Riverside Valley Of Journey
Inspection history, citations, penalties and survey trends for this long-term care facility in Saint Albans, West Virginia.
- Location
- 6500 Maccorkle Avenue Sw, Saint Albans, West Virginia 25177
- CMS Provider Number
- 515035
- Inspections on file
- 20
- Latest survey
- December 18, 2025
- Citations (last 12 mo.)
- 14
Citation history
Health deficiencies cited at Riverside Valley Of Journey during CMS and state inspections, most recent first.
A resident receiving enteral nutrition had tube feeding equipment at bedside that was not dated as required by physician orders and standard nursing care. Staff confirmed that the syringe and graduate, used for feeding and flushes, should be dated daily and replaced every 24 hours, but this was not done. The DON acknowledged the omission.
A resident with pressure ulcers did not receive prescribed wound care for the sacrum and left thigh, as dressings were not applied according to physician orders. The sacral wound was found without a dressing and soiled, and the left thigh dressing was not completed despite being marked as done on the TAR by an RN. The resident's care plan included interventions for skin integrity, but these were not followed.
Multiple residents did not receive care according to physician orders and professional standards, including missing or incomplete neurological assessments after falls, improper wheelchair transfers without nurse assessment, lack of documentation and adherence to mobility care plans, and administration of insulin despite orders to hold for low blood glucose.
Surveyors found expired milk stored with consumable items, undated and unlabeled crackers in nourishment rooms, and a dietary aide preparing food without a beard net. Staff confirmed that food items were not properly labeled or dated, and that attire requirements were not followed, contrary to facility policy.
A nursing assistant documented that a resident who was mentally intact and able to self-feed had consumed most of her lunch, but direct observation showed the meal was largely untouched. This discrepancy between observed intake and medical record documentation was not clarified by the DON during the survey.
The facility failed to provide timely and proper notification to the State Long Term Care Ombudsman and, in some cases, to residents or their representatives regarding transfers and discharges. In multiple instances, required notices were either not delivered, not documented, or only sent after surveyor intervention, including a case involving a resident who was discharged following threats and illegal drug use. This deficiency was found in all reviewed cases of transfer and hospitalization.
A resident was prescribed Remeron as an appetite stimulant, but the care plan inaccurately documented its use for depression and included interventions for depression despite no diagnosis of depression. The DON confirmed the care plan did not reflect the actual purpose of the medication.
Surveyors found that two residents were exposed to accident hazards: one had unauthorized medication stored at bedside without proper assessment for self-administration, and another, dependent on staff for hygiene and with a history of depression, had multiple disposable razors left accessible in her room. Facility policy was not followed regarding safe storage of medications and sharps.
A resident with a physician's order for a two-handled cup was observed eating lunch with a standard cup lacking handles. The tray ticket specified the need for adaptive equipment, but the required cup was not provided, as confirmed by an RN.
A resident with localized shingles was observed to have contact precautions signage at their room, but a nurse aide entered the room wearing only gloves and not a gown, contrary to facility policy. The resident's care plan required both gloves and gown for contact precautions, but there was no physician's order for contact precautions at the time. The DON confirmed that staff should have followed the posted precautions.
A dependent, non-interviewable resident did not receive scheduled twice-weekly showers, with documentation showing gaps of six and eight days without a shower. Discrepancies between electronic and handwritten records confirmed the missed care, and the DON acknowledged possible documentation errors.
A resident with a known cranberry allergy was served and consumed a beverage containing cranberry juice by a CNA. The incident was documented, and the resident required monitoring and precautionary medication but experienced no adverse effects. Other residents with food allergies reported no similar issues, and staff described existing allergy identification procedures.
The facility failed to maintain a clean and homelike environment, with black substance buildup found on heating units, windowsills, and doorjambs in multiple rooms. A resident's restroom had a bedpan improperly placed in a trash can, and another resident reported inadequate water flow, which was later fixed. Unsanitary conditions, such as grime at the commode base and uncleaned bedside commode buckets, were observed, indicating a lapse in housekeeping protocols.
The facility failed to complete comprehensive MDS assessments for mood and behavior for six residents, with missing sections on cognitive patterns and mood. The Corporate Nurse confirmed these omissions during interviews, noting that assessments were conducted remotely, which may have contributed to the deficiencies.
The facility failed to identify Major Depressive Disorder on the PASSR for two residents. One resident's PASSR included diagnoses of cerebral infarction and other conditions but omitted Major Depressive Disorder, which was diagnosed later. Another resident's PASSR included schizophrenic disorder and bipolar disorder but also missed Major Depressive Disorder. The DON confirmed these omissions.
The facility failed to store medical supplies according to manufacturers' standards, potentially affecting residents. In the Medication Storage Room East, a temperature log was not recorded, and in the West room, temperatures exceeded recommended levels for certain IV medications. This could compromise medication efficacy, as per U.S. Pharmacopeia guidelines.
A facility failed to transmit a discharge MDS for a resident within the required timeframe. The discharge MDS was completed but not transmitted or accepted as required. This deficiency was identified during a record review and confirmed through a staff interview with the DON. The issue had the potential to affect a limited number of residents in the facility.
A facility failed to renew a PASARR for a resident after the original had expired. The resident was admitted with a PASARR marked for three months or less, which was not updated. The DON acknowledged the issue and confirmed the expiration during an interview.
A facility failed to develop a comprehensive care plan for a resident with Schizophrenia, omitting the diagnosis and necessary monitoring. This was confirmed by the DON during a review, risking the resident's quality of life by not addressing their medical, physical, mental, and psychosocial needs.
A facility failed to revise a care plan for a resident regarding their CPR status. The resident's records showed a focus on CPR preference, but the intervention listed was unrelated, indicating a preference to be left alone with family. The DON acknowledged the error and noted it needed correction.
