Trinity Health Care Of Mingo
100 Hillcrest Drive, Williamson, WV 25661 · For profit - Corporation · 90 certified beds · (304) 235-7005 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
- it has an abuse, neglect, or exploitation citation (F0600), cited Mar 2024
- it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0604, F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- it has 1 actual-harm citation
- a high number of inspection citations overall (30) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $25,237 in federal fines (most recent 2024-03-13)
- its facility-reported quality-measure rating is low (1/5)
- nursing-staff turnover (60%) runs well above the national median (45%)
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 | 4 of 5 |
| StaffingFrom payroll records (PBJ) | 3 of 5 |
| Quality measuresSelf-reported by the facility | 1 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 1 of 5 |
| Long-stay residentspeople who live here | 1 of 5 |
| Short-stay residentsrehab / post-hospital | 1 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 held steady at 3 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 19.6% | 14.7% | 15.4% | worse |
| Long-stay residents who lose too much weight | 7.6% | 6.3% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 0.6% | 0.4% | 0.9% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 3.2% | 1.6% | 2.0% | worse |
| Long-stay residents with depressive symptoms | 3.2% | 7.6% | 6.5% | better |
| Long-stay residents who were physically restrained | 0.0% | 0.2% | 0.1% | better |
| Long-stay residents with falls causing major injury | 5.2% | 4.4% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 28.9% | 15.9% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 32.2% | 27.0% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 97.6% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 7.7% | 4.2% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 22.8% | 22.1% | 21.2% | typical |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 13.0% | 13.4% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 2.0% | 1.0% | 1.4% | worse |
| Short-stay residents rehospitalized after admission | 28.0% | 22.5% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 16.3% | 11.3% | 12.0% | worse |
| Long-stay hospitalizations per 1,000 resident days | 2.93 | 1.80 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 3.27 | 1.84 | 1.80 | worse |
‡ 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 0.31 therapist hours per resident per day in 2026Q1 — more than 51% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 10% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 11.2%CMS range 7.5–17.2 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 3.5% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 6.9% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 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 | 1.17 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 90 beds and averages 77.3 residents a day — about 86% occupied, or roughly 13 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 5.49 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 2.47 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 4.21 hrs/resident/day on weekends vs 6.00 on weekdays — 30% thinner on weekends — a notable drop. RN hours go from 0.65 to 0.22 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 60% is well above the national median of 45%. 2 administrators have left in the past year — frequent leadership churn is a warning sign families often miss.
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 unchanged from the previous inspection. 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.
30 citations, most serious first. The 11 most serious are shown; the remaining 19 are one tap away and print in full.
- Actual harm · Gcited before2024-03-13 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on review record, staff interviews, reportable's (immediate and five (5) day), and staff education, time line of the incident and plan of correction, the facility failed to ensure a resident was protected from neglect. Resident #42 sustained a fractured hip and a subdural hematoma from an unwitnessed event. The resident was sent to a local hospital where the subdural hematoma had ceased and the hip was repaired. This caused physical harm to the resident and will be cited a G at F600. Resident identifier: #42 Facility census: 81. Findings included: a) Resident #42 Resident #42 was originally admitted on [DATE]. Diagnoses included Alzheimer's disease, history of falling, left artificial hip joint, hypertension, heart failure, adult failure to thrive, and Dementia severe with agitation. An annual Minimum Data Set (MDS) with Assessment Reference Date (ARD) 01/16/24 had a Brief Interview of Mental Status (BIMS) of 3. The BIMS score of three (3) indicates severe cognitive impairment. A review of the 5-day PPS…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2025-08-28 · 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
