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Braxton Healthcare Center

859 Days Drive, Sutton, WV 26601 · For profit - Corporation · 65 certified beds · (304) 765-2861 Medicare & Medicaid certified

Call the home — (304) 765-2861 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse-prevention, restraint, or reporting citation — no harm found (F0609) — cited Apr 2022
Insights

On the public record, this home looks stronger than most — but visit before you decide.

In its favor
  • a strong health-inspection score (5/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
  • no federal fines or payment denials on record
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • a high number of inspection citations overall (25) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • about 32% of its spending goes to commonly-owned related companies

One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.

A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.

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

Location & what’s nearby

Hospital
Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
40 Reston Place
Pharmacy
266 Skidmore Ln · (304) 765-4400 · Call to confirm hours
Grocery
(304) 765-4077 · Call to confirm hours
Park
Holly Gray Park Dr · (304) 765-7603 · Typically dawn to dusk

Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Overall quality measures 4 of 5
Long-stay residentspeople who live here 4 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 5 stars. From monthly CMS archive snapshots.

Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.

Overall rating5★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased14.8%14.7%15.4%typical
Long-stay residents who lose too much weight2.5%6.3%5.4%better
Long-stay residents with a catheter left in their bladder0.0%0.4%0.9%better than state — see note marked double-dagger below the table
Long-stay residents with a urinary tract infection1.7%1.6%2.0%better
Long-stay residents with depressive symptoms0.5%7.6%6.5%better
Long-stay residents who were physically restrained0.0%0.2%0.1%better
Long-stay residents with falls causing major injury5.1%4.4%3.3%worse
Long-stay residents whose ability to walk worsened13.7%15.9%16.1%better
Long-stay residents on antianxiety or hypnotic medication35.6%27.0%18.9%worse
Long-stay residents given the seasonal flu vaccine96.6%97.6%95.3%typical
Long-stay residents with pressure ulcers1.8%4.2%4.7%better
Long-stay residents with worsening bladder/bowel control13.5%22.1%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table12.6%13.4%17.1%better
Short-stay residents who newly got an antipsychotic medication0.0%1.0%1.4%better
Short-stay residents given the seasonal flu vaccine95.6%79.4%79.4%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.

36.9% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that worse than the national rate. This is CMS’s risk-adjusted rate over 29 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

36.9%U.S. median 51.5%
Got home and stayed home
11.1%U.S. median 10.7%
Went back to hospital
0.31U.S. median 0.31
Therapy hours / resident / day
0.13hours / resident / day
Physical therapy
0.10hours / resident / day
Occupational therapy
0.08hours / resident / day
Speech therapy

Therapy staffing: this home’s payroll records show 0.31 therapist hours per resident per day in 2026Q1 — more than 50% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 20% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF36.9%CMS range 24.7–50.351.5%Oct 2022–Sep 2024worse than U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF11.1%CMS range 7.5–16.510.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at dischargenot 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 dischargenot 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 dischargenot 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 identified100.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care settingnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay12.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened4.0%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalizationnot 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 SNFs1.061.02Oct 2022–Sep 2024CMS makes no comparison for this measure

From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.

Staffing

0.53
RN hours/ resident / day
1.15
LPN hours/ resident / day
2.16
Aide hours/ resident / day
3.85
Total nurse hours/ resident / day
0.24
RN hoursweekends
38.2%
Total nursing turnover
55.6%
RN turnover

How full it usually is: this home is certified for 65 beds and averages 62.5 residents a day — about 96% occupied, or roughly 2 beds typically open. It runs essentially full — expect a waiting list. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.85 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.53 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.16 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 4.09 on weekdays — 20% thinner on weekends — a notable drop. RN hours go from 0.64 to 0.24 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

5
deficiencies at the latest standard inspection (2025-04-23)
12
at the previous standard inspection (2023-07-12)

Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

ABCDEFGHIJKL

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

25 citations, most serious first. The 10 most serious are shown; the remaining 15 are one tap away and print in full.