A resident was discharged without a comprehensive discharge summary, including a recapitulation of stay, final status summary, and medication reconciliation. The facility also failed to provide a post-discharge plan of care. The resident refused medication refills, stating they were unnecessary, and expressed dissatisfaction with the discharge process, believing it was due to insurance issues.
A facility failed to maintain accurate transfer records for a resident, with discrepancies found in the dates on transfer forms for two separate hospitalizations. The corporate nurse and DON were informed of the errors and planned to investigate the incorrect dates.
A facility failed to maintain proper infection control during meal service when a nurse aide was observed handling a resident's food with bare hands. The aide stated they sanitize hands between trays, but did not use gloves. The incident was reported to the DON.
The facility failed to maintain an effective pest control program, resulting in a gnat infestation in a resident's room. Gnats were observed on the over bed table, affecting the resident's drinks and pudding. A nurse aide confirmed the issue and stated that the room would be cleaned.
Failure to Date and Replace Tube Feeding Equipment per Physician Orders
Penalty
Summary
Surveyors observed that the facility failed to follow physician orders and standard nursing care practices regarding the management of tube feeding equipment for a resident receiving enteral nutrition. Specifically, on 12/18/25, the tube feeding syringe and graduate container at the resident's bedside, used for tube feeding flushes, residual checks, and administration, were not dated as required. The resident had physician orders for enteral feeding, including instructions to change and date the enteral irrigation syringe and graduate every night shift, and to discard them after 24 hours. Staff interviews confirmed that the equipment should have been dated daily and replaced according to protocol, but this was not done. The Director of Nursing acknowledged that the required dating had not occurred.
Failure to Provide Ordered Pressure Ulcer Care and Accurate Documentation
Penalty
Summary
A deficiency occurred when a resident with pressure ulcers did not receive necessary wound care as ordered by the physician. On observation, the resident was found without a dressing on the sacral wound, which was also soiled due to a bowel movement. The responsible LPN acknowledged the absence of the dressing and indicated that the resident would be cleaned and the dressing applied. Additionally, the dressing for the resident's left thigh wound had not been completed, despite being documented as done on the Treatment Administration Record (TAR) by an RN, who later confirmed that the treatment had not actually been performed. The resident's care plan identified altered skin integrity and a risk for further skin impairment due to underlying conditions such as hemiplegia and cardiovascular disease, with hospice services in place. The plan included interventions such as administering treatments as ordered and monitoring for effectiveness. However, the failure to provide wound care as prescribed and the inaccurate documentation on the TAR led to the resident not receiving the necessary treatment and services to promote healing and prevent infection or new ulcers.
Failure to Follow Physician Orders and Professional Standards of Care
Penalty
Summary
The facility failed to provide treatment and care in accordance with physician orders and professional standards for multiple residents. One resident experienced two unwitnessed falls, but neurological assessments were either missing or incomplete, with several required evaluation intervals not documented. Another resident was observed sitting unsafely on the calf rests of a wheelchair, and two staff members repositioned the resident without a licensed nurse present to assess or guide the transfer, despite the care plan requiring total dependence with two staff and a mechanical lift for transfers. A third resident had physician orders to be encouraged and assisted to be up in a chair and in the dining room for meals, with specific instructions for wheelchair positioning. Observations revealed the resident's wheelchair was not set up as ordered, and documentation for assistance was missing on multiple occasions, as confirmed by the Director of Nursing. Additionally, a fourth resident had a physician order to hold insulin administration if blood glucose was less than 140, but insulin was administered multiple times when blood glucose readings were below this threshold, as shown in the medication administration records and confirmed by the Director of Nursing. These findings were based on record reviews, staff interviews, and direct observations, demonstrating that the facility did not consistently follow physician orders or ensure that care was provided according to professional standards for several residents. The deficiencies included failures in documentation, medication administration, post-fall assessment, and adherence to care plans for mobility and transfers.
Deficient Food Storage, Labeling, and Staff Attire Practices
Penalty
Summary
Surveyors observed multiple deficiencies in food storage and preparation practices within the facility. During an initial kitchen tour, a gallon of milk with a best by date that had already passed was found stored with milk intended for consumption. The Certified Dietary Manager acknowledged the issue and separated the expired milk only after it was pointed out. Additionally, in the nourishment rooms, numerous individually wrapped saltine and graham crackers were found stored in plastic bags and containers without any labeling or expiration dates. These items were not dated or labeled either in the nourishment rooms or in the boxes in which they arrived, as confirmed by staff interviews. Further observations revealed that a dietary aide was preparing food and wrapping silverware on the serving line without wearing a beard net, in violation of facility policy. The Certified Dietary Manager confirmed the lack of proper attire. Facility policies require that all food storage areas be neat, arranged for easy identification, and date marked as appropriate, and that staff attire includes proper hair and facial hair restraints. These requirements were not met during the survey, as evidenced by the observations and staff acknowledgments.
Inaccurate Meal Intake Documentation for Mentally Intact Resident
Penalty
Summary
A nursing assistant was observed removing a meal tray from a resident's room, with the tray showing little food consumed and the silverware still wrapped, indicating the meal was likely untouched. The nursing assistant stated that the resident was able to feed herself. However, a review of the resident's electronic health records for that meal documented that the resident had eaten 76 to 100% of her lunch, which conflicted with the direct observation. The resident was noted to be mentally intact, with a BIMS score of 15, and her records confirmed she could feed herself after set up. The discrepancy between the observed meal consumption and the documentation in the medical record was brought to the attention of the Director of Nursing, but no further clarification or information was provided during the survey.