Based on record review and staff interviews the facility failed to ensure the comprehensive care plan in the area for dental services for resident #5 and activity preferences for Resident's #8 and #50 were developed. This was found true for three (3) of 25 residents' care plans reviewed during the long-term care survey process. Resident identifiers #8, #50, and #5 Facility Census: 82 a) Resident #8 During record review on 08/27/25 at approximately 2:00 PM of Resident #8's section F of the Minimum Data Set (MDS) revealed the resident enjoys Music, Pets, Religious activities and doing things with groups of people. Further record review of resident #8's personalized care plan interventions revealed the following interventions; Staff will assist her to/from group activities as needed Staff will give her verbal praise for her attendance in any group activity Staff will invite/encourage her to attend group activities of her choice. Staff will post a monthly activity calendar in her room for her review. Music, Pets, religious activities, which were activities she enjoys doin were not in…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-08-28 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
What the surveyor found here — the official record, unedited, may be distressing
Based on record review and staff interview, the facility failed to ensure a complete and accurate Minimum Data (MDS) assessment in the area of hospice. This deficient practice had the potential to affect one (1) of one (1) residents reviewed for the care area of hospice. Resident Identifiers: #62. Facility Census: 82.Findings included:a) Resident #62 Review of Resident #62's physician's orders showed an order written on 03/14/25 for Hospice Care, Do Not Resuscitate, Comfort Treatments. Review of Resident #62's comprehensive care plan confirmed the resident was receiving hospice services. Resident #62's quarterly Minimum Data Set (MDS) assessment with Assessment Reference Date (ARD) 05/01/25 documented the resident was receiving hospice services. Resident #62's quarterly MDS with ARD 07/17/25 documented the resident was not receiving hospice services. On 08/26/25 at 3:33 PM, the Director of Nursing (DON) confirmed Resident #62's MDS with ARD 07/17/25 was incorrect and should have indicated the resident was receiving hospice services. The DON stated she corrected the MDS.
- Potential for harm · D2025-08-28 · tag F0679 — failed to provide activities — isolatedProvide activities to meet all resident's needs.
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 ensure that a comprehensive activities assessment was completed for one (1) of two (2) residents (Resident #8) reviewed for activities during the long-term care survey. Facility census: 82. Resident identifier: #8 Findings Include:a) Resident #8The facility's policy titled Timeframe for Completion of Activities Assessment on New Admissions states: An initial activities interest screening shall be completed by Activities staff or designee within 72 hours of admission to identify immediate preferences and needs. A full Activities Assessment, consistent with the Minimum Data Set (MDS) and facility policy, shall be completed within 14 calendar days of admission. The Activities Assessment will be used to develop an individualized Activity Care Plan. completed and entered in the resident's comprehensive care plan within 7 days after completion of the MDS assessment reference date, per CMS guidelines.On 08/27/25 at 12:30 PM, record review revealed that Resident #8 had an Activity evaluation opened on…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-08-28 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — the official record, unedited, may be distressing
Based on observation, record review, and staff interview the facility failed to ensure hazardous chemicals were stored and used safely, creating a potential chemical exposure hazard for residents residing in the long-term care facility, this was a random opportunity for discovery. Facility Census: 82. Findings include:a) On 08/25/25 at 11:25 AM, the NA (Nurse Aide) cart was observed to contain a container of Sumer Sani-Cloth Germicidal Wipes.During an interview on 08/25/25 at 11:30 AM, the Infection Preventionist (IP Nurse #81) stated, These aint suppose to be on the NA cart, we use these to wipe equipment down after use like, the lifts, glucose machines, vitals machines, I'll educate staff now, and removed the wipes from the cart. confirming they should not be accessable to residents expecially residents who does not have capacity.Recoird Review completed on 08/25/25 at 12:12 PM of the Safety Data Sheet (SDS) revealed the following hazards:Causes serious eye irritationMay cause drowsiness or dizzinessFlammable liquid and vaporMay be harmful if swallowed or inhaled
- Potential for harm · Dcited before2025-08-28 · 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 provide respiratory services in accordance with professional standards of practice. For one (1) of one (1) residents reviewed for the care area of respiratory care, the supplemental oxygen flow rate was not set to the rate ordered by the physician. Resident Identifier: #74. Facility Census: 82.Findings included: a) Resident #74 Review of Resident #74's physician's orders showed an order written on 08/01/25 for oxygen at 3 liters per minute (LPM) via nasal cannula per concentrator as needed for chronic obstructive pulmonary disorder (COPD). An observation on 08/25/25 at 1:05 PM showed the resident was in bed with oxygen 1.5 LPM infusing via nasal cannula. An observation on 08/26/25 at 9:35 AM showed the resident was in bed with oxygen 2 LPM infusing via nasal cannula. An observation on 08/27/25 at 10:35 AM showed the resident was in bed with oxygen 2 LPM infusing via nasal cannula. This was confirmed by the Director of Nursing (DON). The DON increased the resident's oxygen to 3 LPM in accordance with the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-08-28 · tag F0791 — failed to provide routine dental services — isolatedProvide or obtain dental services for each 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 