Montgomery General Elderly Care
501 Adams Street, Montgomery, WV 25136 · For profit - Corporation · 60 certified beds · (304) 442-2469 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- a middle-of-the-pack inspection score (3/5)
- no federal fines or payment denials on record
- a high payroll-based staffing rating (4/5)
- it has an abuse, neglect, or exploitation citation (F0600), cited Oct 2024
- it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0607, F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- it has 1 actual-harm citation
- 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 facility-reported quality-measure 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.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 3 of 5 |
| StaffingFrom payroll records (PBJ) | 4 of 5 |
| Quality measuresSelf-reported by the facility | 2 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 2 of 5 |
| Long-stay residentspeople who live here | 2 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 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.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 19.1% | 14.7% | 15.4% | worse |
| Long-stay residents who lose too much weight | 10.6% | 6.3% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 3.0% | 0.4% | 0.9% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 3.1% | 1.6% | 2.0% | worse |
| Long-stay residents with depressive symptoms | 1.0% | 7.6% | 6.5% | better |
| Long-stay residents who were physically restrained | 0.0% | 0.2% | 0.1% | better |
| Long-stay residents with falls causing major injury | 4.3% | 4.4% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 22.3% | 15.9% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 22.7% | 27.0% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 98.2% | 97.6% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 2.9% | 4.2% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 31.4% | 22.1% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 18.9% | 13.4% | 17.1% | worse |
| Long-stay hospitalizations per 1,000 resident days | 2.57 | 1.80 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 1.28 | 1.84 | 1.80 | better |
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
Therapy staffing: this home’s payroll records show 0.23 therapist hours per resident per day in 2026Q1 — more than 29% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 54% of this home’s weekday level — it runs therapy at close to weekday levels right through the weekend. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 11.9%CMS range 7.1–17.3 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.98 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 60 beds and averages 58.2 residents a day — about 97% occupied, or roughly 2 beds typically open. It runs essentially full — expect a waiting list. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.99 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.51 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.64 is at or above 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 3.43 hrs/resident/day on weekends vs 4.22 on weekdays — 19% thinner on weekends. RN hours go from 0.58 to 0.34 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 40% is about the same as the national median of 45%. 1 administrator has left in the past year.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
28 citations, most serious first. The 11 most serious are shown; the remaining 17 are one tap away and print in full.
- Actual harm · Hcited before2022-12-14 · tag F0600 — failed to protect residents from abuse and neglect — patternProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review, staff interview, and resident interview the facility failed to protect Residents from mental, physical, and sexual abuse resulting in actual harm, including physical pain, mental anguish and psychosocial harm to multiple residents, as perpetrated by Resident #49's ongoing pattern of irrational and aggressive behaviors. This was true for seven (7) of 58 residents. Two (2) residents had to be sent to the hospital for physical harm resulting from Resident #49's actions. Several residents complained of living in fear of Resident #49 which is psychosocial harm. Resident #49 was found in another residents room in their bed completely nude and touching the other resident which is a form of sexual abuse. Resident identifiers: Resident #49, Resident #31, Resident #27, Resident #52, Resident #16, Resident #20, Resident #44 and Resident # 54. Facility census: 58. Findings Included: a) Policy Review A review of the facility policy titled Resident Abuse/Neglect reads as follows: I. POLICY: .to ensure that residents are not subjected to abuse by staff, other residents,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2025-11-26 · tag F0880 — failed to prevent and control infections — widespreadProvide 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 observation, record review, and staff interview the facility failed to maintain an infection prevention and control program to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of communicable diseases and infections. This failed practice was a random opportunity for discovery and had the potential to effect all residents currently residing in the facility during