  • Potential for harm · Ecited before2025-04-23 · tag F0550 — failed to protect resident dignity and rights — pattern
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation and staff interview the facility failed to promote a dignified dining experience. These were random opportunities for discovery. Resident identifiers: #1, #3, #6, #8, #9, #14, #20, #24, #26, #38, #61 and #62. Facility Census: #65 Findings Include a) Resident #8 and #62 On 04/21/25 beginning at 11:15 AM during observation of the noon meal in the dining room it was observed that staff were not distributing meals to all residents seated together at an individual table. Resident #8 and #62 were sitting together at a table in the dining room. Resident #62 was served their meal at 11:25 AM. Resident #8 did not received a meal. Staff continued serving meals at various tables throughout the dining room. At 11:50 AM Resident #8 left the dining room. At 11:58 AM it was confirmed with Licensed Practical Nurse #82 that Resident #8 had left without a meal. b) Resident #6, #26 and #61 On 04/21/25 beginning at 11:15 AM during observation of the noon meal in the dining room it was observed that staff were not distributing meals to all residents seated together at an individual…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-04-23 · tag F0582 — isolated
    Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
    What the surveyor found here — the official record, unedited, may be distressing

    Based upon record review and staff interview, the facility failed to complete SNF ABN, Form CMS-10055 and send to the resident or resident's representative in a timely manner. This was true for 1 (one) of 3 (three) residents reviewed during the annual survey process. Resident identifier: #20. Facility census: 65 Findings included: a) Resident #20 Upon entering the survey on 04/21/25, the facility completed the Beneficiary Notices of residents discharged within the last six months form. From this, three(3) residents were selected to review for required notifications. Resident #20, who was discharged on 03/12/25, but remained in the facility. SNF-ABN Form was not completed until the surveyor requested the SNF Beneficiary Notification Review form be completed during the annual survey process. Notice was not provided to the resident or resident's representative until 04/21/25. On 04/23/25, at approximately 1:35 PM, in discussion with the NHA, NHA stated the facility had discovered this failure during, an audit of ABNs.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-04-23 · tag F0644 — isolated
    Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based upon record review and staff interview, the Facility failed to ensure preadmission screening and resident review (PASARR) was updated and completed with new diagnoses of Dementia (Non-Alzheimer's) and Alzheimer's . This was true for one (1) of five (5) residents reviewed. Resident identifier: #38. Facility censes: 65. Findings included: a) Resident #38 The resident's PASARR was initially completed on 10/07/24 by the facility. In Section III, MI/MR Assessment, the current diagnoses was marked for major depression. No other selections were marked in this section. The Resident had current diagnoses of: Major Depressive Disorder Anxiety Disorder Vascular Dementia with mood disturbance The last MDS Assessment was completed on 04/18/25. A review of Section I, Active Diagnoses documented: Alzheimer's Disease Non-Alzheimer's Dementia Anxiety Disorder Depression (other than Bi-polar) The PASARR should have been updated when the diagnoses of dementia and Alzheimer's were added for the resident. The resident's record was reviewed with the NHA on 04/23/25 at approximately 12:10 PM. When…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-04-23 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, the facility failed to ensure Residents #24 and #53's care plans included sensory and one (1) on one (1) activities, even though the residents were receiving them. This was true for two (2) of 21 resident care plans reviewed during the survey process. Resident identifiers: #24, #53. Facility census: 65. Findings include: a) Resident #24 During review of Resident #24's activity participation records on 04/22/25, it was noted during the last 30 days, the resident had received one (1) on one (1) activities six (6) times during this period. The resident received one (1) on one (1) activities for the following days: -03/27/25 -03/28/25 -04/09/25 -04/12/25 -04/16/25 -04/18/25 During review of the same activities records, it was noted the resident received sensory activities 12 times. Resident #24 received sensory activities on the following days: -03/26/25 -03/30/25 -03/31/25 -04/01/25 -04/07/25 -04/08/25 -04/10/25 -04/11/25 -04/14/25 -04/20/25 -04/21/25 -04/22/25 During…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-04-23 · tag F0842 — failed to keep accurate, complete medical records — isolated
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on record review and staff interview, the facility failed to accurately document the completion of behavior monitoring for Resident #18. This was true for one (1) of five (5) residents reviewed for unnecessary medications during the survey process. Resident identifier: 18. Facility census: 65. Findings include: A) Resident #18 During a review of Resident #18's behavior monitoring record for the last 90 days, on 04/22/25, it was determined no behavior monitoring was conducted on March 29th, 2025 on day shift, April 8th, 2025 on day shift, and April 14th, 2025 on day shift. On 4/23/2025 at approximately 11:30 AM, an interview was conducted with the Director of Nursing (DON), she confirmed the behavior monitoring was missing. However, the DON was able to supply CNA documentation with behavior monitoring taking place on the aforementioned days. The DON stated It's expected the nurses will complete their documentation appropriately when referring to the missing dates on the Behavior Monitoring record.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-07-12 · tag F0623 — pattern
    Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on medical record review and staff interview, the facility failed to provide evidence a resident's representative was provided a written Notice of Transfer/Discharge when a resident was discharged from the facility. This was true for five (5) of five (5) residents reviewed for hospitalizations in the long-term care survey process. Resident identifiers: #1, #39, #48, #23, and #52. Facility census: 54. Findings included: a) Resident #1 A medical record review completed on 07/11/23 at 8:56 AM, identified the following details: -Resident #1 was transferred to the hospital on 4/26/23. -There was no evidence of a Notice of Transfer/Discharge being provided to resident and/or resident's representative. During an interview on 07/11/23 at 12:02 PM, the Administrator reported the facility had no evidence a Notice of Transfer/Discharge had been issued. The Administrator went on to explain the notice had been part of the old form and the facility had not identified the fact that it did not carry over to the new form…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-07-12 · tag F0625 — pattern
    Notify 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 medical record review and staff interview, the facility failed to provide evidence residents and/or resident representatives were provided written Bed Hold Notice when transferred from the facility to the hospital. Additionally, the facility had no evidence a written notice of bed hold was reviewed with residents / resident representatives upon admission. This was true for five (5) of five (5) residents reviewed for hospitalizations in the long-term care survey process. Resident identifiers: #1, #39, #48, #23, and #52. Facility census: 54. Findings Included: a) Resident #1 A medical record review completed on 07/11/23 at 8:56 AM, identified the following details: -Resident #1 was transferred to the hospital on 4/26/23. -There was no evidence of a written bed hold notice being provided to resident and/or resident's representative. -Additionally, there was no evidence the bed hold policy had been discussed and shared with resident and/or resident's representative upon admission to the facility. During…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-07-12 · tag F0761 — failed to label and store drugs safely — pattern
    Ensure 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

