Cycle 1
Health 2025-09-25 · Fire 2025-09-25
12 health deficiencies
Top issue: Resident Assessment and Care Planning (4 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Spencer, WV
Roane General Hospital
5-star overall rating with 4-star inspections with 12 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
200 Hospital Drive, Spencer, WV
(304) 927-4444
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
35
Certified beds
Average residents
33
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1989-02-09
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Hospital-based
Yes
CMS reports the provider resides in a hospital
Staffing
Hours and turnover
RN hours / resident day
0.42
Registered nurse staffing · state 0.71 · national 0.68
LPN hours / resident day
1.52
Licensed practical nurse staffing · state 0.92 · national 0.87
Aide hours / resident day
2.78
Nurse aide staffing · state 2.07 · national 2.35
Total nurse hours
4.72
All reported nurse hours · state 3.69 · national 3.89
Licensed hours
1.94
RN + LPN hours · state 1.62 · national 1.54
Weekend hours
4.01
Weekend nurse staffing · state 3.18 · national 3.43
Weekend RN hours
0.33
Weekend registered nurse coverage · state 0.39 · national 0.47
Physical therapist
0.00
Reported PT staffing · state 0.05 · national 0.07
Adjusted RN hours
0.53
CMS adjusted RN staffing hours
Adjusted total hours
5.84
CMS adjusted total nurse staffing hours
Case-mix index
1.11
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
42%
Annual nurse turnover · state 43% · national 46%
SNF VBP
Value-based purchasing
Program rank
340
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
72.67
Composite VBP score used to determine payment impact.
Payment multiplier
1.0236
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Total nurse turnover
7.65
Baseline 28.57% · Performance 32.43% · Measure score 7.65 · Achievement 7.65 · Improvement 0
Adjusted total nurse staffing
6.89
Baseline 4.43 hours · Performance 5.04 hours · Measure score 6.89 · Achievement 6.89 · Improvement 3.99
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | Not Available |
10.72%
|
Not Available · Eligible stays Not Available · Observed rate Not Available · Lower 95% interval Not Available · No data were submitted for this measure. |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays Not Available · Observed rate Not Available · Lower 95% interval Not Available · No data were submitted for this measure. |
| Medicare spending per beneficiary | Not Available |
1.02
|
No data were submitted for this measure. |
| Drug regimen review with follow-up | Not Available |
95.27%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator Not Available · Adjusted rate Not Available · No data were submitted for this measure. |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays Not Available · Observed rate Not Available · Lower 95% interval Not Available · No data were submitted for this measure. |
| Staff COVID-19 vaccination coverage | 3.45% |
8.2%
4.7 pts worse
|
Numerator 3 · Denominator 87 |
| Staff flu vaccination coverage | 94.04% |
42%
52 pts better
|
Numerator 379 · Denominator 403 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0.3 |
1.9
1.6 pts better
|
1.9
1.6 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.3 · Observed 0.2 · Expected 1.3 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.9 |
1.9
1 pts better
|
1.8
0.9 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.9 · Observed 0.6 · Expected 1.2 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 79.4% |
96.7%
17.3 pts worse
|
93.4%
14 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 41.9% · Q2 90.3% · Q3 93.9% · Q4 90.3% · 4Q avg 79.4% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 90.9% |
97.6%
6.7 pts worse
|
95.5%
4.6 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 90.9% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.4% |
4.5%
2.1 pts better
|
3.3%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.2% · Q2 3.2% · Q3 3.0% · Q4 0.0% · 4Q avg 2.4% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 7.5% |
6.8%
0.7 pts worse
|
11.4%
3.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.6% · Q3 9.7% · Q4 16.7% · 4Q avg 7.5% |
| Percentage of long-stay residents who lose too much weight | 6.1% |
6.6%
0.5 pts better
|
5.4%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.4% · Q2 3.4% · Q3 6.7% · Q4 6.9% · 4Q avg 6.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 22.6% |
27.0%
4.4 pts better
|
19.6%
3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 22.2% · Q2 24.1% · Q3 26.7% · Q4 17.2% · 4Q avg 22.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 11.5% |
15.5%
4 pts better
|
16.7%
5.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.0% · Q2 14.3% · Q3 9.1% · Q4 9.5% · 4Q avg 11.5% · 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 | 29.0% |
19.5%
9.5 pts worse
|
16.3%
12.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 29.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 20.6% |
17.6%
3 pts worse
|
14.9%
5.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 12.0% · Q2 17.9% · Q3 17.9% · Q4 34.6% · 4Q avg 20.6% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.5%
0.5 pts better
|
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% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.8% |
1.8%
1 pts better
|
1.7%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.2% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 15.6% |
22.4%
6.8 pts better
|
19.8%
4.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.4% · Q2 16.2% · Q3 17.3% · Q4 18.4% · 4Q avg 15.6% |
| Percentage of long-stay residents with pressure ulcers | 5.0% |
4.7%
0.3 pts worse
|
5.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.5% · Q2 7.1% · Q3 3.2% · Q4 3.1% · 4Q avg 5.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 36.0% |
78.8%
42.8 pts worse
|
81.7%
45.7 pts worse
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 36.0% |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-12-06 · Fire 2023-12-06
11 health deficiencies
Top issue: Resident Assessment and Care Planning (3 deficiencies)
3 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Cycle 3
Health 2022-05-18 · Fire 2022-05-18
13 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
2025-09-25
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-12-04
C · Minimal harm
2023-12-06
K347 · Smoke Deficiencies
Fire Safety
Properly provide smoke detection systems in areas open to corridors.
