Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Best Care Health And Rehabilitation during CMS and state inspections, most recent first.
A resident with multiple comorbidities, impaired mobility, and a documented need for two-person substantial/maximal assist with a gait belt for transfers was assisted to the bathroom by a single CNA without a gait belt. During the toilet transfer, the resident reported knee pain, was holding a grab bar, and then fell to the floor, where an LPN later found the resident with pain and abrasions. Imaging and hospital records confirmed a left distal femur fracture and right hip fracture, with subsequent treatment for hypotension, hemorrhagic shock, and medical decline following the fractures. The facility’s fall investigation identified the fall during transfer and major injury but did not address that only one staff member assisted and that the gait belt and two-person assist requirements in the care plan were not followed; leadership later acknowledged the transfer was performed improperly and led to the resident’s injuries.
The facility did not notify the Ombudsman when three residents with complex medical conditions were discharged to the hospital. Medical records and staff interviews confirmed the lack of required notification, and facility policies related to discharge were either not followed or not available for review.
A resident with multiple chronic conditions and an indwelling Foley catheter did not have physician orders in place for the catheter at admission. Medical records, nursing notes, and the care plan lacked documentation of the catheter order, although CNA documentation confirmed care was provided and surveyors observed the catheter in use. The DON confirmed the absence of physician orders, and the facility lacked a related policy.
Several newly admitted residents did not receive prescribed medications for multiple days due to delays in pharmacy delivery, with staff documenting repeated attempts to obtain the medications and confirming that the facility's medication system did not always have the required drugs on hand. Nursing staff did not consistently notify the physician or NP when medications were missed, as required by facility policy.
The facility failed to address residents' repeated requests for information on free government phones during Resident Council meetings. Despite ongoing inquiries, there was no documented response or resolution, and staff interviews revealed a lack of communication and follow-up on these concerns.
The facility failed to secure medication carts on the front hall, leaving them unlocked and unattended, which could affect seven cognitively impaired and independently mobile residents. An LPN confirmed the carts should have been locked, as per the facility's policy on medication storage.
A resident with multiple medical conditions was issued a 30-day discharge notice for violating the facility's smoking policy, despite only one documented instance of noncompliance. Interviews revealed no further violations in the months following the incident, raising concerns about the justification for the discharge.
The facility failed to update PASARRs for two residents who had new diagnoses and were prescribed psychotropic medications. One resident was admitted with various diagnoses, including depression and anxiety, and later diagnosed with dementia and psychosis, receiving medications like Seroquel and Paxil. Another resident with bipolar disorder was prescribed medications such as Vraylar, but no new PASARR was completed. The Social Services Director confirmed the oversight and lack of a written policy for PASARR completion.
A facility failed to conduct regular care plan conferences for a resident admitted with multiple diagnoses, including Parkinson's disease and dementia. Despite being cognitively intact, the resident's medical record lacked documentation of a care conference since admission. This deficiency was confirmed by the Social Services Director.
A resident with a precancerous lesion on the forehead was not adequately monitored or treated, as observed by surveyors. The resident, who was cognitively impaired, had a soiled bandage over the lesion without any physician's orders for its application. The bandage was not consistently maintained, and the lesion had not been assessed since July, leading to a deficiency in care.
A facility failed to provide adequate oxygen therapy for a resident with COPD, as there were no physician's orders for oxygen, and vital signs were not recorded since June. The resident was observed using oxygen without a valid order, contrary to facility policy.
A resident with chronic low back pain was inadequately monitored for pain management, despite being prescribed medications like Zanaflex, gabapentin, and hydrocodone. Observations showed the resident frequently yelling in pain, with no pain assessments documented since a specific date. Interviews confirmed the ineffectiveness of the medications and the absence of nonpharmacological interventions, violating the facility's pain management policy.
A facility failed to assess and address the PTSD of a resident, who was admitted with multiple diagnoses including PTSD. The care plan did not include the cause of the PTSD, potential triggers, or interventions to prevent re-traumatization. The DON confirmed the lack of assessment and care plan strategies for managing the resident's PTSD.
Two residents experienced significant medication errors. One resident missed doses of prescribed insulin due to unavailability, while another was administered naloxone without a physician's order, despite no history of substance abuse. These errors were confirmed by interviews with staff and the DON.
