Worthington Healthcare Center
2675 36th Street, Parkersburg, WV 26104 · For profit - Corporation · 105 certified beds · (304) 485-7447 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- it has abuse, neglect, or exploitation citations (F0600, F0604) — most recent Feb 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
- inspectors cited 4 immediate-jeopardy problems — the most serious level
- a high number of inspection citations overall (34) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $104,142 in federal fines (most recent 2024-02-23)
- its independent health-inspection 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 | 2 of 5 |
| StaffingFrom payroll records (PBJ) | 3 of 5 |
| Quality measuresSelf-reported by the facility | 3 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 | 3 of 5 |
| Long-stay residentspeople who live here | 4 of 5 |
| Short-stay residentsrehab / post-hospital | 3 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 1 to 2 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 | 13.1% | 14.7% | 15.4% | better |
| Long-stay residents who lose too much weight | 6.4% | 6.3% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 0.2% | 0.4% | 0.9% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 2.4% | 1.6% | 2.0% | worse |
| Long-stay residents with depressive symptoms | 5.6% | 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 | 4.2% | 4.4% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 13.5% | 15.9% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 24.5% | 27.0% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 97.6% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 2.5% | 4.2% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 24.4% | 22.1% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 7.1% | 13.4% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 1.1% | 1.0% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 84.0% | 79.4% | 79.4% | typical |
| Short-stay residents rehospitalized after admission | 29.3% | 22.5% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 4.3% | 11.3% | 12.0% | 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.
41.5% 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 72 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 70.4% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 27 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 0.30 therapist hours per resident per day in 2026Q1 — more than 47% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 15% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 41.5%CMS range 31.1–52.5 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 10.9%CMS range 8.2–17.0 | 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 | 70.4% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 63.0% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 70.4% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 82.8% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 1.7% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 10.3% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 7.0%CMS range 3.7–12.4 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.99 | 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 105 beds and averages 89.9 residents a day — about 86% occupied, or roughly 15 beds typically open. It runs fairly full. 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 3.81 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.73 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.15 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 3.25 hrs/resident/day on weekends vs 4.04 on weekdays — 19% thinner on weekends. RN hours go from 0.87 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 50% 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
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.
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.
34 citations, most serious first. The 14 most serious are shown; the remaining 20 are one tap away and print in full.
- Immediate jeopardy · Jcited before2024-04-09 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and staff interview, the facility failed to maintain a safe and accident-free environment as possible. This deficient practice had the potential for Resident #46 to harm himself in the absence of 1:1 supervision. Resident identifier: #46. Facility census: 93. The state agency determined this failure placed Resident #46's 1:1 observation status in an immediate jeopardy situation due to the potential of serious injury and/or death because of recent documented suicidal ideations and recent suicide attempt. The state agency notified the Nursing Home Administrator of the immediate jeopardy at 3:52 PM on 04/03/24. The facility submitted a plan of correction (POC) at 5:41 PM. At 5:48 PM, the POC was accepted by the state agency. The state agency verified the POC was implemented by conducting staff interviews and the immediate jeopardy was abated at 12:05 PM on 04/08/24. Findings included: a) Resident #46 On 04/03/24 at 2:16 PM, an observation was made of Resident #46 alone lying 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.
- Immediate jeopardy · L2024-02-23 · tag F0835 — failed to run the facility competently — widespreadAdminister the facility in a manner that enables it to use its resources effectively and efficiently.
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 be administered in a manner which enabled it to use its resources effectively and efficiently to enable each resident to attain or maintain the highest practicable physical mental and psycho social well being. The facility's administration failed to identify and substantiate physical abuse and involuntary seclusion and take appropriate actions to ensure the alleged perpetrators did not abuse residents in the future. Neither resident was able to verbalize how these actions made them feel therefore the reasonable person standard was applied. These actions placed these two (2) residents and the remaining 93 residents at risk for serious harm and/or death because both alleged perpetrators were still employed by the facility and actions were not taken to ensure they did not abuse other residents in the future. All 95 residents were in an immediate jeopardy (IJ) situation. The facility was first notified of the IJ at 6:15 PM, on 02/20/24. The state agency (SA) received the Plan of Correction (POC) at…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Immediate jeopardy · K2024-02-23 · 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 ensure residents were free from physical abuse due to being physically restrained. Resident #43 was physically restrained by a nurse aide who held her head preventing movement when a nurse swabbed her nose to test for COVID. Resident #11 became agitated and a nurse took the resident to their room where they locked the resident's wheelchair and physically held the resident's wheelchair preventing the residnet from moving and leaving the room. Neither resident was able to verbalize how these actions made them feel therefore the reasonable person standard was applied. These actions placed these two (2) residents and the remaining 93 residents at risk for serious harm and/or death because both alleged perpetrators were still employed by the facility and actions were not taken to ensure they did not abuse other residents in the future. All 95 residents were in an immediate jeopardy (IJ) situation. The facility was first notified of the IJ at 6:15 PM, on 02/20/24. The state agency (SA) received the Plan…
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.
