Teays Valley Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Hurricane, West Virginia.
- Location
- 1390 North Poplar Fork Road, Hurricane, West Virginia 25526
- CMS Provider Number
- 515106
- Inspections on file
- 26
- Latest survey
- February 18, 2026
- Citations (last 12 mo.)
- 17
Citation history
Health deficiencies cited at Teays Valley Center during CMS and state inspections, most recent first.
Surveyors found that staff failed to provide and accurately document ADL assistance for multiple residents, including oral hygiene and scheduled showers. One resident’s oral care was marked as “not applicable” without any indication of refusal, and another resident had severe dental plaque despite a care plan requiring twice-daily teeth brushing. The DON acknowledged that staff were using “not applicable” instead of documenting refusals. A resident with Dementia and Parkinson’s Disease, who depended on staff for ADLs and preferred showers, was scheduled for twice-weekly showers but received only a few showers and bed baths over a month, with several missed showers recorded as “not applicable.”
The facility failed to maintain an effective pest control program and adequate environmental cleanliness, as evidenced by mouse droppings observed in the dining area and in multiple resident rooms and bathrooms, along with resident reports of seeing mice. Surveyors found large amounts of dark, cylindrical pellets on dining room countertops, in utensil drawers, and in cabinets, while several residents reported mice in their rooms and noted poor cleaning. Observations included food debris on floors and linens, holes in walls behind commodes, loose baseboards with openings, damaged drywall, and debris on and around resident furniture, with staff acknowledging ongoing mouse issues and the need for cleaning and repairs.
A resident with a recent history of falls, persistent disorientation, chairbound status, predisposing diseases, and medications increasing fall risk was admitted and assessed as high fall risk. Despite these factors and a subsequent fall, the care plan did not include fall risk interventions until after the incident. The DON confirmed the omission of fall risk in the care plan prior to the fall.
The facility failed to provide liquids in the correct consistency for residents requiring nectar thickened liquids, creating an immediate jeopardy situation. Observations revealed that residents had liquids that were not of the required consistency, and staff interviews indicated improper preparation of thickened liquids. Staff were not following the manufacturer's guidelines for thickening, leading to potential risks for residents.
The facility failed to ensure a clean and well-maintained environment in three resident rooms. Issues included stained blinds, a pink substance on the floor, improperly fitted toilet tank lids, dislodged and dusty light fixtures, and unaddressed resident requests for wall and ceiling maintenance. These deficiencies were confirmed by a Corporate RN.
The facility failed to provide accurate MDS assessments for five residents, leading to discrepancies in their medical records. A resident was noted as having adequate hearing despite being hard of hearing, another had an undocumented IV port, and a third had a cancer diagnosis omitted. Additionally, a resident was incorrectly documented as receiving insulin, and another was inaccurately noted as edentulous. These errors were confirmed by staff and could impact care planning.
The facility failed to implement comprehensive care plans for several residents, leading to improper documentation and execution. A resident's care plan was not followed regarding blood pressure monitoring, while others lacked documentation of religious preferences and food allergies. Additionally, there were significant gaps in monitoring nutritional intake for residents with weight loss, and some care plans did not address medical diagnoses like epilepsy and cirrhosis.
The facility failed to update care plans for several residents, including one who experienced an actual fall, another with a nutritional supplement order, a resident with an incorrect diabetes diagnosis, and a resident with unaddressed psychiatric diagnoses. These deficiencies were confirmed by facility staff.
A resident dependent on staff for showering did not receive the scheduled showers and bed baths. From September to December, the resident received only 10 out of 29 scheduled showers and 19 out of 72 bed baths, with one documented refusal. This deficiency was confirmed through record reviews and staff interviews.
The facility failed to adhere to care plans and physician orders for four residents, resulting in inadequate care. A resident with constipation did not receive prescribed treatments, another with a Foley catheter had no urinary output documentation, a third wore a splint without a physician's order, and a fourth had blood pressure taken from a restricted extremity. These deficiencies were confirmed by facility staff.
The facility failed to maintain proper nutritional care for several residents, resulting in significant weight loss and incomplete meal documentation. A resident did not receive prescribed supplements, while another had incomplete meal intake records. A third resident experienced severe weight loss with missing meal documentation, and another had a downward weight trend with incomplete records. The DON and Corporate RN confirmed the documentation issues.
The facility failed to manage food allergies for three residents, leading to a severe allergic reaction for one resident who was served shrimp despite a shellfish allergy. Other residents had inaccuracies in their allergy documentation, and none had allergies documented in their care plans. Interviews revealed inadequate procedures for communicating and verifying food allergies.