obtain dental services to meet the resident's needs. This deficient practice had the potential to affect one (1) of one (1) residents reviewed for the dental care area. Resident identifier: #5. Facility census: 82.Findings included:a) Resident #5 During an interview on 08/25/25 at 1:58 PM, Resident #5 stated she needed to have a tooth pulled, but she wasn't sure if the extraction had been scheduled. She had an obviously carious front tooth. The resident stated she was beginning to have twinges of pain in the front tooth. Review of Resident #5's medical records showed a consultation report from a dentist dated 12/06/24. The dentist recommended extraction of her remaining maxillary (upper jaw) teeth. A referral was to be made to an oral surgery clinic. The resident's annual Minimum Data Set (MDS) assessment with Assessment Reference Date (ARD) contained the following note in the Care Area Assessment (CAA) process: Resident has natural teeth; she has some missing teeth and potential…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-08-28 · tag F0810 — isolatedProvide special eating equipment and utensils for residents who need them and appropriate assistance.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, and staff interview, the facility failed to provide physician-ordered adaptive eating devices for one (1) of two (2) residents reviewed for the care area of nutrition. Resident identifier: #48. Facility census: 82. Findings included: a) Resident #48 Review of Resident #48's physician's orders showed the following orders: NAS (no added salt) and LCS (low concentrated sugar) diet, pureed texture, honey thick consistency Cup with lid d/t [due to] aspiration precaution. No straws d/t (due to) aspiration precautions. All these orders were written on 07/11/25. On 08/27/25 at 11:18 AM, Nurse Aide (NA) #14 was observed setting up Resident #48's lunch tray on his overbed table while the resident was in bed. The resident had a carton of honey thickened beverage with a straw in it. Resident #48's tray ticket stated, No straws. NA #14 confirmed Resident #48 was to have no straws according to his tray ticket. NA #14 removed the straw from the beverage carton and obtained a lidded cup from the kitchen for the resident's beverage. On 08/27/25, 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 · E2024-01-04 · tag F0644 — patternCoordinate 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 and resident review (PASARR) when four (4) of five (5) reviewed for the care area of PASARR received a new diagnosis of a serious mental disorder. Resident identifiers: 66, 10, 62, 24. Facility Census: 77. Findings included: a) Resident #66 On 01/02/24 at approximately 01:45 PM, record review indicates that Resident #66 was admitted to the facility with a PASARR indicating no diagnosis of Major Depressive Disorder. Resident #66 was diagnosed with Major Depressive Disorder, Single Episode, on 04/14/23 and the PASARR was not updated to reflect the diagnosis. On 01/03/24 at approximately 09:56 AM, the Director of Nursing (DON) #23 presented copies of Resident #66's diagnoses, care plan, and PASARR. The DON #23 acknowledged the diagnosis of Major Depressive Disorder, the missing on the most recent PASARR, and acknowledged there was no updated PASARR to reflect the diagnosis. b) Resident #10 On 01/02/24 at…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-01-04 · tag F0684 — failed to provide proper treatment and quality of care — patternProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview the facility failed to ensure one (1) of one (1) Resident reviewed for the care area of death received medications as ordered by the physician. Resident identifier: 80. Facility census: 77. Findings included: a) Resident #80 Record review found the resident was admitted to the facility on [DATE]. The Resident expired at the facility on [DATE]. Review of the Medication Administration Record (MAR) found an order for Lisinopril, oral tablet, 5 milligrams (mg's) give 1 tablet by mouth, one time a day, The start date of the Lisinopril was [DATE]. HOLD if systolic Blood pressure is less than 120 or if heart rate is less than 60 beats per minute (BPM) and Notify MD (doctor.) The medication was ordered to be given at 9:00 AM. The diagnosis for use of this medication was, Essential Hypertension. Review of the MAR found the following days when the medication was administered, but should have been held according to the physician's order because the systolic blood pressure 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 · Ecited before2024-01-04 · 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 and staff interview the facility failed to ensure food was stored in accordance with professional standards for food service safety. This deficient practice had the potential to affect any resident receiving nourishment from the kitchen. Facility census: 77. Findings included: a) Kitchen tour During the kitchen tour on 01/02/24 at 11:15 AM, it was discovered the drip pan had a large accumulation of grease build up. In the walk-in cooler a bin holding four (4) ounce orange juice cups had two (2) cups that had been crushed and the orange juice had poured out over the other juice cups and accumulated in the bottom of the bin. There was a used paper towel and a strip of cardboard lying on top of the orange juice cups. An interview with the Dietary Manager (DM) on 01/02/24 at 11:15 AM, verified the grease drip pan needed to be cleaned and the two (2) damaged orange juice cups had contaminated the other orange juice cups.
