Hampshire Memorial Hospital
363 Sunrise Blvd, Romney, WV 26757 · Non profit - Corporation · 30 certified beds · (304) 822-4561 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)
- a high payroll-based staffing rating (5/5)
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- inspectors cited 1 immediate-jeopardy problem — the most serious level
- a high number of inspection citations overall (29) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $8,281 in federal fines (most recent 2026-01-23)
- its payroll-based staffing score sits well above its independent inspection score
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) | 5 of 5 |
| Quality measuresSelf-reported by the facility | 3 of 5 |
Worth a closer look. This home's staffing rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the staffing score rests on the facility's own payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 3 of 5 |
| Long-stay residentspeople who live here | 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 3 to 4 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 | 15.7% | 14.7% | 15.4% | typical |
| Long-stay residents who lose too much weight | 1.8% | 6.3% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.0% | 0.4% | 0.9% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 7.8% | 1.6% | 2.0% | worse |
| Long-stay residents with depressive symptoms | 0.0% | 7.6% | 6.5% | check this* — see note marked star below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.2% | 0.1% | better |
| Long-stay residents with falls causing major injury | 2.6% | 4.4% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 34.4% | 15.9% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 12.6% | 27.0% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 97.6% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 11.4% | 4.2% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 19.7% | 22.1% | 21.2% | typical |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 4.3% | 13.4% | 17.1% | better |
* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.
‡ 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 0.04 therapist hours per resident per day in 2026Q1 — more than 2% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 0% of this home’s weekday level — it runs therapy on weekdays, with essentially none at 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 | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| 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 — Newly certified nursing home with less than 12-15 months of data available or the nursing home opened less than 6 months ago, and there were no data to submit or claims 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 — Newly certified nursing home with less than 12-15 months of data available or the nursing home opened less than 6 months ago, and there were no data to submit or claims for this 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 | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality 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 30 beds and averages 27.5 residents a day — about 92% occupied, or roughly 2 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 4.78 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.23 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.70 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 4.11 hrs/resident/day on weekends vs 5.05 on weekdays — 19% thinner on weekends. RN hours go from 1.43 to 0.73 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 38% 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.
29 citations, most serious first. The 11 most serious are shown; the remaining 18 are one tap away and print in full.
- Immediate jeopardy · J2026-01-23 · 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
Based on record review and staff interview, the facility failed to ensure all code status documentation for Resident #20 and Resident #25, who both requested to be a Do Not Resuscitate (DNR) matched. This failure placed Resident #20 and Resident #25 in an immediate risk for serious harm and/or death. The state agency notified the facility of the immediate jeopardy situation on 01/22/26 at 1:37 PM. The state agency accepted the facility's plan of correction on 01/22/26 at 3:28 PM. After observation of the implementation of the plan of correction, the immediate jeopardy was abated at 9:00 AM on 01/23/26.Resident Identifiers: #20 and #25. Facility Census:28.During an interview on 01/22/26 at approximately 12:10 PM, Licensed Practical Nurse (LPN) #19, reported staff could use the following methods to double-check a resident's code status should they be found pulseless and not breathing: --Physician's order--Physician's Order for Scope of Treatment (POST) form--Code status listed on the outside of the medical chart at the nurses' station--Full code list posted in the Medication…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2026-01-23 · 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 follow physician's order for resident care. The physician order for Gabapentin was not properly followed for Resident #7. This failed practice was true for one (1) of five (5) residents reviewed under the Unnecessary Medications pathway in the Long-Term Care Survey Process (LTCSP) pathway. Resident #7. Facility census: 28.a) Resident #7 During a record review, completed on 01/21/2026 at 11:10 AM, the following physician order was found for Resident #7: Gabapentin Oral Capsule (Gabapentin) - Give 100 mg by mouth three times a day for Diabetic Neuropathy.Review of Resident #7's Medication Administration Records (MARs) from August 2025 - January 2026 revealed the following dates and times the MAR was left blank: -08/03/25 at 2:00 PM-10/21/25 at 2:00 PM-12/14/25 at 2:00 PM-01/18/26 at 2:00 PM The Director of Nursing (DON) was interviewed on 01/21/2026 at 1:30 PM. The DON confirmed the blanks in the MARs and reported that the professional standard of practice was for nurses to document on the MAR when medication 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 · E2026-01-23 · 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 — the official record, unedited, may be distressing
Based on observation, record review and staff interview, the facility failed to ensure safe storage of food. This failed practice had the potential to effect more than a limited amount of residents receiving nourishment from the kitchen. Facility census: 28.a) Kitchen During the initial walkthrough of the kitchen it was found that the following food items did not have an 'opened on date or a use by date:-Frozen strawberries-Frozen blueberries-Pickles-Ice cream-Sherbet-Tater tots-Sausage patties-Liquid eggs Dietary Employee #32 and Dietary Employee #53 were not wearing beard nets. It was also found that there was no lid on trash can. The Dietary Manager verified the above-mentioned details.