the Long-Term Care Survey Process. Facility Census: 57. Findings Include: a) Dining room Continuous observation of the dining room on [DATE] from 11:30 AM to 12:01 PM, revealed that at 12:01 PM, (3) three residents at the round table were served their lunch meal. During the continuous observation no hand hygiene was offered and/or performed with the residents in the dining room area. During an interview on [DATE] at 12:03 PM, Nursing Assistant (NA) # 4 stated, They are supposed to lay them wet ones on the table, and nope they are not there today. Further observation of the lunch meal showed,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-11-26 · tag F0584 — failed to keep a safe, clean, comfortable home — patternHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and staff interview the facility failed to maintain a safe, clean, comfortable, and homelike environment by not providing a clean privacy curtain for Resident #27, and ensuring the residents' shower area for B Bath did not have paint peeling, missing caulking and rust on a shower caddy. These failed practices had the potential to affect more than a limited number of residents. Resident Identifier: #27. Facility Census: 57.Findings included: a) On 11/24/2025 at 12:45 Pm, The B Bath shower room was investigated. Peeling paint in the shower area and the bathroom floor area were observed including around the toilet by the state surveyors. The Administrator in Training reported the shower rooms are addressed yearly. On 11/25/2025 at 08:12 AM, the B Bath shower room was observed. The following observations were observed: paint peeling and missing on a large portion of the shower room's floor, caulking was missing around the toilet and in the shower area, large ring of missing paint and brownish substance was around the toilet, and paint was missing from the base of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2025-11-26 · tag F0684 — failed to provide proper treatment and quality of care — patternProvide 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 current standards of practices by not following its policy and physicians orders related to weights. This failed practice was found true for (3) three of (6) six residents reviewed for nutrition during the Long-Term Care Survey Process. Resident identifiers: #55, #9, and #11. Facility Census: 57. Findings Include: a) Weight monitoring policy A review on 11/25/25 at 10:30 AM, of the policy titled {Weight Monitoring}, Section 2, C, reads: If there is a noticeable discrepancy in the current weight vs previous weight, the resident shall be re-weighted and the charge nurse shall follow-up accordingly. b) Resident #55 A record review on 11/24/25 at 2:32 PM, revealed that on 11/05/25 Resident #55 weighted 173 pounds (lbs.), and weighed 183 lbs. on 11/10/25. She was not reweighed for the weight discrepancy until 11/18/25 in which she weighed 173.5 lbs. Further record review for Resident #55, revealed an order…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-11-26 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor 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
Based on observation and staff interview, the facility failed to treat a resident with respect and dignity during the dining experience by referring to the resident's adaptive spoon as a baby spoon. This failed practice had the potential to affect a limited number of residents and was a random opportunity for discovery. Resident Identifier: #8. Facility Census: 57. Findings included: a) Resident #8 On 11/25/25 at 12:10 PM, the State Surveyor was observing the dining room lunch meal service. Nursing Assistant (NA) #31 yelled across the room to the dietary window and told the staff to Throw me a baby spoon. NA #21 confirmed the spoon asked for by NA #31 was a baby spoon and that the resident sometimes eats with her fingers. The resident's diet order stated, NAS (No Added Salt), PUREE Special Instructions: Color suction lip plate, small color coated spoon. On 11/25/25 at 01:46 PM, the Administrator in Training reported they did not have a policy and procedure for dignity, but that they follow the state guidelines for dignity. The facility's Dining Program Policy and Procedure stated,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-11-26 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
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 document the resident's Medical Power of Attorney was notified when the resident experienced significant weight loss. This deficient practice had the potential to affect one (1) of four (4) residents reviewed for the care area of nutrition. Resident identifier: #11. Facility census: 57. a) Resident #11 The facility's policy and procedure titled Weight Monitoring with effective date January 2004 and most recent revision date April 2016 stated the Power of Attorney (POA) or legal representative would be notified when the resident experienced significant weight loss. Review of Resident #11's medical records revealed on 09/09/25 the resident weighed 160 pounds (lbs). On 10/07/25, the resident weighed 144 lbs. This is a 10 percent (%) weight loss in approximately four (4) weeks. The resident continued to lose weight, weighing 141 lbs on 11/17/25. Further review of Resident #11's medical records showed no documentation the resident's POA was notified when the resident was found to have significant weight loss on 10/07/25.