Above average — CMS composite of the measures below.
The next survey window likely opens around March 2027
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 Complete Care At Dawnview Llc during CMS and state inspections, most recent first.
Survey Results Not Easily Accessible: The facility failed to keep the most recent state inspection results clearly visible to residents and visitors. During observation, the results were stored in a wall-mounted box but were obscured by a folder labeled concerns, and the DON later acknowledged that the box lacked a proper label and the results could not be located without assistance.
PASARR screening did not accurately capture mental health diagnoses for four residents before admission. Record review showed that initial PASARRs missed Major Depressive Disorder, Bipolar II, and PTSD diagnoses, and no additional PASARRs were on file. The DOSS verified the omissions and that new PASARRs had not been completed.
Unsafe Room Clutter and Bedside Storage Hazards: Surveyors observed multiple resident rooms with books, papers, boxes, and personal items on the floor and under beds, creating narrow walking paths and trip hazards for residents and staff. In some rooms, items under the bed prevented the bed from lowering fully for safe exit, transfer, and transitioning in and out of bed, and one room had boxes blocking access to the heating/cooling control. The DON confirmed the clutter around the beds and noted the residents were care-planned for hoarding behaviors.
Expired Food Handler Certification for Dietary Staff: A cook worked multiple shifts with an expired food handler's certification. Surveyors confirmed the certification had lapsed and was not renewed until later, and the Administrator verified the cook did not have a valid food handler's certification or a ServSafe certification.
Food was not handled and served according to professional food safety standards during dining room service. Serving trays were reused between residents without being sanitized, and a resident aide was observed handling residents’ food with bare hands while serving two residents at the same table. The aide and ADON both acknowledged the improper practices.
Unfinished drywall, peeling paint, loose or cracked caulking, stained flooring, scuff marks, and hanging baseboard trim were observed in resident rooms #100, #102, and #205. The Administrator and Environmental Manager acknowledged the room and bathroom issues during a walkthrough, and the Environmental Manager stated she would send a list to maintenance for repairs.
A resident’s loud TV was discussed in Resident Council meetings by multiple residents, but the concern was not entered into the formal grievance process. The facility’s grievance policy allowed verbal complaints to a staff member or Grievance Official, yet record review found no reported grievance for the issue, and the Admin confirmed the concern was not advanced.
A resident was discharged, but the EMR did not show that the required MDS Discharge assessment had been completed or submitted. During interview, the MDS Coordinator confirmed the omission and stated the assessment had not been completed or sent.
A facility failed to ensure the nurse staffing post form was easily accessible to residents and included the required census information and nursing staff hours worked. Surveyors observed the form placed between the outer entrance door and the lobby door, and the DON acknowledged that another form in the hall also lacked the required census information.
The facility failed to maintain a clean and homelike environment due to improper storage and maintenance of wheelchairs. A foul odor and debris were found on wheelchairs stored at the end of a hall, affecting several residents. The DON confirmed the issue and presented a blank cleaning schedule, indicating non-compliance with cleaning protocols.
The facility failed to update care plans for two residents, resulting in deficiencies. One resident's care plan did not reflect multiple falls, dehydration, anemia, and the discontinuation of an anticoagulant. Another resident's care plan was not updated to include hospice services and inaccurately documented long-term insulin use. These issues were confirmed by the DON during the survey.
A treatment cart in the facility was found unlocked and unattended behind the nurses' station, accessible to residents, including those who wander. Despite being informed, the DON left the cart unsecured, and it remained so for an extended period. An inventory revealed various medical supplies and medications, posing a potential risk to residents.
The facility failed to properly store and label food, as observed during a kitchen investigation. An open bag of elbow macaroni and loose tea bags were found without dates, and a can of coffee was discovered rusty and dirty without an open date. These deficiencies were confirmed by the CDM.
The facility failed to properly investigate allegations of abuse and neglect involving two residents. In one case, interviews were conducted without obtaining employee signatures, and in another, missing funds were not reported to the police. The facility's policy requires thorough investigation and notification of appropriate agencies, which was not followed.
The facility failed to document mental health diagnoses for two residents in the PASARR process. One resident's PTSD and dementia were not recorded, despite being noted in hospital records. Another resident's paranoid schizophrenia was omitted from the PASARR. The Social Worker lacked access to necessary systems, and the Admissions Director struggled to obtain complete records from a recent hospitalization.
A resident, incapacitated due to severe cognitive impairment, was improperly allowed to appoint a family friend as her POA, witnessed by facility staff. The resident's husband, initially her healthcare surrogate, was later declared incapacitated, and the facility failed to follow proper procedures in appointing the family friend as the new surrogate. This led to a change in the resident's code status without the correct process.