Show the remaining 19 citations
- Potential for harm · Dcited before2024-01-04 · tag F0584 — failed to keep a safe, clean, comfortable home — isolatedHonor 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 — the official record, unedited, may be distressing
Based on observation, resident interview, and staff interview, the facility failed to provide a safe, clean, comfortable and homelike environment. This was a random opportunity for discovery. Resident Identifier: 4. Facility Census: 77. Findings included: a) Resident #4 On 01/02/24 at approximately 12:47 PM, Resident #4 ' s room was observed to have a strong urine odor. There were multiple wet spots in the floor in Resident # 4's room along with dirty wheelchair tracks streaked through the liquid in the floor. Resident #4 stated he/she had soiled their clothes and changed themselves. Soiled clothes were observed laying on the bathroom floor with wet spots leading out into Resident #4's bedroom. Resident #4 stated in the interview he/she had soiled their clothes, and got a pack of underwear from the aides so I could change myself. Resident #4 indicated he/she had changed their clothes and left them on the bathroom floor. On 01/02/24 at 12:50 PM, Housekeeper #100 entered the room and acknowledged the smell, wet spots, dirt spots, and soiled clothes on the floor.
- Potential for harm · D2024-01-04 · tag F0623 — isolatedProvide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and staff interview, the facility failed to ensure a facility initiated thirty day notice of discharge contained the date the discharge notice was issued and the effective discharge date . This was true for one (1) out of two (2) Residents reviewed for discharges. Resident identifier: #29. Facility census: 77. Findings included: a) Resident #29 Record review found resident #29 had multiple physical and verbal altercations with staff and residents. The facility implemented numerous interventions when behaviors occurred with no success. The facility issued a 30 day discharge notice, stating the Resident was a danger to self and other Residents. With no placement being found for Resident #29, he currently remains at the facility. On 01/03/24 at 1:00 PM, record review found the 30 day discharge notice for Resident # 29 did not contain the date the discharge was initiated or the effective discharge date on the letter issued to the responsible party and the required State authorities. On 01/03/24 at 1:54 PM, the administrator confirmed the notice was not dated as 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 · Dcited before2024-01-04 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
What the surveyor found here — the official record, unedited, may be distressing
Based on recorded review, resident interview, and staff interview the facility failed to have an assessment that accurately reflected the resident's status. This was true for one (1) out of four (4) Residents reviewed for the care area of falls. Resident identifier: Resident # 32. Facility census 77. Findings included: a) Resident # 32 During a review of the Minimum Data Set (MDS), it was documented that Resident #32 had a fall with a major injury. On 01/02/24 at 2:23 PM, Resident # 32 was asked about the fall and the major injury. Resident #32 stated he fell out of his chair last summer, but he did not get hurt. On 01/03/24 at 10:28 AM medical records Clerk #103 stated Resident #32 only had one fall on 07/31/23 with no injuries. On 01/03/24 at 1:46 PM, the Director of Nursing (DON) confirmed Resident #32's fall with injury was coded incorrectly by the MDS nurse. The DON said the major injury was from a resident-to-resident altercation on 09/14/23, not from a fall.