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-11-26 · tag F0583 — failed to protect personal privacy — isolatedKeep residents' personal and medical records private and confidential.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on Observation, Interviews and record review the facility failed to ensure residents private and confidential information was kept safe. This was a random opportunity for discovery during the long term care survey process with the potential to affect more than a minimal number of residents. Facility census: 57 On 11/25/2025 at 9:20 AM while conducting rounds this surveyor observed a medication cart and computer left unlocked and screen open while the nurse went to get medication from the med room. A resident's name and information was left on screen and easily viewable to anyone who passed by. The cart left approx. three min unattended.On 11/25/25 at 9:26 AM in an interview with LPN #72 stated that they had to get a med the resident needed to complete a med pass. I was only gone for a minute. During record review on 11/25/2025 at 2:00 PM of the New employee/Med cart and Resident Privacy policy's, It states that all carts and computers shall be locked and secured before stepping away for any length of time. The Administrator stated during an interview on 11/25/2025 at 2:12 PM…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-11-26 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
The facility failed to ensure residents' comprehensive care plans were revised when changes occurred to the residents' interventions and residents' behaviors. This deficient practice had the potential to affect two (2) of 20 residents reviewed during the long-term care survey process. Resident Identifiers: #11 and #2. Facility census: 57. Findings included:a) Resident #11Resident #11's comprehensive care plan had a focus for a potential for nutritional problem. An intervention was initiated for 07/15/25 for monthly weights to be obtained. On 09/09/25, Resident #11 weighed 160 pounds (lbs). On 10/07/2025, the resident weighed 144 lbs. This was a 10 percent (%) weight loss in four (4) weeks. On 10/10/25, an order was written for weekly weights. Prior to this, the resident was weighed monthly. The resident's care plan was not updated when the resident's frequency to be weighed was changed from weekly to monthly. On 11/25/25 at 11:05 AM, the Assistant Director of Nursing (ADON) confirmed Resident #11's care plan was not revised when the resident was ordered to be weighed weekly instead…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-11-26 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review, staff interview, and resident interview, the facility failed to provide Activities of Daily Living (ADL) care related to showers for dependent residents. This failed practice was found to be true for one (1) of three (3) residents reviewed for ADL care during the long term care survey process. Resident identifier:#27 Facility Census: 57 Resident identifier #27 Facility census #57.Findings include:a) Resident #27 On 11/25/25 at 4:00 pm record review shows the following:According to the shower schedule provided by the facility resident #27 is scheduled for showers on Tuesdays and Thursdays on day shift.Resident #27 was scheduled/received showers on the following days:10/28/25 - received no shower 10/30/25 - received no shower11/04/25 - received shower11/06/25 - received shower11/11/25 - received shower11/13/25 - received shower11/18/25 - received no shower11/20/25 - received no showerRecord review completed on 11/25/25 revealed Resident #27 is an extensive total dependence with one person assisting for showers.Further record review on 11/25/25 of Resident #27'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.
- Potential for harm · D2025-11-26 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure 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
Based upon Observation, Interviews and record review the facility failed to ensure the facility remains free from accident hazards due to a medication cart and computer being left unlocked and in the main hallway A. This was a random opportunity for discovery during a long-term survey. Census: 57 Findings include: a) On 11/25/25 at 9:20 AM while conducting rounds this surveyor observed a medication cart and computer left unlocked while the Licensed Practical Nurse (LPN) went to get medication from the med room. A resident's name and information were left on screen, and the med cart was unlocked, and drawers were able to be opened. The cart was left approximately three (3) minutes unattended.On 11/25/25 at 9:26 AM in an interview with LPN #72 the LPN stated that they had to get a medication the resident needed to complete a medication pass. LPN #72 said, I was only gone for a minute. During record review on 11/25/2025 at 2:00 PM of the Med cart and Resident Privacy policy's, it states that all carts and computers shall be locked and secured before stepping away for any length of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-11-26 · tag F0710 — isolatedObtain a doctor's order to admit a resident and ensure the resident is under a doctor's care.