- Potential for harm · E2026-01-23 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — the official record, unedited, may be distressing
Based on observation, record review and staff interview, the facility failed to maintain a proper infection control program for medication administration. These was a random opportunity for discovery. Facility Census: 28.Findings Included: a) Medication Administration On 01/23/26 at 8:34 AM, medication administration for Resident #7 by Licensed Practical Nurse (LPN) #19 was observed. Upon entering Resident #7's room, LPN #19 sat the resident's Flonase nasal spray and Moxifloxin eye drops directly on the over-the-bed table with using a barrier. On 01/23/26 at 8:41 AM, LPN #19 confirmed she did not place the medication on a barrier. On 01/23/26 at 8:48 AM, the Director of Nursing (DON) was notified and confirmed the medication should have been placed on a barrier.
- Potential for harm · Dcited before2026-01-23 · 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 — the official record, unedited, may be distressing
Based on record review and staff interview, the facility failed to develop a comprehensive care plan care which included a resident's preference and potential for future discharge. The facility failed to document whether the resident's desire to return to the community was assessed for Resident #10. This was true for one (1) of 19 residents reviewed throughout the Long-Term Care Survey Process. Resident identifier: #10. Facility census: 28.a) Resident #10 During a record review, completed on 01/21/2026 at 11:44 AM, it was determined that the comprehensive care plan for Resident #10 did not include the resident's preference and potential for future discharge. There was no evidence the facility had assessed the resident's potential for discharge from the facility. During an interview, on 01/21/2026 at 1:35 PM, the DIrector of Nursing (DON) confirmed Resident #10's care plan did not include resident's preference and potential for discharge stating that it had been missed.
- Potential for harm · Dcited before2026-01-23 · 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 ensure an accurate and complete documentation of a discontinued medication for Resident #14. This was true for one (1) of five (5) medications reviewed under the care area of unnecessary medications. Additionally, based on record review and staff interview, the facility failed to maintain an accurate medical record for one (1) out of 19 records reviewed for accurate POST forms. This failed practice applied to Resident #25. Resident identifiers: #14 and #25. Facility census: 28. Findings Included: a) Resident #14 On [DATE] at 1:20 PM, a record review was completed for Resident #14. The review found a physician's order stating, Continue to monitor for antidepressant side effects. However, the antidepressant, Trazodone, had been discontinued on [DATE]. On [DATE] at 1:39 PM, the Director of Nursing (DON) confirmed the physician's order should have been discontinued. b) Resident #25 An electronic medical review, completed on [DATE] at 11:30 AM, 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.