Failure to Notify Ombudsman and Provide Required Transfer/Discharge Documentation
Penalty
Summary
The facility failed to provide required documentation and notifications related to resident transfers, discharges, and hospitalizations, specifically neglecting to notify the State Long Term Care Ombudsman and, in some cases, the residents or their representatives. In one instance, a resident was sent to the hospital after being found using illegal drugs and making threats to return with a gun and harm others. The facility did not provide a 30-day discharge notice at the time of the incident, and when a notice was eventually produced, there was no evidence it was delivered to the resident or sent to the Ombudsman as required. The Ombudsman confirmed that she did not receive the notice until months later, after repeated requests and only after the surveyor's intervention. Similar deficiencies were found in the cases of four other residents who were transferred to acute care facilities for various medical reasons, including abnormal vital signs, shortness of breath, and sepsis. In these cases, the facility either failed to provide timely notification to the Ombudsman or could not produce documentation verifying that such notification had occurred. In some instances, notices were only sent after the surveyor requested verification, and staff confirmed that the required notifications had not been completed at the time of transfer. The review of records, staff interviews, and communication with the State Long Term Care Ombudsman revealed a consistent pattern of noncompliance with federal requirements for notifying the Ombudsman and, when appropriate, the resident or their representative regarding transfers and discharges. This deficiency was identified in all five residents reviewed for discharge and hospitalization during the survey, indicating a systemic issue with the facility's notification and documentation processes.
Inaccurate Care Plan for Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure a complete and accurate care plan regarding the use of psychotropic medications for one resident. Specifically, a resident was prescribed Remeron (Mirtazapine) as an appetite stimulant, but the comprehensive care plan incorrectly documented the medication as being used for depression. The care plan included interventions and monitoring related to antidepressant use for depression, despite the absence of a depression diagnosis in the resident's medical record. A review of the resident's physician orders and nutritional evaluation confirmed that Remeron was initiated to address significant weight loss and support increased appetite. The discrepancy was acknowledged by the Director of Nursing, who confirmed that the care plan did not accurately reflect the resident's current needs and medication purpose. No additional information or corrective actions were provided during the survey process.
Failure to Prevent Accident Hazards Related to Medication and Sharps Storage
Penalty
Summary
The facility failed to ensure that the resident environment was free from accident hazards and did not provide adequate supervision to prevent accidents for two residents. In one instance, a resident was found with a bottle of calcium carbonate stored in a clear plastic drawer by her bedside, which had been brought in by her daughter to address the resident's nausea. There was no documentation in the medical record indicating that the resident had been assessed for self-administration of medication, nor was there a completed Medication Self-Administration Assessment Form as required by facility policy. The facility's policy states that only residents assessed by the interdisciplinary team may self-administer medications, and medications for self-administration must be stored securely to prevent access by other residents. In another instance, a resident who is dependent on staff for personal hygiene and showers, and has a diagnosis of major depressive disorder, was found with two disposable razors on top of the air conditioner and one on the sink in her private room. The facility's Director of Nursing confirmed that sharps such as razors are not to be left in residents' rooms, yet these items were accessible to the resident. These findings demonstrate lapses in the facility's adherence to its own policies regarding medication and sharps storage, resulting in an environment that was not as free from accident hazards as possible.
Failure to Provide Physician-Ordered Adaptive Eating Equipment
Penalty
Summary
A deficiency was identified when a resident with a physician's order for a two-handled cup with all meals was observed eating lunch without the required adaptive equipment. The resident's beverage was served in a cup without handles, despite the tray ticket indicating the need for a two-handled cup. This observation was confirmed by a registered nurse, who acknowledged that the resident did not have the ordered adaptive cup at the time of the meal. No additional information was provided during the survey process regarding this incident.
Failure to Follow Contact Precautions for Resident with Shingles
Penalty
Summary
The facility failed to maintain proper infection prevention and control practices for a resident with shingles. According to the facility's policy, contact precautions, including the use of gloves and gowns upon room entry, were required for certain cases of shingles. During observation, a nurse aide was seen entering the resident's room, which was marked with a contact precautions sign, wearing only gloves and not a gown. The nurse aide later stated she did not see any personal protective equipment (PPE) and assumed only gloves were necessary. The PPE was available in a caddy on the wall between rooms, but was not utilized as required. The Director of Nursing confirmed that contact precautions should have been followed as indicated by the signage and the resident's care plan. The resident in question had a history of shingles, with lesions localized to the right side and trunk, and was being treated with Valtrex. The care plan specified contact precautions, and signage was posted at the room entrance. However, there was no physician's order for contact precautions at the time of the observation, only an order for Enhanced Barrier Precautions due to a history of MRSA. The lack of adherence to posted contact precautions and the absence of a corresponding physician's order contributed to the deficiency identified during the survey.
Failure to Provide Scheduled Showers to Dependent Resident
Penalty
Summary
A deficiency was identified when a dependent resident did not consistently receive scheduled showers as required by the facility's bathing schedule. Documentation review revealed that the resident was to receive showers twice weekly, specifically on Mondays and Thursdays. However, a comparison of electronic task reports and handwritten shower sheets showed discrepancies in the records, with periods where the resident did not receive a shower for six and eight consecutive days, respectively. During these gaps, the resident received bed baths or partial baths instead of the scheduled showers. The resident involved was non-interviewable and fully dependent on staff for activities of daily living, including bathing. The Director of Nursing acknowledged possible inaccuracies in the documentation and provided additional handwritten records, which confirmed the missed showers. No further information or documentation was provided to account for the missed care during the survey process.
Resident with Cranberry Allergy Served Allergenic Beverage
Penalty
Summary
A resident with documented allergies to cranberry fruit extract and cranberry juice was served cranapple juice by a Certified Nursing Assistant. The resident consumed the entire cup before realizing it contained cranberry juice. The incident was documented in the resident's electronic health record, and the resident subsequently reported the event to the Office of Health Facility Licensure and Certification. The resident was given a rescue inhaler and Benadryl as a precaution and was monitored, but did not experience any adverse reactions. Interviews with other residents with food allergies indicated they had not received foods to which they were allergic. Nursing Assistants described the process for identifying residents with allergies, which included a list in the pantry and Post-It notes on the drink cart. However, the event involving the resident with a cranberry allergy demonstrated a failure to consistently follow these procedures, resulting in the resident being served an allergenic beverage.
