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.)
- 16
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
A deficiency occurred when a lunch tray on A Hall was found to be served below required hot-holding temperature standards. During a survey, a random tray containing mashed potatoes and gravy with steak was tested by the Traveling Dietary Manager in the presence of the Administrator, and both food items measured 110°F, which did not meet required serving temperatures. The Traveling Dietary Manager and the Administrator each confirmed that the food temperature was not at the required level, and the administrative team later acknowledged this deficiency.
Surveyors found that the facility failed to provide residents with consistent and accurate readily available menus reflecting their food preferences. The Traveling Dietary Manager reported that residents could choose from multiple egg preparations, but these options were not listed on the posted menu available to residents. Additionally, the “always available” menu used in the kitchen did not match the menu provided to residents, and this discrepancy was confirmed by the Traveling Dietary Manager. The issue was identified on all menus reviewed and had the potential to affect many residents in the facility.
The facility failed to follow its abuse reporting policy when a cognitively intact resident reported that two nurses were frequently sleeping on duty and later provided an audio recording of a nurse calling the resident a "jerk." The allegation was reported by the resident to an LPN and then to an RN Infection Preventionist, but the Administrator remained unaware until the survey, and the incident was not reported to authorities within the required 2-hour timeframe. In a separate case, another resident had a verbal abuse incident reported to the state, but the facility did not complete or submit the required 5-day follow-up report, and the Administrator confirmed there was no record of that follow-up.
A resident reported unknown charges on her debit card and alleged that a former roommate had used the card without permission, estimating losses of several hundred dollars. The facility documented initial steps such as notifying external agencies, involving law enforcement, cancelling the card, separating the roommates, and assisting the resident in obtaining bank statements. However, the facility did not maintain or retain key documentation, including copies of bank statements, the total amount of funds involved, or clear follow‑up on the status and outcome of the allegation. The resident reported not receiving updates, and the BOM acknowledged that the facility lacked the resident’s financial records because they had been turned over to law enforcement and were not requested or reviewed by facility staff until shortly before the survey, resulting in an incomplete internal investigation record of the alleged misappropriation.
A resident who was cognitively intact but lacked capacity for health care decisions left the facility after breakfast and morning meds. An activities assistant saw the resident walking outside and reported this to the Manager on Duty, but no effective action was taken to verify the resident’s whereabouts or initiate a search. Nursing staff later assumed the resident was in the bathroom or out smoking when he was not in his room at mid-morning and lunchtime. The facility did not recognize the resident as missing or begin search efforts until hours later, during which time the resident hitchhiked and accepted a ride from a stranger in the community. Surveyors determined that staff had witnessed the resident outside but failed to intervene or report effectively, and that the facility remained unaware of the resident’s absence for several hours, resulting in an Immediate Jeopardy finding for neglect.
A resident who is blind and requires specific instruction during ambulation was transferred from therapy to Restorative with documented recommendations to ambulate using a walker, gait belt, and a wheelchair behind her, along with ROM and strengthening exercises. Despite a physician’s order for a Restorative Nursing Program for ambulation and ROM and the therapy recommendations communicated via an Excel spreadsheet, Restorative staff ambulated the resident without a gait belt. The resident reported becoming tired while walking, with a wheelchair behind her but not close enough, and then falling hard. She and a PTA both stated that no gait belt was used. The fall resulted in fractures to the resident’s left distal femur and right distal femur/knee area, with osteopenia noted, and the DON acknowledged that therapy recommendations had not been carried over for Restorative staff to follow.
A resident experienced multiple leg fractures after a fall, resulting in a significant change in condition and non–weight-bearing status. Although the MDS reflected that it was important for the resident to participate in group activities, favorite pastimes, and church services, the activity care plan was not revised after the injury to address her new limitations. The existing plan listed numerous preferred activities such as resident council, food committee, religious services, music, gardening, and in-room pursuits, but no new individualized interventions were added, and documentation showed only two 1:1 visits after her return from the hospital. The resident reported she could no longer get into her wheelchair, attend council or church, or join groups she enjoyed, and stated that activity staff did not visit often, while the Director of Recreation confirmed she had not attended groups since the injury and that in-room social visits were not consistently documented, resulting in a decline in activity participation and social isolation.
A resident was discharged to a motel with home health services, a wheelchair, medications, and a follow‑up medical appointment arranged, and received education on medications, blood glucose monitoring, emergency response, and home health services. Discharge planning discussions and a referral to the Take Me Home program were documented, and the facility agreed to pay for an initial period of the motel stay. However, record review and staff interviews confirmed that the resident was not given the required 30‑day written discharge notice prior to leaving, limiting the resident’s ability to prepare for discharge and exercise discharge‑related rights.