- Immediate jeopardy · K2024-02-23 · tag F0604 — failed to not use physical restraints improperly — patternEnsure that each resident is free from the use of physical restraints, unless needed for medical treatment.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review, staff interview and resident interview the facility failed to ensure residents were free from physical abuse. Staff physically restrained two (2) residents. Resident #43 was and #11 were both physically restrained. A nurse aide (NA) nurse aide held her head preventing movement so the nurse could perform a swab of the nose to test Resident #43 for COVID. Resident #11 became agitated and a nurse took the resident to their room where they locked the resident's wheelchair and physically held the resident's wheelchair preventing them from moving and leaving their room. Neither resident was able to verbalize how these actions made them feel therefore the reasonable person standard was applied. Not only did these failures harm Resident #11 and Resident #43 but they also placed them and the remaining 93 residents at risk for serious harm and/or death. The alleged perpetrators were still employed by the facility and actions were not taken to ensure they did not abuse other residents in the future. This placed all 95 residents in an immediate jeopardy (IJ) situation.…
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 before2025-04-02 · tag F0812 — failed to store, cook, and serve food safely — patternProcure 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 and staff interview, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food safety. The staff failed to use proper hand hygiene and don a hairnet while in the kitchen. Lastly, failed to maintain the equipment in safe operating condition. This practice had the potential to affect more than an isolated number of residents. Facility census: 93. Findings included: a) On 04/02/2024 at 12:49 PM, during a visit to the kitchen the following was observed: -Corn flakes found stored without label opening and used by date -Breaded fish found in freezer left open to air. In an interview with The Food Service Supervisor, at 1:10 PM on 04/02/2024, she acknowledged the both the corn flakes were found stored without an opening and used by dated label, and the breaded fish was found left open to air in the freezer. On 04/02/25 at 11:50 PM During lunch dining observation it was observed that NA #79 wheeled a male resident into the dining room to a table and walked into the kitchen. Observing through the window 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.
- Potential for harm · Dcited before2025-04-02 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide 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 obtain labs, as ordered by the physician, for Resident #41. This was true for one (1) of five (5) residents reviewed for unnecessary medications during the survey process. Resident identifier: #41. Facility census: 93. Findings include: A) Resident #41 During a review of Resident 41's record on 04/01/25, it was noted the resident had the following order- CBC, BMP and HGBA1C in the morning every three (3) months starting on the 2nd for one (1) day. This order was entered into the system on 11/4/24. Review of the resident's lab results, and progress notes indicated no labs were drawn in the month of March 2025. According to the order, the labs should have been taken on 03/02/25. Documentation regarding the labs was requested from the facility at approximately 11:45 AM on 04/01/25. On 04/01/25 at approximately 1:44 PM, the facility provided documentation related to Resident #41's labs. The only documentation for lab draws, were from labs completed on 12/02/24. Upon further review of Resident #41's orders, it was noted…
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 · D2025-04-02 · tag F0697 — failed to manage pain — isolatedProvide 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 ensure residents received treatment and care in accordance with professional standards of practice. The facility failed to ensure a physician order for pain was correctly followed for Resident #4. This failed practice was true for one (1) of one (1) residents reviewed for pain. Resident identifier: #4. Facility census: 93. Findings included: a) Resident #4 A medical record review, completed on 05/09/23 at 11:27 AM, revealed the following physician order, dated 02/09/25, Hydrocodone-Acetaminophen Tablet 7.5-325 MG. Give 1 tablet by mouth every 6 hours as needed for moderate to severe pain (5-10) not to exceed 3gm Tylenol in 24hr. Review of the February and March 2025 Medication Administration Records (MARs) revealed the following dates and times the medication was not given in accordance with the physician's order: -On 02/13/25, the medication was given with a pain level of 4 -On 02/22/25, the medication was given with a pain level of 4 -On 02/22/25, the medication was given with a pain level of 4 -On 03/18/25, the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-04-02 · tag F0745 — failed to provide medically-related social services — isolatedProvide medically-related social services to help each resident achieve the highest possible quality of life.
