01 / INSPECTION LEDGER
Survey cycles in this release
| Cycle | Health date | Health deficiencies | Fire date | Fire deficiencies |
|---|---|---|---|---|
| Cycle 1 | 2025-06-05 | 10 | 2025-06-05 | 4 |
| Cycle 2 | 2024-07-25 | 23 | 2024-07-25 | 5 |
| Cycle 3 | 2023-02-15 | 4 | 2023-02-15 | 3 |
CMS CCN 5151742026-08-01 PROCESSING DATE
NURSING HOME PUBLIC RECORD
Complete Care At Oak Ridge Llc
1000 Association Drive · Charleston, WV 25311 · Kanawha County
Certified beds74CMS provider file
Recent citation rows49current CMS citation release
Penalty rows1current CMS penalties file
Read this record carefully.
The citation files cover the three most recent standard inspections plus qualifying complaint and infection-control inspections in the prior three years. A correction date is a CMS field; this site does not independently verify conditions. Absence from a file is not proof that no issue exists.
02 / CITATION DETAIL
49 rows in the current release
1 rows carry G–L scope/severity codes; 0 carry J–L. 9 tag codes appear on more than one survey date. These counts describe citation rows, not residents or incidents.
2025-06-05 · FIREE0006Severity C · widespread; potential for minimal harm
Emergency Preparedness Deficiencies
Conduct risk assessment and an All-Hazards approach.
Correction field: Deficient, Provider has date of correction · 2025-07-012025-06-05 · FIREE0039Severity C · widespread; potential for minimal harm
Emergency Preparedness Deficiencies
Conduct testing and exercise requirements.
Correction field: Deficient, Provider has date of correction · 2025-07-012025-06-05 · HEALTHF0557Severity E · pattern; potential for more than minimal harm
Resident Rights Deficiencies
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
Correction field: Deficient, Provider has date of correction · 2025-06-212025-06-05 · HEALTHF0585Severity E · pattern; potential for more than minimal harm
Resident Rights Deficiencies
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Correction field: Deficient, Provider has date of correction · 2025-06-212025-06-05 · HEALTHF0644Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Correction field: Deficient, Provider has date of correction · 2025-06-212025-06-05 · HEALTHF0684Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Correction field: Deficient, Provider has date of correction · 2025-06-212025-06-05 · HEALTHF0689Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Correction field: Deficient, Provider has date of correction · 2025-06-212025-06-05 · HEALTHF0803Severity C · widespread; potential for minimal harm
Nutrition and Dietary Deficiencies
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Correction field: Deficient, Provider has date of correction · 2025-06-212025-06-05 · HEALTHF0807Severity D · isolated; potential for more than minimal harm
Nutrition and Dietary Deficiencies
Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration.
Correction field: Deficient, Provider has date of correction · 2025-06-212025-06-05 · HEALTHF0812Severity E · pattern; potential for more than minimal harm
Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Correction field: Deficient, Provider has date of correction · 2025-06-212025-06-05 · HEALTHF0842Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Correction field: Deficient, Provider has date of correction · 2025-06-212025-06-05 · HEALTHF0921Severity D · isolated; potential for more than minimal harm
Environmental Deficiencies
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Correction field: Deficient, Provider has date of correction · 2025-06-212025-06-05 · FIREK0345Severity C · widespread; potential for minimal harm
Smoke Deficiencies
Have approved installation, maintenance and testing program for fire alarm systems.
Correction field: Deficient, Provider has date of correction · 2025-07-012025-06-05 · FIREK0918Severity F · widespread; potential for more than minimal harm
Gas, Vacuum, and Electrical Systems Deficiencies
Have generator or other power source capable of supplying service within 10 seconds.
Correction field: Deficient, Provider has date of correction · 2025-07-012024-07-25 · HEALTHF0550Severity E · pattern; potential for more than minimal harm
Resident Rights Deficiencies
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Correction field: Deficient, Provider has date of correction · 2024-09-042024-07-25 · HEALTHF0552Severity D · isolated; potential for more than minimal harm
Resident Rights Deficiencies
Ensure that residents are fully informed and understand their health status, care and treatments.