- Potential for harm · Ecited before2023-08-29 · tag F0584 — failed to keep a safe, clean, comfortable home — patternHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation and staff interview, the facility failed to maintain a safe, clean, comfortable and homelike environment. This failed practice has the potential to affect more than a limited number of residents and was discovered during a complaint investigation. Facility census 85. Findings included: a) Observation on 08/29/23 at approximately 9:44 a.m., revealed the shared restroom for Resident Rooms 313/315 had a strong sewer smell and the floor was stained with a brown/watery substance. b) Observation on 08/29/23 at approximately 9:56 a.m., revealed the shared restroom for Resident Rooms 208/210 had strong sewer smell and the toilet appeared shifted / unsecured to the floor and would not flush and appeared to be stopped up. c) Observation on 08/29/23 at approximately 10:03 a.m., revealed the toilet appeared shifted / unsecured to the floor and the sealant at the base of the toilet appeared to be stained with a mold/mildew substance in the shared restroom for Resident Rooms 204/206. d) Observation on…
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 before2022-11-02 · tag F0812 — failed to store, cook, and serve food safely — patternProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, facility documentation and staff interview the facility failed to have completed temperature logs for the refrigerators, freezer and dishwasher. The facility failed to complete and document food temperatures of food before serving on 11/01/22 for breakfast and lunch. This was a random opportunity for discover. The failed practice had the potential to affect more than a limited number of residents. Facility census: 77. Findings included: a) Refrigerators/Freezer Temps An observation during the initial kitchen tour on 10/31/22 8:45 AM, showed incomplete temperature logs for the refrigerators and freezer as followed: 1. Refrigerator (Walk-In)Temperature Log: 10/02/22- Morning (AM) and Evening (PM) temperatures missing 10/20/22- PM temperature missing 10/31/22- AM temperature missing 2. Refrigerator (Kitchen) Temperature Log 10/02/22- PM temperature missing 10/18/22- PM temperature missing 10/20/22- PM temperature missing 10/22/22- PM temperature missing 10/23/22- PM temperature missing 10/26/22- PM temperature missing 10/31/22- AM temperature missing 3. Freezer…
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 · E2022-11-02 · tag F0838 — failed to assess facility resources and resident needs — patternConduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
What the surveyor found here — the official record, unedited, may be distressing
Based on facility documentation and staff interview the facility failed to include direct staffing levels / direct overall number of staff for the resident acuity in the facility assessment. This has the potential to affect all resident in the facility. The Facility census 77. Findings included: a) Facility Assessment Review of the facility assessment on 11/02/22 at 4:21 PM, found a lack of information provided for nursing staff and nurse aides providing resident care. Position: --Registered Nursing. Job Description & Qualifications: --Individuals who have successfully completed a state approved training and competency evaluation program and required testing. Standard Deployment Plan: --Licensed Practical Nurse (LPN) see PBJ reports. Average Hours a Day. --Eight (8) to 12 per Registered Nursing Aide (RNA) During an Interview with the Administrator and the Assistant Director of Nursing (ADON) on 11/02/22 at 5:13 PM the ADON verified that the Direct Care Staff needed by the facility was incomplete and the Facility Assessment was not correct without the information. .