The facility failed to ensure that two residents received up-to-date pneumococcal vaccinations as per CDC guidelines. One resident with hypertension and intellectual disabilities and another with chronic obstructive pulmonary disease did not receive the recommended PCV15 or PCV20 vaccines after their last Pneumovax 23 dose. The Director of Nursing confirmed the oversight, which was contrary to the facility's policy to follow CDC recommendations.
Failure to Follow Two-Person Transfer and Gait Belt Requirements Resulting in Fall With Fractures
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate assistance and supervision during a transfer for a resident who was known to be at high risk for falls and required extensive help. The resident had diagnoses including congestive heart failure, polyneuropathy, difficult ambulation, muscle weakness, and COPD, and was assessed as being at risk for falls. A Lift, Transfer, Reposition Assessment documented that the resident required a two-person substantial/maximal assist for transfers with the use of a gait belt. The care plan and MDS further documented that the resident was cognitively intact but had weakness, poor balance, and was not steady, requiring substantial/maximal physical assistance for all transfers and being unable to stabilize without staff assistance for standing, walking, and surface-to-surface transfers. On the date of the incident, the resident was being assisted to the bathroom by a single CNA, contrary to the documented requirement for a two-person assist and use of a gait belt. The CNA’s witness statement indicated that the resident reported knee pain while being taken to the restroom and was holding onto the bathroom grab bar. The CNA moved the wheelchair and stood behind the resident when the resident began to fall to her side and then fell backward toward another bathroom door. The LPN who responded to the CNA’s request for help found the resident on the bathroom floor, complaining of left knee pain and with multiple abrasions, and assisted the resident back to bed. Subsequent imaging and hospital records showed that the resident sustained a left distal femur fracture and a right hip fracture. The facility’s own QAPI fall investigation documented that the resident fell during transfer to the toilet and sustained a major injury, with a possible root cause identified as the resident’s knee giving out. However, the investigation did not address that the transfer had been performed by only one staff member instead of the required two, and that a gait belt, which was part of the resident’s plan of care, had not been used. During interviews, facility leadership, including the DON, ADON, President of Clinical Operations, and Regional Resource Nurse, confirmed that the CNA had improperly transferred the resident alone and without a gait belt, and that the resident sustained fractures of the right hip and left femur as a result of this transfer. Hospital documentation further described the resident’s condition following the fall. At the first hospital, the resident was found to have a left distal femur fracture and right hip fracture, hypotension without external signs of bleeding, anemia, and acute hypotension, and was transferred to a higher-level trauma center due to suspected internal bleeding of the left thigh. At the second hospital, the resident was treated for hemorrhagic shock and acute on chronic shock, and the left femur fracture was described as pathological due to a combination of osteopenia and trauma. The death certificate and coroner’s report listed the cause of death as medical decline following a left distal femur fracture with surgical therapy as a consequence of a ground-level fall. The facility’s falls/accidents/incidents policy defined an avoidable accident as one in which the facility failed to implement interventions, including adequate supervision and assistive devices, consistent with the resident’s needs and care plan to eliminate or reduce the risk of an accident.
Failure to Notify Ombudsman of Resident Discharges
Penalty
Summary
The facility failed to notify the Ombudsman of resident discharges as required, affecting three out of four residents reviewed for discharge. Medical record reviews for these residents showed that each had been admitted, discharged to the hospital, and in some cases readmitted, with diagnoses including chronic lymphocytic leukemia, chronic kidney disease, cirrhosis of the liver, diabetes mellitus type two, fibromyalgia, mood disorder, atrial fibrillation, congestive heart failure, pleural effusion, and Clostridium difficile infection. Despite these discharges, there was no documentation in the nursing progress notes indicating that the Ombudsman had been notified of the residents' discharges to the hospital. Interviews with facility staff confirmed the lack of notification. The DON acknowledged that the facility had not been notifying the Ombudsman of discharges, and the Social Services Director, who was new to the position, was unaware of the requirement until recently. Review of the facility's Bed Hold and Return to Center policy referenced a Notice of Transfer Discharge policy, but this policy was not provided for review. The deficiency was identified during an investigation under a specific complaint number.