A resident sustained multiple lower extremity fractures after a fall, resulting in hospitalization, non-weight-bearing status, and loss of prior functional abilities such as standing, pivoting, and walking with therapy. Before the fall, the resident actively participated in out-of-room activities including Resident Council, food committee, church, and socials, but after returning from the hospital she no longer attended group activities and had only two documented 1:1 visits. Despite an MDS indicating a significant change in status and clear changes in activity participation, the activity care plan—last revised months earlier—was not updated with new interventions to address her altered condition and in-room activity needs, as confirmed by record review and staff interviews.
A resident with intact cognition and a history of active participation in group activities, Resident Council, and church sustained bilateral lower-extremity fractures and returned from the hospital non–weight bearing. The MDS significant change assessment and the activity care plan documented that group involvement, church services, and various preferred activities were important to the resident, yet no new interventions were added to the care plan after the change in condition. Activity participation records showed that the resident had no out-of-room activities and only two documented 1:1 visits, while the Director of Recreation acknowledged that group attendance had stopped and that in-room social visits were not consistently documented. The resident reported feeling unable to attend her usual groups, Resident Council, or church and stated that activity staff did not visit often, leading surveyors to find that the facility failed to provide an activities program that met her needs and interests following her significant change.
Improper Hot Food Serving Temperatures During Lunch Service
Penalty
Summary
The facility failed to provide resident meals at proper serving temperature during a lunch meal service on A Hall. On 03/24/26 at approximately 12:10 PM, a surveyor had a random lunch tray on A Hall temperature-tested by the Traveling Dietary Manager, with the facility Administrator present. The tested items—mashed potatoes and gravy with steak—were both measured at 110°F. During an interview at approximately 12:15 PM, the Traveling Dietary Manager confirmed that the food did not meet the required serving temperature, and at approximately 12:16 PM, the Administrator also confirmed that the food did not meet the required serving temperature. This deficiency was acknowledged by the facility’s administrative team upon survey exit on 03/25/26 at approximately 4:00 PM. No additional resident-specific clinical information or conditions were provided in the report.
Inconsistent Readily Available Menus for Resident Food Preferences
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to provide residents with consistent and accurate information about readily available menu items that accommodate resident preferences. During document review and staff interviews, the Traveling Dietary Manager stated that residents could choose from several egg preparations (omelet, scrambled eggs, hard-boiled egg, or hard-fried egg) as part of the facility’s readily available items. However, the posted readily available menu accessible to residents did not list these egg options. Additionally, the “always available” menu used in the kitchen did not match the menu provided to residents, and the Traveling Dietary Manager confirmed that the readily available menus did not correlate. This inconsistency was found on 2 of 2 menus reviewed and had the potential to affect more than a limited number of residents in a facility with a census of 90. On a subsequent interview, the facility Administrator acknowledged the deficiency during the exit interview.
Failure to Timely Report Verbal Abuse Allegation and Submit Required 5-Day Follow-Up
Penalty
Summary
The facility failed to follow its abuse prohibition policy requiring that allegations of abuse be reported to the proper authorities within two hours of identification and that required follow-up reports be completed. The policy defined verbal abuse as the willful use of disparaging or derogatory language toward residents or within their hearing. A cognitively intact resident with a BIMS score of 15 reported that two nurses who worked Monday through Thursday were "always sleeping" and that, after he reported this to administration, one of the nurses called him a "jerk." The resident had an audio recording dated 03/11/26 capturing a staff member calling him a "jerk" and confirming this characterization when questioned by the resident. The resident stated he informed an LPN, who then reported it to the RN Infection Preventionist. The RN Infection Preventionist acknowledged awareness of a phone conversation in which someone called the resident a jerk but stated she did not know the full details and thought it might have been discussed in a care plan meeting. The Administrator reported being unaware of the situation until interviewed by the surveyor, at which time the incident had not been reported within the required two-hour timeframe. The facility also failed to complete and submit a required five-day follow-up report for a separate allegation of verbal abuse involving another resident. Record review showed that this resident had been admitted and later discharged to the hospital, and that a verbal abuse incident involving this resident had been reported to the state agency on 04/15/25. However, review of the facility’s list of reportable incidents for one year revealed no evidence that the corresponding five-day follow-up report was ever sent. The Administrator confirmed there was no record of that reportable incident or of a five-day follow-up. These failures were identified for two of two residents reviewed for abuse, with a facility census of 67.
