Charleston, WV

Complete Care At Oak Ridge LLC

3-star overall rating with 3-star inspections with $16,039 in total fines with 10 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle

1000 Association Drive, Charleston, WV

(304) 347-4372

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

3 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

74

Certified beds

Average residents

72

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

Complete Care

Operator or chain grouping

Approved since

2000-10-01

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

No

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

0.94

Registered nurse staffing · state 0.71 · national 0.68

LPN hours / resident day

0.52

Licensed practical nurse staffing · state 0.92 · national 0.87

Aide hours / resident day

1.98

Nurse aide staffing · state 2.07 · national 2.35

Total nurse hours

3.43

All reported nurse hours · state 3.69 · national 3.89

Licensed hours

1.46

RN + LPN hours · state 1.62 · national 1.54

Weekend hours

2.94

Weekend nurse staffing · state 3.18 · national 3.43

Weekend RN hours

0.36

Weekend registered nurse coverage · state 0.39 · national 0.47

Physical therapist

0.06

Reported PT staffing · state 0.05 · national 0.07

Adjusted RN hours

0.88

CMS adjusted RN staffing hours

Adjusted total hours

3.22

CMS adjusted total nurse staffing hours

Case-mix index

1.46

Higher values indicate more complex resident acuity

RN turnover

47%

Annual RN turnover · state 40% · national 45%

Total nurse turnover

59%

Annual nurse turnover · state 43% · national 46%

SNF VBP

Value-based purchasing

Program rank

11,160

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

Performance score

17.84

Composite VBP score used to determine payment impact.

Payment multiplier

0.9819

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

0

Baseline 19.00% · Performance 21.32% · Measure score 0 · Achievement 0 · Improvement 0

Healthcare-associated infections

4

Baseline 6.95% · Performance 6.64% · Measure score 4 · Achievement 4 · Improvement 1.08

Total nurse turnover

0

Baseline 57.14% · Performance 74.78% · Measure score 0 · Achievement 0 · Improvement 0

Adjusted total nurse staffing

3.13

Baseline 3.86 hours · Performance 3.97 hours · Measure score 3.13 · Achievement 3.13 · Improvement 0.05

SNF QRP

Medicare quality reporting measures

Measure Facility National Note
Potentially preventable 30-day readmission 10.86%
10.72%
0.1 pts worse
No Different than the National Rate · Eligible stays 106 · Observed rate 10.38% · Lower 95% interval 7.99%
Discharge to community 56.48%
50.57%
5.9 pts better
No Different than the National Rate · Eligible stays 80 · Observed rate 53.75% · Lower 95% interval 46.59%
Medicare spending per beneficiary 1.02
1.02
About the same
Drug regimen review with follow-up 100%
95.27%
4.7 pts better
Numerator 65 · Denominator 65
Falls with major injury 3.08%
0.77%
2.3 pts worse
Numerator 2 · Denominator 65
Discharge self-care score 68.42%
53.69%
14.7 pts better
Numerator 26 · Denominator 38
Discharge mobility score 76.32%
50.94%
25.4 pts better
Numerator 29 · Denominator 38
Pressure ulcers or injuries, new or worsened 13.85%
2.29%
11.6 pts worse
Numerator 9 · Denominator 65 · Adjusted rate 11.49%
Healthcare-associated infections requiring hospitalization 6.64%
7.12%
0.5 pts better
No Different than the National Rate · Eligible stays 71 · Observed rate 5.63% · Lower 95% interval 4.23%
Staff COVID-19 vaccination coverage 1.04%
8.2%
7.2 pts worse
Numerator 1 · Denominator 96
Staff flu vaccination coverage 56.76%
42%
14.8 pts better
Numerator 84 · Denominator 148
Discharge function score 71.05%
56.45%
14.6 pts better
Numerator 27 · Denominator 38
Transfer of health information to provider 100%
95.95%
4 pts better
Numerator 34 · Denominator 34
Transfer of health information to patient Not Available
96.28%
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly.
Resident COVID-19 vaccinations up to date 52.78%
25.2%
27.6 pts better
Numerator 19 · Denominator 36