    Based on observation and staff interview, the facility failed to ensure medications were stored under proper temperatures, in accordance with current accepted professional practices and manufacturer's instruction for storage. This was true for one (1) of one (1) medication storage rooms inspected. Facility census: 54. Findings included: a) Policy Review A review of the policy, titled: Storage of Medications, effective date of 09/01/2020, under Section J., noted the medication storage conditions were to be monitored on a monthly basis by the consultant pharmacist, pharmacy designee, or facility staff and corrective action taken if problems were identified. Under the section, labeled; Temperature, under sub-section C. showed Medications requiring refrigeration were to be kept in a refrigerator at temperatures between 36 degrees Fahrenheit (F) and 46 degrees F. b) Medication Storage Room Inspection An observation of the Medication Room, on 07/11/23 at 10:30 AM , revealed a medication refrigerator temperature log showing a temperature recorded for 07/05/23 to be 51.9 degrees Fahrenheit…

    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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-07-12 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation, record review, and staff interview, the facility failed to establish and maintain an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infections. The facility did not properly dispose of personal protective equipment (PPE) after use. This deficient had the potential to affect more than a limited number of residents. Additionally, the facility failed to ensure the infection surveillance line listing was accurate and complete for two (2) of three (3) residents reviewed for antibiotics. Resident identifiers: #212 and #24. Facility census: 54. Findings included: a1) Resident #212 - personal protective equipment disposal Review of Resident #212's physician's orders showed the resident was on Enhanced Barrier Precautions due to a history of multi-drug resistant organisms. During observation of Resident #212's room on 07/11/23 at 11:48 AM, used isolation gowns were noted to be overflowing from the trash can and onto…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-07-12 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on observation and staff interview, the facility failed to preserve the resident's dignity by not changing his clothing when it was soiled with food. Resident Identifier: #19. Facility census: 54. Findings included: a) Resident #19 On 07/11/23 at 12:20 PM, Resident #19 was observed being fed by a staff member. On 07/11/23 at 12:55 PM, Resident #19 was observed sitting in a wheelchair in the hallway outside of his room. The resident's shirt was soiled with food. On 07/11/23 at 2:15 PM, Resident #19 was observed to still be sitting in a wheelchair in the hallway outside of his room. The resident was wearing the same shirt soiled with food. On 07/11/23 at 2:18 PM, the Director of Nursing acknowledged Resident #19 had food spilled on his shirt. She stated she would change the resident's shirt. No further information was provided through the completion of the survey process.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
Show the remaining 15 citations
  • Potential for harm · D2023-07-12 · tag F0584 — failed to keep a safe, clean, comfortable home — isolated
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation and staff interview, the facility failed to provide a safe, clean, comfortable, and homelike environment for one (1) of 18 resident rooms observed during the long-term care survey process. Resident identifier: #39. Facility census: 54. Findings included: a) Resident #39 During the initial tour of the facility on 07/10/23 at 1:33 PM, the following issue was identified: -The left side of Resident #39's bed was against the wall. It was immediately visible that the wall was in poor repair. There were many, multiple long scratches approximately 12 inches in length and spanning approximately 16 inches across the wall that was just above where the mattress on the bed was positioned. These scratches had removed the paint from the wall. Additionally, there was a circular hole with the approximate circumference size of a racquetball that was below the scratches. The Director of Nursing at 1:30 PM on 07/11/23 observed the above-mentioned concerns and stated the damage to the wall was from the bed…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-07-12 · tag F0640 — isolated
    Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
    What the surveyor found here — the official record, unedited, 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 accurately complete a discharge tracking form for Resident #59, when he was discharged home on [DATE]. Resident identifier: #59. Facility census: 54. Findings include: a) Resident #59 Review of Resident #59's medical records show he was admitted to the facility on [DATE]. On 06/21/23 at 10:59 AM nurses' notes reads: Resident will be discharging home today based on resident's request. Review of the Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 06/21/23- Under Section A02100- Discharge status was indicated as 03- which is acute hospital when in fact it should be coded 01- Community (private home, apt., board/care, assisted living, and group home. During an interview with the Director of Nursing, on 07/12/23 at 10:15 AM, she confirmed the discharge tracking form completed on 06/21/23 for a transfer to an acute care hospital was inaccurate. She confirmed it should have been coded discharge to home. .

