. The life sustaining decision for Resuscitation (CPR) was indicated with full interventions, completed by Resident #56. A continued review revealed, Resident #56's Physician Determination of Capacity found, she had continued to demonstrated Capacity to make medical decisions on [DATE]. Subsequent review discovered, Resident #56's Physician Determination of Capacity completed [DATE], found she demonstrated Incapacity to make medical decisions, with the expected duration of incapacity to be short term. Following medical record review found a Physician Orders for Scope of Treatment (POST)…

    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 before2023-03-01 · tag F0583 — failed to protect personal privacy — isolated
    Keep residents' personal and medical records private and confidential.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on record review and staff interview, the facility failed to honor Resident #16's privacy when taking a skin and wound assessment picture . This was a random opportunity for discovery. Resident identifier: #16. Facility census: 67. Findings included: a) Resident #16 Record review, completed on 02/21/23 at 2:36 PM, found the following: -Skin & Wound Assessment Picture for a Deep Tissue Injury of the right heel, taken in the day room area of the facility with what appeared to be another resident and that resident's visitor in the room. This picture was scanned into Resident #16's electronic medical record and was dated 01/18/23 at 11:30 AM. During an interview on 02/27/23 at 3:15 PM, the Director of Nursing (DON) confirmed the picture had been taken in a public area of the building [in the day room by the nurses station] with what appeared to be a resident and a resident's visitor present. The DON acknowledged this practice failed to honor Resident #16's privacy. .

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-03-01 · tag F0585 — failed to handle grievances — isolated
    Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review the facility failed to follow up on a grievance regarding lost dentures. This is true for one (1) of two (2) reviewed for dental care during the Long-Term Care Survey Process (LTCSP). Resident identifiers: #56. Facility census: 66. Findings Included: a) Resident #56 On 02/22/23 at 11:08 AM during an interview Resident #56's Health Care Surrogate (HCS) stated that he reported her dentures missing about three weeks ago to the facility. He stated that he asks about the dentures every time he visits, and the staff states that they are looking for the dentures. A review of the facility concerns, and grievance log found no issue for Resident #56's lost dentures. During an interview on 02/28/23 at 3:47 PM the Social Worker (SW) stated that she had heard about Resident #56's missing dentures. She continued to say that she though they had found them. During an interview with the SW and Director of Nursing on 02/28/23 at approximately 4:11 PM the SW stated that Resident #56 has lost her dentures multiple times, and they have found them within a day or so,…

    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 before2023-03-01 · 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 — 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 care and services in accordance with acceptable standards of practice. This was true for one (1) out of 21 residents sampled during the annual recertification survey. Resident identifier: #45. Facility Census: 67. Findings included: a) Resident #45 A record review, completed on [DATE] at 7:15 PM, revealed the following discrepancy: --The code status listed on the profile page of the electronic medical record stated: DNR - Comfort Measures --The Physician order, dated [DATE], stated: DNR/Comfort Measures --The Physician Orders for Scope of Treatment (POST) form, signed [DATE], stated CPR, Full Treatments, and Feeding Tube. Additionally, the following documentation incorrectly listed Resident #45's code status: --Family Nurse Practitioner Encounter note, dated [DATE], listed code status as DNR - Comfort Measures --SBAR [situation, background, assessment and recommendation] Communication Form and Progress Note, dated [DATE], listed code…

    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 · D2023-03-01 · tag F0791 — failed to provide routine dental services — isolated
    Provide or obtain dental services for each resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review the facility failed to provide prompt dental treatment for lost dentures. This is true for one (1) of two (2) reviewed for dental care during the Long-Term Care Survey Process (LTCSP). Resident identifiers: #56. Facility census: 66. Findings Included: a) Resident #56 On 02/22/23 at 11:08 AM during an interview Resident #56's Health Care Surrogate (HCS) stated that he reported her dentures missing about three weeks ago to the facility. He stated that he asks about the dentures every time he visits. The staff states that they are looking for the dentures. A review of the facility concerns, and grievance log found no issue for Resident #56's lost dentures. During an interview on 02/28/23 at 3:47 PM the Social Worker (SW) stated that she had heard about Resident #56's missing dentures. She continued to say that she though they had found them. During an interview with the SW and Director of Nursing on 02/28/23 at approximately 4:11 PM the SW stated that Resident #56 has lost her dentures multiple times, and they have found them within a day or so,…

    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

“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

No federal fines in the current CMS record.

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 5 of 52.4+2.6 vs chain
Health inspection 4 of 52.3+1.7 vs chain
Staffing 2 of 52.5-0.5 vs chain
Quality measures 5 of 53.5+1.5 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 WV HOLDINGS LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST100%since 04/01/2011
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
GENESIS OPERATIONS 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 03/02/2015
BRIDGEFORD, LAURAIndividualCORPORATE OFFICERsince 06/01/2024
MENDELSON, AVIIndividualCORPORATE OFFICERsince 06/01/2024
ALBAUGH, MIRANDAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 02/27/2025
HEFFNER, MEGANIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 02/27/2025
MORRIS, DIANEIndividualOPERATIONAL/MANAGERIAL CONTROLsince 10/01/2021

CMS files one row per role, so the 19 rows in the source record cover these 17 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.

$10.2M
Net patient revenuemost recent cost report
+14.1%
Operating marginrevenue minus expenses
$542K
Related-party expense6% of expenses
Who pays — share of resident-days
Medicaid 84%Medicare 11%Other / private 6%

About 84% 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 $542K 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

$364per resident / day
operating cost
$11,065per month
≈ monthly operating cost
$424per 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 515178. 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.

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