- Potential for harm · Fcited before2024-02-22 · tag F0868 — widespreadHave the Quality Assessment and Assurance group have the required members and meet at least quarterly
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and staff interview, the Quality Assessment Performance Improvement meetings did not include all required members for two (2) of four (4) meetings. This deficient practice had the potential to affect all residents residing in the facility. Facility census: 27. Findings included: a) Review of Quality Assessment Performance Improvement (QAPI) meeting sign-in sheets On 02/22/24 at 9:04 AM, the Quality Assessment Performance Improvement (QAPI) meeting sign-in sheets were reviewed for the past four (4) quarters. The sign-in sheet for 05/31/23 indicated neither the Medical Director nor a designee for the Medical Director had attended the QAPI meeting. The sign-in sheet for 09/01/23 indicated the Medical Director, the Director of Nursing, the facility vice-president, and the Infection Preventionist had attended the meeting. The meeting was also attended by a member of the therapy/rehabilitation staff. However, another member of staff did not attend the meeting as required. During an interview on 02/22/24 at 9:20 AM, the Director of Nursing confirmed the Medical…
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 before2024-02-22 · 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 observation and staff interview the facility failed to provide residents the opportunity to file grievances anonymously by not making grievance forms accessible to residents. This has the potential to affect more than a limited number of residents. Facility Census: #27 Findings included: a) Facility On 02/20/24 at 11:10 AM observation found that there were no grievance forms accessible to residents to obtain on their own accord. Upon discussion with the Director of Nursing on 02/20/24 at 12:10 PM, she states the forms are kept in her office in a file cabinet. The Residents must go through a staff member to file a grievance. When asked how the Residents file an anonymous grievance, she states they do not. According to the regulation: 483.10(j) Grievances. . Notifying resident individually or through postings in prominent locations throughout the facility of the right to file grievances orally (meaning spoken) or in writing; the right to file grievances anonymously; During a Resident Council meeting on 02/21/24 residents present (14 residents) stated they can not file a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-02-22 · 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 and/or implement the comprehensive care plan for seven (7) of fourteen (14) residents reviewed in the long term care survey sample. Resident Identifiers: #1, #27, #24, #11, #13, #20 and #3. Facility Census: #27. Findings included: a) Resident #1 On 02/20/24 at 03:10 PM record review show Resident #1 has a history of weight loss. Weights were documented as: 02/08/24 203.8 01/23/24 203.8 11/02/23 217.5 08/04/23 233.5 Further review of Resident #1's care plan found that there was no care plan developed for weight loss. This was confirmed with the Director of Nursing on 02/20/24 at 03:58 PM who agreed that Resident #1 should be care planned for weight loss. b) Resident #27 On 02/20/24 at 11:50 AM record review shows Resident #27 was admitted on [DATE] with contractures to the left shoulder and elbow. Review of the care plan in place found the contractures were not included on the care plan in place. This was confirmed with the Director 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 before2024-02-22 · 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 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 document vital signs when medications were held for Resident #13 and Resident #7. The facility failed to follow the physician's orders for side rails for Resident #11. This deficient practice had the potential to affect three (3) of 14 residents reviewed in the long-term care survey sample. Resident identifiers: #13, #7, #11. Facility census: 27. Findings included: a) Resident #13 Review of Resident #13's physician's orders showed the following order written on 10/06/23, Lisinopril, oral tablet, 5 mg [milligrams], one time a day related to essential (primary) hypertension. Hold for SBP [systolic blood pressure] < [less than] 100. On 12/13/24 at 8:00 AM, Resident #13's Medication Administration Record (MAR) was marked 5 for Lisinopril administration. According to the MAR code, 5 means hold/see nurse notes. However, there was no nurse note in the progress notes. The area on the MAR to record 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 · E2024-02-22 · tag F0758 — failed to limit and justify psychotropic drugs — patternImplement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
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 each resident's drug/medication regimen is managed and monitored to promote or maintain the resident's highest practicable mental, physical, and psychosocial well-being. Resident's #13, #24, #7 and #3 received psychotropic medications without adequate indication for use. Nonpharmacological interventions were not provided prior to starting the medication and the facility failed to monitor medications for side effects and efficacy. This was true for four (4) of five residents reviewed for unnecessary medications. Resident identifiers: #13, #24, #7, and #3. Facility census: 27. Findings included: a) Resident #13 Resident #13 was admitted to the facility on [DATE]. On 10/17/23, a physician determined the Resident lacked capacity to make medical decisions due to a diagnosis of Dementia and his wife was appointed as his health care surrogate. The Resident was admitted without any psychotropic medications. On 11/05/23, Lexapro 20 milligrams…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 18 citations
- Potential for harm · E2024-02-22 · tag F0761 — failed to label and store drugs safely — patternEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and staff interview, the facility failed to ensure medications were stored in accordance with currently accepted professional principles of practice. This was a random opportunity for discovery that had the potential to affect more than a limited number of residents. Facility census: 27. Findings included: a) Expired intravenous fluids On [DATE] at 8:30 AM, observation of the medication room was made with Registered Nurse (RN) #36 in attendance. Two (2) of three (3) bags of intravenous fluids locked in a cart in the medication room were found to have expiration dates of [DATE]. Both of these intravenous fluids bags contained 5% dextrose and 0.45% sodium chloride. RN #36 confirmed the two (2) bags of 5% dextrose and 0.45% sodium chloride were expired. No further information was provided through the completion of the survey. b) Narcotic emergency box During the medication room observation on [DATE] at 8:30 AM, Registered Nurse (RN) #36 opened a locked cabinet. The locked cabinet contained a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-02-22 · tag F0801 — patternEmploy sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
What the surveyor found here — the official record, unedited, may be distressing
Based on staff interview and record review the facility failed to employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service when one (1) of eight (8) dietary staff members did not have their Food Handlers/SafeServ certification. Facility Identifier: Facility Facility Census: 27 Findings Included: a) Facility On 02/19/24 at 01:17 PM, the Dietary Manager #49 failed to provide the required Food Handler or Safe/Serve certification for one (1) of the eight (8) staff members on the dietary staff. On 02/20/24 at 09:30 AM a telephone interview with the County Sanitarian at the Hampshire County Health Department states they must have the Food Handlers or Safe/Serve certification in order to work in any food area in this county. This was confirmed with the Director of Nursing on 02/20/24 at 02:45 PM.