The facility failed to store and label food items according to professional standards, as observed during a kitchen investigation. Unlabeled and undated food items, such as a Ziploc bag of soup, an opened pie crust, and a trash bag of French bread loaves, were found. Additionally, serving utensils were improperly stored with handles turned in different directions. These issues were confirmed by the Certified Dietary Manager (CDM), who acknowledged the deficiencies.
The facility failed to properly dispose of garbage, with trash overflowing from a can under the kitchen handwashing sink and onto clean pots and baking sheets. Garbage was also found on a storage rack with clean items. In the dining room, food, dirty napkins, and straws were observed on tables and the floor, with dirty silverware left on tables. The Certified Dietary Manager confirmed these findings during an investigation.
The facility failed to maintain accurate and complete medical records for several residents. Observations revealed discrepancies in dental assessments, meal documentation for a resident on NPO status, and missing diagnoses in PASRR. Additionally, vaccination records were incomplete, and attempts to contact the MPOA were not documented.
A facility failed to provide accurate and timely discharge notices for a resident during transfers to an acute care facility. Documentation was incomplete or incorrect for two of the three transfers, with one form listing an incorrect date and another transfer lacking a form entirely. This was confirmed by the DON.
The facility failed to identify and document mental health diagnoses for two residents in their PASARR process. A resident's diagnoses of Bipolar Disorder and PTSD were not identified, and another resident's Bipolar Disorder was omitted from the PASARR, despite being present in medical records. These discrepancies were confirmed by a State Surveyor and a Corporate RN.
A facility failed to document a resident's religious preferences and history as a minister in their care plan, leading to a lack of appropriate activity invitations. The resident, who identified with the Baptist faith, expressed that they were not invited to activities that aligned with their beliefs, such as church services, and did not participate in bingo due to personal beliefs against gambling. This deficiency was confirmed by the Administrator.
A facility failed to evaluate a resident's hearing impairment, despite the care plan recognizing impaired communication due to hearing issues. The medical record lacked documentation of a hearing test or assessment for hearing aids. The DON confirmed that no hearing assessment had been conducted since the resident's admission.
A resident was found to have long, curled toenails due to the facility's failure to provide proper foot care. The resident's medical record showed no diagnosis preventing nail care, and there was no record of a podiatrist visit. The DON confirmed the need for nail trimming and acknowledged the oversight.
A facility failed to use proper PPE for a resident in Enhanced-Barrier Precautions (EBP) due to wounds, a suprapubic catheter, and a feeding tube. A nurse aide provided ADL care without wearing a gown and gloves, and both an RN and an LPN did not don PPE before wound care. The EBP signage was turned backward, contributing to the oversight, as acknowledged by the DON.
A resident's healthcare decision maker was not given complete or accurate information regarding available Medicaid bed-hold days or the cost per day when the resident was transferred to a hospital on multiple occasions. Bed-hold notices were incomplete and lacked documentation that the responsible party was informed or made decisions about paying for the bed-hold.
Failure to Provide and Accurately Document ADL Hygiene and Bathing Care
Penalty
Summary
The deficiency involves the facility’s failure to provide and accurately document assistance with activities of daily living (ADLs), specifically hygiene and bathing, for multiple residents. For one resident, review of hygiene task documentation on a specific date showed oral care marked as “not applicable” without any indication that care was refused, making it appear that no attempt was made to provide oral care. Another resident was observed to have severe plaque buildup on their teeth despite a care plan that required teeth brushing twice daily. During an interview, the DON confirmed that staff were incorrectly selecting “not applicable” instead of documenting when a resident refused care, which made it appear that required care was not provided rather than refused. A third resident’s MPOA reported that the resident often appeared unkempt and that she frequently had to remind staff of the resident’s scheduled shower days; she stated that both she and the resident preferred showers and that staff were aware. Record review showed this resident required assistance or was dependent for multiple ADLs, including bathing, grooming, and personal hygiene, and that it was important to the resident to have a shower. The resident had diagnoses of Dementia and Parkinson’s Disease and was scheduled for showers twice weekly on day shift. Over a 30‑day period, the resident was eligible for eight showers but received three showers and two bed baths, with several scheduled shower days documented as “not applicable.” The DON confirmed that the resident did not receive showers as scheduled.