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 interviews, the facility failed to aid a resident and/or their legal representatives with advance care planning, including but not limited to completion of advanced directives per professional standards. This is true for one (1) of 27 reviewed for advanced directives. Resident identifier #75. Facility census: 93. Findings included: a) Resident #75 A medical record review for Resident #75 revealed an admission to the facility on [DATE]. An Encounter Summary provided to the surveyor from the transferring hospital found the capacity statements from 02/29/25. -- Demonstrates Capacity to make medical decisions was marked. Continued review found that physician determination of capacity was completed on 02/20/25. -- Demonstrates Capacity to make decisions was marked. Subsequent review found that the review of Resident 75's Minimum Data Set (MDS) with the ARD date of 02/26/25, finds the resident has a score of 03. A BIMS score of 3 indicates that the resident is severely…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-04-09 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and staff interview, the facility failed to develop and/or implement the care plan for Resident #92, #84, #39 and #95, four (4) of four (4) residents reviewed. Resident identifiers: #92, #84, #39 and #95. Facility Census: 93. Findings included: a) Resident #92 On 04/03/24 at 9:00 AM, a record review was completed for Resident #92. The review found the care plan had not been developed to include all the interventions based on the physician's orders and the Treatment Administration Record (TAR) dated 03/01/24 through 03/31/24. The interventions that were not found were as follows: --Daily assessment of the unstageable (UN) wound on the right heel --Wound care as ordered On 04/03/24 at 10:00 AM, the Corporate Registered Nurse (RN) was notified and confirmed the interventions were not listed. b) Resident #84 On 04/03/24 at 9:15 AM, a record review was completed for Resident #84. The record review found the care plan had not been developed to include an Unstageable wound on the sacrum and the interventions found in the physician's orders and the TAR dated 03/01/24…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-04-09 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide 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 follow physician's orders four (4) of four (4) residents. Resident identifiers: #92, #84, #39 and #95. Facility Census: 93. Findings included: a) Resident #92 On 04/03/24 at 9:00 AM, a record review was completed for Resident #92. The review found the physician's orders on the Treatment Administration Record (TAR) for 03/01/24 through 03/31/24 were not followed. The following treatments and dates were left blank: --Daily wound treatment to the stage III to the sacrum --03/02/24 day shift --Daily wound assessment for the stage III to the sacrum --03/02/24 day shift --Preventative treatment to the coccyx and bilateral buttocks twice daily --03/25/24 night shift --Bilateral palm guards on hands may remove twice daily to clean and monitor skin --03/25/24 night shift --Float heels when in bed twice daily for preventative measures --03/25/24 night shift --Resident may use pillow cases between knees to prevent skin breakdown due to contractures twice daily --03/25/24 night shift --Ensure resident has been turned and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2024-04-08 · tag F0607 — failed to have anti-abuse policies — widespreadDevelop 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
Based on record review, review of legislative rule § 69-10-1 TITLE 69 Rule Department of Health and Human Resources, Series 10 [NAME] Virgnia Clearance for Access: Registry and Employment Screening and staff interview, the facility failed to implement the facility policies to prohibit and prevent abuse, neglect, exploitation of residents and misappropriation of resident property ensure provisional employment screening. The facility also failed to ensure completion of background checks before allowing staff to work and have direct access to the residents. All residents had the potential to be affected. The facility failed to provisionally employ staff pending the [NAME] Virginia Cares fitness determination and the facility failed to require a fingerprint-based background check before hiring staff. The facility had identified and corrected this issue prior to the survey. Staff identifiers: #28, #44, #80, #109, #110, #119 and #127. Facility Census: 93. Findings included: a) Certified Nursing Assistant (CNA) #28 CNA #28 was hired on 08/30/22. The [NAME] Virginia (WV) Cares…
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 · F2024-04-08 · tag F0836 — widespreadEnsure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review, review of legislative rule § 69-10-1 TITLE 69 Rule Department of Health and Human Resources, Series 10 [NAME] Virgnia Clearance for Access: Registry and Employment Screening and staff interview, the facility failed to operate and provide services in compliance with all applicable State and local laws, regulations, and codes, and with accepted professional standards and principles that apply to professionals providing services in such a facility. The facility failed to ensure provisional employment screening. The facility also failed to ensure completion of background checks before allowing staff to work and have direct access to the residents. All residents had the potential to be affected. The facility failed to provisionally employ staff pending the [NAME] Virginia Cares fitness determination and the facility failed to require a fingerprint-based background check before hiring staff. The facility had identified and corrected this issue prior to the survey. Staff identifiers: #28, #44, #80, #109, #110, #119 and #127. Facility Census: 93. Findings included:…