- Potential for harm · E2024-02-22 · tag F0867 — failed to act on quality-improvement findings — patternSet up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
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 identify and correct quality deficiencies of which it should have been aware. The facility's Quality Assessment and Assurance Committee failed to identify and correct deficiencies regarding psychotropic medications. This deficient practice had the potential to affect four (4) of five (5) residents reviewed for the care area of unnecessary medications. Resident identifiers: #13, #24, #7, #3. Facility census: 27. Findings included: a) Quality Assessment and Assurance (QAA) Committee Interview During an interview on 02/22/24 at 9:20 AM, the Director of Nursing (DON) stated the QAA Committee had not known about deficiencies related to prescribing and monitoring psychotropic medications before the survey began. The DON stated the committee had not been aware of antipsychotic medication being prescribed without adequate documented indications. The DON stated the committee was unaware of the failure to address non-pharmacological interventions prior to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-02-22 · tag F0552 — isolatedEnsure that residents are fully informed and understand their health status, care and treatments.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, the facility failed to inform the resident/responsible party of the risks and benefits of receiving an antipsychotic medication. This was found for one (1) of five (5) residents reviewed for unnecessary medications. Resident identifier: #13. Facility census: 27. Findings included: a) Resident #13 Resident #13 was admitted to the facility on [DATE]. On 10/17/23, a physician determined the Resident lacked capacity to make medical decisions due to a diagnosis of Dementia and his wife was appointed as his health care surrogate. Record review found on 01/04/24, the Resident's physician prescribed a new antipsychotic medication Seroquel, oral Tablet, 25 milligrams (mg's) 1 tablet by mouth two (2) times a day for a diagnosis of depression. The Resident was already receiving Lexopro, an antidepressant for a diagnosis of depression. Further review of the medical record found no evidence the responsible party, the Resident's wife, was notified of the risks and benefits of taking…
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 · D2024-02-22 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, the facility failed to notify the residents' representatives when Resident #20 had a significant change in status and when Resident #13 had a significant alteration in treatment. This deficient practice had the potential to affect two (2) of 14 residents reviewed in the long-term care survey sample. Resident identifiers: #20, #13. Facility census: 27. Findings included: a) Resident #20 Review of Resident #20's weights summary in the electronic health record showed the resident weighed 129.6 pounds (lbs.) on 09/01/23. The weights summary identified the resident had lost 10% of weight in six (6) months when compared to the resident's weight of 144.6 lbs. on 04/05/23. Further review of Resident #20's medical records showed a Physician Certification of Capacity/Incapacity dated 04/19/23 that showed the resident lacked sufficient mental capacity to make health care decisions. In 2021, the resident had chosen a family member to make health care decisions for her if she…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-02-22 · tag F0582 — isolatedGive residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and staff interview, the facility failed to ensure three (3) of three (3) residents reviewed for the care area of beneficiary notices received the required notices when the facility initiated a discharge from Medicare A and the three (3) residents elected to remain at the facility with benefit days remaining. Resident identifiers: #28, #13, and #17. Facility census: 27. Findings included: a) Beneficiary Notices Review of the facility's entrance conference Worksheet indicated three (3) residents who were discharged from Medicare, Part A with benefit days remaining: Resident #28 was discharged from Medicare Part A services on 11/15/23 and remained at the facility with benefit days remaining. Resident #13 was discharged from Medicare Part A services on 11/04/23 and remained at the facility with benefit days remaining. Resident #17 was discharged from Medicare Part A services on 10/29/23 and remained at the facility with benefit days remaining. On 02/20/24 at 3:02 PM, the Director of Nursing (DON) and the Clinical Coordinator, Minimum Data Set (CCMDS) confirmed…