Failure to Maintain a Clean and Sanitary Environment
Penalty
Summary
The facility failed to maintain a clean, comfortable, and homelike environment for its residents, as evidenced by the presence of a black substance on heating and cooling units, windowsills, and doorjambs in multiple resident rooms. Specifically, Resident #32's room had a buildup of black substance around the door jamb, receptacle, and air conditioning unit, along with dry food products and dust webs under the wardrobe. Resident #69's room had a windowsill covered in a black substance, both dry and wet. The housekeeping supervisor acknowledged the buildup and stated it would be addressed. The facility's housekeeping policy required daily cleaning, which was not adhered to, leading to these unsanitary conditions. Additionally, Resident #43's restroom was found with a bedpan improperly placed in a trash can, which was overflowing with trash, and a band of black grime at the base of the commode. Resident #75 reported issues with the faucet's water flow, which was confirmed and repaired by the maintenance director. The resident's restroom also had a black grime band at the commode base, and a bedside commode bucket with dried residue was found in the shower area, which was not cleaned as required. These observations indicate a failure in maintaining sanitary conditions and adhering to cleaning protocols, impacting the residents' living environment.
Incomplete MDS Assessments for Mood and Behavior
Penalty
Summary
The facility failed to complete comprehensive assessments for mood and behavior for six residents during the Long-Term Survey Process. Specifically, the Minimum Data Set (MDS) assessments for these residents were incomplete, with sections on cognitive patterns and mood not being assessed. This deficiency was identified for residents with identifiers #44, #47, #34, #71, #4, and #54. The Corporate Nurse confirmed during interviews that these sections were not completed for the respective MDS assessments, which were conducted remotely. For instance, Resident #44's MDS assessment dated 06/19/24 lacked assessments in sections C and D, which cover cognitive patterns and mood. Similarly, Resident #47's assessment dated 06/30/24 and Resident #34's assessment dated 06/18/24 were also missing these critical sections. Additionally, Residents #4 and #54 had incomplete MDS assessments with no information on the Brief Interview for Mental Status (BIMS), leaving their cognitive status unknown. Resident #71's MDS assessment was also incomplete, lacking both cognitive and mood assessments, despite a physician's determination of capacity. The Corporate Nurse acknowledged these omissions but did not provide a clear explanation for the deficiencies.
Failure to Identify Major Depressive Disorder on PASSR
Penalty
Summary
The facility failed to identify Major Depressive Disorder on the Preadmission Screening and Resident Review (PASSR) for two of the five residents reviewed during the long-term care survey process. For Resident #22, the PASSR completed on November 4, 2016, included diagnoses of cerebral infarction, hemiplegia, adjustment disorder with disturbance, cognitive communication deficit, and ataxic gait. However, it did not include Major Depressive Disorder, which was diagnosed later. The Director of Nursing (DON) confirmed that this diagnosis should have been identified on the PASSR. Similarly, for Resident #26, the PASSR completed on February 13, 2024, included diagnoses of schizophrenic disorder and affective bipolar disorder but failed to identify Major Depressive Disorder, which was also diagnosed later. The DON confirmed that this diagnosis should have been included in the PASSR.
Improper Storage of Medications in Facility
Penalty
Summary
The facility failed to ensure that all medical supplies in the medication storage room were stored according to the manufacturers' recommended standards, which could potentially affect more than a limited number of residents. During an inspection of the Medication Storage Room East, it was observed that the temperature log for the refrigerator on a specific date had not been recorded. A registered nurse confirmed that the temperature had not been logged, indicating a lapse in monitoring the storage conditions of medications. In the Medication Storage Room West, the temperature was found to be 80 degrees Fahrenheit, which was confirmed by a licensed practical nurse. The temperature log showed fluctuations between 80 to 82 degrees Fahrenheit, exceeding the recommended storage temperature of 60 to 77 degrees Fahrenheit for certain IV medications, including Normal Saline and Metronidazole Injection. This discrepancy in temperature control poses a risk of compromising the efficacy of the medications, as outlined by the U.S. Pharmacopeia guidelines.
Failure to Transmit Discharge MDS Timely
Penalty
Summary
The facility failed to transmit a discharge Minimum Data Set (MDS) for a resident within the required timeframe. Specifically, the discharge MDS for Resident #45 was completed on March 27, 2024, but was not transmitted or accepted as required. This deficiency was identified during a record review and confirmed through a staff interview with the Director of Nursing on July 31, 2024. The Director of Nursing acknowledged that the discharge MDS should have been transmitted within 14 days after the assessment was completed. This issue was found during the Long Term Care Survey and had the potential to affect a limited number of residents in the facility, which had a census of 80 residents.
Failure to Renew PASARR for Resident
Penalty
Summary
The facility failed to complete a new Preadmission Screening and Resident Review (PASARR) for a resident when the original PASARR had expired. This deficiency was identified during the Long-Term Care Survey Process for one of five residents reviewed for PASARR compliance. The resident in question was admitted to the facility with a PASARR marked for three months or less, which subsequently expired. During an interview, the Director of Nursing acknowledged the issue, stating that an audit on PASARRs had just been initiated and confirmed the expiration of the resident's PASARR.
Failure to Develop Comprehensive Care Plan for Resident with Schizophrenia
Penalty
Summary
The facility failed to develop and implement a person-centered comprehensive care plan for a resident diagnosed with Schizophrenia. The care plan did not include the diagnosis of Schizophrenia or any monitoring related to it. This deficiency was identified during a review of the resident's care plan and confirmed in an interview with the Director of Nursing (DON). The lack of a comprehensive care plan addressing the resident's medical, physical, mental, and psychosocial needs placed the resident at risk of not receiving services that would meet their desires or wants, potentially decreasing their quality of life.