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 · E2024-02-23 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and staff interview, the facility failed to maintain appropriate infection control standards for the cleaning and disinfecting of the [NAME] Unit and maintaining the storage of clean linen. These were random opportunities for discovery. Facility Census: 95. Findings Include: a) Cleansing Dwell Time On 02/20/24 at 9:25 AM, Housekeeper (HK) #46 on the [NAME] wing was asked what type of cleanser does the facility use for surfaces and floors? HK #46 stated (Name of Cleanser) for the floors and surfaces. HK #46 was then asked, what is the dwell time? HK #46 stated, about 5 (five) minutes . On 02/20/24 at 9:40 AM, the Housekeeping Director (HKD) #41 confirmed the name of the cleanser and the dwell time was 10 minutes .it must remain wet . HKD #41 stated, we have reviewed the dwell times .I'm not sure why HK #46 didn't know. On 02/20/24 at 10:00 AM, the label and directions were reviewed for the facility cleanser. The directions state, Treated surfaces must remain visibly wet for 10 minutes. No further information was obtained during the survey process. b) Linen Cart…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-02-23 · tag F0607 — failed to have anti-abuse policies — isolatedDevelop 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
Based on record review, staff interview and resident interview the facility failed to ensure their policy as it pertained to abuse, abuse investigation, and abuse prevention was implemented. Two (2) residents were found to have been abused by being physically restrained. Resident #43 was physically and restrained by a nurse aide who held her head preventing movement so the nurse could perform a swab of the nose to test Resident #43 for COVID. Resident #11 became agitated and a nurse took the resident to her room where they locked the residents wheelchair and physically held the resident's wheelchair preventing her from moving and leaving her room. The state agency (SA) determined these failures caused Resident #11 and Resident #43 to suffer physically and mentally. Neither resident was able to verbalize how these actions made them feel. Not only did these failures harm Resident #11 and Resident #43 but they also placed the remaining 93 residents at risk for serious harm and/or death because both alleged perpetrators were still employed by the facility and actions were not taken to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 20 citations
- Potential for harm · Dcited before2024-02-23 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review and staff interview the facility failed to implement care plans related to fall interventions. This failed practice was found true for (2) two of (3) three residents reviewed for falls. Resident identifiers #44 and #1. Facility Census 95. Findings Include: a) Resident #44 A record review on 02/19/24 at 1:00 PM of Resident #44's care plan revealed the resident was at risk for falls and had a fall from bed on 02/10/24. Further record review of Resident #44's care plan found an intervention for, Fall mat to side of bed this intervention was initiated 02/13/24. An observation on 02/19/24 at 1:46 PM of Resident #44 found her lying in bed. No fall mat was beside the bed or in the room. An Observation on 02/21/24 at 11:30 AM of Resident # 44 in her bed, the fall mat was not at bedside. An interview on 02/21/24 at 11:40 AM with Clinical Manager (CM) # 109, confirmed the fall mat was not at bedside. b) Resident #1 A record review on 02/19/24 at 1:10 PM of Resident #1's care plan revealed Resident #1was at risk for falls and has had the following falls:…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-02-23 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on record review and staff interview, the facility failed to maintain a complete and accurate medical record for Resident #97. This is true for one (1) of five (5) residents reviewed during the survey process. Resident Identifier: #97. Facility Census: 95. Findings Included: a) Resident #97 On 02/20/24 at 11:00 PM, a record review was completed for Resident #97. The record review found a Discharge summary dated [DATE]. The discharge summary under the section 3 Course of Illness/Progress stated, Resident has been unable to participate in getting up with therapy due to FX (fracture). (Typed as written.) After reviewing the physical therapy notes throughout the stay at the facility, the resident did participate fully and attended the therapy sessions in the facility gym while seated in a wheelchair. In addition, other therapy progress notes state, Pt (patient) propel wc (wheelchair) x (times) 75' (feet) sba (stand by assistance). On 02/20/24 at 1:30 PM, Clinical Manager (CM) #109 reviewed the discharge…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-08-28 · 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 observation, staff interview, and record review the facility failed to report alleged violation related to, neglect, or abuse, and report the results of investigations to the proper authorities within prescribed time frames. This was true for three (3) of five (5) grievances reviewed during a complaint investigation. Resident identifiers: #2, #4 and #3. Facility Census: 89. Findings Included: a) Resident #2 A review of the facility's concern forms revealed a concern form from Resident #2 which read as follows: -Resident States on 06/11/23 and the morning of 06/12/23 he had to wait for up to two hours to receive a changing of a soiled adult brief. Subsequent review of the medical record revealed the complaint/concern on 06/12/23 for Resident #2 was not investigated or reported to the appropriate agencies as required. Resident #2's Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/03/23 noted the resident had a score for Brief Interview for Mental Status (BIMS) of 13. A BIMS score of 13 indicates the resident is cognitively intact and has capacity.