Lack of Physician Orders for Indwelling Foley Catheter
Penalty
Summary
The facility failed to ensure that physician orders were in place for a resident with an indwelling Foley catheter at the time of admission. The resident, who was admitted with multiple diagnoses including atrial fibrillation, congestive heart failure, liver cirrhosis, diabetes mellitus type 2, and chronic kidney disease with dialysis, was cognitively intact and required significant assistance with activities of daily living. Medical record review showed no physician orders for the Foley catheter, and there was no documentation in the nursing progress notes or plan of care regarding the catheter. Certified Nursing Assistant documentation confirmed care was provided for the catheter, and observations during the survey verified the presence of the indwelling Foley catheter. The Director of Nursing confirmed the absence of physician orders, and the facility did not have a policy related to physician orders for indwelling Foley catheters.
Delayed Medication Administration for New Admissions Due to Pharmacy Issues
Penalty
Summary
The facility failed to ensure that newly admitted residents received their prescribed medications in a timely manner due to delays in obtaining medications from the pharmacy. Multiple residents experienced missed doses of critical medications for several days after admission. For example, one resident with diagnoses including pleural effusion, chronic kidney disease, cirrhosis, atrial fibrillation, diabetes, and C. difficile did not receive Vancomycin, Sucralfate, and Gabapentin as ordered, with documentation indicating repeated notes of 'awaiting pharmacy' and no evidence that the physician or nurse practitioner was notified of the missed doses. Another resident admitted with conditions such as weakness, COPD, cirrhosis, hepatitis C, diabetes, and congestive heart failure did not receive several ordered medications, including Clopidogrel, Lantus insulin, nicotine patch, Sertraline, Trelegy inhaler, Cefazolin, and Creon, for several days. Nursing notes repeatedly documented that medications were not delivered or were on order, and the nurse practitioner was not notified of the missing doses until several days after admission. The medication Creon was eventually placed on hold until it became available. A third resident with atrial fibrillation, congestive heart failure, liver cirrhosis, diabetes, and chronic kidney disease did not receive lactulose for two days after admission, with nursing notes indicating the medication was 'awaiting from pharmacy.' Interviews with staff confirmed ongoing issues with timely pharmacy delivery, especially for new admissions, and that the facility's medication dispensing system did not always have the required medications on hand. There was also a lack of documentation that the physician or nurse practitioner was notified when medications were missed, contrary to facility policy.
Failure to Address Resident Concerns on Free Government Phones
Penalty
Summary
The facility failed to adequately address concerns raised by residents during Resident Council meetings, specifically regarding the availability of free government phones. The issue was first noted in the meeting minutes from April 15, 2024, where the social worker reported difficulty in securing free phones. Despite this, the response documented was that the social worker would meet with residents about the phones. In subsequent meetings on August 26 and September 16, 2024, residents continued to inquire about free government phones, but there was no documented response or resolution provided. The social worker's efforts were noted as unsuccessful, and no alternative solutions were offered. Interviews conducted on October 3, 2024, revealed a lack of communication and follow-up on the residents' requests. The Social Service Director, who had been with the facility since August 2024, was unaware of any requests for free phones. The Activities Director confirmed that residents had repeatedly requested assistance with obtaining government phones, but the process for addressing these concerns was unclear. The Administrator was responsible for addressing the concerns, but it was uncertain how or if they were resolved. A resident confirmed that the facility had not provided a response to their inquiries about government phones, indicating a breakdown in addressing resident concerns.
Medication Cart Security Lapse
Penalty
Summary
The facility failed to ensure that medication carts on the front hall were locked and secured, which had the potential to affect seven cognitively impaired and independently mobile residents out of the 22 residing on the front hall. During an observation, it was noted that two medication carts were left unlocked and unattended by staff. An interview with an LPN confirmed that the medication carts were indeed unlocked and unattended, and acknowledged that they should be locked when not attended by staff. The facility's policy on the storage of medications, dated November 2020, requires that drugs and biologicals be stored in locked compartments under proper conditions, and that unlocked medication carts should not be left unattended. This policy was not adhered to, leading to the deficiency observed by the surveyors.
Unjustified Resident Discharge Due to Smoking Policy Violation
Penalty
Summary
The facility failed to ensure that a resident was not discharged without a justified and documented reason, affecting one resident out of three reviewed for discharge rights. The resident, who had multiple medical diagnoses including Parkinson's disease, dementia, and depression, was admitted to the facility and had signed the facility's smoking policy upon admission. On one occasion, the resident was documented as violating the smoking policy by leaving the facility to purchase cigarettes and was observed smoking on the facility's front patio. Despite this single documented instance of noncompliance, the facility issued a 30-day discharge notice to the resident for violating the smoking policy. Interviews with the resident, the Ombudsman, and the Social Service Director revealed that the only documented violation of the smoking policy occurred several months prior to the discharge notice, with no further instances of noncompliance recorded in the subsequent months. The Ombudsman expressed concerns about the strength of the facility's case for an involuntary discharge based on the single documented incident. The resident expressed a desire to remain in the facility, and the Social Service Director confirmed the lack of additional documented violations.
