Above average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
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 Minnie Hamilton Health Care during CMS and state inspections, most recent first.
A resident council interview and unit observation showed residents did not know how to file a grievance and had no grievance forms readily available on the unit. An AD later retrieved a concern form from a file cabinet and stated she did not know the forms had to be available for residents to access on their own.
A CNA was observed standing while assisting a resident with lunch in the dining room. When told this was a dignity issue, the CNA said she could not get a chair, then obtained one and continued the meal assist. The issue was confirmed with the CEO.
A resident with contractures to both hands had a physician order for hand rolls due to immobility, contractures, and seizures, and the care plan listed hand rolls as an intervention. However, surveyors observed the resident without the hand rolls in place, and an LPN confirmed they were not on as written in the care plan.
The facility failed to follow physician orders for two residents. One resident had two unwitnessed falls, including one where she was found beside the bed and another where she was found on the floor wrapped in blankets, but no ordered neuro checks were documented after either event. Another resident with hand contractures and a physician order for hand rolls was observed without the hand rolls in place, and an LPN confirmed they were not on as ordered.
A resident with a history of CVA, non-ambulatory status, poor condition, and deconditioning had natural teeth with cavities, inflamed/bleeding gums, and teeth appearing broken off at the gum line. Record review showed earlier dental assessments marked no problems, while later assessments documented obvious cavities and inflamed gums. An LPN/medical record auditor stated no dental consult could be found and that the facility only obtained a consult if a problem was found or reported.
A resident in an LTC facility suffered neglect when staff failed to identify and report a suspicious area on her breast, which was later diagnosed as melanoma. Despite daily care, the area was not documented or followed up on until the resident pointed it out during a dermatology appointment. The DON admitted that some staff noticed the area but did not notify the physician, and the issue was not addressed in QAPI meetings.
A resident's melanoma went unnoticed by facility staff despite regular care, as no documentation or physician notification was made regarding a visible spot on her breast. The issue was only identified during a dermatology appointment, leading to a biopsy and diagnosis.
A resident at high risk for skin breakdown developed pressure ulcers despite having a care plan in place. The resident experienced significant weight loss, and the discontinuation of a nutritional supplement may have contributed to the ulcers. The facility did not conduct a root cause analysis or discuss the issue in Quality Assurance meetings, and no protein levels were checked to ensure adequate nutrition.
The facility failed to implement adverse event monitoring and performance improvement activities, affecting all residents. A resident's melanoma was not documented by staff, and the incident was not reported to state officials. The facility also did not fill a weekend RN position, impacting care quality. The DON prioritized hiring an MDS Coordinator over the RN role and did not monitor quality areas beyond re-hospitalizations.
The facility's QAA committee was found non-compliant due to the absence of the Medical Director or an appropriate designee and the Administrator at meetings. The CNO was improperly serving dual roles, and the Administrator's substitutes lacked authority to make necessary system changes, violating CMS guidelines.
The facility failed to update care plans for two residents following significant changes in their medical conditions. One resident was diagnosed with severe depression with psychotic symptoms, but the care plan was not revised to address this. Another resident developed pressure ulcers, but the care plan did not reflect necessary interventions despite physician orders. The DON acknowledged the care plans lacked a comprehensive, person-centered approach.
The facility's medication error rate was 7.41%, exceeding the acceptable 5%. An LPN administered incorrect water flush amounts for a PEG tube feeding and insulin outside the prescribed time window for two residents.
The facility failed to properly store pans in the kitchen, as observed when three wet pans were stacked together after washing and sanitizing. The Dietary Manager confirmed that the pans should have been dried before storage. This deficiency had the potential to affect more than a minimum number of residents in the facility.
The facility failed to properly clean and disinfect shared glucometers according to the manufacturer's instructions. An LPN used an alcohol pad instead of the recommended germicidal wipes, and the DON acknowledged the facility's non-compliance with its own policy, resulting in a deficiency in infection prevention and control.