Quality measures

Resident outcomes and process scores

Measure Facility State National Note
Number of hospitalizations per 1000 long-stay resident days 2.7
1.9
0.8 pts worse
1.9
0.8 pts worse
Long Stay · 20240701-20250630 · Adjusted 2.7 · Observed 2.3 · Expected 1.6 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days 3.3
1.9
1.4 pts worse
1.8
1.5 pts worse
Long Stay · 20240701-20250630 · Adjusted 3.3 · Observed 2.7 · Expected 1.4 · Used in QM five-star
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine 99.6%
96.7%
2.9 pts better
93.4%
6.2 pts better
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 98.4% · Q3 100.0% · Q4 100.0% · 4Q avg 99.6%
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 5.5%
4.5%
1 pts worse
3.3%
2.2 pts worse
Long Stay · 2024Q4-2025Q3 · Q1 5.5% · Q2 4.8% · Q3 6.6% · Q4 5.0% · 4Q avg 5.5% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms 12.8%
6.8%
6 pts worse
11.4%
1.4 pts worse
Long Stay · 2024Q4-2025Q3 · Q1 15.7% · Q2 6.7% · Q3 15.5% · Q4 14.0% · 4Q avg 12.8%
Percentage of long-stay residents who lose too much weight 6.2%
6.6%
0.4 pts better
5.4%
0.8 pts worse
Long Stay · 2024Q4-2025Q3 · Q1 6.0% · Q2 7.4% · Q3 5.7% · Q4 5.7% · 4Q avg 6.2%
Percentage of long-stay residents who received an antianxiety or hypnotic medication 23.5%
27.0%
3.5 pts better
19.6%
3.9 pts worse
Long Stay · 2024Q4-2025Q3 · Q1 19.6% · Q2 26.3% · Q3 28.6% · Q4 19.3% · 4Q avg 23.5%
Percentage of long-stay residents who received an antipsychotic medication 13.8%
15.5%
1.7 pts better
16.7%
2.9 pts better
Long Stay · 2024Q4-2025Q3 · Q1 12.2% · Q2 14.9% · Q3 14.9% · Q4 13.0% · 4Q avg 13.8% · 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 14.8%
19.5%
4.7 pts better
16.3%
1.5 pts better
Long Stay · 2024Q4-2025Q3 · Q3 4.5% · 4Q avg 14.8% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased 10.3%
17.6%
7.3 pts better
14.9%
4.6 pts better
Long Stay · 2024Q4-2025Q3 · Q1 6.7% · Q2 5.9% · Q3 10.0% · Q4 18.4% · 4Q avg 10.3% · 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 0.0% · Q2 0.0% · Q3 1.9% · Q4 0.0% · 4Q avg 0.5% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection 0.9%
1.8%
0.9 pts better
1.7%
0.8 pts better
Long Stay · 2024Q4-2025Q3 · Q1 1.9% · Q2 1.7% · Q3 0.0% · Q4 0.0% · 4Q avg 0.9% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence 25.0%
22.4%
2.6 pts worse
19.8%
5.2 pts worse
Long Stay · 2024Q4-2025Q3 · Q1 25.9% · Q2 27.5% · Q3 27.0% · Q4 19.2% · 4Q avg 25.0%
Percentage of long-stay residents with pressure ulcers 4.5%
4.7%
0.2 pts better
5.1%
0.6 pts better
Long Stay · 2024Q4-2025Q3 · Q1 6.5% · Q2 6.8% · Q3 3.4% · Q4 1.3% · 4Q avg 4.5% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine 80.3%
78.8%
1.5 pts better
81.7%
1.4 pts worse
Short Stay · 2024Q4-2025Q3 · Q1 82.1% · Q2 73.4% · Q3 79.7% · Q4 85.3% · 4Q avg 80.3%
Percentage of short-stay residents who had an outpatient emergency department visit 19.0%
12.4%
6.6 pts worse
12.0%
7 pts worse
Short Stay · 20240701-20250630 · Adjusted 19.0% · Observed 21.0% · Expected 12.3% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication 2.7%
1.1%
1.6 pts worse
1.6%
1.1 pts worse
Short Stay · 2024Q4-2025Q3 · Q1 1.9% · Q2 4.7% · Q3 2.2% · Q4 2.2% · 4Q avg 2.7% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine 82.8%
79.4%
3.4 pts better
79.7%
3.1 pts better
Short Stay · 2024Q3-2025Q2 · 4Q avg 82.8%
Percentage of short-stay residents who were rehospitalized after a nursing home admission 25.4%
23.0%
2.4 pts worse
23.9%
1.5 pts worse
Short Stay · 20240701-20250630 · Adjusted 25.4% · Observed 28.4% · Expected 26.6% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-06-05 · Fire 2025-06-05