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 · D2024-02-22 · tag F0692 — failed to prevent malnutrition and dehydration — isolatedProvide enough food/fluids to maintain a resident's health.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview the facility failed to assess, monitor and provide timely interventions for residents experiencing weight loss. This was true for two (2) of three (3) residents reviewed for nutrition. Resident Identifiers: #17 and #20. Facility Census: #27 Findings included: a) Policy Review On 02/21/24 at 09:20 AM review of the facility Policy for Resident Weights, revised 05/2023 found the following: Purpose: . that residents maintain acceptable parameters of nutritional status, such as body weight. Weights can be a useful indicator of nutritional status when evaluated within the context of the individuals personal history and overall conditions. A standard protocol is needed to reduce errors. Policy: A. Nursing facility residents will be weighed on admission and weekly (at minimum) for the next consecutive 4 weeks. Thereafter, they will be weighed monthly unless otherwise ordered to help identify any trends such as insidious weight loss. B. Weight loss can be avoidable (resident did…
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 · D2024-02-22 · 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 after significant weight loss was supervised by the physician. This deficient practice had the potential to affect two (2) of three (3) residents reviewed for the care area of nutrition. Resident identifier: #20, #1. Facility census: 27. Findings included: a) Resident #20 Review of Resident #20's weights summary in the electronic health record showed the resident weighed 129.6 pounds (lbs.) on 09/01/23. The weights summary identified the resident had lost 10% of weight in six (6) months when compared to the resident's weight of 144.6 lbs. on 04/05/23. The resident was receiving feeding via a percutaneous endoscopic gastrostomy (PEG) tube. The resident received no nutrition by mouth. There was no indication in the medical records that the physician had been notified of the resident's weight loss. Resident #20 weighed 130.1 lbs. on 10/02/23 and 121.2 lbs. on 11/08/23. Although the weights summary did not identify this change as significant weight loss, the resident had lost 7% of weight in one…
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 · D2024-02-22 · tag F0744 — failed to care for residents with dementia — isolatedProvide 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 and staff interview the facility failed to ensure a resident who is diagnosed with dementia, received the appropriate treatment and services to attain or maintain his or her highest practicable physical, mental, and psychosocial well-being. The facility failed to identify and address the needs of a resident diagnosed with dementia and develop a person-centered care plan that included individual non-pharmacological approaches to care using meaningful activities to address the resident's customary routines, interests, preferences and choices to enhance the resident's well-being. This was found for one (1) of two (2) residents reviewed for dementia care. Resident identifier: #13. Facility census: 27. Findings include: a) Resident #13 Resident #13 was admitted to the facility on [DATE]. On 10/17/23, a physician determined the Resident lacked capacity to make medical decisions due to a diagnosis of Dementia and his wife was appointed as his health care surrogate. The Resident was admitted to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-02-22 · tag F0803 — failed to meet residents' dietary needs — isolatedEnsure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, resident interview, and staff interview, the facility failed to ensure dietary preferences were honored. Two (2) of six (6) residents reviewed for the care area of food did not receive the food items indicated on their tray ticket. Resident identifiers: #3, #10. Facility census: 27. Findings included: a) Resident #3 On 02/19/24 at 12:15 PM, Resident #3 was observed eating in her room. Her lunch tray consisted of grilled cheese, tomato soup, and peaches. Resident #3 stated, I can't stand tomato soup. She stated the staff was going to get chicken soup for her. Review of Resident #3's tray ticket indicated she was to receive double noodle chicken soup for that meal. Resident #3 stated she often did not receive the food items she wanted. On 02/19/24 at 12:20 PM, Clinical Coordinator #6 confirmed Resident #3 had received tomato soup when her tray ticket indicated she was supposed to have received chicken noodle soup. No further information was provided through the completion of the survey process. b) Resident #10 On 02/19/24 at 12:12 PM, Resident #10…
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 before2024-02-22 · 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 ensure complete and accurate medical records were available pertaining to Physicians Order for Scope of Treatment (POST). Resident Identifier: #17 and #27 Facility Census: #27 Findings Included: a) Resident #17 On 02/19/24 at 03:10 PM, record review shows that the POST form for Resident #17 was not completed in its entirety. The patient information on page one (1) did not have identifying information for a middle initial, last four (4) numbers of the social security number and an address. Section D for Medically Assisted Nutrition was not addressed. Page two (2) of the POST only provided a resident name and the Medical Power of Attorney name. The Primary Care Provider Name or telephone number was provided. This was confirmed with the Director of Nursing on 02/20/24 at 10:40 AM, who agreed that Section D should have been addressed and Resident identification information on page one (1) should be completed in its entirety. b) Resident #27 On 02/19/24 at 03:15 PM, record review shows that the POST form for Resident #27…