Failure to Update PASARRs for Residents with New Diagnoses and Psychotropic Medications
Penalty
Summary
The facility failed to update the Preadmission Screening and Resident Reviews (PASARRs) for two residents who had new diagnoses and were prescribed psychotropic medications. Resident #39 was admitted with diagnoses including depression, anxiety, diabetes mellitus type two, hypertension, and congestive heart failure. The PASARR dated 07/21/23 did not indicate any serious mental illness or prescriptions for psychotropic medications. However, dementia and psychosis were later added to the resident's diagnoses, and the resident was prescribed several psychotropic medications, including Seroquel, Ativan, Trazodone, and Paxil. Despite these changes, a new PASARR was not completed. Similarly, Resident #52 was admitted with a diagnosis of bipolar disorder. The PASARR dated 06/07/24 did not list any antipsychotic medications. The resident's care plan included interventions for bipolar disorder, and the resident was later prescribed psychotropic medications, including Paxil, Trazodone, and Vraylar. Again, the facility did not complete a new PASARR following these changes. The Social Services Director confirmed the oversight and acknowledged the absence of a written policy regarding PASARR completion.
Failure to Conduct Regular Care Plan Conferences
Penalty
Summary
The facility failed to provide regular care plan conferences for residents and their representatives, specifically affecting one resident out of three reviewed for care conferences and care planning. The resident in question was admitted with multiple diagnoses, including cellulitis, Parkinson's disease, cerebral infarction, bipolar disorder, hypertension, and dementia. Despite being cognitively intact, as indicated by the Minimum Data Set (MDS) assessment, the resident's medical record lacked documentation of a care conference since their admission in 2020. This deficiency was confirmed through an interview with the Social Services Director, who acknowledged that no care conference had been conducted for the resident since their admission.
Inadequate Monitoring and Treatment of Skin Alteration
Penalty
Summary
The facility failed to ensure adequate monitoring and treatment of skin alterations for a resident with a precancerous lesion on the forehead. The resident, who was cognitively impaired and had diagnoses including Parkinson's disease, dysphagia, and Alzheimer's disease, was observed with a soiled white bandage over the lesion. The bandage was undated and lacked initials to indicate who applied it. Despite the lesion frequently bleeding, there were no physician's orders for bandage application, and the area had not been assessed since July. Observations revealed the bandage was not consistently maintained, as it was found soiled and eventually fell off, exposing a half-dollar sized lesion with dried blood. An LPN confirmed the absence of an order for the bandage and acknowledged the lack of assessment since July. The facility's inaction in monitoring and treating the skin alteration led to the deficiency, affecting the resident's care and treatment.
Failure to Ensure Adequate Oxygen Therapy for a Resident
Penalty
Summary
The facility failed to provide adequate care and services for a resident requiring oxygen therapy. Resident #8, who was admitted with chronic obstructive pulmonary disease (COPD), diabetes mellitus, and hypertension, had a care plan indicating altered respiratory status and difficulty breathing related to COPD. However, there were no physician's orders for oxygen therapy in the resident's medical records for October 2024, and the Minimum Data Set (MDS) assessment did not indicate that the resident received oxygen therapy during the review period. Additionally, vital signs records from June to October 2024 showed no recorded oxygen saturation levels or respiratory rates since June 8, 2024. On October 1, 2024, an observation revealed that Resident #8 was using oxygen delivered through a nasal cannula at a rate of two liters per minute, despite the absence of a physician's order. The resident confirmed using oxygen when experiencing shortness of breath. An interview with LPN #49 confirmed the lack of a physician's order and the absence of recorded oxygen saturation levels or respiratory rates. The facility's policy on oxygen administration, revised in October 2010, required a valid physician's order and monitoring of vital signs and oxygen saturation levels, which were not adhered to in this case.
