Fort Ashby, WV

Complete Care At Dawnview LLC

3-star overall rating with 3-star inspections with $42,982 in total fines with 8 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle

1 Diane Drive, Fort Ashby, WV

(304) 298-3602

Compare this facility

Overall

3 / 5

CMS overall stars

Health inspections

3 / 5

Survey and complaint cycles

Staffing

2 / 5

RN + nurse staffing

Quality measures

4 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

Certified beds

Average residents

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

Complete Care

Operator or chain grouping

Approved since

1998-06-15

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Chain footprint

85 facilities

Chain averages 3 overall / 3 health / 3 staffing / 4 quality stars

Changed ownership

Within the last 12 months

Family council

Yes

Resident and family council reported

Sprinklers

Yes

Automatic sprinklers in all required areas

Staffing

Hours and turnover

RN hours / resident day

0.62

Registered nurse staffing · state 0.71 · national 0.68

LPN hours / resident day

0.60

Licensed practical nurse staffing · state 0.92 · national 0.87

Aide hours / resident day

2.48

Nurse aide staffing · state 2.07 · national 2.35

Total nurse hours

3.70

All reported nurse hours · state 3.69 · national 3.89

Licensed hours

1.22

RN + LPN hours · state 1.62 · national 1.54

Weekend hours

3.21

Weekend nurse staffing · state 3.18 · national 3.43

Weekend RN hours

0.30

Weekend registered nurse coverage · state 0.39 · national 0.47

Physical therapist

0.10

Reported PT staffing · state 0.05 · national 0.07

Adjusted RN hours

0.53

CMS adjusted RN staffing hours

Adjusted total hours

3.17

CMS adjusted total nurse staffing hours

Case-mix index

1.59

Higher values indicate more complex resident acuity

RN turnover

69%

Annual RN turnover · state 40% · national 45%

Total nurse turnover

57%

Annual nurse turnover · state 43% · national 46%

SNF VBP

Value-based purchasing

Program rank

10,848

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

18.89

Composite VBP score used to determine payment impact.

Payment multiplier

0.9821

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

Baseline 17.57% · Performance 21.46% · Measure score 0 · Achievement 0 · Improvement 0

Healthcare-associated infections

3.50

Baseline 8.24% · Performance 6.94% · Measure score 3.50 · Achievement 2.98 · Improvement 3.50

Total nurse turnover

1.31

Baseline 57.75% · Performance 58.33% · Measure score 1.31 · Achievement 1.31 · Improvement 0

Adjusted total nurse staffing

2.75

Baseline 3.39 hours · Performance 3.86 hours · Measure score 2.75 · Achievement 2.75 · Improvement 1.46

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	11.34%	10.72% 0.6 pts worse	No Different than the National Rate · Eligible stays 86 · Observed rate 15.12% · Lower 95% interval 7.75%
Discharge to community	53.14%	50.57% 2.6 pts better	No Different than the National Rate · Eligible stays 81 · Observed rate 43.21% · Lower 95% interval 43.09%
Medicare spending per beneficiary	1.29	1.02 0.3 pts worse
Drug regimen review with follow-up	100%	95.27% 4.7 pts better	Numerator 72 · Denominator 72
Falls with major injury	0%	0.77% 0.8 pts better	Numerator 0 · Denominator 72
Discharge self-care score	66.67%	53.69% 13 pts better	Numerator 30 · Denominator 45
Discharge mobility score	68.89%	50.94% 18 pts better	Numerator 31 · Denominator 45
Pressure ulcers or injuries, new or worsened	2.78%	2.29% 0.5 pts worse	Numerator 2 · Denominator 72 · Adjusted rate 2.85%
Healthcare-associated infections requiring hospitalization	6.94%	7.12% 0.2 pts better	No Different than the National Rate · Eligible stays 78 · Observed rate 7.69% · Lower 95% interval 4.46%
Staff COVID-19 vaccination coverage	18.42%	8.2% 10.2 pts better	Numerator 14 · Denominator 76
Staff flu vaccination coverage	75%	42% 33 pts better	Numerator 63 · Denominator 84
Discharge function score	73.33%	56.45% 16.9 pts better	Numerator 33 · Denominator 45
Transfer of health information to provider	100%	95.95% 4 pts better	Numerator 24 · Denominator 24
Transfer of health information to patient	Not Available	96.28%	Numerator Not Available · Denominator 17 · Too few residents or stays to report publicly.
Resident COVID-19 vaccinations up to date	25%	25.2% 0.2 pts worse	Numerator 9 · Denominator 36