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-08-28 · tag F0610 — failed to investigate and act on abuse reports — isolatedRespond appropriately to all alleged violations.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, staff interview, and record review, the facility failed to take actions to investigate an alleged violation related to neglect. This was true for three (3) of five (5) grievances reviewed during a complaint investigation. Resident identifier #2, #4 and # 3. Facility Census 89. Findings included: a) Resident #2 A review of the facility's concern forms revealed a concern form from Resident #2 which read as follows: -Resident States on 06/11/23 and the morning of 06/12/23 he had to wait for up to two hours to receive a changing of a soiled adult brief. Subsequent review of the medical record revealed the complaint/concern on 06/12/23 for Resident #2 was not investigated or reported to the appropriate agencies as required. Resident #2's Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/03/23 noted the resident had a score for Brief Interview for Mental Status (BIMS) of 13. A BIMS score of 13 indicates the resident is cognitively intact and has capacity. An interview with the administrator on 08/28/22 at 3:13 PM verified the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2023-03-22 · 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 observation, record review and staff interview the facility failed to provide care/treatment and services in accordance with professional standards of practice. The facility failed to assess Resident #350 after a fall. The pharmacist and physician declined to complete the required Food and Drug Act (FDA) paper work to be able to continue to prescribe and administer Clozapine in a safe manner for Resident #395. Physician orders were not followed for house supplements for Resident #88. These findings are true for one of four reviewed for falls, one of six reviewed for psychotropic medications and one of two reviewed for food preferences. Resident identifiers: 350, 395, 88. Facility census: 93. Findings include: a) Resident (R) 350 Review of the medical record on 3/21/23 revealed a note by the nurse practitioner on 05/13/22 at 9:46 PM stating R#350 had a fall earlier at 2:00 PM which was not reported. The nurses notes lack any information related to this fall until a hematoma was identified by a nurse aide at 9:30 PM on 05/13/23. On 03/22/23 at 10:30 AM, Licensed Practical…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-03-22 · tag F0578 — failed to honor advance directives / code status — isolatedHonor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on medical record review and staff interview, the facility failed to ensure Advance Directive paperwork was part of the resident's medical record. This was true for one (2) of 19 residents reviewed in the Long-Term Care Survey process. Resident identifier: #31 and #72. Facility census: 93. Findings included: a) Resident #31 A medical record review, completed on 03/20/23 at 3:07 PM, indicated that Resident #31 was admitted to the facility on [DATE]. It also identified the following details: -A Physician Determination of Capacity was on file and indicated Resident #31 lacked capacity to make her own medical decisions. -A WV Physician Orders for Scope of Treatment (POST) form was on file and indicated Resident #31's legal representative had signed the form. -There was a copy of a Power of Attorney (POA) scanned into the electronic record. There was also a copy of the POA on the resident's paper chart at the nurses station. However, the POA specifically stated, This power of attorney does not authorize the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-03-22 · 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 observation, record review, and staff interview, the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition. This was a random opportunity for discovery. Resident Identifier #33. Facility census: 93. Findings included: a) Resident #33 A record review, completed on 03/21/23 at 11:24 AM, found the following: -There was a Grievance/Concern Form on file that was dated 01/18/23. Description of concern read: Resident states she cannot see well enough to feed herself meals and that she doesn't get enough to eat because of this. States she would like to have assistance with meals. -The Annual Minimum Data Set (MDS), with an assessment reference date of 02/09/23, read Eating: One person physical assist. On 03/21/23 at 2:20 PM, visible from hallway outside of Resident #33's room, it was evident the noon meal was still at her bedside and Resident #33 had 1/2 of a dropped, uneaten grilled cheese sandwich resting on her chest. Once by the bedside, it was evident Resident #33 had accidentally…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-03-22 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, staff interview and resident interview, the facility failed to ensure respiratory care was provided according to professional standards of practice. These were random opportunities for discovery. Resident Identifiers: #6 and #49. Facility Census: 93. Findings Included: a) Resident #6 On 03/20/23 at 1:10 PM, a continuous