The facility failed to maintain accurate medical records for two residents regarding their transfer dates to acute care facilities. One resident's record inaccurately documented a transfer date months earlier than the actual event, while another resident's record showed incorrect dates for two separate transfers. These discrepancies were confirmed by the DON.
A facility failed to protect a non-communicative resident from sexual abuse by another resident with severe cognitive impairment. Despite staff intervention, the incident was not reported to the NHA or authorities within the required timeframe, violating the facility's abuse policy. Both residents involved had severe cognitive impairments, and the delay in reporting highlighted a breakdown in communication and protocol adherence.
A resident with severe cognitive impairment was caught attempting non-consensual contact with another incapacitated resident. Although staff intervened, the incident was not reported to the NHA or state agency within the required two-hour timeframe, leading to a deficiency citation.
A resident with respiratory failure experienced a lapse in oxygen supply for about 20 minutes due to improper connection and an empty portable tank. The resident called for help, and staff eventually restored the oxygen supply, stabilizing the resident's condition. The facility was cited for failing to ensure continuous oxygen availability.
Survey Results Not Easily Accessible
Penalty
Summary
The facility failed to ensure that the most recent state inspection results were easily accessible to residents and visitors without having to ask. During an entry observation on 04/13/2026 at 12:47 PM, the most recent state inspection results were found stored in a wall-mounted box but obscured by a folder labeled concerns, so the results were not clearly visible to residents or visitors. In a follow-up interview on 04/14/2026 at 12:25 PM, the DON acknowledged that the survey results box lacked a proper label and that the state inspection results could not be located without assistance. The facility census was 61.
PASARR Screening Failed to Capture Mental Health Diagnoses
Penalty
Summary
PASARR screening for mental disorders or intellectual disabilities was not completed accurately for four new residents prior to admission. Record review showed that Resident #7’s initial PASARR did not capture a diagnosis of Major Depressive Disorder, Resident #1’s initial PASARR did not capture a diagnosis of Bipolar II, Resident #30’s PASARR did not capture a diagnosis of Major Depressive Disorder, and Resident #45’s initial PASARR did not capture a diagnosis of PTSD. For each of these residents, there were no other PASARRs on file. The Director of Social Services verified for each resident that the initial PASARR failed to include the documented mental health diagnosis and that a new PASARR had not been completed. The deficiency was identified during record review and staff interview as part of the survey process, and it affected 4 of 22 residents reviewed.
Unsafe Room Clutter and Bedside Storage Hazards
Penalty
Summary
The facility failed to maintain a safe, accident hazard free environment for residents when multiple rooms contained clutter and stored items around and under beds. During a facility walk-through, surveyors observed books, papers, boxes, and other personal items on the floor and under beds in several resident rooms, including residents #33, #52, #36, #38, #45, and #3. These items created narrow walking paths, trip and fall hazards, and made normal movement and resident care difficult in the rooms. Surveyors also observed that boxes under beds prevented some beds from being lowered fully, which affected safe exit, transfer, and transitioning in and out of bed for residents #36 and #45. In resident #3's room, boxes surrounded the bed and were lined along the wall in front of the heating/cooling unit, creating a trip and fall hazard and blocking access to the air/heating control. The DON confirmed that items were on the floor around residents' beds and stated the residents were care-planned for hoarding behaviors.
Expired Food Handler Certification for Dietary Staff
Penalty
Summary
The facility failed to provide dietary staff with a proper food handlers certification. During record review and staff interview, surveyors found that Cook #20 did not have a valid food handler's certification because it expired on March 6, 2026 and was not renewed until April 14, 2026. The Mineral County Health Department confirmed that dietary staff in a long-term care facility must have a valid food handler's certification and stated that once it expires, it is expired. Healthcare Services Group, INC. job descriptions also stated that employees must maintain a current food handler's certification as required by state/county law. Cook #20 was scheduled to work on multiple dates between March 8, 2026 and April 12, 2026 while the certification was expired, and the Administrator verified that Cook #20 did not hold a valid food handler's certification and did not have a ServSafe certification.
Improper Food Handling and Tray Sanitization During Dining Service
Penalty
Summary
Food was not distributed and served in accordance with professional standards for food safety during dining room service. During observation, serving trays were being used to serve residents, then trash was placed on the trays, dumped into the trash, and the same trays were reused without being sanitized before serving the next resident. In addition, a resident aide was observed serving and assisting two residents at the same table while handling corn bread with bare hands, spreading butter, and removing brownies from a baggie without gloves. The resident aide acknowledged she should not have handled the residents' food without wearing gloves, and the ADON acknowledged the trays had not been sanitized between residents and that the employee had not been wearing gloves while handling resident food.