A resident's melanoma diagnosis was delayed due to the facility's failure to report and document a visible spot on her breast. Despite staff noticing the area, it was not reported to a physician, violating the facility's neglect policy.
The facility did not accommodate wheelchair-bound residents by placing the Ombudsman information board too high for them to read. This was confirmed by staff interviews, including a Nurse Aide/Activity Director and the DON, who acknowledged the board's inaccessibility.
A resident experienced significant weight loss and developed pressure ulcers while receiving enteral feedings. Despite having a care plan, the facility failed to comprehensively assess the resident using the CMS-specified RAI process. The resident's weight continued to decline, and the DON acknowledged the need for a comprehensive assessment but did not complete it, believing the pressure ulcers were healing.
A facility failed to complete a new PASARR for a resident diagnosed with major depressive disorder, recurrent severe with psychotic symptoms. Despite the resident being admitted with a correct PASARR, the new diagnosis was not reflected in an updated PASARR or care plan. This oversight was confirmed by the DON during the survey.
A resident at high risk for skin breakdown did not have their care plan updated to address new pressure ulcers and significant weight loss. Despite interventions like PEG tube feeding, the care plan was not revised to reflect the resident's changing condition, leading to a deficiency noted by surveyors.
The facility failed to securely store Schedule II-V drugs requiring refrigeration, as observed during a medication administration with an LPN. These controlled drugs were not in a box permanently affixed to the medication refrigerator. The DON acknowledged the issue and was unsure how to resolve it without damaging the refrigerator.
A facility failed to report an alleged neglect incident involving a resident's undiagnosed melanoma to state agencies. Staff did not document or notify a physician about a suspicious area on the resident's breast, which was later diagnosed as melanoma. The Director of Nursing acknowledged the failure to implement the facility's reporting policy, and the incident was not reviewed in quality management meetings.
Resident Grievance Access Not Made Available
Penalty
Summary
The facility failed to ensure residents knew how to file a grievance and that they could do so anonymously if desired. During the Resident Council meeting, the residents stated they did not know how to file a grievance. An observation on the unit found that no grievance forms were readily available to residents. During an interview, the Activity Director went behind the nurses' station, retrieved a concern form from a file cabinet, and stated that she did not know the forms had to be available for residents to get on their own.
Failure to Maintain Resident Dignity During Meal Assistance
Penalty
Summary
The facility failed to treat a resident with respect and dignity during a meal when Certified Nurse Aide #28 was observed standing in the dining room while assisting Resident #14 with lunch. During the observation on 08/12/2025 at 12:23 PM, the CNA stated she could not get a chair in the dining room. The observer told the CNA that she could move the resident if needed but could not stand while assisting because it was a dignity issue. The CNA then obtained a chair and continued assisting the resident. This was confirmed with the Chief Executive Officer on 08/12/2025 at 1:15 PM.
Care Plan Not Followed for Hand Rolls
Penalty
Summary
Failure to develop and implement a complete care plan for Resident #16 related to hand rolls for contractures was identified during survey. Resident #16 had contractures to both hands, and the physician’s order directed hand rolls to both hands due to immobility, contractures, and seizures. Although the care plan dated 07/09/25 included hand rolls to both hands as an intervention, an observation on 08/12/25 found the resident in a geri chair watching television without the hand rolls in place as ordered. During interview, LPN #37 stated therapy usually puts them on after splints and was unsure, and confirmed the resident did not have the hand rolls on as written in the care plan.