positive airway pressure (CPAP) mask was observed hanging from the night stand for Resident #6. The CPAP mask was not stored in a respiratory bag which decreases the risk of infections. On 03/20/23 at 1:12 PM, Licensed Practical Nurse (LPN) #37 confirmed the CPAP mask was not stored in a respiratory bag. LPN #37 stated, let me go get a respiratory bag. On 03/20/23 at 3:00 PM, the Directory of Nursing (DON) was notified and confirmed the CPAP mask should be stored in a respiratory bag. b) Resident #49 On 03/20/23 at 1:05 PM, a nebulizer mask was observed hanging by the bed rail. The nebulizer mask was not stored in a respiratory bag which decreases the risk of infections. On 03/20/23 at 1:07 PM, LPN #37 confirmed the nebulizer mask…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-03-22 · tag F0809 — failed to serve meals on a reasonable schedule — isolatedEnsure 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 — an excerpt from the official record, may be distressing
Based on resident interviews during resident council, and staff interview, the facility failed to ensure a substantial/nourishing snack was provided between the evening meal and breakfast. This had the ability to affect all residents who did not have a dietary order to receive an evening snack or the cognitive and/or physical ability to make their way to the nurse's station to request something to eat from the nourishment room. Facility Census: 93. Findings included: a) Resident Council Meeting During the resident council meeting with Surveyor on 03/21/22 at 1:00 PM, three (3) out of five (5) residents in attendance stated the facility did not offer an evening snack to residents. They went on to say they felt the majority of facility residents would enjoy a bedtime snack. One (1) resident stated, They used to do that, but they don't do it anymore. Another resident explained if he was hungry before bedtime, he independently made his way to the nurse's station and asked for something. When asked if all residents in the facility knew how to acquire something from the nourishment room…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-03-22 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and staff interview, the facility failed to maintain accurate and complete medical records for the Physician Orders for Scope of Treatment (POST) form for Resident #92 and Resident #39, a capacity form for Resident #92 and documentation of supplements for Resident #88. This is true for three (3) of 25 medical records reviewed during the long-term survey process. Resident Identifiers: #92, #39 and #88. Facility Census: 93. Findings Included: a1.) Resident #92 On 03/22/23 at 8:01 AM, a record review was completed for Resident #92. The review found the POST form was incomplete. The preparer's signature was not dated upon completion of the form. On 03/22/23 at 8:20 AM, the Director of Nursing (DON) was notified and confirmed the POST form was incomplete. No further information was obtained during the long-term survey process. a-2) Resident #92 On 03/22/23 at 8:01 AM, a record review was completed for Resident #92. The review found the capacity form was incomplete. The capacity form did not list the duration, nature or causes of the incapacity finding. On 03/22/23…
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 · E2022-01-06 · tag F0623 — patternProvide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on record review and staff interview, the facility failed to ensure timely notification was made to a representative of the Office of the State Long-Term Care Ombudsman when residents were transferred to the hospital. This was true for three (3) of four (4) residents reviewed for the care area of hospitalization. Resident identifiers: #29, #192, #190, and #60. Facility census: 91. Findings included: a) Resident #29 Record review found the resident was transferred and admitted to a local hospital on [DATE]. On 01/05/22 at 3:06 PM, the corporate nurse #133 confirmed she had no documentation to verify the ombudsman was notified of the residents transfer to the hospital. b) Resident #192 Review of Resident #192's medical records showed the resident had been sent to an appointment at the wound care clinic on 06/02/21. The resident was transferred from the wound care clinic to the hospital, where she was admitted . On 01/05/22 at 10:06 AM, the Director of Nursing was asked for documentation that the Ombudsman…
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 · E2022-01-06 · tag F0625 — patternNotify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
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 residents/responsible party were made aware of the facility's bed-hold notice when transferred to the hospital. This was true for three (3) of four (4) residents reviewed for the care area of hospitalization. Resident identifiers: #29, #192, #190, and #60. Facility census: 91. Findings included: a) Resident #29 Record review found the facility transferred the resident to the hospital on [DATE]. On 01/05/22 at 3:06 PM, the corporate nurse #133 said the facility had nothing to verify a copy of the bed hold policy was sent with the resident at the time of discharge. b) Resident #192 Review of Resident #192's medical records showed the resident had been sent to an appointment at the wound care clinic on 06/02/21. The resident was transferred to the hospital from the wound care clinic. On 01/05/22 at 3:21 PM, Corporate Nurse #133 stated she had no documentation that Resident #192's representative had been made aware of the facility's bed hold…