Failure to Maintain Effective Pest Control and Environmental Cleanliness
Penalty
Summary
The facility failed to ensure an effective pest control program was in place, as evidenced by repeated observations of mouse droppings and resident reports of mice in multiple areas. The written pest control policy, shared between Dining Services and the facility, focused on food preparation, service, and storage areas and referenced coordination between the Dining Service Director and Director of Maintenance for pest control services. During an initial tour of the dining room, surveyors observed a large amount of small, dark brown-to-black, cylindrical pellets resembling grains of rice on the countertop along the wall/backsplash, in utensil drawers, in a cabinet labeled for a suction machine, and in a drawer labeled for clothing protectors. Staff present during these observations acknowledged prior issues with mice and stated the area needed to be cleaned, but the pellets remained present when rechecked later the same day. Multiple residents reported seeing mice in their rooms within the prior week, and surveyors observed environmental conditions consistent with pest activity and inadequate cleaning. One resident stated that rooms did not get cleaned properly and had food debris on the floor under the bed, on bed linens, and around the bathroom sink. Another resident reported seeing a mouse under a roommate’s cabinet, where surveyors then observed several small, dark brown-to-black, cylindrical pellets along the floor near the wall and a large amount of debris on top of the cabinet. Additional residents reported mice coming from bathrooms and under closets; in these rooms, surveyors observed holes in walls behind commodes, loose baseboards with holes, damaged drywall, and mouse-like pellets on the floor behind commodes and in corners. Staff, including a CNA and the Administrator, confirmed the presence of debris, wall holes, and the need for cleaning and repairs in these resident rooms and bathrooms.
Failure to Address High Fall Risk in Resident Care Plan
Penalty
Summary
The facility failed to develop and implement a person-centered, comprehensive care plan that addressed all of a resident's needs, specifically omitting interventions for fall risk. Upon admission, the resident was assessed as high risk for falls, with a documented history of one to two falls in the previous three months, disorientation at all times, chairbound status, presence of predisposing diseases, a recent change in condition, and use of medications that could increase fall risk. Despite these findings and a subsequent fall incident, the resident's care plan did not include fall risk or preventive interventions until after the fall occurred. The Director of Nursing confirmed that the care plan did not address the resident's fall risk prior to the incident.
Failure to Provide Correct Liquid Consistency for Residents
Penalty
Summary
The facility failed to provide liquids in the correct consistency to meet the individual needs of residents who were ordered nectar thickened liquids. This deficiency was observed in five residents, creating an immediate jeopardy situation due to the risk of physical harm and complications such as aspiration pneumonia. During the survey, it was noted that residents had liquids at their bedside that were not of the required nectar consistency, despite having orders for such. For instance, Resident #73 had thin water at the bedside, which was not in accordance with the nectar thickened liquid order, and was observed coughing during the interview. Staff interviews revealed inconsistencies in the preparation of thickened liquids. Nursing staff, including nurse aides and registered nurses, were using incorrect amounts of thickener for the liquids, leading to improper consistency. The directions on the thickener packets were not being followed, as staff were using one or two packets for 16-ounce cups instead of the correct amount specified for achieving nectar-like consistency. This inconsistency in preparation was confirmed by multiple staff members, including the Dietary Manager, who stated that all liquids were thickened on the floor by nursing staff using the packets of thickener.
Facility Fails to Maintain Clean and Repaired Resident Rooms
Penalty
Summary
The facility failed to maintain a clean and well-repaired environment for residents in three rooms on the 400 and 500 halls. During an initial tour, several issues were identified: in one room, the blind had brown stains, the floor had a pink substance that could not be wiped up, the toilet tank lid did not fit properly, and the sink was not securely affixed to the wall. In another room, the bathroom light fixture was dislodged and covered in dust. A resident in a third room expressed dissatisfaction with decorative flowers on the wall and brown spots on the ceiling, which she had requested to be painted over for a year. Additionally, her fan and the bathroom light were covered in dust. These observations were confirmed during a subsequent tour with a Corporate Registered Nurse.
Inaccurate MDS Assessments for Multiple Residents
Penalty
Summary
The facility failed to provide accurate Minimum Data Set (MDS) assessments for five residents, leading to discrepancies in their medical records. Resident #10 was found to be hard of hearing, yet the MDS indicated adequate hearing ability, and no hearing assessment had been conducted since admission. Resident #99 had an implanted right subclavian port for IV access, which was not documented in the MDS. Resident #93's diagnosis of polycythemia vera, a type of blood cancer, was omitted from the MDS. Resident #79 was incorrectly noted as receiving insulin in the MDS, while the resident was actually prescribed Ozempic, a non-insulin diabetes medication. Lastly, Resident #56 was inaccurately documented as edentulous in the MDS, despite having some teeth remaining, as confirmed by a dental consultation. These inaccuracies were confirmed through staff interviews and record reviews, highlighting a failure in the facility's assessment and documentation processes. The Director of Nursing and Corporate Registered Nurse acknowledged the discrepancies, confirming that the MDS entries did not reflect the residents' actual conditions. These errors in the MDS could potentially impact the care and treatment plans for the affected residents, as accurate assessments are crucial for appropriate care planning.