Failure to Revise Care Plan for CPR Status
Penalty
Summary
The facility failed to revise the care plan for a resident regarding their cardiopulmonary resuscitation (CPR) status. During a record review, it was found that the resident had a focus area indicating a preference for CPR, but the intervention listed was unrelated, stating a preference to be left alone with family. This discrepancy was identified during a review of the resident's records, and the Director of Nursing (DON) acknowledged the error, indicating a need for correction.
Failure to Provide Comprehensive Discharge Summary and Plan
Penalty
Summary
The facility failed to develop a comprehensive discharge summary for a resident, which included a recapitulation of the resident's stay, a final summary of the resident's status, and reconciliation of all pre and post-discharge medications. Additionally, the facility did not create a post-discharge plan of care or provide adequate discharge instructions. The resident was discharged via public bus, and although discharge instructions were reportedly reviewed with the resident, there was no documentation of a formal discharge summary or plan. The resident refused to have her medication called into the pharmacy, stating she would not take it. Interviews and document reviews revealed that active discharge planning was not occurring, and the previous social worker was unavailable for comment. The interim social worker confirmed the lack of a discharge summary and post-discharge plan. The resident expressed dissatisfaction with the facility, stating she was discharged because her insurance refused to pay for further therapy, which she believed was necessary for her recovery. The resident also expressed that the medications prescribed were unnecessary, further indicating a lack of proper discharge planning and communication.
Inaccurate Transfer Records for Resident
Penalty
Summary
The facility failed to maintain accurate and complete medical records for a resident's transfers to an acute care facility. During a record review, it was found that a resident was transferred on two separate occasions, but the dates on the transfer forms were incorrect. The first transfer occurred on June 12, 2024, but the form was dated April 14, 2024. The second transfer took place on July 9, 2024, yet the form was dated June 12, 2024. These discrepancies were identified during a review on August 1, 2024, and the corporate nurse and Director of Nursing were informed of the errors. The corporate nurse acknowledged the issue and indicated an intention to investigate the incorrect dates.
Infection Control Breach During Meal Service
Penalty
Summary
The facility failed to maintain an appropriate infection control program during meal service for a resident. During an observation, a nurse aide was seen handling a resident's hamburger buns with bare hands while assisting with meal setup. When questioned, the nurse aide stated that they sanitize their hands between trays, indicating a lack of glove use during the process. This incident was reported to the Director of Nursing, who acknowledged the observation.
Pest Control Deficiency: Gnat Infestation in Resident Room
Penalty
Summary
The facility failed to implement an effective pest control program, as evidenced by the presence of gnats in one of the resident rooms. During an initial tour, gnats were observed on the over bed table, including on the resident's drinks and pudding. A nurse aide confirmed the issue, acknowledging the presence of gnats in the room and indicating that someone would be called to clean the area.
Latest citations in West Virginia
The facility failed to prevent accident hazards and adequately supervise residents when two residents obtained cannabis gummies and CBD products via DoorDash, kept them in a bedside box with vape pens and OTC medications, and offered gummies to another resident, resulting in altered mental status, red eyes, paranoia, and ER transfers without a documented thorough investigation by administration. In a separate incident, a resident with decision-making capacity reportedly used a vape in a room with an active oxygen concentrator and refused a room search, leaving a potential fire hazard unresolved. Additional observations showed that a resident care planned for bilateral fall mats was in bed with one mat propped against the wall instead of on the floor, and another high-fall-risk resident was in bed with the bed not in the lowest position as required by the care plan, with staff confirming these fall-prevention interventions were not in place.
Two residents were not protected from neglect when one was left overnight in a soiled brief despite requests for incontinence care, resulting in raw, excoriated skin to the sacrum and scrotum, and another was served a grilled cheese sandwich despite an order for a mechanical soft diet, causing coughing before the tray was replaced. Staff interviews and documentation confirmed that the first resident had not been changed during the night and that prior skin assessments showed no issues, while the second resident’s diet order and the facility’s nutrition manual identified grilled sandwiches as inappropriate for a mechanical soft diet; neither incident was entered into the facility’s reportables or grievance systems.
The facility failed to accurately post daily nurse staffing information, with incorrect dates, unclear corrections, and mismatched total hours worked on most reviewed days. The daily staffing sheet was not readily visible on entry and, when located, contained multiple discrepancies between posted staffing and actual time-punch records. During one night shift, the posted sheet listed more LPNs and NAs than were actually present, with one NA found sleeping and another conducting personal business on a laptop in the breakroom, while one NA was assigned 1:1 to a resident, leaving two NAs to care for the remaining residents. These issues were confirmed through record review, observation, and staff interviews.
The facility failed to ensure adequate nursing staff on all shifts, leading to prolonged call light response times and unmet care needs. Multiple residents reported waiting from 45 minutes to several hours for assistance, including toileting and incontinence care, and described staff leaving the floor during smoke breaks and meal tray pass, leaving minimal coverage. Staffing records showed nursing HPPD below required minimums on at least one reviewed day, and an external report flagged low weekend staffing. One resident reported being left overnight in a soiled brief while having diarrhea, later found with raw, red skin to the sacral and scrotal areas, and this incident was not documented as a grievance or reportable event. A night-shift observation also revealed fewer staff on duty than posted, with one NA sleeping and another conducting personal business, while only two NAs were left to care for more than fifty residents.
Surveyors found that residents were not provided a way to file anonymous grievances and reported fear of retaliation for making complaints. During a Resident Council meeting, multiple residents stated they had no anonymous grievance option and felt their concerns raised in council were not taken seriously. The Social Worker confirmed there was no anonymous grievance mechanism and that residents and families had to request grievance forms from nursing or department heads, despite a written policy stating that residents and representatives have the right to file grievances orally or in writing and that staff will make prompt efforts to resolve them.