Unfinished Repairs and Visible Damage in Resident Rooms
Penalty
Summary
The facility failed to provide a clean, comfortable, and homelike environment in resident rooms #100, #102, and #205. During survey observations, Room #100 had black scuff marks on the left wall near the bathroom door, unfinished drywall patching around the light switch and on the bathroom wall, peeling paint above the sink, loose caulking around the sink and counter, and stained tile on the floor around the wall and under the sink. Room #102 had unfinished drywall under the light on the back wall above the sink, loose caulking around the sink and counter, stains on the floor under the sink and down the right side wall, cracked bathroom caulking around the sink, and loose, hanging baseboard trim on the back wall under the window. In Room #205, during a resident interview, surveyors observed long black scuff marks on the left side wall near the bathroom door, unfinished drywall marks on the wall to the right of the bathroom door, cracked and loose caulking around the sink, and loose, hanging baseboard trim on the back wall under the window. During a walkthrough with the Administrator and Environmental Manager, the manager acknowledged the observed issues in rooms #100, #102, and #205 and stated she would send a list to maintenance for repairs.
Failure to Process Resident Council Grievances
Penalty
Summary
The facility failed to report verbal grievances raised during Resident Council meetings through its formal grievance process. Review of the facility’s Resident and Family Grievances policy showed that grievances could be voiced verbally to a staff member or Grievance Official. Interviews with Residents #68, #3, #13, and #54 revealed that concerns about Resident #8’s loud television disrupting other residents were discussed in Resident Council meetings. Review of Resident Council meeting minutes confirmed that the issue was discussed on October 22, 2025 and November 19, 2025, but a record review found no reported grievances regarding this matter. The Administrator confirmed in interview that the concerns were discussed in Resident Council but were not advanced to the formal grievance process.
Late MDS Discharge Submission
Penalty
Summary
The facility failed to ensure that MDS Discharge assessments were completed and submitted in a timely fashion for a discharged resident. Record review showed that Resident #46 was discharged from the facility on 08/21/24, but the electronic record did not reflect that a Minimum Data Set (MDS) Discharge assessment had been completed or submitted. During interview on 04/14/26 at 2:07 PM, the MDS Coordinator confirmed that the MDS Discharge assessment had not been completed and submitted for Resident #46 and stated she would immediately address that oversight.
Nurse Staffing Post Not Accessible and Missing Required Census Information
Penalty
Summary
The facility failed to ensure the nurse staffing post form, including the required census information, was easily accessible to residents. On 04/13/2026 at 11:00 AM, surveyors observed the post staffing form located between the outer entrance door and the lobby door, which made it inaccessible to residents. The form also did not include the required census information or nursing staff hours worked. During an interview on 04/15/2026 at 12:48 PM, the DON acknowledged that the post did not list the required census information and was not easily accessible to residents, and stated that another form in the hall also did not list the required census information.
Deficiency in Wheelchair Maintenance and Storage
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment due to improper storage and maintenance of wheelchairs. During a survey, a foul odor was detected at the end of the 100-hall near the conference room, where several wheelchairs were stored. Upon inspection, the wheelchairs and their cushions were found to have debris and a dried substance, contributing to the unpleasant smell. The wheelchairs were labeled with residents' names, indicating they were assigned to specific individuals. The Director of Nursing (DON) was informed of the issue and confirmed the presence of the foul odor and debris on the wheelchairs. Although the DON mentioned a cleaning schedule for the wheelchairs, the schedule presented was blank, indicating a lack of adherence to the cleaning protocol. This deficiency affected multiple residents, as their wheelchairs were stored in the area with the noted issues. No additional information was provided during the survey process.
Failure to Update Care Plans for Residents
Penalty
Summary
The facility failed to revise the care plans for two residents, leading to deficiencies in their care management. For one resident, the care plan did not reflect multiple falls with injuries, abnormal laboratory results indicating dehydration and anemia, the administration of intravenous fluids, and the discontinuation of an anticoagulant. These omissions were confirmed by the Director of Nursing (DON) during the survey process, who acknowledged that the care plan should have been updated to reflect these significant changes in the resident's condition. For another resident, hospice services were ordered, but the care plan was not updated to include this change. Additionally, there was a discrepancy in the care plan regarding the long-term use of insulin, which had been discontinued. The DON confirmed that the care plan was outdated and had not been revised to reflect the resident's current medical status. These findings were confirmed during the survey, highlighting a failure in maintaining accurate and up-to-date care plans for residents.