- Potential for harm · E2022-11-02 · tag F0919 — failed to provide a working call system — patternMake sure that a working call system is available in each resident's bathroom and bathing area.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, resident interview, and staff interview the facility failed to Resident #23 had a call system within reach. The bathrooms in rooms 405, 407, 404, and 406 did not a cord to activate the call system to contact staff. These observations were a random opportunity for discovery. Facility census 77. Findings included: a) Resident #23 During an interview on 10/31/22 at 9:30 AM, Resident #23 was in a wheelchair, located between the two beds in the Resident's room. Resident #23 was asked if she could reach her call light. Resident #23 stated she did not know where it was, but if she needed something she would wheel down to the nurse's station. On 10/31/22 at 9:45 AM, Nurse Aide #45 was asked if she could find the call light for Resident #23. NA #45 located the call light which was on the floor behind the nightstand and was tied to the bed not occupied by Resident #23. On 10/31/22 at 9:50 AM, Resident #23 confirmed she slept in the bed next to the door of the room. The call light was tied to the bed next to the window. b) Bathroom call lights On 10/31/22 at 9:52 AM, NA…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2022-11-02 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on resident interview, record review and staff interview the facility failed to ensure a Resident was free from neglect. The failed practice was true for one (1) of three (3) Residents reviewed for abuse. Resident identifier: #20. Facility census: 77. Findings included: a) Resident #20 During an interview on 10/31/22 at 10:20 AM, Resident #20 stated that she wished the facility would get her a wheelchair so she could get out of bed. An observation on 10/31/22 at 10:20 AM, showed Resident #20 lying in bed with no available wheelchair located in Resident # 20's room. During an interview on 11/01/22 at 3:25 PM, Resident # 20 stated she was not able to get out of bed yesterday and had not been out of bed today. Resident # 20 stated she asked her Nurse Aides (NA) to get up out of bed earlier today and was told they did not have time to get her up and out of bed today. Resident # 20 stated she would love a wheelchair so she could wheel around the facility. An observation on 11/01/22 at 3:25 PM, showed Resident #20 lying in bed and there was no available wheelchair located in…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-11-02 · tag F0604 — failed to not use physical restraints improperly — isolatedEnsure that each resident is free from the use of physical restraints, unless needed for medical treatment.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review, observation and staff interview, the facility failed to ensure one (1) of (1) residents having a physical restraint, received care according to standards of practices during the time in which a restraint was used. Resident #48 did not receive restraint checks and releases from the restraint in a timely manner. The facility failed to ensure Resident #48 had the correct device applied as ordered by the physician, and did not receive periodic evaluations by all members of the interdisciplinary team to identify less restrictive means to the restraint usage. The facility also failed to identify a continued need for treatment on a periodic basis. Resident identifier: Resident #48. Census: 77. Findings included: a. Resident #48 A review of the Policy: Restraints (physical) policy, dated 07/2008: showed the physician order must include instructions for release and positioning/ toileting every two (2) hours, release during activities, meals or periods of 1:1 (meals, personal care, etc.) If physical restraints are used, each resident must be reviewed at least quarterly…
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 · D2022-11-02 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on resident interview, record review and staff interview the facility failed to ensure a Resident was free from neglect. The failed practice was true for one (1) of three (3) Residents reviewed for abuse. Resident identifier: #20. Facility census: 77. Findings included: a) Resident #20 During an interview on 10/31/22 at 10:20 AM, Resident #20 stated that she wished the facility would get her a wheelchair so she could get out of bed. An observation on 10/31/22 at 10:20 AM, showed Resident #20 lying in bed with no available wheelchair located in Resident # 20's room. During an interview on 11/01/22 at 3:25 PM, Resident # 20 stated she was not able to get out of bed yesterday and had not been out of bed today. Resident # 20 stated she asked her Nurse Aides (NA) to get up out of bed earlier today and was told they did not have time to get her up and out of bed today. Resident # 20 stated she would love a wheelchair so she could wheel around the facility. An observation on 11/01/22 at 3:25 PM, showed Resident #20 lying in bed and there was no available wheelchair located in…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2022-11-02 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on record review and staff interview the facility failed to develop a comprehensive care plan. This was true for two (2) out of twenty-three (23) Residents reviewed during the long term care survey process. Resident Identifiers: #330 and #77 Facility Census: 77 a) Resident # 77 Resident #77 is currently a smoker. Her name is on the smokers list provided by the facility. She has a smoking