10 health deficiencies

Top issue: Nutrition and Dietary (3 deficiencies)

4 fire-safety deficiencies

Top issue: Emergency Preparedness (2 deficiencies)

Cycle 2 Health 2024-07-25 · Fire 2024-07-25

23 health deficiencies

Top issue: Resident Rights (5 deficiencies)

5 fire-safety deficiencies

Top issue: Smoke (3 deficiencies)

Cycle 3 Health 2023-02-15 · Fire 2023-02-15

4 health deficiencies

Top issue: Infection Control (1 deficiency)

3 fire-safety deficiencies

Top issue: Egress (1 deficiency)

Fire safety

Fire-safety citations

F · Potential for more than minimal harm 2025-06-05

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2025-07-01

C · Minimal harm 2025-06-05

E39 · Emergency Preparedness Deficiencies

Fire Safety

Conduct testing and exercise requirements.

Corrected 2025-07-01

C · Minimal harm 2025-06-05

E6 · Emergency Preparedness Deficiencies

Fire Safety

Conduct risk assessment and an All-Hazards approach.

Corrected 2025-07-01

C · Minimal harm 2025-06-05

K345 · Smoke Deficiencies

Fire Safety

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

Corrected 2025-07-01

F · Potential for more than minimal harm 2024-07-25

K324 · Smoke Deficiencies

Fire Safety

Provide properly protected cooking facilities.

Corrected 2024-08-07

F · Potential for more than minimal harm 2024-07-25

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2024-08-07

E · Potential for more than minimal harm 2024-07-25

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2024-08-07

D · Potential for more than minimal harm 2024-07-25

K363 · Smoke Deficiencies

Fire Safety

Install corridor and hallway doors that block smoke.

Corrected 2024-08-07

D · Potential for more than minimal harm 2024-07-25

K511 · Services Deficiencies

Fire Safety

Have properly installed electrical wiring and gas equipment.

Corrected 2024-08-07

F · Potential for more than minimal harm 2023-02-15

K222 · Egress Deficiencies

Fire Safety

Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.

Corrected 2023-03-07

D · Potential for more than minimal harm 2023-02-15

K363 · Smoke Deficiencies

Fire Safety

Install corridor and hallway doors that block smoke.

Corrected 2023-03-07

D · Potential for more than minimal harm 2023-02-15

K920 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure proper usage of power strips and extension cords.

Corrected 2023-03-07

Inspection history

Recent health citations

E · Potential for more than minimal harm 2025-06-05

F557 · Resident Rights Deficiencies

Health

Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.

Corrected 2025-06-21

E · Potential for more than minimal harm 2025-06-05

F585 · Resident Rights Deficiencies

Health

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.

Corrected 2025-06-21

E · Potential for more than minimal harm 2025-06-05

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 2025-06-21

D · Potential for more than minimal harm 2025-06-05

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 2025-06-21

D · Potential for more than minimal harm 2025-06-05

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2025-06-21

D · Potential for more than minimal harm 2025-06-05

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 2025-06-21

D · Potential for more than minimal harm 2025-06-05

F807 · Nutrition and Dietary Deficiencies

Health

Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration.

Corrected 2025-06-21

D · Potential for more than minimal harm 2025-06-05

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 2025-06-21

D · Potential for more than minimal harm 2025-06-05

F921 · Environmental Deficiencies

Health

Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

Corrected 2025-06-21

C · Minimal harm 2025-06-05

F803 · Nutrition and Dietary Deficiencies

Health

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.

Corrected 2025-06-21

G · Actual harm 2024-07-25

F692 · Quality of Life and Care Deficiencies

Health

Provide enough food/fluids to maintain a resident's health.

