Citations in West Virginia
Statistics, citations and compliance trends for long-term care facilities in West Virginia.
Statistics for West Virginia (Last 12 Months)
Financial Impact (Last 12 Months)
Latest citations in West Virginia
Failure to Notify Residents of Room Changes: The facility did not complete room change notifications for two residents whose rooms were changed, and no documentation of notice was found in the medical record. One resident with BIMS 15 said she was okay with the move but did not know until the day of the change. An LSW confirmed the notifications were not completed and could not show the resident was aware of the room change.
Failure to timely notify a resident’s MPOA of a hospital transfer related to a change in condition. The DON confirmed the resident was transferred to the hospital, but the MPOA was not notified at the time of transfer and was not documented as notified until an email was sent later. The DON acknowledged the delay was not consistent with facility expectations or federal requirements.
Failure to provide timely incontinent care: A cognitively intact resident was found in urine-soaked clothing and linens with a strong urine odor in the room. Although an NA documented care and later stated she had not actually changed the resident, the resident remained unchanged even after the DON directed staff to provide care, and the resident was tearful when she said she still had not been changed.
Staff incorrectly told resident representatives that transfers to a higher level of care would be treated as AMA discharges and that the residents could not return. One resident with a UTI, IV therapy, refusal of care, and repeated IV removal was sent to the hospital after the family requested transfer, and another resident was transferred for behavioral issues after the family had asked for acute care. In both cases, staff communications to the family and hospital incorrectly labeled the transfers as AMA.
The facility failed to timely notify the Ombudsman of resident transfers and discharges. Record review showed multiple months in which notices were not sent, and for one resident transferred to the hospital, the Ombudsman notification was delayed until months later. The DON confirmed the late notification and stated an action plan was in place.
A resident with osteomyelitis of the toes of the R foot was admitted with an identified need for wound care, but the facility did not obtain wound care orders or start treatment until several days after admission. The record also showed prescribed meds were not ensured to be available and administered as ordered, and there was no documentation of interim wound care, protective measures, or physician notification about the delay.
Failure to Notify Residents of Room Changes
Penalty
Summary
The facility failed to notify residents and their representatives of room changes for 2 of 3 residents reviewed for room change notifications during the complaint survey. Resident #60 had been in one room since admission and was moved to another room on 07/02/25, but no room change notification was found in the medical record. Resident #68 was admitted to one room on 03/10/26, moved to another room on 04/27/26, and then moved again on 06/16/26, and no room change notification was found in the medical record. During interview, a resident with BIMS of 15 stated that she was okay with her room change but did not know she was moving until the day of the move. The LSW stated that the room change notifications were not completed for the two residents and said she had a text conversation with Resident #68’s daughter about it, but could not show that the resident was aware of the room change. The facility policy titled Notification of Change states that the facility must inform the resident and, when applicable, consult with the physician and/or notify the resident’s family member or legal representative when there is a change requiring notification, including a change of room or roommate assignment.
Failure to Timely Notify MPOA of Hospital Transfer
Penalty
Summary
The facility failed to ensure the resident’s Medical Power of Attorney (MPOA) was notified when Resident #100 was transferred to an acute care facility for a change in condition. During record review and staff interview on 7/29/26, the DON confirmed the resident was transferred to the hospital on the referenced date and acknowledged that the MPOA was not notified at the time of transfer. Review of the clinical record showed the MPOA was not notified until April 28, 2026, when an email was sent, and there was no documentation supporting notification on or near the date of transfer. The DON stated the facility practice is to notify the resident’s representative as soon as practicable after a transfer so the representative is informed of the resident’s condition and location and can participate in care decisions, and acknowledged the delay was not consistent with facility expectations or federal requirements.
Failure to Provide Timely Incontinent Care
Penalty
Summary
The facility failed to ensure that Resident #71, a cognitively intact resident with a BIMS score of 15, received timely incontinent care and was protected from neglect. During an interview, the resident stated she had not been changed since approximately 11:00 PM the previous evening and believed she would not be changed until later in the day. A strong odor of urine was noted upon entering the room, and the resident reported that this happened all the time because there were only three staff members working the night shift. Record review showed Nurse Aide #30 documented incontinent care for the resident at 8:55 AM, but during interview the aide stated she had not changed the resident that day and had not had any help. The surveyor observed the resident’s bed linens were completely saturated with urine. After the DON arrived and directed staff to provide incontinent care, the resident was still not changed more than an hour later, and at 12:30 PM the room still smelled of urine. The resident tearfully stated she had not been changed yet, and the DON later stated staff were then in the room doing it, while the Administrator offered no additional comment.