Failure to Thoroughly Investigate and Document Alleged Financial Exploitation
Penalty
Summary
The deficiency involves the facility’s failure to ensure a thorough investigation and ongoing documentation of an allegation of misappropriation of resident property for one resident. Record review showed that the resident reported unknown charges on her debit card, and the facility initiated an investigation and notified OHFLAC, APS, the Ombudsman, and local law enforcement. Progress notes documented that law enforcement interviewed the resident, the resident cancelled her debit card, and she planned to obtain information from her bank. Notes also showed that the resident obtained bank statements, attempts were made to contact the investigating officer, and law enforcement later returned to obtain the resident’s banking information and ask additional questions. The facility’s 5‑day investigation report documented that the Administrator and DON reported the allegation, assisted the resident in obtaining bank statements, reviewed charges with her, identified the alleged perpetrator as the former roommate, separated the residents, and deactivated the debit card. The investigation was labeled inconclusive with law enforcement continuing the investigation, and a later Grand Jury subpoena was issued for the resident related to alleged fraudulent use of her debit card. Despite these initial steps, at the time of survey the facility was unable to provide additional documentation or evidence of follow‑up regarding the alleged misappropriation, including the total amount of funds involved, the outcome of the investigation, or any ongoing tracking of the allegation until requested by the State Agency. In interviews, the resident stated that her former roommate used her debit card without permission, estimated that approximately $800–$900 had been spent, and reported she had not received any updates about the situation. The BOM stated the facility did not have copies of the resident’s bank statements because they had been turned over to law enforcement and that law enforcement would not release information due to an ongoing investigation. In a follow‑up interview, the resident reported that no one from the facility had requested or attempted to review her bank statements, aside from law enforcement, until shortly before the interview when the BOM inquired, demonstrating that the facility did not maintain documentation necessary to determine the extent of the alleged misappropriation. A staff member later provided a written statement that they accompanied the resident to a Grand Jury proceeding related to fraudulent use of the debit card, but the facility still lacked internal documentation of the scope and outcome of the allegation.
Failure to Respond to Known Resident Elopement and Prolonged Unnoticed Absence
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from neglect by not responding to a known elopement. A cognitively intact resident, who had a BIMS score of 14 but had been deemed by the physician to lack capacity to make health care decisions, left the facility in the morning after having breakfast and receiving morning medications. The resident’s elopement risk evaluation score was 0, indicating low risk for elopement, and the MDS indicated no wander/elopement alarm was used less than daily. The resident’s care plan identified adjustment issues related to change in lifestyle and difficulty accepting placement, with interventions focused on coping and adjustment, but did not identify elopement risk prior to the incident. At approximately 9:00 AM, an activities assistant saw the resident walking outside down a public street near a store. The activities assistant contacted the social worker, who was the Manager on Duty, shortly thereafter to report the resident’s location. The activities assistant then clocked in for her shift around 9:03–9:05 AM. Despite this report, no effective action was taken by facility staff at that time to verify the resident’s whereabouts, intervene, or initiate a search. The social worker later stated she did not realize anything was going on until early afternoon, explaining that she missed the information about the resident being at the store while she was talking with other residents during the phone call. During the period from roughly 9:15 AM to 1:55 PM, there was a delay in supervision and monitoring of the resident. The LPN assigned to the resident reported administering morning medications and exchanging pleasantries with the resident earlier that morning, consistent with the facility’s elopement timeline. The CNA assigned to the resident stated that the resident was in the room during breakfast, but when she entered the room around 10:30 AM to provide a snack to the roommate, the resident was not present and she assumed he was in the bathroom. At lunchtime, when the CNA did not see the resident, she assumed he was out smoking. The facility did not recognize the resident as missing or initiate search or recovery actions until approximately 1:30 PM, when the activities assistant reported that the resident was not present for a smoke break. The State Agency determined that staff had witnessed the resident outside the facility but failed to intervene or report effectively, and that the facility remained unaware of the resident’s absence for about 4.5 hours, creating an Immediate Jeopardy situation due to the resident being unsupervised in the community for an extended period. The resident later reported that he was attempting to travel to another town to attend to personal business, hitchhiking to a nearby city and then walking further when he found the bus station closed. He described being offered a ride and food by a man who drove him to a restaurant, where he was eventually picked up by someone from the nursing home. The State Agency concluded that the facility’s failure to act on the known elopement and to promptly identify and respond to the resident’s absence constituted neglect and placed the resident at immediate risk for serious harm or death.