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-07-12 · tag F0644 — isolated
    Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on record review and staff interview, the facility failed to complete a new Pre-admission Screening (PAS) for one (1) of one (1) residents reviewed for the category of PASARR (Pre-admission Screening Resident Review), during the long-term care survey process. Resident identifier: #16. Facility census 54. Findings included: a) Resident #16 A record review, completed on 07/12/23 at 9:44 AM, found the following details: -Resident #16 was admitted to the facility on [DATE] with the following diagnoses: Hemiplegia, unspecified affecting left nondominant side, Tinea Unguium (toenail fungus), Gastro-Esophageal Reflux Disease, Post Traumatic Seizures, and Traumatic Brain Injury. -There was a Pre-admission Screen (PAS) dated 07/28/14. This PAS was completed by the hospital for admission to the facility and did not include any mental health diagnosis under Section III, Question #30. -There was a Pre-admission Screen (PAS) dated 03/0/23. This PAS was completed by the facility and did not include any mental health…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-07-12 · tag F0697 — failed to manage pain — isolated
    Provide safe, appropriate pain management for a resident who requires such services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and staff interview, the facility failed to monitor the resident's pain in accordance with current professional standards of practice. This deficient practice had the potential to affect one (1) of one (1) residents reviewed for the care area of pain. Resident identifier: #27. Facility census: 54. Findings included: a) Resident #27 The facility's policy titled Pain Management and Assessment, with no implementation date given, stated pain relief and response to medication would be documented. No time frame for monitoring pain relief and response to pain medication was given in the facility's policy. According to an education program by John Hopkins Medicine titled Pain Management, available on-line, If pain medication is administered, the patient is reassessed within 60 minutes. Review of Resident #27's progress notes showed a note written on 07/03/23 at 2:31 PM that stated, Resident has c/o [complaint of] of increased pain in hands, shoulders, and arms. [Nurse practitioner] notified. New order for Tramadol 25 mg one time only now. [Power of attorney] notified…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-07-12 · tag F0803 — failed to meet residents' dietary needs — isolated
    Ensure 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 and staff interview, the facility failed to ensure menus were developed and prepared to meet resident choices including their nutritional needs and preferences for one (1) of five (5) reviewed under the food care area. Resident #53 did not receive an entree when there was a known dislike to the item on the menu. Resident identifier: #53. Facility census: 54. Findings included: An observation, during the noon meal on 07/10/23 at 11:40 AM, revealed Resident #53 was served rice, green beans, a dinner roll and chocolate cake. No entree was observed on the tray. When questioned at this time, Resident #53 stated she did receive an entree. The menu item served during the noon meal on 07/10/23, was chicken spaghetti with a pork chop as a substitute. A record review, revealed progress notes dated, 6/23/2023 at 12:12 PM, showing the resident had expressed a food preference dislike of chicken and pork chops. The progress note further indicated changes would be made into effect as soon as possible to help aid in higher meal/snack intakes and documentation…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-07-12 · tag F0804 — failed to serve food at safe, palatable temperature — isolated
    Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation and staff interview, the facility failed to provide food at a safe and appetizing temperature. This had the potential to affect more than a limited number of residents. Resident identifier: #42. Facility census: 54. Findings included: a) 200 Hall Lunch Time Meal Observation During an observation on 07/11/23 at 12:29 AM, it was noted that a food truck was brought out of the kitchen with all resident lunch trays for residents on the 200 hall who preferred to eat in their rooms. On 07/11/23 at 12:29 PM, Registered Dietician #101 tested the temperature of Resident #42's lunch tray, the last tray to be served on the 200 Hall, with the following results: -Puree Ham: 109.0 degrees Fahrenheit (F) -Puree Sweet Potatoes: 118.0 degrees F -Puree Peas: 109.0 degrees F -Watermelon: 58.0 degrees F Registered Dietician #101 agreed the food temperatures obtained were not considered to be the appropriate desired temperature for the point of service. The dietician stated in order for food to be considered at a palatable temperature, hot foods should be served at 120 degrees F or…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-07-12 · tag F0887 — isolated
    Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on record review and staff interview, the facility failed to provide COVID-19 immunization booster to a resident who consented to the immunization. This deficient practice had the potential to affect one (1) of five (5) residents reviewed for the care area of immunizations. Resident identifier: #48. Facility census: 54. Findings included: a) Resident #48 Review of Resident #48's medical records showed on 06/02/23 the resident's representative consented for the resident to receive the COVID-19 bivalent booster. The resident's medical records contained no evidence the resident had received the COVID-19 bivalent booster after consent. During an interview on 07/12/23 at 8:32 AM, the Administrator confirmed Resident #48 had not been given the COVID-19 bivalent booster even though the resident's representative consented for the resident to receive. No further information was provided through the completion of the survey. .

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2022-04-13 · tag F0882 — widespread
    Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on facility documentation and staff interview, the facility failed to have a certified Infection Preventionist. This failed practice had the potential to affect all residents residing at the facility. Facility census: 58. Findings included: a) Infection Preventionist Record review of the facility's documentation of infection control practices found the facility was unable to provide the required Infection Control Preventionist Certification or documentation. During an interview on 04/12/22 at 1:05 PM the Director of Nursing stated that there was no staff at the facility that has completed specialized training in infection prevention and control at this time. No other information was provided prior to the end of survey on 04/13/22 at 10:00 AM. .

