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
The facility failed to timely escalate a resident with signs of sepsis, respiratory distress, hypoxia, hypotension, and acute decline for hospital transfer despite NP and telehealth recommendations for immediate ED evaluation; the resident was later admitted with sepsis, obstructing kidney stone, and hypoxic respiratory failure. The facility also missed documentation for ordered wound care for one resident and administered PRN hydrocodone-acetaminophen to another resident without documenting the required pain level.
Excessive ambient temperatures were observed at the 100/200 and 300/400 nurses' stations when the wall thermostat and facility temperature monitoring device both showed readings in the low 80s. The surveyor verified the readings with the Facility Maintenance Director while residents were seated in nearby common areas.
Food was not consistently temped before leaving the kitchen, and a test tray showed both hot and cold items served at improper temperatures. The DAM could not produce food temp logs, dietary staff only recorded four item temps before tray line, and a tray sent to a hall had a ham & cheese sandwich, coleslaw, lettuce and tomato, and mixed fruit all outside expected temp ranges. Residents also reported that room trays were often hot when they should be cold and cold when they should be hot.
Infection control lapses were observed with trash stored on the floor in soiled utility rooms and with missed hand hygiene during meal service. Residents did not receive hand sanitation during lunch pass, an LPN did not perform hand hygiene while helping with trays, and no resident or staff hand hygiene was completed during meal service on the 100 wing.
Care plan meetings were not consistently held or documented, and residents were not included in their own care planning. One resident’s care plan was also not revised after she was fitted for an upper denture and was awaiting delivery. The DON and DoSS acknowledged that care plan meetings were behind, and records showed missing quarterly reviews and no documented invitations or attendance for some residents.
Improper POST Form Consent for Resident Without Capacity: A resident with vascular dementia, major depressive disorder, hallucinations, unspecified mood disorder, and anxiety signed a POST form selecting CPR with full treatment even though a physician determined the resident lacked capacity to make medical decisions. The resident’s representative did not sign the form, and the DoA acknowledged the error during survey review.
Delayed Transfer, Missed Wound Care, and Incomplete Pain Documentation
Penalty
Summary
The facility failed to ensure timely assessment, intervention, and transfer for a resident who developed acute clinical deterioration consistent with sepsis. Resident #123 was noted during an acute visit to be more lethargic than normal, responsive only to verbal stimuli, cool and clammy, tachypneic, with oxygen saturation of 86-89% on room air, heart rate up to 125 beats per minute, and hypotension. The nurse practitioner assessed septicemia, tachypnea, tachycardia, and acute hypotension and ordered labs, IV fluids, ceftriaxone, and close monitoring. Later the same day, after-hours telehealth review documented that the resident appeared acutely ill with respiratory distress, increased work of breathing, oxygen saturation fluctuating between 80% and 92% despite oxygen, fever, acute kidney injury, suspected infection/sepsis, leukocytosis, anemia, and thrombocytopenia. The telehealth consultant directed that the resident be transferred immediately to the ED. The resident was not transferred until later that evening and was subsequently admitted to the hospital with sepsis, an obstructing kidney stone, and hypoxic respiratory failure. Interviews with the nurse practitioner, RN, family members, and other staff described delays in sending the resident out and disagreement from the DON about hospital transfer. The facility also failed to follow ordered treatment for another resident’s skin and wound care. For Resident #129, the TAR showed multiple dates when skin tear treatment, stage 2 pressure ulcer treatment, and left lower limb wound care were not signed off as completed or refused. In addition, the facility failed to provide pain management as ordered for Resident #4. The physician ordered hydrocodone-acetaminophen 5/325 mg, 2 tablets every 4 hours as needed for pain level 4-6, but the MAR showed the medication was administered on multiple days without a documented pain level of 4-6 before administration.