Failure to Use Gait Belt During Restorative Ambulation Resulting in Resident Fractures
Penalty
Summary
The facility failed to provide care and services in accordance with professional standards of practice when a resident participating in Restorative Therapy ambulation was walked without a gait belt, contrary to therapy recommendations. Record review showed the resident experienced a fall and was sent to the emergency room with pain in both legs, where diagnostic imaging revealed an anterior apex angulated distal femur diametaphyseal fracture with impaction in the left femur and an impaction and comminuted anterior apex angulated fracture of the distal fifth metaphysis in the right knee, with osteopenia noted. The resident, who is blind and requires specific instruction when ambulating, had been transferred from therapy to Restorative with recommendations documented on an Excel spreadsheet to ambulate with a walker, gait belt, and wheelchair behind the resident, up to 70 feet, along with ROM and strengthening exercises. A physician’s order for a Restorative Nursing Program for ambulating and ROM was in place, with the expectation that Restorative staff would refer back to therapy’s recommendations for safety measures. Interviews confirmed that on the day of the fall, staff ambulated the resident without a gait belt. The PTA identified the location of the fall and stated that a gait belt had not been used while walking the resident. The DOR reported that therapy staff had always used a gait belt with this resident and that the recommendation to use a gait belt was communicated via the Excel spreadsheet used by Restorative Therapy to receive therapy orders and recommendations. The resident, who had a BIMS score of 15 and thus had capacity, stated that she became tired while walking with Restorative staff, that a wheelchair was behind her but not close enough, and that she fell hard; she reported that staff did not have a gait belt on her and believed that if a gait belt had been used, she would not have fallen so hard. The DON stated she was not aware of the Excel spreadsheet and confirmed that therapy recommendations were not carried over for Restorative Therapy to follow.
Failure to Revise Activity Care Plan After Significant Change in Condition
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident received ongoing opportunities to participate in meaningful activities consistent with her interests and preferences following a significant change in condition. The resident experienced a fall on 02/18/26, was sent to a local emergency room for pain in both legs, and diagnostic radiology revealed an anterior apex angulated fracture of the distal left femur with impaction and an impaction and comminuted anterior apex angulated fracture of the distal right femur metaphysis, with osteopenia noted. She was hospitalized for these fractures and returned to the facility on 02/24/26. A subsequent MDS with an ARD of 02/27/26 documented a significant change in status and indicated that it was important for the resident to do things with groups of people, participate in her favorite activities, and attend church services. Record review showed that the resident’s activity care plan, originally initiated in 2020 and revised multiple times through 03/03/2025, contained numerous interventions reflecting her preferences, including in-room visits, participation in food committee and resident council, church and religious services, group singing and cooking, gardening, pet visits, listening to religious/bluegrass/country music, watching TV and keeping up with the news, and engaging in favorite activities such as church, sewing, cooking, reading, and gardening. The care plan also noted her use of a wheelchair and need for accommodations for visual impairments. However, there were no new or revised activity interventions added to address her new non–weight-bearing status and functional limitations after the fractures, and no changes to the activity care plan were documented following the significant change in condition. During interview, the resident, who had decision-making capacity and a BIMS score of 15, reported that prior to the fall she had been able to stand, pivot, and walk with therapy, and that she had been active in resident council, church, and social activities. She stated that since her return from the hospital she could not get into her wheelchair, could not attend resident council meetings or church, and could not participate in the group activities she enjoyed. She reported that activity staff did not visit her very often and became tearful while describing her situation. The Director of Recreation confirmed that the resident had not attended group activities since returning from the hospital, was non–weight-bearing for 10 weeks, and that anything done with her was now in-room. The Director of Recreation also stated that the resident did not receive one-to-one visits “per se” and that social visits were not documented. Surveyors identified that only two one-to-one visits had been documented since the resident’s return from the hospital and that there was a significant decline in her activity participation without corresponding revisions to her care plan, which led to the finding of failure to provide consistent, individualized activity interventions and ongoing opportunities for meaningful activities.
Failure to Provide Required 30‑Day Written Discharge Notice
Penalty
Summary
The facility failed to provide a required 30‑day written discharge notice to a resident prior to discharge. A complaint was received by the State Agency stating that the resident was being discharged to a hotel and that the facility would pay for the first 28 days, after which the resident would be responsible for their own expenses. The complainant reported the resident had no income and uncertainty existed about how the resident would obtain food and medications. Record review showed that on one date, Social Services documented discharge planning discussions and a referral to the Take Me Home program at the resident’s request, and an assessment note indicated discharge planning documentation was completed. Further record review revealed that on the day of discharge, Social Services documented that the resident was discharged to a motel with home health services arranged, a wheelchair provided, medications supplied, and a follow‑up appointment scheduled. Nursing documentation from the same day showed the resident received education on medications, blood glucose monitoring, emergency response, and home health services prior to discharge. However, there was no evidence in the medical record that the resident was provided a written 30‑day discharge notice before leaving the facility. In an interview, the Social Worker, in the presence of the Administrator, confirmed that the resident had chosen discharge to a motel and that the facility paid for 28 days at the hotel and provided 14 days of medications, and also confirmed that a 30‑day discharge notice was not issued. The deficient practice had the potential to affect the resident by limiting the ability to adequately prepare for discharge and exercise rights regarding the discharge process.