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 before2022-06-30 · 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 observation, resident council meeting and interview, the Resident Council members did not know how to file a grievance or with whom to file a grievance. This had the potential to affect more than a limited number of residents. Facility censs: 27. Findings included: a) Grievance Policy and Procedure A review of the facility grievance policy and procedure titled Resident Grievance Policy was conducted on 06/29/22 at 4:16 PM with an effective and approved date of 05/2022. The Grievance Officer was identified as the Social Worker or designee including the Director of Nursing (DON), Minimum Data Set (MDS) Coordinator, or a Registered Nurse (RN) on duty. The procedure stated that an investigation of all grievances will be done within 24 hours, with the resident/responsible party notified in writing of corrective or appropriate action taken. In addition, a file with be kept in Social Workers office with a log kept by the DON of all grievances for three (3) years. b) Resident Council (RC) Meeting On 06/29/22 at 2:59 PM a meeting of the Resident Council was held. The President 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 · E2022-06-30 · tag F0725 — failed to have enough nursing staff — patternProvide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
What the surveyor found here — the official record, unedited, may be distressing
Based on a review of nursing staffing sheets and interview, the facility failed to indicate Charge Nurse on the nursing schedules. This had the potential to affect more than a limited number of residents. Facility census: 27. Findings included: A review of the nursing schedule dated 04/17/22 through 07/08/22 revealed that no designated Charge Nurse was identified on the schedule. On 06/30/22 at 9:23 AM an schedule. The DON stated that it would be the Registered Nurse (RN) working that shift. When asked if there were two (2) RN's working the same shift who would be charge nurse and how would staff who was the Charge Nurse. The DON stated Staff would not know. I didn't know that needed to be on the schedule. .
- Potential for harm · Ecited before2022-06-30 · tag F0868 — patternHave the Quality Assessment and Assurance group have the required members and meet at least quarterly
What the surveyor found here — an excerpt from the official record, may be distressing
Based on facility documentation, staff interview, Centers for Medicare and Medicaid Services (CMS) Guidance and policy review the facility's Quality Assessment and Assurance (QAA) Committee did not meet at least quarterly. The failed practice had the potential to affect more than a limited number of residents. Facility census: 27. Findings included: Record review of the facility's policy titled, Quality Assurance Improvement Plan,established date of 05/2019, stated that the QAA Committee Team meets at least every three (3) months. a) QAA Committee Review of the QAA Committee sign in sheets showed the facility's QAA committee met on 12/17/21 and again on 04/29/22. During an interview, on 06/29/22 at 2:20 PM, Director of Nursing (DON) stated the facility's QAA Committee meets every six (6) months or is it four (4) times a year? DON asked which one is it? The requirement of quarterly was revealed and DON then stated, yes, the facility does QAA Committee meetings quarterly. Additional review of the QAA Committee meeting sign in sheets showed that the facility's QAA Committee team last…
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 · D2022-06-30 · 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 and staff interview, the facility failed to administer oxygen to a Resident at the appropriate flow rate as directed by the physician order. The failed practice was true for for one (1) of two (2) residents reviewed for oxygen. Resident identifier: #127. Facility census: 27. Findings included: a) Resident #127 An observation on 06/28/22 at 1:18 PM , showed Resident #127 was resting in bed. Resident #127 was being administered oxygen through a nasal cannula at a flow rate of four (4) liters per minute. A record review of Resident #127's medical chart showed a physician order dated 11/01/2017 that stated, oxygen @ 3 liters per min at bedtime for sleep apnea. An observation on 06/30/22 at 8:30 AM, showed Resident #127 was resting in bed. Resident #127 was being administered oxygen through a nasal cannula at a flow rate of four (4) liters per minute. During an interview on 06/30/22 at 8:30 AM, Registered Nurse (RN) #10 stated that Resident #127's oxygen was set at four (4) liters per minute and that was wrong as the flow rate was ordered to be…
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 · D2022-06-30 · tag F0757 — failed to avoid unnecessary drugs — isolatedEnsure each resident’s drug regimen must be free from unnecessary drugs.