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' care was supervised by a physician. The facility failed to document the physician was aware of Resident #11's significant weight loss. This deficient practice had the potential to affect one (1) of four (4) residents reviewed for the care area of nutrition. Resident Identifier: #11. Facility Census: 57. Findings included: a) Resident #11 The facility's policy and procedure titled Weight Monitoring with effective date January 2004 and most recent revision date April 2016 stated the attending physician would be notified when the resident experienced significant weight loss. Review of Resident #11's medical records revealed on 09/09/2025 the resident weighed 160 pounds (lbs). On 10/07/2025, the resident weighed 144 lbs. This is a 10 percent (%) weight loss in approximately four (4) weeks. The resident continued to lose weight, weighing 141 lbs on 11/17/25. Further review of Resident #11's medical records showed no documentation the resident's attending physician was notified when the resident was found…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 17 citations
- Potential for harm · D2025-11-26 · tag F0802 — failed to prepare enough nourishing food — isolatedProvide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
What the surveyor found here — the official record, unedited, may be distressing
Based on record interview and staff interview, this facility failed to ensure all kitchen staff were up to date with their food handler cards. This failed practice was a random opportunity for discovery during the Long Term Care survey process. Employee identifiers: #4, #48, #55. Facility census: 57.Findings include: a) Food handler cards A record review on 11/25/25 at 1:45 PM of all dietary staff and up to date food handler cards revealed: Cook/aide #4 hire date was 03/17/23 with food handler card dated as completed on 11/24/25. Cook/aide #48 hire date of 08/26/23 with food handler card dated as completed on 11/25/25. Cook/aide #55 had an expired card as of 05/10/25. During interview with Certified Dietary Manager (CDM) on 11/25/25 at 2:00pm, he confirmed the hire dates and expiration dates
- Potential for harm · D2025-11-26 · tag F0812 — failed to store, cook, and serve food safely — isolatedProcure 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 observations, staff interview and policy review this facility failed to store food in accordance with professional standards for food service safety. This failed practice was a random opportunity of discovery during the Long Term Care survey process. Facility Census: 57 Findings includea) During observation with kitchen inspection on 11/24/25 at 10:55 AM, noted the following items in the walk-in with label and dating missing and/or outdated.Container of pineapples- no label or use by dateContainer with slice of cake- no label or use by datePan of mashed potatoes- no label or use by dateContainer of chocolate pudding- no label or use by dateContainer of lettuce with expired use by date of 11/16/25Container of potato salad with expired use by date of 11/17/25Container of peas and carrots with expired use by date of 11/21/25Container of pasta salad with expired use by date of 11/21/25Container of sliced cheese -no label or use by date. During an interview on 11/24/25 at 11:15AM , [NAME] # 4 confirmed the above findings. During an interview on 11/25/25 at 2:56 PM, the Certified…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-11-26 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and staff interviews the facility failed to ensure medical records were accurate for Resident #11 regarding DNR (do not Resuscitate) POST (Physician Orders for Scope of Treatment) and Resident #45 orders to offer thin liquids if refused thicken liquids. These failed practices were random opportunities for discovery and had the potential to affect more than a minimal number of residents residing in the long term care facility. Resident identifier: #11 and #45 Facility Census: 58 a) Resident #45 During record review of Resident #45's orders, revealed the following Diet order Start date: 11/04/25- End Date: Open Ended Description: REGULAR, MILDLY THICK LIQUIDS, PUREE Further [NAME] review of Resident #45's care plan revealed the following; Problem- start date 07/07/2022 Category: Nutritional status: Potential for nutritional problem related to resident requires mechanically altered diet due to difficulty chewing and thickened liquids due to difficulty swallowing (dysphagia), also has vitamin…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-10-24 · tag F0585 — failed to handle grievances — patternHonor 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 observations and resident council interviews, the facility failed to uphold residents' rights to voice grievances freely, without fear of reprisal, as required by CMS standards. This deficiency poses a potential risk to more than a limited number of who currently reside in the facility by creating an environment where individuals may hesitate to utilize the grievance process. Faiclity Census: 58. Findings Included: a) Resident Council Meeting On 10/22/24 at 2:04 PM, a special resident council meeting was held in the facility's main dining room, attended by the activities coordinator (permitted by the residents) and this surveyor. The meeting followed a standard agenda to review ongoing and new matters. During the meeting, the surveyor asked residents if they understood how to file an official grievance. After a brief pause, only Resident #7, identified as the council president, responded, indicating the location of the grievance folder. Other residents were silent, with several displaying hesitant or reserved body language. The surveyor then posed a follow-up question about…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-10-24 · tag F0600 — failed to protect residents from abuse and neglect — patternProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on record review, resident interview and staff interview, the facility failed to provide an environment free from abuse. This was true for 2 (two) of 4 (four) residents reviewed during the Long Term Care Survey process. Resident identifiers: Resident #158, #30, #15. Facility census: 58. Findings included: a) Resident #158 On 10/22/24 at approximately 2:30 PM, a review of the Facility Reported Incident (FRI) revealed Resident #158 bumped another Resident #30's wheelchair with a physical altercation occurring with Resident #30 having sustained bruising to the top of the left hand and left elbow as a result of this altercation. On 10/22/24 at 3:08 PM, a medical record review was completed for Resident #158 which revealed the following diagnoses and medications: Diagnoses: 1. Hallucinations 2. Vascular Dementia with other behavioral disturbance 3. Alzheimer's disease 4. Major depressive disorder recurrent, 5. Delusional disorders 6. Anxiety Medications: 1. Xanax 0.5 milligrams (mg) 1/2 tablet by mouth twice…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-10-24 · tag F0607 — failed to have anti-abuse policies — patternDevelop and implement policies and procedures to prevent abuse, neglect, and theft.