Deficiencies in Care Plan Implementation and Documentation
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for 12 out of 34 residents reviewed. This deficiency was evident in several areas, including the improper documentation and execution of care plans. For instance, Resident #26's care plan specified that no blood pressure or lab sticks should be taken from the right extremity, yet records showed that blood pressure was repeatedly taken from the right arm on multiple occasions. The Director of Nursing confirmed that the care plan was not being followed. Additionally, the facility did not adequately document or address residents' religious preferences and past experiences, as seen with Resident #48, whose care plan lacked information about their Baptist faith and history as a minister. Furthermore, several residents, including Residents #366, #61, #103, and #70, had food allergies that were not included in their care plans, indicating a significant oversight in addressing dietary needs and potential health risks. The facility also demonstrated a lack of proper documentation and monitoring of nutritional intake for residents experiencing significant weight loss, such as Residents #102, #12, #98, and #65. Meal intake documentation was frequently incomplete or missing, undermining the care plans' effectiveness in managing residents' nutritional status. Moreover, the care plans for Residents #99 and #93 did not address their medical diagnoses of epilepsy, cirrhosis, and polyneuropathy, further highlighting the facility's failure to develop comprehensive care plans tailored to individual resident needs.
Failure to Revise Care Plans for Multiple Residents
Penalty
Summary
The facility failed to revise care plans for five out of 34 residents reviewed during the survey process. For Resident #31, the care plan was not updated to reflect an actual fall that occurred, despite the resident being identified as at risk for falls due to decreased mobility. The Administrator confirmed that the care plan had not been revised to address this incident. Resident #266's care plan did not reflect a physician's order for a house supplement to be administered twice daily, which was confirmed by the Director of Nursing. Resident #79's care plan inaccurately included a diagnosis of insulin-dependent diabetes, although the resident did not have a physician's order for insulin, as confirmed by a Corporate RN. Additionally, Resident #55's care plan did not include a diagnosis of major depressive disorder, which was identified in the Pre Admission Screening and Resident Review (PASRR), but not reflected in the medical diagnoses. This discrepancy was confirmed by a Corporate RN. These oversights indicate a failure to maintain accurate and up-to-date care plans for the residents involved.
Failure to Provide Scheduled Showers and Bed Baths
Penalty
Summary
The facility failed to ensure that a resident, who is dependent on staff for showering, received the scheduled showers. The resident was supposed to receive two showers per week on Mondays and Thursdays. However, from September 1, 2024, to December 11, 2024, the resident only received 10 showers out of the 29 that were scheduled, with one documented refusal. This deficiency was confirmed through a review of the resident's medical records and interviews with the corporate Registered Nurse and the Director of Nursing. Additionally, the resident was supposed to receive bed baths on days when showers were not scheduled, totaling 72 bed baths during the same period. However, the resident only received 19 bed baths, with no documented refusals. The Director of Nursing confirmed that the resident was not receiving the showers and/or bed baths as scheduled, indicating a failure in providing the necessary care for activities of daily living.
Failure to Follow Care Plans and Physician Orders
Penalty
Summary
The facility failed to provide appropriate care and services to four residents, impacting their physical, mental, and psychosocial well-being. Resident #98 experienced repeated episodes of constipation without receiving the prescribed interventions, such as Milk of Magnesia, Dulcolax suppository, or Fleet Enema, despite having physician orders for these treatments. The Director of Nursing confirmed that the bowel protocol was not followed, as evidenced by the lack of documentation in the medication administration records. Resident #99, who had an indwelling Foley catheter, did not have her urinary output documented as required by her care plan, which was confirmed by the Nursing Home Administrator. Resident #89 was observed wearing a right hand splint without a corresponding physician's order, and Resident #26 had blood pressure readings taken from the right extremity despite orders and a care plan specifying not to do so. These deficiencies highlight a lack of adherence to care plans and physician orders, resulting in inadequate care for the residents involved.