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Number of hospitalizations per 1000 long-stay resident days	1.6	1.9 0.3 pts better	1.9 0.3 pts better	Long Stay · 20240701-20250630 · Adjusted 1.6 · Observed 2.2 · Expected 2.7 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days	2.2	1.9 0.3 pts worse	1.8 0.4 pts worse	Long Stay · 20240701-20250630 · Adjusted 2.2 · Observed 2.7 · Expected 2.1 · Used in QM five-star
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	99.0%	96.7% 2.3 pts better	93.4% 5.6 pts better	Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 98.0% · Q4 98.1% · 4Q avg 99.0%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	100.0%	97.6% 2.4 pts better	95.5% 4.5 pts better	Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0%
Percentage of long-stay residents experiencing one or more falls with major injury	5.0%	4.5% 0.5 pts worse	3.3% 1.7 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 1.9% · Q2 4.2% · Q3 8.2% · Q4 5.8% · 4Q avg 5.0% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	23.6%	6.8% 16.8 pts worse	11.4% 12.2 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 38.1% · Q2 32.5% · Q3 8.9% · Q4 17.0% · 4Q avg 23.6%
Percentage of long-stay residents who lose too much weight	9.0%	6.6% 2.4 pts worse	5.4% 3.6 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 10.6% · Q2 2.4% · Q3 6.1% · Q4 16.0% · 4Q avg 9.0%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	22.1%	27.0% 4.9 pts better	19.6% 2.5 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 24.5% · Q2 24.4% · Q3 20.4% · Q4 19.2% · 4Q avg 22.1%
Percentage of long-stay residents who received an antipsychotic medication	12.8%	15.5% 2.7 pts better	16.7% 3.9 pts better	Long Stay · 2024Q4-2025Q3 · Q1 21.6% · Q2 22.6% · Q3 7.5% · Q4 2.4% · 4Q avg 12.8% · Used in QM five-star
Percentage of long-stay residents who were physically restrained	0.0%	0.2% 0.2 pts better	0.1% 0.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0%
Percentage of long-stay residents whose ability to walk independently worsened	32.3%	19.5% 12.8 pts worse	16.3% 16 pts worse	Long Stay · 2024Q4-2025Q3 · Q4 0.0% · 4Q avg 32.3% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	25.6%	17.6% 8 pts worse	14.9% 10.7 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 34.8% · Q2 39.0% · Q3 16.7% · Q4 11.6% · 4Q avg 25.6% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	0.5%	0.5% About the same	1.0% 0.5 pts better	Long Stay · 2024Q4-2025Q3 · Q1 2.1% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.5% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection	0.5%	1.8% 1.3 pts better	1.7% 1.2 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.0% · Q4 0.0% · 4Q avg 0.5% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	29.4%	22.4% 7 pts worse	19.8% 9.6 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 29.6% · Q2 39.9% · Q3 31.4% · Q4 17.8% · 4Q avg 29.4%
Percentage of long-stay residents with pressure ulcers	3.2%	4.7% 1.5 pts better	5.1% 1.9 pts better	Long Stay · 2024Q4-2025Q3 · Q1 1.2% · Q2 2.7% · Q3 2.7% · Q4 6.2% · 4Q avg 3.2% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	75.6%	78.8% 3.2 pts worse	81.7% 6.1 pts worse	Short Stay · 2024Q4-2025Q3 · Q1 76.2% · Q2 68.9% · Q3 78.9% · Q4 80.0% · 4Q avg 75.6%
Percentage of short-stay residents who had an outpatient emergency department visit	8.8%	12.4% 3.6 pts better	12.0% 3.2 pts better	Short Stay · 20240701-20250630 · Adjusted 8.8% · Observed 8.8% · Expected 11.1% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication	0.0%	1.1% 1.1 pts better	1.6% 1.6 pts better	Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	82.6%	79.4% 3.2 pts better	79.7% 2.9 pts better	Short Stay · 2024Q3-2025Q2 · 4Q avg 82.6%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	19.4%	23.0% 3.6 pts better	23.9% 4.5 pts better	Short Stay · 20240701-20250630 · Adjusted 19.4% · Observed 19.3% · Expected 23.8% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2024-11-06 · Fire 2024-11-06

8 health deficiencies

Top issue: Resident Assessment and Care Planning (3 deficiencies)

4 fire-safety deficiencies

Top issue: Smoke (4 deficiencies)

Cycle 2 Health 2023-01-10 · Fire 2023-01-10

18 health deficiencies

Top issue: Pharmacy Service (6 deficiencies)

0 fire-safety deficiencies

No concentrated fire-safety issue counts in this cycle.

Cycle 3 Health 2021-09-15 · Fire 2021-09-15

14 health deficiencies

Top issue: Resident Rights (5 deficiencies)

0 fire-safety deficiencies

No concentrated fire-safety issue counts in this cycle.

Fire safety

Fire-safety citations

F · Potential for more than minimal harm 2024-11-06

K331 · Smoke Deficiencies

Fire Safety

Construct fire resistant interior walls.