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, resident interview and staff interview, the facility failed to implement the facility Abuse policy and procedure. This was true for 2 (two) of 4 (four) residents reviewed during the Long Term Care Survey Process. Resident identifiers: Resident #158, Resident #30 and Resident #15. Facility census: 58. Findings include: a) a) Resident #158 On 10/22/24 at approximately 2:30 PM, a review of the Facility Reported Incident was completed which revealed Resident #158 bumped another Resident #30's wheelchair with a physical altercation occurring with Resident #30 having sustained bruising to the top of the left hand and left elbow as a result of this altercation. On 10/22/24 at 3:08 PM, a medical record review was completed for Resident #158 which revealed the following diagnoses and medications: Diagnoses: 1. Hallucinations 2. Vascular Dementia with other behavioral disturbance 3. Alzheimer's disease 4. Major depressive disorder recurrent, 5. Delusional disorders 6. Anxiety Medications: 1. Xanax…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-10-24 · tag F0609 — failed to report abuse allegations — patternTimely 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, the facility failed to ensure all allegations of abuse and or neglect were reported to appropriate state agencies as required. This was true for two (2) of four (4) residents reviewed for the care area of abuse during the long term care survey. Resident Identifiers: #4 and #158. Facility Census: 58. Findings Include: a) Resident #4 A review of the facilities grievance and concerns on 10/22/24 at 5:38 PM, revealed a concern that reads as follows: (Resident #4 named) wanted put in bed during mealtime and two staff have to put her in bed and most staff were feeding other residents and told her soon as they could put her to bed they would. Resident stated that a nurse said Poor Thing to her because she was ready to go to bed and stated her hips were hurting from the wheelchair. The staff that made the comment received verbal disciplinary action. During an interview on 10/22/24 at 5:41 PM, the Administrator stated, I remember the incident. The original person she said it…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-10-24 · tag F0610 — failed to investigate and act on abuse reports — patternRespond appropriately to all alleged violations.
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, resident interview, observation and staff interview, the facility failed to complete a through and complete investigation regarding allegations of verbal abuse for Resident #15 and physical abuse for Resident #158. This was true for two (2) of four (4) residents reviewed under the care area of abuse. Resident Identifiers: #15 and #158. Facility Census: 58. Findings Include: a) Resident #15 On 10/21/24 at 1:30 PM, a review of the facility's reported incidents (FRI) was completed. The review found a FRI dated 09/16/24 for Resident #15 (however, the date range for the incident is noted from 09/13/24 through 09/15/24). The information obtained from the FRI, stated verbal abuse from Licensed Practical Nurse (LPN) #73. Resident #15 stated, LPN #73 was fussing at her and became loud and was yelling at the resident. The resident reported LPN #73 made derogatory statements such as calling her fat, telling her we are afraid to leave any food around you, and telling her a list a mile long of people…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-10-24 · tag F0656 — failed to write and follow a full care plan — patternDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, the facility failed to develop the care plan which includes all diagnoses for Resident #54, Resident #15 and Resident #16; and implement the care plan for Resident #15 and Resident #29. This was true for four (4) of 18 residents reviewed during the survey process. Resident Identifiers: #54, #15, #16 and #29. Facility Census: 58. Findings Included: a) Resident #54 On 10/22/24 at 1:00 PM, the care plan was reviewed for Resident #54. The care plan did not include the following diagnoses: --Vascular dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. --Pain, unspecified --Shortness of Breath --Hyperlipidemia, unspecified --Hypomagnesemia --Hypokalemia --Other peripheral vertigo, unspecified ear --Hypertensive heart and heart failure --Chronic Kidney Disease --Unspecified Atrial Fibrillation --Gastro-esophageal reflux disease without esophagitis On 10/22/24 at 1:25 PM, Registered Nurse (RN) #66 