evaluation dated 10/13/22. According to this evaluation she is to be supervised while smoking. The resident was observed smoking with supervision on 11/01/22 at 1:10 PM. According to the Smoking Policy with a revision date of 4/2021 .The resident's smoking status will be documented in the care plan . Resident #77 does not have a focus of smoking on her care plan. This was confirmed with Licensed Practical Nurse (LPN) # 32 at 11/02/22 at 9:45 AM. b) Resident #330 Resident #330 has an current order dated 10/26/22 for a life vest to be worn at all times, change the battery every 24 hours. Upon the initial long term survey…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2022-11-02 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on record review and staff interview the facility failed to follow a physicians order for a life vest to be on the Resident at all times. This was a random opportunity for discovery. Resident identifier: #330 Facility Census: 77. a) Resident #330 Resident #330 has an current order dated 10/26/22 for a life vest to be worn at all times, change the battery every 24 hours. Upon the initial long term survey process on 10/31/22 at 10:10 AM, the Resident was not wearing the life vest. This was confirmed with Licensed Practical Nurse (LPN) #32 on 10/31/22 at 10:12 AM. On 11/01/22 at 9:08 AM, the Resident did not have the life vest on. This was confirmed with LPN #61 at 9:10 AM. At this time, LPN #61 stated she could not find the life vest. On 11/01/22 at 12:01 PM, there was documentation that Registered Nurse (RN) #62 spoke with the Residents wife and she has taken the life vest to her house. The order for the life vest was then discontinued. The Resident was admitted on [DATE] at which time there was an…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2022-11-02 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review and staff interview, the facility failed to ensure supervision and devices to prevent accidents that could lead to injury. Resident #130 had orders for devices to prevent injury due to poor safety awareness that were not provided in accordance to the physician's orders This was true to one (1) of one (1) reviewed for accident/injury concerns. Resident identifier: Resident #130. Census: 77. Findings included: Resident #130 A record review for Resident #130 showed the resident being at risk for falls/injuries because of poor safety awareness. Physician's orders were noted for Resident #130 to include the following: - Geri sleeves bilateral upper extremities due to fragile skin integrity - Hipsters to be worn at all times which would aid in the prevention of a hip fracture in case of falls - Abdominal binder to be worn to prevent tugging and pulling out peg tube An observation made, on 10/31/22 at 12:40 PM, revealed Resident #130 laying in bed with no geri sleeves, abdominal binder or hipsters noted being applied to the resident for safety measures…
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 · D2022-11-02 · 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 provide care and services to maintain acceptable parameters of nutritional status to prevent weight loss. This failed practice was true for one (1) out of six (6) residents reviewed for nutrition. Resident identifier: #15. Facility census 77. Findings included: a) Resident #15 A review of medical records revealed Resident #15 was a admitted to the facility on [DATE], with an admission weight of 168.2 pounds. Diagnoses included: Hypertension, acute and chronic respiratory failure, Vitamin D deficiency, Chronic kidney disease, and diabetes. On 04/08/2022, the resident weighed 168.2 pounds. On 10/22/22, the resident weighed 127 pounds which is a -24.49 % Loss. A review of the medical chart found a form titled, Physicians Progress Notes, dated 07/20/22 revealed the following information: It was mentioned by the physician about a weight loss from admission to July and a weight of 135 pounds. However, there was no new orders for any supplements or any…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-11-02 · tag F0693 — failed to provide proper feeding-tube care — isolatedEnsure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, and staff interview, the facility failed to ensure enteral feedings were administered in accordance to professional standards. The facility failed to ensure enteral feedings were identified with a label as to the type of feeding being administered, by a pump and time of administration to ensure safety of contents and accuracy of administration, to a resident. This was found to be true for one (1) of one (1) resident reviewed during the Long-Term Care Survey Process (LTCSP). Resident identifier: Resident #130. Census: 77 Findings included: a.) Resident #130 A record review, for Resident #130, showed physician's orders for Isosource 1.5 via pump per feeding tube. The feeding was to be off at 10:00 AM daily and started at 14:00 (2:00 PM) daily. An observation, on 10/31/22 at 09:55 AM, revealed Resident #130 was receiving an enteral feeding though a pump. The bag was half full with feeding contents. The feeding being administered was not labeled to show the type of feeding being administered or the time the feeding was placed on the pump.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2022-11-02 · 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 interview, the facility failed to provide oxygen therapy in accordance with professional standards and practices. The facility failed to ensure the flow rate of oxygen was administered in accordance with physician's orders. This failed practice was true for two (2) of two (2) residents receiving oxygen therapy, reviewed during the Long -Term Care Survey Process (LTCSP). Resident identifiers: Resident #68 and #61. Census: 77. The findings included: a) Resident #68 An observation, on 10/31/22 at 10:00 AM, revealed Resident #68 was receiving oxygen therapy with a flow rate of four (4) liters (L) per minute. An additional observation made on 10/31/22 at 01:30 PM, revealed Resident #68 continued to receive the oxygen at a flow rate of 4L/minute. On 10/31/22 at 01:30 PM, LPN #3 verified the oxygen flow rate to be set on 4 L/min. On 10/31/22 at 01:35 PM, LPN #3 stated, during an interview, the order had been verified and Resident #68 should have been receiving the oxygen therapy at a flow rate of 2L/minute. Additionally, LPN #3 confirmed , at this…