Inadequate Pain Management Monitoring
Penalty
Summary
The facility failed to ensure adequate monitoring and management of pain for a resident with chronic low back pain. The resident, admitted with diagnoses including low back pain and restlessness, was prescribed medications such as Zanaflex, gabapentin, and hydrocodone for pain management. Despite these prescriptions, the resident's medical record showed no pain assessments or documentation of pain levels since a specific date. Observations over several days revealed the resident frequently yelling out in pain, grimacing, and holding her back, indicating ongoing discomfort. Interviews with the resident and staff confirmed the resident's persistent pain and the ineffectiveness of the prescribed medications. The facility's policy on pain assessment and management, which emphasizes a multidisciplinary approach and regular monitoring using standardized tools, was not adhered to. The Director of Nursing confirmed the absence of pain assessments and documentation of nonpharmacological interventions for the resident's chronic pain. This lack of monitoring and documentation contributed to the deficiency in providing safe and appropriate pain management for the resident.
Failure to Address PTSD in Resident Care Plan
Penalty
Summary
The facility failed to ensure that a resident with post-traumatic stress disorder (PTSD) was appropriately assessed to identify the cause of the PTSD and minimize triggers and/or re-traumatization. This deficiency affected one resident, who was admitted with multiple diagnoses including PTSD. The resident's Minimum Data Set (MDS) assessment confirmed the diagnosis of PTSD, yet the care plan did not address the cause of the PTSD, potential triggers, or interventions to reduce the risk of re-traumatization. The medical record for the resident lacked an assessment to identify the cause of the PTSD and potential triggers. An interview with the Director of Nursing (DON) confirmed that the facility had not completed an assessment of the cause of the PTSD or identified possible triggers that could cause re-traumatization. Additionally, the care plan did not include strategies for providing care to a resident with PTSD, highlighting a significant oversight in the resident's care management.
Medication Errors Affect Two Residents
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, affecting two residents. Resident #228, who was newly admitted with diagnoses including end-stage renal disease, diabetes mellitus type two, and chronic obstructive pulmonary disorder, did not receive prescribed doses of Admelog insulin and Tresiba due to the medications not being available. The resident missed two doses of Admelog insulin and one dose of Tresiba on the day following admission. Interviews with the resident, a registered nurse, and the Director of Nursing confirmed the missed doses and the unavailability of the medications in the facility's emergency stock. Resident #45, who had moderately impaired cognition and was admitted with diagnoses including low back pain and seizures, was administered naloxone without a physician's order. The resident was found nonresponsive but breathing, and a nurse administered naloxone, which increased the resident's responsiveness before being sent to the hospital. The Director of Nursing confirmed that there was no order for naloxone and no documented history of substance abuse that would necessitate its administration, indicating the medication was given in error.
Failure to Administer Up-to-Date Pneumococcal Vaccinations
Penalty
Summary
The facility failed to ensure that residents were offered and received up-to-date pneumococcal vaccinations, as required by CDC guidelines. This deficiency was identified during a review of medical records and interviews with staff. Specifically, two residents, one with intact cognition and another with moderately impaired cognition, were affected. Resident #43, who had diagnoses including hypertension and intellectual disabilities, received a dose of Pneumovax 23 in 2018 but was not offered or administered any subsequent pneumococcal vaccines. Similarly, Resident #3, diagnosed with chronic obstructive pulmonary disease and muscle weakness, received a dose of Pneumovax 23 in 2014, with no further pneumococcal vaccines documented. The Director of Nursing confirmed that these residents had not been offered or received the recommended PCV15 or PCV20 vaccines, which should be administered at least one year after the last dose of Pneumovax 23. The facility's policy, revised in March 2022, stated that pneumococcal vaccines should be administered in accordance with CDC recommendations. However, the facility did not adhere to these guidelines, as evidenced by the lack of updated vaccinations for the affected residents. This oversight was identified through a combination of record reviews, staff interviews, and a review of CDC online resources.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Wheelersburg
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Concord Health & Rehab Ctr | 0.6 mi | ★★★★★ | 0 | 0 |
| River Run Healthcare Of Portsmouth | 7.5 mi | ★★★★★ | 1 | 1 |
| South Shore Nursing And Rehabilitation | 7.6 mi | ★★★★★ | 0 | 0 |
| Crystal Care Center Of Franklin Furnace | 7.6 mi | ★★★★★ | 10 | 0 |
| Bridgeport Health Care Center | 7.8 mi | ★★★★★ | 9 | 0 |
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