Unsecured Treatment Cart Poses Hazard
Penalty
Summary
The facility failed to maintain a secure environment by having a treatment cart that did not lock properly on three separate occasions. The treatment cart was observed unlocked behind the nurses' station, an area accessible to residents, including those who wander. Despite being notified, the Director of Nursing acknowledged the issue but left the cart unsecured, stating that maintenance would be called. The cart remained unlocked and unattended for an extended period, during which time no staff were observed monitoring the area. An inventory of the unlocked treatment cart revealed various medical supplies and medications, including germicidal wipes, antifungal powder, ointments, creams, and other treatment items. The presence of these items in an unsecured cart posed a potential risk, especially with four residents known to wander in the vicinity. Two residents approached the surveyors during the inventory process, indicating the accessibility of the area to residents. The facility's failure to secure the treatment cart and provide adequate supervision contributed to the deficiency.
Food Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to store and label food in accordance with professional standards for food service safety, which had the potential to affect more than a limited number of residents. During an investigation of the Nutrition Pantry, several deficiencies were observed. An open bag of elbow macaroni and a bag of loose tea bags were found without any dates. Additionally, a loose tea bag was found lying outside of its bag. A can of ground roast coffee with a best by date of 02/29/24 was discovered without an open date, and the can was rusty and dirty on the bottom. These findings were confirmed by the Certified Dietary Manager (CDM) during the kitchen investigation.
Deficient Investigation of Abuse and Neglect Allegations
Penalty
Summary
The facility failed to thoroughly investigate allegations of abuse and neglect involving two residents. In the case of Resident #11, the facility administrator conducted interviews with four employees regarding an incident but did not have the employees sign the statements. The administrator stated that interviews were conducted over the phone, which was her standard practice, and she did not usually have employees sign the statements. This lack of proper documentation and acknowledgment by the employees indicates a deficiency in the investigation process. For Resident #38, the resident reported $100 missing from his lockbox, which he kept locked with a key around his neck. The facility's investigation included 15 staff interviews, but 13 of these interviews lacked documentation of the interviewer's name or signature, and none were signed by the interviewed staff. The administrator acknowledged these deficiencies and admitted that she did not contact the police regarding the allegation of misappropriation of funds. The facility's policy requires thorough investigation and notification of appropriate agencies, which was not fully adhered to in this case. The facility's policy for abuse, neglect, and exploitation requires immediate reporting and thorough investigation of such allegations. However, in both cases, the facility did not follow its own procedures, resulting in incomplete investigations and failure to notify law enforcement in the case of misappropriation of funds. These actions and inactions led to the identified deficiencies during the survey process.
Failure to Document Mental Health Diagnoses in PASARR
Penalty
Summary
The facility failed to properly identify and document mental health diagnoses for two residents upon admission, as required by the Preadmission Screening and Resident Review (PASARR) process. For Resident #42, the diagnoses of PTSD and dementia were not indicated on the initial PASARR, despite the hospital's history and physical (H&P) report listing dementia as a past medical history since November 2021. The Social Worker admitted to not having access to the necessary systems to attach the diagnosis list and acknowledged that summaries were not redone upon residents' arrival from the hospital. The Admissions Director also acknowledged the oversight and expressed an intention to improve the process. For Resident #36, the initial PASARR dated March 2022 only listed dementia, omitting a diagnosis of paranoid schizophrenia. The Admissions Director attempted to obtain the most recent PASARR from a hospitalization in July 2024 but only received the signature page without the diagnosis details. The failure to include the diagnosis of paranoid schizophrenia in the PASARR was confirmed during the survey process, indicating a lapse in the facility's admission procedures and documentation practices.
Improper Appointment of Healthcare Surrogate
Penalty
Summary
The facility failed to follow proper procedures in appointing a healthcare surrogate for a resident who was incapacitated. The resident, who had been admitted to the facility after a hospital stay, was determined by both the hospital and the facility's physician to lack the capacity to make medical decisions due to severe cognitive impairment. Despite this, the resident signed paperwork to appoint a family friend as her Power of Attorney (POA), witnessed by facility staff, even though she had a Brief Interview for Mental Status (BIMS) score of 3, indicating severe cognitive impairment. This action was acknowledged by the Director of Nursing (DON) and Business Office Manager (BOM) as inappropriate, given the resident's incapacity. Additionally, the resident's husband, who was initially appointed as her healthcare surrogate, was later declared incapacitated himself. The facility then allowed the newly appointed POA, a family friend, to change the resident's code status to Do Not Resuscitate (DNR) without following the proper healthcare surrogate selection process. The facility's administrator admitted that the decision to appoint the family friend as POA was made without the necessary procedural steps, as the paperwork was completed before the husband was deemed incapacitated. This oversight led to a deficiency in the facility's handling of advance directives and healthcare surrogate appointments.