Two residents did not receive care according to physician orders and professional standards. One resident with a documented right hand contracture had orders and a care plan directing splinting of the left, functional hand, and surveyors observed the contracted right hand tightly fisted without a splint in place; the OT and DON later confirmed the order should have been for the right hand. Another resident with an order for Humalog Kwikpen requiring the provider to be called for blood sugar (BS) readings over 400 had multiple BS values above 400 documented on the MAR, but there was no documentation that the provider was notified on those occasions, which was confirmed by an RN consultant.
Surveyors identified multiple failures to follow food safety and sanitation policies, including soiled food service equipment, outdated and improperly labeled food items, and inadequate documentation of manual ware washing procedures. Personal items such as employee coats were stored on bread racks, and trash bins were placed on the same shelves as milk containers on beverage carts used for residents. These observations showed that staff did not consistently maintain clean food preparation areas, properly label and date TCS foods, or separate trash and personal belongings from food and food-contact surfaces.
The facility did not follow its own food safety and sanitation policies requiring trash to be contained in covered, leak-proof containers. During a kitchen walkthrough with the Director of Dining Services (DDS), a surveyor observed an uncovered trash can next to the juice machine and another uncovered trash can in the dish room. The DDS confirmed that these trash receptacles lacked lids, contrary to Healthcare Services Group (HCSG) policies that require the DDS to ensure appropriate lids are provided for all containers.
Two residents reported and staff observed sexually inappropriate behavior by a male resident, including entering a resident’s room uninvited while naked from the waist down and pulling on her in bed, and placing his hands under another resident’s blanket and rubbing near and on her private area. Both residents described the contact as unwanted, and one was documented as cognitively intact with capacity. Despite staff corroboration and resident statements to clinical providers, the facility’s investigations concluded that sexual abuse was not substantiated, citing lack of physical harm and inconsistent statements, and failed to adequately assess or address whether the residents felt safe or to alleviate their expressed anxiety.
The facility failed to ensure food was palatable, attractive, and maintained at a safe and appetizing temperature, as shown by tray temperature checks and interviews with several residents and staff. At lunchtime, kitchen staff were not taking or recording temperatures for items on the always-available menu, including beef patties, hotdogs, and brown gravy, before meal service began. The DDS acknowledged that temperatures for these always-available menu items were not being monitored or documented.
Failure to Control Resident Access to Non-Prescribed Substances and Implement Fall-Prevention Measures
Penalty
Summary
The facility failed to maintain an environment as free from accident hazards as possible and did not provide adequate supervision to prevent accidents, particularly related to resident access to non-prescribed substances and implementation of fall-prevention measures. An anonymous resident reported that two female residents purchased cannabis gummies via DoorDash and offered them to another resident, who refused. These two residents were later sent to the hospital after one was noticeably impaired. Record review showed no investigation documented in the facility’s reportable or grievance logs regarding these residents’ changes in condition due to cannabis gummies being brought into the facility and offered to other residents. Nursing documentation for one of the involved residents described a change in condition with altered mental status, suspicion of substance abuse, and tachycardia, leading to transfer to the ER for evaluation and toxicology screening. A late-entry note indicated the resident was educated on facility policies prohibiting OTC medications and CBD products in the room. Another nursing note detailed that a CNA reported a resident had consumed a gummy given by another resident, then discarded the second gummy, which the CNA retrieved from the trash. On assessment, the resident was found lying in bed with reddened eyes, reporting feeling tired, and vital signs were obtained. The resident stated she had consumed “pot gummies” and allowed the nurse to inspect a wooden box at the bedside, which contained several red sugar-coated gummies, three vape pens (including a suspected CBD vape pen), a bottle of Benadryl, and several Imodium tablets. The resident reported purchasing the gummies and CBD vape pen from DoorDash, and the items were removed with her consent. Further documentation showed that another nurse was informed that two residents had consumed an unknown gummy-like substance. On assessment, one resident had very red eyes and reported feeling paranoid, with vital signs recorded. This resident stated she had received two gummies from another resident and that a third resident knew about the gummies. The nurse interviewed the third resident, who reported that the resident supplying the gummies had told her she had gummies and THC pens and planned to give gummies to another resident. The nurse also noted that as staff were going to check on the resident who supplied the gummies, a DoorDash delivery person arrived and handed a bag to the nurse containing a pack of cigarettes and a receipt showing two CBD purchases. Facility administration had no evidence that a thorough investigation into this incident had been completed, and only limited action was taken following the event, leading surveyors to identify an immediate jeopardy situation due to residents being susceptible to drug abuse from other residents. The facility also failed to address other accident hazards and fall-prevention interventions for additional residents. One resident, who had capacity to make her own medical decisions, was involved in an incident where she reportedly used a vape in her room while an oxygen concentrator was present and turned on. The resident was verbally educated by the Administrator about the dangers of vaping near oxygen equipment, the smoking policy requiring smoking paraphernalia to be stored by nursing staff, and the prohibition of vaping inside the facility. However, during the survey period it remained unknown whether the resident still had vape pens in her possession, and she refused a room search, leaving a possible serious fire hazard unresolved at the time of review. In separate observations related to fall prevention, one resident was observed lying in bed with a fall mat that was supposed to be in place on the floor instead leaned against the wall behind the headboard. Record review confirmed the care plan required fall mats on both sides of the bed while the resident was in bed, and an LPN acknowledged that the floor mat was not in place. Another resident, care planned as at risk for falls due to multiple factors including muscle weakness, cognitive impairment, incontinence, psychoactive medication use, recent hospitalizations, visual impairment, and a history of traumatic brain injury and multiple CVAs, was observed lying in bed with the bed not in the low position despite a care plan intervention specifying that the bed should be in the lowest position. A RN consultant confirmed that the bed was not in the lowest position while the resident was in bed.