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2022-04-13 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on observations and staff interview, the facility failed to ensure a negative air flow in the laundry to prevent contamination of clean linens. This practice had the potential to affect more than a limited number of residents residing in the facility. Facility census: 58. Findings included: a) Laundry Services An observation on 04/14/22 at 2:15 PM found the laundry room did not have separation from soiled laundry area to the clean laundry area. There was also no negative air flow pulling from the clean area to the soiled area, failing to maintain a functional and safe laundry area to avoid contamination. The laundry was in progress in both areas, with clean, folded laundry exposed on the laundry room table. During an interview with the Environmental Supervisor #81, on 04/12/22 at 2:20 PM, confirmed there was no separation from soiled laundry area to the clean laundry area. .

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2022-04-13 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, resident interview, staff interview and facility documentation, the facility failed to remove a sign of personal care from a previous resident's room when discharged and failed to ensure staff were seated when feeding assistance was provided. These were random opportunities for discovery. Resident identifiers: Residents #207 and #15. Facility census: 58. Findings included: a) Resident #207 An observation on 04/11/22 at 11:30 AM, showed a sign that was taped to the light above Resident #207's head of bed (HOB) that read HOB>30 degrees at all times During an interview on 04/11/22 at 11:30 AM, Resident #207 stated that the sign was not meant for her plan of care and was displayed when Resident #207 was placed in the room. Resident #207 stated, I am new here and that sign was there when I came. During an interview on 04/11/22 at 11:33 AM, Nurse Aide (NA) #44 stated that Resident #207's bed was not at 30 degrees but believed the sign above Resident #207's head of the bed was not ordered or part of Resident #207's care. During an interview on 04/11/22 at 11:35 AM,…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-04-13 · tag F0578 — failed to honor advance directives / code status — isolated
    Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on record review and staff interview, the facility failed to ensure one (1) of 25 residents reviewed during the long-term care survey process had a Physician Orders for Scope of Treatment (POST) form completed per directions specified by the [NAME] Virginia Center for End-of-Life Care in conjunction with the [NAME] Virginia Health Care Decisions Act (16-30-1). The POST forms were unsigned by the Resident or Medical Power of Attorney (MPOA). Resident identifier: Resident #24. Facility census: 58. Findings Included: a) Resident #24 Record review on 04/11/22 at 2:16 PM found, a POST Form on Resident #24's chart was unsigned by the Resident or MPOA. The POST form was dated 09/10/18. During an interview on 04/12/22 at 8:53 AM with the Administrator, confirmed Resident #24's POST form was incomplete without a Resident or MPOA signature. .