Failure to Follow Orders for Post-Fall Neuro Checks and Hand Rolls
Penalty
Summary
The facility failed to follow physician orders for neurological checks after unwitnessed falls for Resident #10. The resident had an unwitnessed fall on 4/29/25 at about 10:30 PM and was found on her knees beside the bed holding a blanket, with the pad hanging off the side of the bed and the wedge on the floor. The event summary noted severe thunderstorms in the area and that the resident would jump and grab the nurse’s arm when thunder boomed. A second fall occurred on 6/13/25, when the resident was found lying on the floor beside the bed wrapped in blankets and asleep, with the bed in the lowest position and the call light on the bed; the event summary stated the resident had rolled out of bed. The facility policy required neurological checks for 72 hours after an unwitnessed fall, but no neurological checks were documented for either event, which was confirmed by the Licensed Social Worker. The facility also failed to follow a physician order for Resident #16. An observation showed the resident had contractures to both hands, and the physician order required hand rolls to both hands due to immobility, contractures, and seizures. The resident was observed sitting in a Geri Chair watching television without the hand rolls in place as ordered. The care plan also included hand rolls to both hands due to immobility and contractures. During interview, an LPN stated therapy usually puts them on after splints, but was not sure, and confirmed the resident did not have the hand rolls on as written in the physician order.
Failure to Obtain Dental Services for a Resident With Dental Problems
Penalty
Summary
The facility failed to promptly provide and/or obtain routine and emergency dental services for a Medicaid-funded resident. During observation, the resident was lying in bed and his teeth appeared to be broken off at the gum line. Record review showed earlier dental assessment worksheets marked that he had no problems with his teeth or gums, but a later worksheet marked obvious cavities and inflamed or bleeding gums. A readmission assessment also documented that he had his own teeth and inflamed gums. The resident’s care plan identified that he had a self-care deficit related to a history of CVA, was non-ambulatory, and had poor condition and deconditioning, with natural teeth, cavities, and occasional bleeding gums. The plan included dental consult as needed and gentle mouth care due to the history of bleeding gums. During interview, the LPN/medical record auditor stated that no dental consult could be found for the resident and that the facility only obtained a consult if a problem was found or reported, adding that the resident likely would not be able to tell staff if he had a problem.
Neglect in Identifying Resident's Skin Condition
Penalty
Summary
The facility failed to ensure a resident was not neglected, resulting in actual physical harm. A resident had an area on her breast that was not identified by the facility staff, despite being showered and dressed daily. This area was later biopsied and diagnosed as melanoma. The resident and her MPOA attended a dermatology appointment for skin irritations on her face, during which the resident herself pointed out the spot on her breast, leading to the biopsy. The facility's records showed no documentation of the area on the resident's breast prior to this appointment, and the weekly summaries by nursing staff did not mention it. During an interview, the DON acknowledged that some staff had noticed the area and reported it, but no follow-up notification was made to the physician. The area was not identified as a concern in the weekly skin assessments conducted by the facility's nursing staff. The incident had not been discussed or reviewed in the facility's Quality Assurance and Performance Improvement (QAPI) meetings, and no audits were performed to ensure that weekly skin assessments were being conducted properly.
Failure to Identify and Report Skin Condition
Penalty
Summary
The facility failed to provide necessary services to a resident, resulting in physical harm. A resident had an area on her breast that was not identified by the facility staff, despite receiving regular baths and assistance with dressing. The resident and her MPOA attended a dermatology appointment for skin irritations on her face, during which the resident requested the dermatologist to examine a spot on her breast. This led to a biopsy and a diagnosis of melanoma. The facility's records showed no prior documentation or notification to the physician regarding the area on the resident's breast. During an interview, the DON acknowledged that some staff had noticed the area and reported it, but no follow-up action was taken. The weekly summaries conducted by the nursing staff did not identify the area as a concern requiring attention. The lack of documentation and communication resulted in a delay in addressing the resident's condition, which was only brought to the facility's attention after the dermatology appointment.
Failure to Prevent Pressure Ulcers in High-Risk Resident
Penalty
Summary
The facility failed to prevent the development of pressure ulcers in a resident who was at high risk for skin breakdown. The resident was incontinent and dependent on staff for activities of daily living. Despite having a care plan in place to prevent skin impairment, the resident developed pressure ulcers on the coccyx and left foot. The care plan included measures such as weekly skin assessments, monitoring for redness or breakdown, and using moisture barrier cream, but these measures were not effective in preventing the ulcers. The resident experienced significant weight loss over several months, and there was a discontinuation of Prosource, a nutritional supplement, which may have contributed to the development of pressure ulcers. The facility did not conduct a root cause analysis or discuss the issue in their Quality Assurance/Integrated Quality Management meetings. Additionally, no protein, albumin, or prealbumin levels were obtained to ensure the resident was receiving adequate nutrition to maintain healthy skin.