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 before2022-01-06 · tag F0578 — failed to honor advance directives / code status — isolatedHonor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on record review and staff interview, the facility failed to ensure the documented used by the facility to convey end of life care, the State's Physician Orders for Scope of Treatment (POST) form, was completed correctly. For Resident #28, the POST form contained conflicting documentation regarding placement of a feeding tube. For Resident #71, the facility changed the resident's wishes for end of life care without the residents consent. This was true for two (2) of three (3) Residents reviewed for the care area of advance directives. Facility census: 91. Findings included: a) Resident #28 Review of the resident's most recent POST form completed on [DATE], by the facility social worker SW #28, found Section D, Medically Assisted Nutrition, instructs only one of the following choices can be made and says- (PICK 1) 1. Provide nutrition through new feeding tube through new or existing surgically placed tube 2. Time limited trial of ______ days but no surgically placed tubes 3. No artificial means desired 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 · Dcited before2022-01-06 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on resident interview, staff interview, and record review, the facility failed to ensure activities of daily living were completed for a dependent resident. This was true for one (1) of two (2) residents reviewed under the care area of activities of daily living during the long-term survey process. Resident Identifier: #63. Facility Census: 91. Findings included: a) Resident #63 Upon the initial interview on 01/03/22 at 11:22 AM, Resident #63 stated, I want my showers on my scheduled days. The staff don't ask me they just put down I refuse. On 01/04/22 at 10:55 AM, Licensed Practical Nurse (LPN) #54 stated the shower days would be located on the Plan of Care (POC) or the [NAME]. LPN #54 also stated Resident #63's shower days are Monday and Friday during the hours of 6:00 AM to 2:00 PM. On 01/04/22 at 11:00 AM, Resident #63 stated, I did not get a shower yesterday and they (staff) didn't even ask me. Review of the bath/shower documentation from 12/06/21 through 01/03/22, showed no documentation of any…
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 before2022-01-06 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide 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 Residents received treatment and care in accordance with professional standards of practice. Physician's orders were not followed for neurological checks after an unwitnessed fall for Resident #70. In addition, weights were not obtained for Resident #201. This practice affected two (2) of (20) residents reviewed, during the Long-Term Care Survey Process (LTCSP). Resident identifier #70 and #201. Facility census: 91. Findings included: a) Resident #70 Review of Resident #70's medical record on 01/04/22 at 08:33 AM, showed an unwitnessed fall on 12/10/21 at 7:30 PM. Further review revealed Resident #70 was found on the floor, face down with head turned to the right. Neurological checks (neuro checks) were initiated. Subsequent review of the neurological check evaluations found no neuro checks were completed after 12/11/21 at 2:00 AM in the medical record for the unwitnessed fall on 12/10/21. During an interview with the Clinical Manager Registered Nurse #60 verified the Neuro Checks were…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2022-01-06 · 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 on observation and staff interview the facility failed to ensure an environment free of accident hazards by leaving a refrigerator unlocked an unattended in the facility dinning room. This was a random opportunity for discovery. This has the potential to affect more than a limited number of residents. Facility Census 91 Findings Included: a) Unlocked refrigerator in dining room. On 01/04/22 at 11:01 AM, during a visit to the social service (SS) office in the dinning room this surveyor observed a refrigerator sitting in the corner unattended and unlocked. A second surveyor also observed the refrigerator. The refrigerator opened without difficulty. Upon opening the refrigerator several lunch bags and loose food items were noted. On 01/04/22 at 1:45 PM, Personal Care Attendant (PCA)# 74 , who was sitting in the dinning room eating lunch, confirmed the refrigerator in the dinning room was used for staff food and was left unattended. On 01/04/22 at 1:50 PM, the Clinical Manager #13 confirmed the refrigerator was for staff use and was left unattended at times and could be opened by…
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 · D2022-01-06 · tag F0693 — failed to provide proper feeding-tube care — isolatedEnsure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
What the surveyor found here — 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 the administration of enteral nutrition followed the physician's orders. In addition, the facility failed to ensure direction for staff regarding how to manage and monitor the rate of flow of the feeding was consistent. This was true for two (2) of two (2) residents reviewed for tube feeding. Resident identifiers: #29 and #71. Facility census: 71. Findings included: a) Resident #29 Record review found the resident was sent to the hospital on [DATE]. The resident returned to the facility on [DATE] with a new feeding tube. On 10/14/21, the resident was receiving Jevity 1.0 to infuse at 70 milliliters (ml's) per hour. On 12/23/21, the physician increased the order to Jevity 1.0 calorie at 100 ml's / via g-tube per hour to equal 2400 ml daily. Observation of the feeding pump on 01/04/22 at 12:20 