Failure to Prevent Neglect in Incontinence Care and Diet Texture Management
Penalty
Summary
The deficiency involves failure to protect residents from neglect by not providing timely incontinence care and by not providing the correct diet texture. One resident reported during interview that he had been left overnight without his brief being changed while experiencing diarrhea, despite requesting to be changed. Two CNAs separately stated that when they saw the resident the following morning, he reported not having been changed all night, that aides had come in only to change his roommate and then left, and that his skin was "raw," "pretty bad," and red. Both CNAs reported the condition of his skin to an LPN, and an order was written later that day for wound care to excoriated sacrum and scrotum every shift. Prior skin assessments from earlier in the month documented no issues to the sacrum or scrotum, and the incident was not found in the facility’s reportables or grievances. The Administrator confirmed that, if accurate, this situation would constitute neglect under the facility’s abuse policy, which defines neglect as failure to provide necessary goods and services to avoid physical harm, pain, mental anguish, or emotional distress. A second deficiency concerns failure to provide the correct food texture to another resident who had an active diet order for mechanical soft texture. Progress notes document that this resident was served a grilled cheese sandwich on a dinner tray, which she began to eat before an NA noticed and removed the tray. The resident coughed a few times and then was fine, and the NA obtained another tray with food the resident could eat without problem. The resident’s diet order specified mechanical soft foods, and the facility’s Diet and Nutrition Care Manual lists grilled sandwiches as foods to avoid on a mechanical soft diet. A nurse consultant later confirmed that this incident occurred as documented and that it was not reported.
Failure to Accurately Post Daily Nurse Staffing Information
Penalty
Summary
The deficiency involves the facility’s failure to accurately post daily nurse staffing information in a prominent, accurate manner as required, with inaccuracies identified on 22 of 23 reviewed days. Upon surveyor entrance, the daily nurse staffing sheet was not readily visible and was ultimately located on a wall near the nurse’s station. Review of posted staffing sheets and time punch detail reports revealed multiple discrepancies, including incorrect dates on several postings and numerous errors in the total hours worked for various dates. On some days, corrections were written over original entries, making it impossible to clearly determine the actual number of nurse aides working or the correct total hours. In several instances, the posted total hours did not match the actual hours worked as shown on time detail reports, with both understatements and overstatements of staffing hours documented. During a nighttime observation, the posted staffing sheet listed two LPNs, three NAs, and zero RNs on duty, but a visual count showed only one LPN and two NAs actually present, with no RN. One NA was found sleeping on duty upon arrival, and another NA was in the breakroom with a makeshift office setup using a table, laptop, battery charger, and large rolling briefcase. It was later learned that one NA was assigned 1:1 to a resident, leaving two NAs to cover the remaining 56 residents. When questioned, an LPN stated that another LPN listed on the staffing sheet had called in sick due to pregnancy. These observations and documentation reviews were discussed with the Regional Director of Operations and an RN consultant, confirming that the posted staffing information did not accurately reflect the actual staffing levels and hours worked on multiple dates.
Insufficient Staffing Leading to Delayed Care and Resident Neglect
Penalty
Summary
The deficiency involves the facility’s failure to provide sufficient nursing staff on all shifts to meet residents’ needs, resulting in delayed responses to call lights and inadequate incontinence care. During a resident council meeting, multiple residents reported waiting 1–3 hours for call lights to be answered, with staff sometimes stating they would return but not coming back for hours, and some residents reporting staff said they had been outside smoking with a resident. Individual resident interviews corroborated these concerns, with residents stating that night shift took a long time to answer call lights, that it could take 45 minutes to an hour or more to receive assistance, and that staff would delay changing residents during meal tray pass or after a scheduled smoke break when most aides and a nurse accompanied residents outside, leaving only one nurse to cover the floor. Staffing record reviews for specific dates showed Hours Per Patient Day (HPPD) below the minimum required 2.25 on at least one day, and the facility’s CASPER report triggered for low weekend staffing. A specific incident of neglect was identified for one resident who reported being left overnight in a soiled brief while experiencing diarrhea, despite requesting to be changed. Two CNAs independently stated that when they saw this resident the following morning, he reported not having been changed all night, and both described his skin as raw, bad, and red; one CNA stated she had changed him the previous day and that he reported no changes overnight, and both CNAs reported the condition to an LPN, who then notified an RN, leading to a wound care order for excoriation to the sacrum and scrotum. Prior skin assessments earlier in the month showed no issues in those areas, and the incident was not documented in reportables or grievances. Additionally, a night-shift observation found a discrepancy between the posted staffing sheet and actual staff present: the sheet listed two LPNs, three NAs, and no RNs, but only one LPN and two NAs were observed, with one NA found sleeping on duty and another engaged in personal business on a laptop, while a third NA was assigned 1:1 to a resident, leaving two NAs to cover 56 other residents. The administrator confirmed that the described incontinence incident would constitute neglect if accurate.
Failure to Provide Anonymous Grievance Process and Protect Residents From Fear of Retaliation
Penalty
Summary
Surveyors identified that the facility failed to honor residents’ rights to voice grievances without fear of reprisal and to provide a method for anonymous grievance submission. During a Resident Council meeting attended by 11 residents, residents reported they had no way to file an anonymous grievance, did not want to report complaints due to fear of retaliation, and felt that concerns raised in Resident Council were not taken seriously. An interview with the Social Worker confirmed there was no method for anonymous grievances and that residents and family members had to request a grievance form from a nurse or department head. Review of the facility’s Grievances/Complaints policy showed that residents and their representatives have the right to file grievances orally or in writing with facility staff or the designated agency, and that the Administrator and staff will make prompt efforts to resolve grievances, but the facility’s actual practice did not provide an anonymous option or alleviate residents’ fear of retaliation. This deficiency involved at least one identified resident (Resident #22) and the broader resident group, who reported barriers to exercising their grievance rights and lack of confidence that their concerns raised in Resident Council would be addressed, in contrast to the facility’s written grievance policy.