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-04-13 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on review of facility documentation, and staff interview, the facility failed to ensure all allegations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately to all officials in accordance with State law and failed to report the results of all investigations in accordance with State law. The facility failed to report the allegation immediately and results of the investigation within five (5) working days to Law Enforcement related to misappropriation of resident medications. This failed practice was identified through a random opportunity for discovery and had the potential to affect more than a limited number of residents in the facility. Employee identifier: LPN #100. Census: 58. Findings included: A review of the facility's policy and procedure, titled: Freedom from Abuse, Neglect and Exploitation, dated 12/05/19, showed the following: --Under Section 5 of the policy, noted upon receiving an allegation of abuse, neglect, exploitation or misappropriation of resident…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2022-04-13 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on staff interview and medical record review, the facility failed to develop comprehensive person-centered care plans to meet the psychosocial needs of the residents. Resident (R) #8 and R #31's care plans lacked measurable goals and non-pharmacological interventions to assist in dealing with anxiety and depression. This is true for two (2) of five (5) residents reviewed for unnecessary medications. Resident identifiers: Residents #8 and #31. Facility census: 58. Findings included: a) Resident (R) #8 Review of the medical record showed R #8's current diagnoses included acute respiratory failure with hypoxia, anxiety and depression. R #8 receives Buspirone hydrochloride/Buspar (anxiolytic) 10 milligrams (mg) three (3) times a day, Zoloft (antidepressant) 100 mg twice a day, and has an order for Ativan (benzodiazepine used for calming) 1 mg every 12 hours as needed for anxiety. R #8's care plan notes she is receiving the antidepressant Zoloft and the anti-anxiety medication Buspar. The goals were related to side effects or discomfort from the medications. The interventions 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-04-13 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — 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 provide assistance with eating for a dependent resident. This was a random opportunity for discovery. Resident identifier: #19. Facility census: 58. Findings included: a) Resident #19 On 04/11/22 at 11:50 AM, observation of the dining room found Resident #19 sitting alone at a table for over 15 minutes. When Resident #19 was asked if he or she could feed themselves the resident stated No. At 12:10 PM on 04/11/22, during an interview with the Director of Nursing (DON) they were asked why Resident #19 had not been assisted with lunch, the DON stated, We assist residents as needed. Resident #19 is unable to feed [him or herself] for over a year. The DON immediately sat down and started assisting Resident #19 lunch. On 04/12/22 at 9:35 AM, an interview with the DON verified the [NAME] dated 04/12/22 inaccurately reflected Resident #19 supervision with set up and at times required one (1) staff assist. DON statement from 04/11/22 at 12:10 PM, that…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-04-13 · tag F0688 — failed to keep residents mobile / prevent decline — isolated
    Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