What the surveyor found here — the official record, unedited, may be distressing
Based on record review and staff interview the facility failed to ensure unscheduled/as needed (PRN) narcotics were not in excessive duration. The failed practice was true for one (1) of five (5) residents reviewed for unnecessary medications. Resident identifiers: #12. Facility census: 27. Findings included: a) Resident #12 A record review of Resident #12's medical record showed a physician order dated 07/07/21, stated Percocet Tablet 5-325 MG (oxyCODONE-Acetaminophen) *Controlled Drug* Give 1 tablet by mouth every 6 hours as needed for Moderate Pain. The May and June 2022 Medication Administration Record (MAR) showed Resident #12 had a 0 pain level with no Percocet administered for the date range of 05/01/22 through 06/29/2022. During an interview on 06/30/22 at 10:37 AM, Director of Nursing, (DON) stated, I did not know that physicians had to write a rationale or re-write another prescription to extend PRN narcotics after 14 days. DON stated that the medication should be assessed by the consulting pharmacist and discontinued in 60 days for non use. .
- Potential for harm · D2022-06-30 · 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
Based on record review, staff interview and policy review the facility failed to offer and educate a Resident on the annual influenza vaccination. The failed practice was true for one (1) of five (5) residents reviewed for vaccinations. Resident identifier: #10. Facility census: 27. Findings included: Record review of the facility's policy titled, Immunizations in Long Term Care, reviewed on 05/2022, stated, the influenza vaccine is given during appropriate months of October 1st through March 31st. Resident or Resident representative will be given information about the vaccine including the benefits and risks. a) Resident #10 A record review of Resident #10's medical record showed Resident #10 refused all vaccinations. Refusal forms and education provided for each vaccine were located in the medical record and were signed and dated for 03/23/20. There was no refusal form or education found in the medical record that was signed and provided for the annual influenza vaccination for the months of 10/01/21 though 03/31/22. During an interview on 06/29/22 at 10:40 AM , Director 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.
- No harm found · C2024-02-22 · tag F0732 — widespreadPost nurse staffing information every day.
What the surveyor found here — the official record, unedited, may be distressing
Based on observation and staff interview, the facility failed to ensure the daily staff posting included the actual amount of hours worked per each shift for Nurse Aides, Licensed Practical Nurses and Registered Nurses. This had the potential to affect all residents at the facility. Facility census: 27. Findings included: a) Staff posting Observation of the staff posting for 02/19/24 found the facility failed to record the actual number of hours worked per each shift by Nurse Aides, Licensed Practical Nurses and Registered Nurses. At 1:43 PM on 02/20/24, the Director Of Nursing (DON) said she didn't realize the hours had to be recorded for each shift, she thought the hours just needed to be recorded for the day. Review of the daily posted staffing sheets with the DON from 02/06/24 until present found the facility only recorded the hours worked by each discipline for the day, not for each shift.
“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
$8,281 in federal fines across 1 penalty.
- $8,281 — penalty dated 2026-01-23
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.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| VALLEY HEALTH SYSTEM | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL | NO PERCENTAGE PROVIDED | since 01/01/2008 |
| CHAMBERS, JILL | Individual | W-2 MANAGING EMPLOYEE | — | since 12/31/2021 |
| AMOS, ROBERT | Individual | CORPORATE OFFICER | — | since 10/04/2009 |
CMS files one row per role, so the 4 rows in the source record cover these 3 parties — each is shown once here with every role it holds. Nothing is omitted.
1 organizational owner 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.
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 515080. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-01-23, 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 →
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