Failure to Follow Splinting and Blood Glucose Notification Orders
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care in accordance with professional standards and physician orders for two residents. For one resident with a documented right hand contracture, surveyors observed that the right hand was tightly fisted and that no splinting device was in place. Record review showed active orders to apply and remove a splint to the left hand every night shift for mobility, and the care plan directed left hand splinting as ordered, despite the medical record listing a diagnosis of a right hand contracture. During interviews, the occupational therapist confirmed the splinting order should have been for the right hand, and the Director of Nursing confirmed that both the orders and care plan were written to place a splint on the resident’s functional hand instead of the contracted hand. For another resident with an order for Humalog Kwikpen, the physician’s order specified to hold the medication for blood sugar (BS) less than 100 and to call the provider for BS over 400. Review of the Medication Administration Record for March and April showed multiple dates on which the resident’s blood sugar exceeded 400. The facility was unable to provide documentation that the provider was contacted on those dates when the blood sugar was over 400, as required by the order. A registered nurse consultant confirmed that, according to the documentation, the provider was not notified when the resident’s blood sugar readings were over 400 on the identified dates.
Food Storage and Sanitation Deficiencies in Dietary Services
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with its own food safety and sanitation policies and professional standards. During an initial kitchen walkthrough, the surveyor, accompanied by the Director of Dining Services, observed multiple sanitation and storage issues, including a juice machine top soiled with debris, crumbs in the toaster tray, and a soiled microwave in the pantry. In the dry storage room, there was an opened, outdated brownie mix past its use-by date, and employee coats were found hanging on the bread rack. In the walk-in cooler, a case of bacon lacked an open or use-by date, and the meat slicer, though covered, had old food debris on and around the blade. The three-compartment sink log for that morning’s breakfast lacked recorded water temperature and sanitizer concentration, contrary to policy requirements for monitoring and documenting manual ware washing. Additional observations showed improper handling and storage of food and related items outside the main kitchen. A beverage in the pantry refrigerator was not labeled or dated. During a dining observation, beverage carts for two halls had trash bins placed on the same shelf as milk containers intended for residents. On a subsequent day, an employee’s coat was again found hanging on the bread rack, despite prior identification of this issue. These findings demonstrated that staff did not consistently follow facility policies requiring clean, sanitary food preparation and service areas, proper labeling and dating of TCS foods, and appropriate separation of personal items and trash from food and food-contact surfaces.
Uncovered Trash Receptacles in Food Service Areas
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional food safety standards and did not follow proper sanitation practices for food preparation equipment, with the potential to affect all 60 residents. Healthcare Services Group (HCSG) Policy #28 requires all trash to be contained in covered, leak-proof containers to prevent cross-contamination, and HCSG Policy #30 requires the Dining Services Director to ensure appropriate lids are provided for all containers. During an initial kitchen walkthrough with the Director of Dining Services (DDS), the surveyor observed that the trash can beside the juice machine had no lid and that the trash can in the dish room also had no lid. The DDS confirmed both observations and acknowledged that there was no lid available for the dish room trash can.
Failure to Substantiate and Address Resident Sexual Abuse Allegations
Penalty
Summary
The deficiency involves the facility’s failure to appropriately use investigation results and residents’ reports to determine and substantiate sexual abuse allegations involving one male resident and two female residents. In the first incident, a cognitively intact resident reported that she awoke in her bed to find a male resident in her room, uninvited, naked from the waist down and pulling on her leg, and stated she thought he was going to try to rape her. Staff responding to her yelling found the male resident in her room wearing only a t‑shirt, with no brief or pants, and the resident told staff to remove him from her room. During examination by an NP, she again reported that a man came into her room and pulled her down in bed. Despite these observations and statements, the facility’s Five‑Day Follow‑Up report concluded that allegations of sexual abuse were not substantiated, and the facility’s position, as verified by the Administrator, was that no physical harm was done, which was the basis for not substantiating sexual abuse. The facility did not adequately evaluate whether this resident felt safe or address her expressed anxiety about the incident. In the second incident, another cognitively intact resident with a BIMS score of 14 and a physician determination of capacity reported sexual abuse by the same male resident. A CNA witnessed the male resident’s hands under this resident’s blanket, rubbing close to her private parts, and when staff intervened and asked if he had touched her private area, she stated yes. During the facility’s investigation, the resident told the Social Worker and Administrator that the male resident rubbed her private area and that she believed the contact was intentional, and she also told her attending physician that he had touched her private area. When later seen by a psychologist, she voiced no recollection of the event. The facility’s Five‑Day Follow‑Up report stated that sexual abuse could not be substantiated due to inconsistency in statements, and the Administrator confirmed that the male resident had touched her but asserted it was accidental while rubbing her leg under the blanket. The facility failed to recognize and address this resident’s expression of anxiety about the unwanted touching and did not adequately evaluate whether she felt safe, leaving her and other residents vulnerable during and after the investigative process.
Failure to Monitor and Record Food Temperatures for Always-Available Menu Items
Penalty
Summary
The facility failed to ensure that food and drink were palatable, attractive, and maintained at a safe and appetizing temperature, as evidenced by food tray temperatures, resident interviews, and staff interviews involving four identified residents (#47, #33, #42, and #9) out of a census of 60. On 4/28/26 at 12:00 PM, it was observed that kitchen staff were not taking and recording temperatures for items on the always-available menu prior to the start of the lunch meal service. Specifically, beef patties, hotdogs, and brown gravy did not have recorded temperatures before meal service began. The Director of Dining Services acknowledged that temperatures for always-available menu items were not being taken or recorded. No additional medical history or specific clinical conditions of the involved residents were provided in the report.
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