    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 the services, care and equipment to assure a resident's maintains and/or improves to their highest level of range of motion (ROM) and mobility. This was a random opportunity for discovery. Resident identifier: Resident #9. Facility census: 58. Findings included: a) Resident #9 An observation on 04/11/22 at 12:09 PM found Resident #9 had a right-hand contracture with no palm/hand protector in place. A review of Resident #9's medical record revealed, two (2) Physicians orders for: -- Resident to utilize Left palm protector with finger separators during the day, and off at night dated 07/29/20. --Resident to tolerate Left Hand Therapy Carrot x four (4) Hours to Reduce Risk of Further Contracture Development with an order date of 10/03/18. A second observation on 04/12/22 at 10:20 AM found Resident #9 did not have a left-hand palm protector in place. On 04/12/22 at 10:27 AM during an interview with License Practical Nurse (LPN) #17 confirmed Resident #9 did not have palm protectors in place. LPN #17 stated that 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
  • Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
  • State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

Fines & penalties

No federal fines in the current CMS record.

Part of a chain

This home belongs to 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 →

RatingThis homeChain avg
Overall 5 of 53.2+1.8 vs chain
Health inspection 5 of 52.7+2.3 vs chain
Staffing 3 of 52.6+0.4 vs chain
Quality measures 4 of 54.5-0.5 vs chain
The other 109 homes this chain runs (chain average 3.2★, per CMS)
1 of 5Allen View Healthcare CenterSpringfield, OH 1 of 5Annandale Healthcare CenterAnnandale, VA 1 of 5Canfield Healthcare CenterYoungstown, OH 1 of 5Dixon Healthcare CenterWintersville, OH 1 of 5Holbrook Healthcare CenterBuckhannon, WV 1 of 5Mount Vernon Healthcare CenterAlexandria, VA 1 of 5Southwood Healthcare CenterTerre Haute, IN 1 of 5Summers Healthcare CenterHinton, WV 1 of 5Valley View Healthcare CenterElkhart, IN 2 of 5Allison Pointe Healthcare CenterIndianapolis, IN 2 of 5Battlefield Park Healthcare CenterPetersburg, VA 2 of 5Beckley Healthcare CenterBeckley, WV 2 of 5Belmont Healthcare CenterBelmont, WV 2 of 5Berkeley Springs Healthcare CenterBerkeley Springs, WV 2 of 5Cedars Healthcare CenterCharlottesville, VA 2 of 5Columbus Healthcare CenterColumbus, OH 2 of 5Crestwood Care CenterShelby, OH 2 of 5Cumberland Healthcare CenterCumberland, MD 2 of 5Eagle Pointe Healthcare CenterParkersburg, WV 2 of 5Ellicott City Healthcare CenterEllicott City, MD 2 of 5Evergreen Crossing And The LoftsIndianapolis, IN 2 of 5Grande Pointe Healthcare CommuRichmond Heights, OH 2 of 5Great Lakes Healthcare CenterDyer, IN 2 of 5Greenbrier Health CenterParma Heights, OH 2 of 5Hagerstown Healthcare CenterHagerstown, MD 2 of 5Hanover Healthcare CenterMassillon, OH 2 of 5Holly Hill Healthcare CenterTowson, MD 2 of 5Keyser Healthcare CenterKeyser, WV 2 of 5Mercer Healthcare CenterBluefield, WV 2 of 5Morgantown Healthcare CenterMorgantown, WV 2 of 5Mount Airy Nursing and Rehab CenterMount Airy, MD 2 of 5Petersburg Healthcare CenterPetersburg, VA 2 of 5Riverside Nursing And Rehabilitation CenterDayton, OH 2 of 5Rolling Hills Healthcare CenterNew Albany, IN 2 of 5Salem West Healthcare CenterSalem, OH 2 of 5Wedgewood Healthcare CenterClarksville, IN 2 of 5Westminster Rehabilitation and Wellness CenterWestminster, MD 2 of 5Wildwood Healthcare CenterIndianapolis, IN 2 of 5Worthington Healthcare CenterParkersburg, WV 2 of 5Wyant Woods Healthcare CenterAkron, OH