Corrected 2024-11-25

C · Minimal harm 2024-11-06

K321 · Smoke Deficiencies

Fire Safety

Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

Corrected 2024-11-25

C · Minimal harm 2024-11-06

K324 · Smoke Deficiencies

Fire Safety

Provide properly protected cooking facilities.

Corrected 2024-11-25

C · Minimal harm 2024-11-06

K345 · Smoke Deficiencies

Fire Safety

Have approved installation, maintenance and testing program for fire alarm systems.

Corrected 2024-11-25

Inspection history

Recent health citations

E · Potential for more than minimal harm 2024-11-06

F584 · Resident Rights Deficiencies

Health

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Corrected 2024-12-14

E · Potential for more than minimal harm 2024-11-06

F657 · Resident Assessment and Care Planning Deficiencies

Health

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Corrected 2024-12-14

E · Potential for more than minimal harm 2024-11-06

F689 · Quality of Life and Care Deficiencies

Health

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected 2024-12-14

E · Potential for more than minimal harm 2024-11-06

F812 · Nutrition and Dietary Deficiencies

Health

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Corrected 2024-11-25

D · Potential for more than minimal harm 2024-11-06

F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Respond appropriately to all alleged violations.

Corrected 2024-12-14

D · Potential for more than minimal harm 2024-11-06

F644 · Resident Assessment and Care Planning Deficiencies

Health

Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.

Corrected 2024-12-14

D · Potential for more than minimal harm 2024-11-06

F745 · Quality of Life and Care Deficiencies

Health

Provide medically-related social services to help each resident achieve the highest possible quality of life.

Corrected 2024-12-14

D · Potential for more than minimal harm 2024-11-06

F842 · Resident Assessment and Care Planning Deficiencies

Health

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Corrected 2024-12-14

J · Immediate jeopardy 2024-04-10

F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Corrected 2024-06-14

J · Immediate jeopardy 2024-04-10

F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Corrected 2024-06-14

D · Potential for more than minimal harm 2024-04-10

F695 · Quality of Life and Care Deficiencies

Health

Provide safe and appropriate respiratory care for a resident when needed.

Corrected 2024-06-14

E · Potential for more than minimal harm 2023-01-10

F755 · Pharmacy Service Deficiencies

Health

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Corrected 2023-03-02

E · Potential for more than minimal harm 2023-01-10

F759 · Pharmacy Service Deficiencies

Health

Ensure medication error rates are not 5 percent or greater.

Corrected 2023-03-02

E · Potential for more than minimal harm 2023-01-10

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2023-03-02

E · Potential for more than minimal harm 2023-01-10

F908 · Environmental Deficiencies

Health

Keep all essential equipment working safely.

Corrected 2023-03-02

D · Potential for more than minimal harm 2023-01-10

F550 · Resident Rights Deficiencies

Health

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Corrected 2023-03-02

D · Potential for more than minimal harm 2023-01-10

F583 · Resident Rights Deficiencies

Health

Keep residents' personal and medical records private and confidential.

Corrected 2023-03-02

D · Potential for more than minimal harm 2023-01-10

F584 · Resident Rights Deficiencies

Health

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Corrected 2023-03-02

D · Potential for more than minimal harm 2023-01-10

F656 · Resident Assessment and Care Planning Deficiencies

Health

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Corrected 2023-03-02

D · Potential for more than minimal harm 2023-01-10

F688 · Quality of Life and Care Deficiencies

Health

Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.

Corrected 2023-03-02

D · Potential for more than minimal harm 2023-01-10

F695 · Quality of Life and Care Deficiencies

Health

Provide safe and appropriate respiratory care for a resident when needed.

Corrected 2023-03-02

D · Potential for more than minimal harm 2023-01-10

F744 · Quality of Life and Care Deficiencies

Health

Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.

Corrected 2023-03-02

D · Potential for more than minimal harm 2023-01-10

F756 · Pharmacy Service Deficiencies

Health

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

Corrected 2023-03-02

D · Potential for more than minimal harm 2023-01-10

F758 · Pharmacy Service Deficiencies

Health

Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

Corrected 2023-03-02

D · Potential for more than minimal harm 2023-01-10

F760 · Pharmacy Service Deficiencies

Health

Ensure that residents are free from significant medication errors.

Corrected 2023-03-02

D · Potential for more than minimal harm 2023-01-10

F761 · Pharmacy Service Deficiencies

Health

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Corrected 2023-03-02

E · Potential for more than minimal harm 2021-09-15

F578 · Resident Rights Deficiencies

Health

Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

Corrected 2021-11-12

E · Potential for more than minimal harm 2021-09-15

F732 · Nursing and Physician Services Deficiencies

Health

Post nurse staffing information every day.

Corrected 2021-11-12

E · Potential for more than minimal harm 2021-09-15