Nutritional Maintenance Deficiency in LTC Facility
Penalty
Summary
The facility failed to ensure nutritional maintenance for several residents, leading to significant weight loss and incomplete documentation of meal intake. Resident #266 experienced significant weight loss and was supposed to receive house supplements twice daily. However, the Medication Administration Record (MAR) indicated that the resident did not take the supplements on numerous occasions, as confirmed by the Director of Nursing (DON). Resident #102 also experienced significant weight loss, and the care plan included monitoring meal intake and offering alternate choices. However, the documentation of meal intake was incomplete, with several meals not recorded. Corporate RN #156 confirmed the issues with documentation, indicating a lack of proper monitoring and recording of the resident's nutritional intake. Resident #98 experienced severe weight loss over six months, with incomplete documentation of meal intake. The Registered Dietician (RD) noted that the resident's meal intakes were usually between 50% to 100%, but documentation was missing for a significant number of meals. Similarly, Resident #65 experienced a downward trend in weight, with incomplete meal documentation since admission. The RD assessed the resident multiple times, noting varying meal consumption percentages, but the documentation was found to be incomplete, missing 52% of meal percentage documentation since admission.
Failure to Acknowledge and Manage Food Allergies
Penalty
Summary
The facility failed to properly acknowledge and manage food allergies for three residents, leading to a significant deficiency in care. Resident #103, who is allergic to shellfish, was served shrimp during a lunch meal, resulting in a severe allergic reaction. The resident reported symptoms such as facial swelling, itchy skin, and breathing difficulties, which previously required hospitalization. The resident provided photographic evidence of the meal served, which included shrimp in contact with other foods on the plate. Additionally, the lunch menu listed shrimp as an alternate meal option, indicating a lack of proper allergy management. Further deficiencies were noted in the documentation and communication of food allergies for other residents. Resident #70's tray card failed to list an allergy to pecans, while Resident #61's tray card inaccurately included an allergy to shellfish, which was not documented in the medical record. None of the food allergies for these residents were documented in their care plans. Interviews with the Director of Nursing (DON) and the Certified Dietary Manager (CDM) revealed a lack of clear procedures for communicating and verifying food allergies, with the DON unable to provide information on how allergies were care planned.
Improper Food Storage and Labeling
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed during a kitchen investigation. Several food items, including a Ziploc bag of soup, an opened pie crust, and a trash bag of French bread loaves, were found opened, unlabeled, and undated. Additionally, serving utensils were improperly stored in a drawer with handles turned in different directions. These deficiencies were confirmed by the Certified Dietary Manager (CDM), who acknowledged the lack of proper labeling and dating, and noted that the cook preferred to keep serving utensils in the drawer. The CDM admitted that there were dates on the food items at one point, but they were no longer present.
Improper Garbage Disposal in Kitchen and Dining Areas
Penalty
Summary
The facility failed to properly dispose of garbage in accordance with professional standards for food service safety. Observations made on December 9th revealed that garbage was overflowing from a trash can located under the handwashing sink in the kitchen, with trash hanging out and onto clean pots and baking sheets in the surrounding area. Additionally, garbage from the trash can was found on the storage rack with clean pots and baking sheets. The Certified Dietary Manager (CDM) was present and questioned whether the trash can should be removed. Further observations in the dining room showed food on tables and the floor, along with dirty napkins and straws. The CDM reported that housekeeping cleans the area after dinner, and noted that breakfast was not served in the dining room. Dirty silverware was also observed on the table. The CDM picked up some of the food and trash off the floor while kitchen staff were preparing for lunch. These findings were confirmed by the CDM during the initial kitchen investigation.
Inaccurate and Incomplete Medical Records Identified
Penalty
Summary
The facility failed to maintain complete and accurate medical records for four residents during the long-term care survey. For one resident, an observation revealed multiple missing teeth, yet the most recent oral health evaluation inaccurately documented the resident as edentulous. This discrepancy was confirmed by the Director of Nursing (DON), who acknowledged the absence of a more recent dental assessment. Another resident's medical record contained a physician order indicating the resident was NPO and fed by a feeding tube, yet meal percentages were documented on multiple dates, which the DON confirmed as inaccurate. Additionally, a resident's Pre Admission Screening and Resident Review (PASRR) was coded for Major Depressive Disorder, but there was no corresponding diagnosis in the medical record or care plan. A Corporate Registered Nurse (CRN) was unable to explain the origin of this diagnosis. Furthermore, another resident's record lacked documentation of current vaccinations, and attempts to contact the Medical Power of Attorney (MPOA) were not documented, as confirmed by the Infection Preventionist Registered Nurse (IPRN).