Corrected 2024-01-02
C · Minimal harm
2023-12-06
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2024-01-02
C · Minimal harm
2023-12-06
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-01-02
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-09-25
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 2025-11-11
E · Potential for more than minimal harm
2025-09-25
F636 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Corrected 2025-11-11
E · Potential for more than minimal harm
2025-09-25
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 2025-11-11
E · Potential for more than minimal harm
2025-09-25
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-11-11
D · Potential for more than minimal harm
2025-09-25
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 2025-11-11
D · Potential for more than minimal harm
2025-09-25
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2025-11-11
D · Potential for more than minimal harm
2025-09-25
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2025-11-11
D · Potential for more than minimal harm
2025-09-25
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 2025-11-11
D · Potential for more than minimal harm
2025-09-25
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 2025-11-11
D · Potential for more than minimal harm
2025-09-25
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-11-11
D · Potential for more than minimal harm
2025-09-25
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 2025-11-11
D · Potential for more than minimal harm
2025-09-25
F887 · Infection Control Deficiencies
Health
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
Corrected 2025-11-11
E · Potential for more than minimal harm
2023-12-06
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 2024-01-31
E · Potential for more than minimal harm
2023-12-06
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-01-31
D · Potential for more than minimal harm
2023-12-06
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 2024-01-31
D · Potential for more than minimal harm
2023-12-06
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2024-01-31
D · Potential for more than minimal harm
2023-12-06
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 2024-01-31
D · Potential for more than minimal harm
2023-12-06
F637 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident when there is a significant change in condition
Corrected 2024-01-31
D · Potential for more than minimal harm
2023-12-06
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 2024-01-31
D · Potential for more than minimal harm
2023-12-06
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-01-31
D · Potential for more than minimal harm
2023-12-06
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 2024-01-31
D · Potential for more than minimal harm
2023-12-06
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 2024-01-31
D · Potential for more than minimal harm
2023-12-06
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2024-01-31
F · Potential for more than minimal harm
2022-05-18
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 2022-06-24
E · Potential for more than minimal harm
2022-05-18
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 2022-06-24
E · Potential for more than minimal harm
2022-05-18
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 2022-06-24
E · Potential for more than minimal harm
2022-05-18
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-06-24
D · Potential for more than minimal harm
2022-05-18
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2022-06-24
D · Potential for more than minimal harm
2022-05-18
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 2022-06-24
D · Potential for more than minimal harm
2022-05-18
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 2022-06-24
D · Potential for more than minimal harm
2022-05-18
F636 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Corrected 2022-06-24
D · Potential for more than minimal harm
2022-05-18
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 2022-06-24
D · Potential for more than minimal harm
2022-05-18
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 2022-06-24
D · Potential for more than minimal harm
2022-05-18
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 2022-06-24
D · Potential for more than minimal harm
2022-05-18
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 2022-06-24
D · Potential for more than minimal harm
2022-05-18
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 2022-06-24
Penalties and ownership
What sits behind the stars
Ownership
Hospital Development Co.
5% Or Greater Direct Ownership Interest · Organization
Atkinson, Gloria
Corporate Director · Individual
Bentz, Douglas
Corporate Director · Individual
Bentz, Douglas
W-2 Managing Employee · Individual
Boggs, Gregory
Corporate Director · Individual
Downey, William
Corporate Director · Individual
Garrett, Jack
Corporate Director · Individual
Hedges, Christine
Corporate Director · Individual
Hospital Development Co.
Operational/Managerial Control · Organization
Hughes, Paul
Corporate Director · Individual
Mcculty, Jennifer F
Corporate Director · Individual
Ng, Hong-Kin
Corporate Director · Individual
Parkins, Grant
W-2 Managing Employee · Individual
Taylor, John
Corporate Director · Individual
Titus, Gerald
Corporate Director · Individual
Varda, John
Corporate Director · Individual
Zdanek, Robert E.
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
Miletree Center
Spencer, WV
3-star overall rating with 4-star inspections with 10 recent health deficiencies
#2
Elizabeth Care Center
Elizabeth, WV
5-star overall rating with 5-star inspections with 3 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
#3
Minnie Hamilton Health Care
Grantsville, WV
2-star overall rating with 4-star inspections with 5 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
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