Correction field: Deficient, Provider has date of correction · 2024-09-042024-07-25 · HEALTHF0580Severity D · isolated; potential for more than minimal harm
Resident Rights Deficiencies
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Correction field: Deficient, Provider has date of correction · 2024-09-042024-07-25 · HEALTHF0600Severity E · pattern; potential for more than minimal harm
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Correction field: Deficient, Provider has date of correction · 2024-09-042024-07-25 · HEALTHF0607Severity E · pattern; potential for more than minimal harm
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Correction field: Deficient, Provider has date of correction · 2024-09-042024-07-25 · HEALTHF0609Severity E · pattern; potential for more than minimal harm
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Correction field: Deficient, Provider has date of correction · 2024-09-042024-07-25 · HEALTHF0623Severity D · isolated; potential for more than minimal harm
Resident Rights Deficiencies
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Correction field: Deficient, Provider has date of correction · 2024-09-042024-07-25 · HEALTHF0625Severity E · pattern; potential for more than minimal harm
Resident Rights Deficiencies
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Correction field: Deficient, Provider has date of correction · 2024-09-042024-07-25 · HEALTHF0644Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Correction field: Deficient, Provider has date of correction · 2024-09-042024-07-25 · HEALTHF0656Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Correction field: Deficient, Provider has date of correction · 2024-09-0403 / ENFORCEMENT FILE
Penalties reported by CMS
Fine amounts and payment-denial days are shown exactly as aggregated from the current penalties file. They do not imply an unpaid balance.
| Date | Type | Fine amount | Payment-denial days |
|---|---|---|---|
| 2024-07-25 | Fine | $16,039 | 0 |
04 / OWNERSHIP DISCLOSURES
Who appears in the CMS file
- PC WV OPCOS LLCOrganization · 5% OR GREATER DIRECT OWNERSHIP INTEREST100% · since 06/01/2021
- PC WTA OPCO HOLDCO LLCOrganization · 5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDED · since 05/01/2021
- SMS 2021 TRUSTOrganization · 5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDED · since 06/01/2021
- STEIN, SHALOMIndividual · INDIRECT OWNERSHIP INTERESTNOT APPLICABLE · since 06/01/2021
- WELLTOWER INCOrganization · 5% OR GREATER SECURITY INTERESTNOT APPLICABLE · since 07/30/2021
- STEIN, SHALOMIndividual · MANAGING CONTROL - GOVERNING BODYNOT APPLICABLE · since 06/01/2021
- STEIN, SHALOMIndividual · CORPORATE OFFICERNOT APPLICABLE · since 06/01/2021
- BOWDEN, ROYIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 06/01/2021
- COX, VICKIEIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 06/01/2021
- MANSFIELD, MELISSAIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 06/01/2021
- SILVERBERG, NISANELIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 06/01/2021
- TRIANA, JOSEPHIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 06/01/2021
- STEIN, SHALOMIndividual · TRUSTEE OF THE SNFNOT APPLICABLE · since 06/01/2021
- AURORA GUARDIAN HOLDCO II CO-BORROWER, LLCOrganization · ADP OF THE SNFNOT APPLICABLE · since 07/30/2021
- AURORA GUARDIAN HOLDCO II MEZZ BORROWER, LLCOrganization · ADP OF THE SNFNOT APPLICABLE · since 07/30/2021
- AURORA GUARDIAN HOLDCO II, LLCOrganization · ADP OF THE SNFNOT APPLICABLE · since 07/30/2021
- AURORA GUARDIAN II REALTY, LLCOrganization · ADP OF THE SNFNOT APPLICABLE · since 07/30/2021
- AURORA GUARDIAN PARTNERS II LLCOrganization · ADP OF THE SNFNOT APPLICABLE · since 07/30/2021
Names and roles are self-reported CMS disclosure fields. Exact-name pages do not prove that similarly named people or organizations are the same entity.
05 / CMS STAFFING FIELDS
Reported hours and turnover
Staffing fields are provider-reported and case-mix context matters. CMS applies footnotes and exclusions not reproduced as a new score here.
Total nurse hours3.65per resident day
RN hours0.67per resident day
Weekend nurse hours3.21per resident day
Staff turnover51.4%CMS reported field
06 / LOCAL RECORDS
Open the Charleston ledger →