Improper AMA Classification of Resident Transfers
Penalty
Summary
The facility failed to ensure that residents were allowed to return after requests to be sent to an acute care facility were honored, and staff incorrectly treated those transfers as Against Medical Advice (AMA) discharges. This deficiency involved two residents. In both cases, staff told the resident representatives that if the resident was sent out for a higher level of care, it would be considered AMA, even though the transfers were initiated by the facility or requested by the family and later carried out by the facility. For one resident, the record showed the resident was receiving IV fluids and antibiotics for refusal of medications, meals, and treatment for a UTI, and repeatedly pulled out the IV. The resident’s son insisted the resident be sent to the hospital so she could be restrained to keep the IV in place. Staff documented that the physician assistant did not want the resident sent out, and the son was told that sending her out would be AMA. The resident was then sent to the hospital due to worsening edema at the IV site, and the hospital later reported pneumonia, difficulty maintaining blood pressure, intermittent BiPAP use for shortness of breath, oxygen by nasal cannula while awake, and use of restraints for safety because the resident was combative. For the second resident, the family requested transfer to an acute care facility for behavioral issues, but was told the resident could be cared for in the facility and that sending the resident out would be an AMA discharge. Within a few hours, the resident was transferred anyway. The resident representative later reported being told by the hospital social worker that the resident was not allowed to return because of leaving AMA, although the resident had not left AMA. The administrator later confirmed the facility liaison told the acute care facility the resident could not return because the resident left AMA, and the corporate nurse stated the residents were not AMAs and that staff were confused.
Delayed Ombudsman Notification for Resident Transfer
Penalty
Summary
The facility failed to send required notices to the Office of the State Long-Term Care Ombudsman for resident transfers and discharges. Record review showed that for January, February, and March 2026, the Ombudsman was not notified of transfers and discharges until April 2026. For Resident #100, who was transferred from the facility to the hospital on January 3, 2026, the facility did not notify the Long-Term Care Ombudsman until April 28, 2026, by email. The DON confirmed during interview that the resident had been transferred to the hospital on January 3, 2026 and acknowledged that the Ombudsman notification email was not sent until April 28, 2026.
Delayed wound care and medication administration for resident with osteomyelitis
Penalty
Summary
The facility failed to provide necessary care and services for Resident #100 by not timely initiating physician-ordered wound care and prescribed medication after admission. Record review showed the resident was admitted with an identified need for wound care, but the facility did not obtain wound care orders or begin wound treatment until 12/19/2025, leaving the resident without physician-ordered wound care for four consecutive days after admission. The clinical record contained no documentation that wound care was provided during that period, no evidence of interim protective interventions by nursing staff, and no documentation that the physician was contacted about the delay in establishing treatment orders. Hospital records reviewed by the surveyor showed Resident #100 was diagnosed with osteomyelitis of the toes of the right foot, a serious bone infection. The facility also failed to ensure prescribed medications were available and administered as ordered. Based on the record review and interview with the corporate nurse on 07/30/2026 at 9:00 AM, these omissions delayed treatment for the resident’s documented infection and were identified during the survey review.
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Compliance trends in West Virginia
Data through Jun 2026Comparisons below measure the most recent period Jul 2025 – Jun 2026 against the prior period Jul 2024 – Jun 2025 (two equal 12-month windows). The most recent 1 months are excluded because CMS is still publishing them.
Top tags by month · last 24 months
dashed = still reportingMonthly citation counts for the 5 most-cited tags. The dashed tail is the 1-month reporting lag.
Frequency movers
Biggest change in how often each tag is cited, as a rate per 100 inspections (so it isn't skewed by survey volume): Jul 2025 – Jun 2026 vs the prior period Jul 2024 – Jun 2025. Only tags with at least 20 citations in both periods are shown.
Severity movers
Tags whose average scope/severity shifted the most: Jul 2025 – Jun 2026 vs the prior period Jul 2024 – Jun 2025. The number is the average severity on the A–L scale (A=0…L=11); the letter is the band it falls in. A rise means the same tag is being cited at a more serious level — note the average can move enough to rank here while staying within the same letter. Same 20-citation minimum applies.
Care domain movers
Citations grouped into CFR care domains — F-tags by their §483 regulatory section (CMS State Operations Manual, Appendix PP) — measured as a rate per 100 inspections: Jul 2025 – Jun 2026 vs the prior period Jul 2024 – Jun 2025. Share is the domain's portion of citations this period; avg severity is the mean scope/severity letter and immediate jeopardy the percentage cited at J–L, both over the current period. Domains with at least 20 citations in both periods are shown; the sparkline tracks the last 12 months (left = oldest).
Immediate jeopardies · this period
Citations at the most serious scope/severity — J–L, immediate jeopardy, residents placed at risk of serious harm or death — over Jul 2025 – Jun 2026 vs the prior period Jul 2024 – Jun 2025. "Surveys with an IJ" counts distinct health inspections that had at least one.
Survey activity · by month
faded/dashed = still reportingCitations each month split into complaint-driven (unscheduled, triggered by grievances) vs standard surveys — bars, left axis — with the number of inspections as a line on the right axis. Rising inspections signal more scrutiny; a rising complaint share means more off-cycle surveys. The most recent 1 months are still being reported.
Deficiency-free survey rate
Share of health surveys that found zero deficiencies — the odds of a clean survey. Jul 2025 – Jun 2026 vs the prior period Jul 2024 – Jun 2025; the most recent 1 months are still being reported (dashed).
Penalties · by month
faded = still reportingTotal civil money penalty dollars imposed on the state's facilities each month — how hard the state is enforcing. The most recent 1 months are still being reported, and penalties often lag citations by several months.
Emerging tags
Tags that weren't established last period but surged — an early warning, distinct from movers (which track already-common tags). Criteria: fewer than 20 citations in the prior period, but at least 10 this period and 2.5× their prior volume. The sparkline shows monthly counts over the last 12 months (left = oldest).
Trusted data from CMS and state health departments
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