stated, I…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-10-24 · tag F0684 — failed to provide proper treatment and quality of care — patternProvide 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 record review and staff interview, the facility failed to provide treatment and care in accordance with professional standards of practice. Resident #23 refuses all AM and PM medications and has had no physician intervention since 05/24. In addition the facility failed to offer hospice to Resident #158. This failed practice was found true for (2) two of 18 sample residents reviewed during the long term care survey process. Resident identifier: #23 and #158. Facility Census 58. Finding Included: a) Resident #23 A record review on 10/21/24 at 2:06 PM, revealed Resident #23 had multiple notes from 05/24 to present of refusing AM and PM medications. The notes also revealed Resident #23 was educated on the risk of refusing the medications; however Resident #23's Brief Interview for Mental Status (BIMS) score is 99. Further record review revealed Resident #23 was ordered the following medications: Famotidine 20 Milligrams (mg) one time a day at 9:00 AM. Levothyroxine 112 mcg one time a day at 9:00 AM. Lipitor 10 mg one time a day at 9:00 PM. Metoprolol tartrate 25 mg every 12…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-10-24 · tag F0697 — failed to manage pain — patternProvide 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 record review and staff interview the facility failed to identify, treat, monitor, and manage the resident's pain to the extent possible in accordance with the comprehensive assessment and care plan, current professional standards of practice, and the resident's goals and preferences. This is due to the facility ' s failure to implement a formal pain assessment process and develop a comprehensive, individualized pain management plan. This was true for 1 (one) of 2 (two) resident's reviewed for the Long Term Care Survey Process. Resident identifier: Resident #158. Facility census: 58. Findings included: a) Resident #158 On 10/22/24 at approximately 2:30 PM, a review of the Facility Reported Incident (FRI) was completed which revealed Resident #158 bumped Resident #30's wheelchair with a physical altercation occurring with Resident #30 having sustained bruising to the top of the left hand and left elbow as a result of this altercation. On 10/22/24 at 03:08 PM, a medical record review was completed for Resident #158 which revealed the following diagnoses and medications:…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-10-24 · tag F0842 — failed to keep accurate, complete medical records — patternSafeguard 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 an accurate and complete record for Resident #15's Physician's Orders for Scope of Treatment (POST) form, Resident #54's activity participation record, Resident #16's administration of the pneumococcal vaccination, and Resident #37's POST form. This was true for four (4) of 18 residents reviewed during the survey process. Resident Identifiers: #15, #54, #16, and #37. Facility Census: 58. Findings Included: a) Resident #15 On [DATE] at 11:00 AM, a record review was completed for Resident #15. The review found the POST form did not include the Preparer's signature and date. On [DATE] at 11:50 AM, the Administrator was notified and confirmed the POST form was incomplete. b) Resident #54 On [DATE] at 4:15 PM, a record review was completed for Resident #54. The review found the Activity Participation record dated 08/24 indicated the Resident was actively participating on the dates of [DATE] through [DATE]. Also, the date of [DATE] 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.
- Potential for harm · D2024-10-24 · tag F0623 — isolatedProvide 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
Based on record review and staff interview, the facility failed to notify the State Ombudsman of a discharge to the hospital. This failed practice was found true for (1) one of (2) two residents reviewed for hospitalizations during the Long-Term Care Survey Process. Resident identifier: #49. Facility Census 58. Findings included: a) Resident #49 A record review on 10/23/24 at 1:30 PM revealed that Resident #49 had been transferred out to the hospital for an extended stay on 08/04/24. Further record review revealed that no notification had been sent to the state Ombudsman. During an interview on 10/23/24 at 2:52 PM, the Licensed Social Worker (LSW) stated, No, I did not send notification to the Ombudsman. I did not know that we had to do that.