PM, found the pump was infusing at 70 ml's per hour instead of the 100 ml's ordered. Licensed Practical Nurse LPN #96 confirmed the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2022-01-06 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, medical record review, and staff interview, the facility failed to provide respiratory care services consistent with professional standards of practice. The physician's order for oxygen was not followed. This practice affected two (2) of four (4) residents reviewed for respiratory care services during the Long-Term Care Survey Process (LTCSP). Resident Identifier: #17 and #19 Facility census: 91 Findings included: a) Resident #17 A medical record review completed on 01/03/22 revealed Resident #17 had an physician's order to receive oxygen at three (3) liters per minute (LPM) via nasal cannula for shortness of breath every day and night shift with a start date of 10/07/21. During an observation on 01/04/22 at 9:42 AM, it was discovered the oxygen concentrator was set on four (4) LPM and not the prescribed three (3) LPM. The Licensed Practical Nurse (LPN) #96 verified the oxygen concentrator was set on four (4) LPM and not the prescribed three (3) LPM. b) Resident #19 An observation of Resident #19, on 01/03/22 at 12:17 PM, revealed the Resident was receiving…
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 before2022-01-06 · 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 — the official record, unedited, may be distressing
Based on observation and staff interview, the facility failed to maintain the kitchen in a safe and sanitary manner in accordance with professional standards of practice. During the kitchen tour it was discovered nectar thickening was not dated after opening and two (2) of four (4) reach-in refrigerators were dirty. This deficient practice had the potential to affect a limited number of residents receiving nourishment from the kitchen. Facility census: 91 Findings included: a) Kitchen tour During the kitchen tour on 01/03/22 at 10:48 AM, it was discovered nectar thickening was not dated after opening and two (2) of four (4) reach-in refrigerators had food debris on the bottom sections. An interview with the Dietary Manager on 01/03/22 at 10:55 AM, verified the nectar thickening was not dated after opening and the two (2) reach-in refrigerators needed to be cleaned. .
- Potential for harm · D2022-01-06 · tag F0883 — failed to offer flu and pneumonia vaccines — isolatedDevelop and implement policies and procedures for flu and pneumonia vaccinations.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on medical record review and staff interview, the facility failed to ensure influenza and pneumonia immunizations were provided to one (1) of five (5) residents reviewed for the care area of immunizations. Resident identifier: #57. Facility census: 91. Findings included: a) Resident #57 Review of Resident #57's medical records showed the resident was admitted to the facility on [DATE]. There was no documentation in the medical records the resident had received or been offered influenza or pneumonia vaccines. During an interview on 01/04/22 at 3:30 PM, the Infection Control Nurse (ICN) presented an Influenza Vaccine Consent and Screen form and a Consent/Declination for Pneumonia Vaccine form that came from Resident #57's medical file. Both forms had a handwritten notification that stated, Says he wants it. The ICN stated he didn't know who wrote the notations or when they were written. The ICN acknowledged Resident #57 had not received influenza or pneumonia vaccines. The Infection Control Nurse stated he…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“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
$104,142 in federal fines across 1 penalty. 1 Medicare payment denial on record.
- $104,142 — penalty dated 2024-02-23
- Medicare payment denial — starting 2024-05-10 for 34 days
Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.
Part of a chain
This home belongs to COMMUNICARE HEALTH — 110 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 2 of 5 | 3.2 | -1.2 vs chain |
| Health inspection | 2 of 5 | 2.7 | -0.7 vs chain |
| Staffing | 3 of 5 | 2.6 | +0.4 vs chain |
| Quality measures | 3 of 5 | 4.5 | -1.5 vs chain |
The other 109 homes this chain runs (chain average 3.2★, per CMS)
Showing 40 of 109; lowest-rated first.
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| PC MSTR LSCO, LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 05/01/2017 |
| RRW, LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | 93% | since 05/01/2017 |
| ROMEO, DOMINIC | Individual | CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL | — | since 04/01/2023 |
| STOLTZ, CHARLES | Individual | CORPORATE OFFICER | — | since 05/01/2017 |
| WILHEIM, RONALD | Individual | CORPORATE OFFICER | — | since 05/01/2017 |
| THIRTY SIX MGT CO., LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 04/16/2025 |
| GROVES, DONNA | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 04/14/2023 |
| MONTGOMERY, TAMARA | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 01/01/2023 |
| WRIGHT, RANDY | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 11/04/2024 |
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.
3 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
About 82% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $1.5M paid to related parties — landlords or management companies under common ownership — equal to about 13% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 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 515047. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-04-02, 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.