Deficiency in Adverse Event Monitoring and RN Staffing
Penalty
Summary
The facility failed to implement adverse event monitoring and performance improvement program activities, which had the potential to affect all residents. A specific incident involved a resident whose Medical Power of Attorney (MPOA) raised concerns about an area on the resident's breast discovered during a dermatology visit. The staff failed to recognize and document this area, which was later diagnosed as melanoma requiring surgery. The Director of Nursing (DON) and the Director of Quality Assurance (DOQA) acknowledged that the incident was not reported to state officials and was not presented to their Quality Assurance/Integrated Quality Management meeting, despite identifying areas for improvement. Additionally, the facility was approved for a waiver to have a Registered Nurse (RN) on weekends, but the position remained vacant. The Human Resources department and the DON did not make sufficient efforts to recruit for this position, relying primarily on job postings on Indeed.com, which yielded minimal applicants. The DON prioritized hiring a Minimum Data Set (MDS) Coordinator RN over filling the weekend RN position, despite acknowledging that the weekend RN role would provide more direct care and potentially improve the quality of care for residents. The DON also failed to monitor quality of care areas beyond re-hospitalizations, such as urinary tract infections, pressure ulcers, pneumonia, falls, and nutrition declines. Although a Plan Do Check Act (PDCA) plan was in place to monitor these areas, the DON did not report monthly as required and discontinued the plan after six months, even though the weekend RN position remained vacant. This lack of comprehensive monitoring and reporting contributed to the deficiency in ensuring quality care for residents.
Non-compliance in QAA Committee Attendance
Penalty
Summary
The facility failed to maintain a compliant Quality Assessment and Assurance (QAA) committee, as discovered during a Long Term Care survey. The deficiency was identified due to the absence of the Medical Director or an appropriate designee and the Administrator at the QAA meetings. The Director of Nursing (DON) revealed that the Chief Nurse Officer (CNO) was acting as the Medical Director's designee while also serving as the Infection Control Nurse, which is not permissible according to CMS guidelines. The guidelines specify that the Medical Director's designee cannot hold another required role, such as the Infection Control Nurse, which the CNO was fulfilling. Additionally, the facility's Administrator was not attending the QAA meetings, and instead, the Social Worker/System Practice Administrator and the Executive Assistant were attending in their place. However, these individuals did not have the authority to make changes to the facility systems, which is a requirement for the role of the Administrator in these meetings. The DON acknowledged that the attendance of these individuals did not meet the compliance requirements as outlined by CMS guidelines.
Failure to Update Care Plans for Residents with New Diagnoses
Penalty
Summary
The facility failed to update the care plan for two residents following significant changes in their medical conditions. Resident #8 was diagnosed with major depressive disorder, recurrent, severe with psychotic symptoms, but the care plan was not updated to address this new diagnosis. The Director of Nursing confirmed that the care plan had not been revised to include interventions for managing the resident's mental health condition. Resident #11 developed pressure areas, including a pressure ulcer on the left foot and coccyx breakdown, but the care plan was not updated to reflect the necessary interventions for these conditions. Despite physician orders for specific treatments and the use of an air mattress, the care plan remained unchanged. The Director of Nursing acknowledged that the care plan did not reflect a comprehensive, person-centered approach to the resident's care needs.
Medication Error Rate Exceeds 5% Due to Incorrect Administration
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with a reported rate of 7.41% during the Long-Term Survey Process. This deficiency was observed in two out of five residents. For Resident #07, an LPN administered a PEG tube feeding with an incorrect amount of water flush. The physician's order specified 110 ml of water before and after the feeding, totaling 220 ml. However, the LPN administered 420 ml of water, acknowledging the error after being questioned by the surveyor. For Resident #15, the LPN obtained a blood sugar reading at an incorrect time and administered insulin outside the prescribed one-hour window. The order required blood sugar checks before meals and at bedtime, with a sliding scale for insulin administration. The LPN administered 4 units of Novolin R insulin based on a blood sugar reading of 286, but this was done outside the designated time frame, as acknowledged by another LPN.