Corrected 2024-09-04

F · Potential for more than minimal harm 2024-07-25

F838 · Administration Deficiencies

Health

Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.

Corrected 2024-09-04

E · Potential for more than minimal harm 2024-07-25

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 2024-09-04

E · Potential for more than minimal harm 2024-07-25

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 2024-09-04

E · Potential for more than minimal harm 2024-07-25

F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Develop and implement policies and procedures to prevent abuse, neglect, and theft.

Corrected 2024-09-04

E · Potential for more than minimal harm 2024-07-25

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 2024-09-04

E · Potential for more than minimal harm 2024-07-25

F625 · Resident Rights Deficiencies

Health

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.

Corrected 2024-09-04

E · Potential for more than minimal harm 2024-07-25

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2024-09-04

E · Potential for more than minimal harm 2024-07-25

F726 · Nursing and Physician Services Deficiencies

Health

Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.

Corrected 2024-09-04

E · Potential for more than minimal harm 2024-07-25

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 2024-09-04

E · Potential for more than minimal harm 2024-07-25

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 2024-09-04

E · Potential for more than minimal harm 2024-07-25

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 2024-09-04

E · Potential for more than minimal harm 2024-07-25

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2024-09-04

E · Potential for more than minimal harm 2024-07-25

F947 · Nursing and Physician Services Deficiencies

Health

Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.

Corrected 2024-09-04

D · Potential for more than minimal harm 2024-07-25

F552 · Resident Rights Deficiencies

Health

Ensure that residents are fully informed and understand their health status, care and treatments.

Corrected 2024-09-04

D · Potential for more than minimal harm 2024-07-25

F580 · Resident Rights Deficiencies

Health

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Corrected 2024-09-04

D · Potential for more than minimal harm 2024-07-25

F623 · Resident Rights Deficiencies

Health

Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

Corrected 2024-09-04

D · Potential for more than minimal harm 2024-07-25

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 2024-09-04

D · Potential for more than minimal harm 2024-07-25

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 2024-09-04

D · Potential for more than minimal harm 2024-07-25

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 2024-09-04

D · Potential for more than minimal harm 2024-07-25

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 2024-09-04

D · Potential for more than minimal harm 2024-07-25

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 2024-09-04

C · Minimal harm 2024-07-25

F732 · Nursing and Physician Services Deficiencies

Health

Post nurse staffing information every day.

Corrected 2024-09-04

E · Potential for more than minimal harm 2023-02-15

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 2023-03-15

D · Potential for more than minimal harm 2023-02-15

F623 · Resident Rights Deficiencies

Health

Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

Corrected 2023-03-15

D · Potential for more than minimal harm 2023-02-15

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2023-03-15

D · Potential for more than minimal harm 2023-02-15

F947 · Nursing and Physician Services Deficiencies

Health

Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.

Corrected 2023-03-15

Penalties and ownership

What sits behind the stars

$16,039 2024-07-25

Fine

Fine · fine $16,039

Fine

Ownership

Pc Wv Opcos LLC

5% Or Greater Direct Ownership Interest · Organization

100% 2 facilities 2021-06-01
Pc Wta Opco Holdco LLC

5% Or Greater Indirect Ownership Interest · Organization

0% 28 facilities 2021-05-01
Peace Capital Holdings LLC (De)

5% Or Greater Indirect Ownership Interest · Organization

0% 57 facilities 2021-06-01
Silverberg, Nisanel

W-2 Managing Employee · Individual

0% 24 facilities 2021-06-01
Sms 2021 Trust

5% Or Greater Indirect Ownership Interest · Organization

0% 63 facilities 2021-06-01
Stein, Shalom

Corporate Officer · Individual

0% 83 facilities 2021-06-01

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Arthur B Hodges Center, The

Charleston, WV

4-star overall rating with 5-star inspections with 5 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle

Overall
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Health
5 / 5
Staffing
5 / 5
Fines
$0
#3

Charleston Healthcare Center

Charleston, WV

3-star overall rating with 2-star inspections with $12,831 in total fines with 23 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle

Overall
3 / 5
Health
2 / 5
Staffing
4 / 5
Fines
$12,831

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