- Potential for harm · Dcited before2024-10-24 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — 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 promptly develop and update Resident #37's care plan to include hospice-specific interventions and care coordination with the hospice provider. This deficiency led to an incomplete care plan lacking essential guidance for staff on the resident's end-of-life needs, creating a risk for inconsistent care delivery and unmet needs. Resident Identifier: #37. Facility Census: 58. Findings Included: a) Resident #37 During an annual recertification survey on 10/22/24, at 11:50 AM, this surveyor observed Resident #37, who was admitted on [DATE] with a BIMS score of 4, indicating severe cognitive impairment. The resident, currently receiving hospice care, responded only with nonverbal sounds, demonstrating limited capacity to participate in care planning. A review of Resident #37's medical records revealed the individualized care plan did not contain hospice-specific interventions or documentation reflecting coordinated services with the hospice provider.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2022-12-14 · tag F0744 — failed to care for residents with dementia — patternProvide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
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 and resident interview the facility failed to address Resident #49's dementia care needs, resulting in the resident's inability to achieve her highest level of functioning and maintain her psychosocial well-being. Resident identifiers: #49. Facility census: 58. Findings Included: a) Progress Notes regarding Resident #49's behaviors affecting other residents. During a record review on 12/13/22 Resident #49 medical record revealed the following progress notes: -10/18/2022 at 6:57 AM Typed as writtenResident went into room A11-2. Scratched resident in bed 11-2 on arm. Resident redirected back into own room. -10/13/22 at 2:33 PM typed as written Resident has been going in resident rooms on b hall. These residents have yelled at her to get out. Some resident's are scared of her. Resident is very difficult to redirect -10/09/22 at 3:43 PM typed as written RESIDENT WAS ROAMING FROM ROOM TO ROOM , PICKING UP PERSONAL BELONGINGS, COMBATIVE WHILE TRYING TO REDIRECT , RESIDENT WAS…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2022-12-14 · tag F0609 — failed to report abuse allegations — isolatedTimely 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 ensure resident to resident altercations resulting in falls and an elopement were reported to the appropriate state agencies within the required time frame. These were random opportunities for discovery during the long-term care survey. Resident Identifiers: Resident #49, Resident # 31, and Resident #27. Facility Census: 58 Findings Included: a) A review of a facility policy titled Resident Abuse/Neglect read as follows: I. POLICY: .to ensure that residents are not subjected to abuse by staff, other residents, consultants, volunteers, staff or other individuals. II. PURPOSE: It is the purpose of this policy to define forms of abuse and neglect in order to facilitate education, recognition and reporting III. DEFINITIONS: Abuse- willful infliction of injury, unreasonable confinement, intimidation or punishment resulting in physical harm, pain, or mental anguish . Sexual Abuse-includes, but limited to sexual harassment, sexual coercion, or sexual assault. Physical Abuse-includes hitting, slapping, pinching, kicking,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-12-14 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on medical record review, staff interviews, and the guidance of the National Pressure Ulcer Advisory Panel (NPUAP), the facility failed to ensure Resident #50, received pressure ulcer care, consistent with professional standards of practice. Specifically, the facility failed to monitor and access the existing pressure ulcers weekly. This was true for one (1) of one (1) resident investigated for pressure ulcers. Resident Identifier: #50. Facility census was 58. Findings included: a) Resident #50 Review of Resident #50's medical records found the resident was admitted to the facility on [DATE] at 6:25 p.m., diagnoses included pressure ulcer to right buttocks, bipolar disorder, intellectual disabilities, seizure disorder, paraplegia from a fall from a cliff resulting in a fracture of the thoracic and the cervical spine with surgical intervention. Review of the admission Minimum Data Set (MDS) assessment, dated 04/04/22, revealed a Brief Interview for Mental Status (BIMS) for Resident #50, the score 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.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
No federal fines in the current CMS record.
Who owns this facility
| Owner / manager | Type | Role | Since |
|---|---|---|---|
| COLLINS, RALEIGH | Individual | CORPORATE DIRECTOR | since 03/19/2012 |
| CRIST, BARBARA | Individual | CORPORATE DIRECTOR | since 03/19/2012 |
| DAGHER, GHASSAN | Individual | CORPORATE DIRECTOR | since 03/19/2012 |
| HILL, DEBORAH A | Individual | CORPORATE DIRECTOR; CORPORATE OFFICER | since 03/25/2022 |
| SMITH, DONALD | Individual | CORPORATE DIRECTOR | since 03/19/2012 |
| TUCKER, PATSY | Individual | CORPORATE DIRECTOR | since 03/19/2012 |
| MURRAY, SHERRI | Individual | CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL | since 03/19/2012 |
| ATASSI, SAMMAR | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 01/01/2010 |
| TAYLOR, MICHAEL | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 01/01/2025 |
CMS files one row per role, so the 13 rows in the source record cover these 9 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
About 88% 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 $445K 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 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in WV
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the West Virginia Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 515152. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-11-26, 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 →
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