Inaccurate Transfer Dates in Medical Records
Penalty
Summary
The facility failed to maintain accurate and complete medical records for two residents regarding their transfer dates to acute care facilities. For Resident #28, the medical record inaccurately documented a transfer date of 06/29/24, while the actual transfer occurred on 08/11/24. This discrepancy was confirmed by the Director of Nursing (DON) upon review. Similarly, for Resident #36, the medical record showed incorrect transfer dates. The resident was transferred on 10/04/24, but the form indicated 09/04/24, and another transfer on 10/27/24 was incorrectly recorded as 10/04/24. These inaccuracies were also confirmed by the DON during the review process.
Failure to Report and Protect Residents from Sexual Abuse
Penalty
Summary
The facility failed to protect a non-communicative resident from sexual abuse by another resident, which was not reported in a timely manner. On March 29, a registered nurse observed a resident with severe cognitive impairment attempting to inappropriately touch another incapacitated resident. Despite intervening and redirecting the perpetrator, the nurse did not report the incident to the Nursing Home Administrator (NHA) or any other authority until April 1, which was beyond the required two-hour reporting window. The incident involved two residents, both with severe cognitive impairments and no noted behaviors of concern in their recent assessments. The victim was unable to communicate, and the perpetrator had no verbal communication abilities. The staff, including nurse aides, were aware of the incident and took steps to separate the residents and monitor the perpetrator, but the failure to report the incident promptly to the appropriate authorities constituted a significant deficiency. The delay in reporting the incident meant that the facility did not comply with its policy on abuse, neglect, and exploitation, which mandates immediate reporting of such allegations. The NHA was not informed until days later, and the state agency received the initial report even later, highlighting a breakdown in communication and adherence to protocol within the facility.
Delayed Reporting of Resident-to-Resident Sexual Abuse
Penalty
Summary
The facility failed to report an allegation of sexual abuse within the required two-hour timeframe. The incident involved a resident who was caught with his hand inside the shirt of another incapacitated resident. The intervention occurred while the hand was near the waistline on the abdomen, and the resident was attempting to reach further. Staff were aware of the situation and redirected the resident multiple times throughout the day. However, the Registered Nurse (RN) involved did not notify anyone about the incident until several days later, delaying the report to the Nursing Home Administrator (NHA) and the state agency. The residents involved both had severe cognitive impairments, with diagnoses including dementia and depression. The victim had a Brief Interview for Mental Status (BIMS) score indicating severe cognitive loss, and the perpetrator also had a BIMS score indicating severe cognitive loss with no verbal communication. Despite the staff's awareness and intervention, the failure to report the incident promptly led to a deficiency being cited during a complaint investigation.
Failure to Ensure Continuous Oxygen Supply
Penalty
Summary
The facility failed to ensure a continuous oxygen supply for a resident, leading to a deficiency in respiratory care. The incident involved a resident with multiple diagnoses, including respiratory failure, who was found without a functioning oxygen supply for approximately 20 minutes. The resident had been returned to her room by a nursing assistant after an incontinent episode, and the oxygen tank was switched due to being empty. However, the oxygen concentrator was not properly connected, and the portable tank was also empty. The resident expressed difficulty breathing and called a family member, who then contacted the facility and emergency services. A nursing assistant overheard the resident calling 911 and found the resident in respiratory distress. The oxygen concentrator was initially off, and the portable tank was empty. Another nursing assistant managed to turn the concentrator on, and the resident's oxygen levels returned to normal. The resident refused to be transported to the hospital by ambulance. The facility's maintenance checked the concentrator and found it functioning correctly, with no issues reported for other residents on oxygen therapy. The deficiency was substantiated as the facility failed to ensure oxygen was available as ordered, resulting in a citation at F695.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 273 citations issued within 25 miles in the last 12 months — including the 3 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Fort Ashby
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Cumberland Healthcare Center | 9.5 mi | ★★★★★ | 27 | 1 |
| Devlin Manor Nursing And Rehabilitation Center | 9.7 mi | ★★★★★ | 29 | 0 |
| Lions Rehab Center | 10 mi | ★★★★★ | 34 | 0 |
| Allegany Health Nursing And Rehab | 10.8 mi | ★★★★★ | 19 | 0 |
| Egle Nursing Home | 11.4 mi | ★★★★★ | 31 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Complete Care At Dawnview Llc.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.