Improper Storage of Wet Pans in Kitchen
Penalty
Summary
The facility failed to ensure that pans were being stored properly in the kitchen. During an observation, it was noted that three pans, which had been washed and sanitized, were stacked together while still wet. This improper storage practice was confirmed by the Dietary Manager, who acknowledged that the pans should have been dried before being stored. This deficiency was identified during a random observation and had the potential to affect more than a minimum number of residents in the facility, which had a census of 24 at the time of the survey.
Improper Cleaning of Shared Glucometers
Penalty
Summary
The facility failed to ensure the safe cleaning and disinfection of glucometers, which were shared among residents. During an observation, an LPN was seen using an alcohol pad to clean a glucometer after performing a blood glucose test on a resident. The LPN was unsure about the dwell time required for the alcohol pad to be effective. The facility's policy stated that cleaning and maintenance processes should follow the manufacturer's recommendations, which specified the use of Clorox Germicidal Wipes or Super Sani-Cloth Germicidal Disposable Wipes for cleaning and disinfecting the glucometers. Upon further investigation, the Director of Nursing (DON) acknowledged that the facility staff were using alcohol pads instead of the recommended germicidal wipes. The manufacturer's instructions explicitly stated not to use any other cleaning or disinfecting solution besides the specified wipes. The DON admitted that the facility had not been adhering to the policy and procedure for cleaning and disinfecting reusable resident care equipment, leading to a deficiency in infection prevention and control.
Failure to Report and Document Skin Condition Leads to Neglect
Penalty
Summary
The facility failed to develop and implement written policies and procedures to prohibit and prevent neglect, which had the potential to affect more than an isolated number of residents. A specific incident involved a resident who had a dermatology appointment for skin irritations on her face, during which a spot on her breast was discovered and diagnosed as melanoma. The resident's MPOA expressed concern that the spot, which was clearly visible and should have been reported and treated, was not mentioned by the facility staff, despite the resident receiving regular baths and assistance with dressing. The investigation revealed that while some staff noticed the area and reported it, there was no documentation or notification made to the physician for follow-up. The Director of Nursing acknowledged that the area on the resident's breast was not identified as an area of concern requiring follow-up during the weekly summaries performed by the facility nursing staff. This lack of documentation and reporting was a violation of the facility's abuse/neglect policy, which mandates that all allegations of neglect be appropriately reported and investigated.
Ombudsman Information Inaccessible to Wheelchair Residents
Penalty
Summary
The facility failed to accommodate the needs of wheelchair-bound residents by not posting the Ombudsman information at an accessible height. During a random observation, it was noted that the Board of Notice for Resident's Rights and Ombudsman information was placed too high for residents in wheelchairs to see and read. This was confirmed by an interview with a Nurse Aide/Activity Director, who acknowledged the issue. Additionally, the Director of Nursing also recognized that the board was positioned too high for residents to view.
Failure to Assess Significant Change in Resident Condition
Penalty
Summary
Resident #11 experienced a significant change in condition, including a notable weight loss while receiving enteral feedings and the development of two pressure ulcers. The resident, who was admitted with diagnoses such as Diabetes Mellitus, Dementia, Depression, Schizophrenia, and lung disease, was at high risk for skin breakdown. Despite having a care plan in place to prevent skin impairment, the resident developed pressure ulcers on the coccyx and left foot. Weekly nursing summaries documented the resident's deteriorating skin condition, but there was no corresponding documentation in the physician's progress notes regarding these skin issues. Treatment orders for the pressure areas were eventually written, but the facility failed to comprehensively assess the resident using the CMS-specified Resident Assessment Instrument (RAI) process. Additionally, the resident's weight was monitored, revealing a consistent decline over several months. Despite being fed via a gastrostomy tube with Glucerna 1.5, the resident's weight continued to decrease. The Registered Dietician noted the resident's weight loss and feeding intolerance but did not make further nutritional recommendations. The Director of Nursing acknowledged the significant change in the resident's condition, which required a comprehensive assessment, but admitted that no significant change was completed on the Minimum Data Set (MDS) because the pressure ulcers were thought to be healing after reintroducing Prosource.