Failure to Update Activity Care Plan After Significant Change in Condition
Penalty
Summary
The deficiency involves the facility’s failure to update an activity care plan following a resident’s significant change in condition and participation. The resident experienced a fall on 02/18/26, resulting in fractures to the left distal femur and right distal femur/knee, with osteopenia noted on diagnostic imaging. She was hospitalized and returned to the facility on 02/24/26. A subsequent MDS with an ARD of 02/27/26 identified a significant change in status. Despite this, the resident’s activity care plan, originally initiated in 2020 and revised multiple times through 03/03/2025, was not revised after the fall and significant change to reflect her new limitations and altered participation in activities. Prior to the fall, the resident had been able to stand, pivot, and transfer to her wheelchair, and was walking up to 100 feet with therapy. She was active in out-of-room activities, including Resident Council, food committee, parties, socials, church, and other group activities. After the fall, she reported that she now had a rod in her left leg, a brace on her right leg, and was non-weight bearing for 10 weeks, which prevented her from getting into her wheelchair and attending the activities she previously enjoyed. She expressed distress about no longer being able to attend Resident Council meetings, church, and family gatherings, and stated that activity staff did not visit very often and that she could not go out to the groups she liked. During the interview, she was observed to be tearful. Record review of activity participation from 01/01/2026 to the present showed that the resident had participated in out-of-room activities before the fall but had no out-of-room participation after her return from the hospital. The records also showed that since the significant change, she had only two documented one-to-one visits, both on 03/04/26. The Director of Recreation confirmed that the resident had not attended group activities since returning from the hospital and was non-weight bearing, and stated that anything done with her was now in-room. The Director also stated that social visits were not documented as one-to-one visits. Surveyors noted that there were no new or revised interventions on the activity care plan since 01/2025 despite the significant change in the resident’s condition and participation, and the Administrator and Director of Recreation confirmed that the documentation reflected this lack of update.
Failure to Adjust Activities Program After Resident’s Significant Change in Condition
Penalty
Summary
The deficiency involves the facility’s failure to provide an activities program that met the interests and needs of a resident who experienced a significant change in condition and activity participation. The resident, who was cognitively intact with a BIMS score of 15 and served as president of the Resident Council, sustained fractures to the left distal femur and right distal femur/knee area after a fall and was hospitalized. Diagnostic imaging showed an anterior apex angulated, impacted distal femur diametaphyseal fracture on the left and an impacted, comminuted anterior apex angulated fracture of the distal fifth metaphysis of the right knee, with osteopenia noted. After hospitalization, the resident returned to the facility and had an MDS with a significant change assessment, with Section F indicating that it was important for her to do things with groups of people, participate in favorite activities, and attend church services. Record review showed that prior to the fall and fractures, the resident participated in out-of-room activities, including Resident Council, food committee, parties, and socials. The activity care plan, originally created in 2020 and revised multiple times through early 2025, documented numerous preferences and important activities for the resident, such as in-room visits, participation in food committee, church, singing, cooking, gardening, going outside in good weather, pet visits, listening to religious and other music, watching TV, reading, and engaging in religious services and voting. The care plan also noted that it was important for her to engage in her favorite activities and to have opportunities to make choices related to meaningful activities. However, there were no new interventions added or changes made to the activity care plan after her significant change in condition and return from the hospital. Activity participation records from the beginning of the year through the time of survey showed that since her readmission from the hospital, the resident had no out-of-room activity participation and only two documented one-to-one visits, both on the same day. During interview, the resident reported that she could no longer stand, pivot, or get into her wheelchair, and that she was now unable to attend Resident Council meetings, church, or be around people as she had before. She expressed distress about missing family gatherings she had been working toward attending and stated that activity staff did not visit very often and that she could not go out to the groups she liked. The Director of Recreation confirmed that the resident had not attended group activities since returning from the hospital due to being non–weight bearing, that anything done with her was now in-room, and that social visits were not consistently documented. The Administrator and Director of Recreation acknowledged that documentation showed only two one-to-one visits and no updated interventions on the care plan since before the significant change, leading to the finding that the facility failed to provide a program of activities to meet this resident’s needs and interests after her change in condition.
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