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 / managerTypeRoleShareSince
RCA NH HOLDINGS OP CO., LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST100%since 04/14/2023
ROMEO, DOMINICIndividualCORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROLsince 04/14/2023
STOLTZ, CHARLESIndividualCORPORATE OFFICERsince 04/14/2023
WILHEIM, RONALDIndividualCORPORATE OFFICERsince 04/14/2023
DAYS MGT CO., LLCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 04/14/2023
BEALL, JODYIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 04/14/2023
GROVES, DONNAIndividualOPERATIONAL/MANAGERIAL CONTROLsince 04/14/2023
JACKSON, JEANETTEIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 04/14/2023
ODENTHAL, RICHARDIndividualINDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFsince 04/23/2025
C.R. STOLTZ FAMILY INVESTMENT COMPANY INCOrganizationADP OF THE SNFsince 04/14/2023
C.R. STOLTZ IRREVOCABLE TRUSTOrganizationADP OF THE SNFsince 04/14/2023
HEALTH CARE HOLDINGS, LLCOrganizationADP OF THE SNFsince 04/14/2023
I. ROSEDALE FAMILY INVESTMENT COMPANY INCOrganizationADP OF THE SNFsince 04/14/2023
I. ROSEDALE IRREVOCABLE TRUSTOrganizationADP OF THE SNFsince 04/14/2023
MARANTZ WV HOLDINGS, LLCOrganizationADP OF THE SNFsince 04/14/2023
R.S. WILHEIM IRREVOCABLE TRUSTOrganizationADP OF THE SNFsince 04/14/2023
RCA HEALTHCARE HOLDINGS, LLCOrganizationADP OF THE SNFsince 04/14/2023
RONALD S WILHEIM 2012 SPOUSAL TRUSTOrganizationADP OF THE SNFsince 04/14/2023
ROSEDALE FAMILY INVESTMENT COMPANY, INCOrganizationADP OF THE SNFsince 04/14/2023
RRW, LLCOrganizationADP OF THE SNFsince 04/14/2023
S.L. ROSEDALE IRREVOCABLE TRUSTOrganizationADP OF THE SNFsince 04/14/2023
WILHEIM FAMILY INVESTMENT COMPANY, INC.OrganizationADP OF THE SNFsince 04/14/2023

CMS files one row per role, so the 26 rows in the source record cover these 22 parties — each is shown once here with every role it holds. Nothing is omitted.

15 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.

$5.9M
Net patient revenuemost recent cost report
-6.7%
Operating marginrevenue minus expenses
$2.1M
Related-party expense32% of expenses
Who pays — share of resident-days
Medicaid 87%Medicare 5%Other / private 8%

About 87% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $2.1M paid to related parties — landlords or management companies under common ownership — equal to about 32% 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. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

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

$415per resident / day
operating cost
$12,622per month
≈ monthly operating cost
$389per day
avg. revenue, all payers

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

Paying with Medicaid

This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the West Virginia Medicaid page.

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

Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 515180. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-04-23, 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 →

Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.

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