Failure to Update PASARR for New Diagnosis
Penalty
Summary
The facility failed to complete a new Preadmission Screening and Resident Review (PASARR) for a resident who received a new medical diagnosis of major depressive disorder, recurrent severe with psychotic symptoms. This deficiency was identified during a record review and staff interview, which revealed that the resident was admitted with a correct PASARR. However, after the resident was diagnosed with major depressive disorder, a new PASARR was not completed, and the care plan was not updated accordingly. The Director of Nursing confirmed this oversight during the survey.
Failure to Update Resident Care Plan for Skin Breakdown and Nutritional Needs
Penalty
Summary
The facility failed to ensure that a comprehensive, person-centered care plan was developed and implemented for a resident, identified as Resident #11, to address their medical, physical, mental, and psychosocial needs. The resident was at high risk for skin breakdown, as noted in their care plan, which included interventions such as assisting with turning and repositioning, conducting weekly skin assessments, and providing incontinence care with moisture barrier cream. However, the care plan was not reviewed or revised to reflect the resident's changing condition, including the development of pressure ulcers and a significant weight loss over six months. The resident's medical records indicated a decline in meal intake, leading to the initiation of a PEG tube feeding regimen. Despite this, the resident experienced skin breakdown, including a pressure ulcer on the coccyx and the left foot, and a decrease in weight. The facility's Director of Nursing acknowledged that the care plan did not reflect a comprehensive approach and had not been updated to include new interventions for the resident's pressure injuries. This lack of timely review and revision of the care plan contributed to the deficiency identified during the survey process.
Deficiency in Secure Storage of Controlled Medications
Penalty
Summary
The facility failed to ensure the safe and secure storage of medications, specifically Schedule II-V drugs requiring refrigeration. During a medication administration observation with an LPN, it was noted that these controlled drugs were not stored in a box permanently affixed to the medication refrigerator. This deficiency was confirmed during an interview with the Director of Nursing, who acknowledged the issue and expressed uncertainty about how to fix it without damaging the refrigerator.
Failure to Report Alleged Neglect and Document Skin Condition
Penalty
Summary
The facility failed to report an alleged violation of neglect to the appropriate state agencies, as required by their policy. This deficiency was identified during a review of a complaint made by the Medical Power of Attorney (MPOA) for a resident. The complaint involved a failure by the facility staff to recognize and document a suspicious area on the resident's breast, which was later diagnosed as melanoma. Despite some staff noticing the area, there was no documentation or notification to the physician for follow-up, and the issue was not identified during the weekly skin assessments conducted by the nursing staff. The Director of Nursing (DON) acknowledged that the incident should have been reported to the state agencies and that the facility's policy on reporting allegations of neglect was not implemented in this case. Additionally, the incident was not discussed or reviewed in the facility's Quality Assurance/Integrated Quality Management meeting, and no audits were performed to ensure compliance with the skin assessment procedures outlined in a letter to the resident's MPOA. The lack of documentation and reporting led to a delay in addressing the resident's medical condition, which required surgical intervention.
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 56 citations issued within 25 miles in the last 12 months — 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 Grantsville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Glenville Health & Rehab | 14.7 mi | ★★★★★ | 15 | 0 |
| Roane General Hospital | 16.7 mi | ★★★★★ | 14 | 0 |
| Miletree Center | 16.8 mi | ★★★★★ | 10 | 0 |
| Elizabeth Care Center | 18.3 mi | ★★★★★ | 11 | 0 |
| Pine View Center | 20 mi | ★★★★★ | 6 | 0 |
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