Inaccurate and Incomplete Discharge Documentation
Penalty
Summary
The facility failed to provide accurate and timely discharge notices for a resident during transfers to an acute care facility. Specifically, the resident was discharged on three occasions, but the documentation was incomplete or incorrect for two of these transfers. On one occasion, the transfer form dated 09/25/24 incorrectly listed the transfer date as 07/19/24. Additionally, there was no transfer form completed for the discharge on 07/19/24. This deficiency was confirmed during an interview with the Director of Nursing, who acknowledged the lack of proper documentation for the resident's transfers.
Failure to Identify Mental Health Diagnoses in PASARR
Penalty
Summary
The facility failed to properly identify and document mental health diagnoses for two residents in their Pre Admission Screening and Resident Review (PASARR) process. For Resident #18, the diagnoses of Bipolar Disorder and Post-Traumatic Stress Disorder (PTSD) were not identified on the most recent PASARR dated 11/14/23. This discrepancy was confirmed by the State Surveyor during a review with the Director of Nursing on 12/17/24. Similarly, for Resident #55, the PASARR did not identify Bipolar Disorder, despite the resident's medical records indicating diagnoses of Schizoaffective Disorder, Anxiety Disorder, and Bipolar Disorder. This oversight was confirmed by Corporate Registered Nurse #155 during a record review on 12/10/24.
Failure to Identify Religious Preferences in Care Plan
Penalty
Summary
The facility failed to provide an ongoing program to support residents in their choice of activities, as evidenced by the lack of identification of religious preferences in the care plan for one of the residents. Specifically, a resident expressed that they were not invited to activities that aligned with their religious beliefs, such as church services, and noted that they did not participate in activities like bingo due to personal beliefs against gambling. The resident, who had a history of being a minister and identified with the Baptist faith, did not have these preferences documented in their care plan. This oversight was confirmed by the facility's Administrator during the survey process.
Failure to Evaluate Resident's Hearing Impairment
Penalty
Summary
The facility failed to evaluate a resident's hearing impairment, which was identified during a survey. The resident, who was hard of hearing, was interviewed and found to have impaired communication due to this condition. Despite the care plan acknowledging the resident's hearing impairment, the medical record lacked any documentation of a hearing test or assessment for hearing aids. The Director of Nursing confirmed that no hearing assessment had been performed since the resident's admission to the facility.
Failure to Provide Proper Foot Care
Penalty
Summary
The facility failed to provide appropriate foot care for a resident, leading to a deficiency in maintaining mobility and good foot health. During an observation, it was noted that the resident had long toenails that extended from the tip of the toes and were curled at the ends. A review of the resident's medical record revealed no diagnosis that would prevent staff from providing nail care, and there was no record of the resident having seen the facility's podiatrist. The Director of Nursing confirmed the resident's toenails were long and needed trimming, and acknowledged that the resident had not seen the podiatrist recently.
Failure to Use PPE for Resident in Enhanced-Barrier Precautions
Penalty
Summary
The facility failed to adhere to proper infection prevention and control protocols by not wearing appropriate personal protective equipment (PPE) while providing care to a resident under Enhanced-Barrier Precautions (EBP). On December 12, 2024, Nurse Aide #35 was observed providing activities of daily living (ADL) care to Resident #12, who was in EBP due to wounds, a suprapubic catheter, and a feeding tube, without wearing the required gown and gloves. Additionally, Registered Nurse #102 and Licensed Practical Nurse #1 did not don PPE before performing wound care on the same resident. The EBP signage was found turned backward, making it invisible to staff entering the room, which contributed to the oversight. The Director of Nursing acknowledged the failure to wear proper PPE during ADL and wound care.
Failure to Provide Accurate Bed-Hold Information Upon Hospital Transfer
Penalty
Summary
The facility failed to provide an accurate accounting of bed-hold days to the healthcare decision maker for a resident who was discharged to an acute care hospital on three separate occasions. Record review showed that the bed-hold notices for each discharge were incomplete, containing only the nurse's signature, the resident's name, medical record number, and state abbreviation, with no information on the number of Medicaid bed-hold days available or the price per day. There was also no documentation indicating that the notice was provided to or reviewed with the resident's responsible party, nor any record of whether the responsible party wished to pay for the bed-hold or declined. The resident was receiving Medicaid services, and the Nursing Home Administrator confirmed that there was no other documentation showing the resident's son was informed of the remaining bed-hold days at the time of each discharge.
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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