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 · D2022-11-02 · tag F0758 — failed to limit and justify psychotropic drugs — isolatedImplement 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 observation, record review and staff interview the facility failed to ensure one (1) of five (5) residents reviewed was free from unnecessary medications. Resident Identifier: #12. Facility census 77. Findings included: a) Resident #12 A review of medical records revealed Resident #12 had a physician's order for Seroquel for Alzheimers disease and behaviors. A review of the nursing behavior notes revealed the last behavior noted was made on 10/26/20. On 11/01/22 at 1:16 PM, the Assistant Director of Nursing (ADON) was interviewed regarding Resident # 12 receiving Seroquel for behaviors and no documented behaviors in two years. On 11/01/22 01:25 PM, ADON confirmed there were no recent behaviors noted. The ADON provided a form from a mental health service that sees the resident. The form was dated 10/11/22, which read, GDR (Gradual Dose Reduction) Determination: GDR clinically inadvisable currently. No other rational was provided. The ADON was asked if the physicians that manages her mental health care…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2022-11-02 · tag F0814 — failed to dispose of garbage properly — isolatedDispose of garbage and refuse properly.
What the surveyor found here — the official record, unedited, may be distressing
Based on observation and staff interview the facility failed to ensure the garbage dumpster was in good and sanitary condition to prevent the harborage and feeding of pests. This was a random opportunity for discovery. The failed practice had the potential to affect a limited number of Residents. Facility census: 77. Findings included: a) Garbage dumpster An observation on 11/02/22 at 11:30 AM, showed a garbage area with three (3) dumpsters. One (1) dumpster located in the middle of the three (3) garbage dumpsters had a big hole in the front of it with garbage hanging out of the hole. Three (3) rats were observed exiting the hole of the dumpster. During an immediate interview on 11/02/22 at 11:30 AM, Dietary Staff (DS) #95 stated those are rats. DS # 95 stated the other day there was also a bear around the garbage dumpster with the rats. .
- No harm found · Ccited before2024-01-04 · tag F0814 — failed to dispose of garbage properly — widespreadDispose of garbage and refuse properly.
What the surveyor found here — the official record, unedited, may be distressing
Based on observation and staff interview the facility failed to ensure garbage storage area was maintained in a sanitary condition to prevent the harborage and feeding of pests. It was discovered the dumpster's were full and overflowing with several garbage bags lying on each of the dumpster's. Facility census: 77. Findings included: a) Garbage storage area During an observation of the garbage storage area on 01/03/24 at 10:45 AM, it was discovered the three (3) dumpster's were full and had several garbage bags lying on top of the lids of the dumpster's. An interview with the Nursing Home Administrator (NHA) the on 01/02/24 at 12:30 PM, verified the area trash disposal company was to deliver an extra dumpster for the holidays. He reported they had not provided an extra dumpster for Christmas or New Years Day. He also reported he had not contacted the company regarding the non delivery of the extra dumpster's.
“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
$25,237 in federal fines across 2 penalties.
- $11,912 — penalty dated 2024-03-13
- $13,325 — penalty dated 2024-02-09
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 |
|---|---|---|---|---|
| TRINITY HEALTH CARE SERVICES INC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 03/07/2008 |
| VANCE, RONALD | Individual | CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL; TRUSTEE OF THE SNF; ADP OF THE SNF | — | since 01/27/2026 |
| BEVINS, KENNETH | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 01/27/2026 |
| REYNOLDS, CHRISTOPHER | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 01/27/2026 |
CMS files one row per role, so the 9 rows in the source record cover these 4 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.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
About 94% 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 $87K paid to related parties (affiliated landlords or management companies) in its most recent cost report.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in WV
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the West Virginia Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 515069. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-08-28, 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.