Excessive Ambient Temperatures at Nurses' Stations
Penalty
Summary
The facility failed to consistently maintain ambient temperatures within the required range in the 100/200 Nurses' Station and the 300/400 Nurses' Station. During direct observation, the wall-mounted thermostat at the 100/200 Nurses' Station displayed 83 F. The surveyor then requested that the Facility Maintenance Director obtain ambient temperature readings using the facility's temperature monitoring device, and the readings were verified by the surveyor as they were obtained. At that time, the Facility Maintenance Director measured 82.2 F at the 100/200 Nurses' Station and 83.0 F at the 300/400 Nurses' Station. The surveyor also observed residents seated in common areas close to both nurses' stations while the temperatures were above the recommended comfort range. The facility census was 118.
Food Served at Improper Temperatures
Penalty
Summary
Food and drink were not ensured to be palatable and served at safe, appetizing temperatures. The facility failed to ensure all food was temped before leaving the kitchen and failed to ensure hot foods were served hot and cold foods were served cold. Healthcare Services Group policies cited in the report stated that food should be prepared to conserve nutritive value, flavor, and appearance, and that food should be served at proper safe and appetizing temperatures. The report also states that all foods are to be prepared in accordance with the FDA Food Code. On 06/29/26 at 11:01 AM, the Dietary Account Manager could not produce the June 2026 food temperature logs and stated she could not find them. When the surveyor asked for any food temperature logs for 2026, the DAM stated she had checked the trash and everywhere but still could not find them. Later that day, before tray line started, dietary staff only recorded temperatures for four regular consistency food items: BBQ Chicken, Coleslaw, [NAME] Beans, and a Ham & Cheese Sandwich. A regular consistency test tray sent to Dogwood Hall at 12:51 PM was checked at 1:02 PM, and the recorded temperatures were 67.5 F for the Ham & Cheese Sandwich, 68 F for Coleslaw, 79.3 F for Lettuce and Tomato, and 55.2 F for Mixed Fruit. During Resident Council on 07/01/26, residents stated that when they ate in their rooms, cold food was hot and hot food was cold, and that the food was the correct temperature only when they ate in the dining room.
Infection Control Lapses During Trash Storage and Meal Service
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. During observation of the soiled utility rooms on the 500 and 600 halls, three large bags of trash were found on the floor in each room, and the ADON verified that the bags should not have been stored on the floor. During lunch pass observations, resident hand sanitation was not performed for Resident #59, and a nursing assistant verified that residents were not being washed. At another lunch pass observation, an LPN did not complete hand sanitation or hand washing while assisting with trays for Resident #53 and stated she had her own hand sanitizer on the desk and did not normally help with trays. During meal service on the 100 wing, no resident or staff hand hygiene was completed while Residents #124, #126, and #122 were eating in the day room, and a nursing assistant stated that residents are usually washed in their rooms and hand wash or hand sanitizer is used.
Care plan meetings were not held or documented as required, and one resident’s care plan was not updated for new dentures
Penalty
Summary
The facility failed to include residents in care plan meetings and failed to ensure care plans were reviewed at least quarterly. Resident #71 stated during interview that she had not been invited to attend care plan meetings. Her record showed a care plan meeting on 03/13/25 in which she participated, but no further care plan meetings were documented after that date. The Social Worker confirmed that 03/13/25 was the last care plan conference held for this resident and stated she was behind on holding resident care plan meetings. The facility also failed to revise Resident #71's care plan after she was fitted for an upper denture and was awaiting its arrival. Her comprehensive care plan still reflected that she was at risk for oral/dental problems related to being edentulous and that she chose not to wear dentures. Resident #9 stated she had not been invited to care plan meetings, and her record contained no documented invitations or attendance since admission. Resident #88 likewise stated he had not been invited to or participated in quarterly care plan meetings, although the electronic record showed participation on 03/27/25 and 03/05/26. The Director of Social Services stated she was the only social worker for 90 residents and was behind on care plan meetings.
Improper POST Form Consent for Resident Without Capacity
Penalty
Summary
The facility failed to obtain consent from the resident’s representative on the POST form for Resident #11, instead allowing the form to be signed by the resident even though the resident did not have capacity at the time of consent. Resident #11 had diagnoses of vascular dementia, major depressive disorder, hallucinations, unspecified mood disorder, and anxiety. The medical record showed that a Virginia POST form was completed and signed by the resident selecting CPR with full treatment, and on the same date a physician determined that the resident did not have capacity to make medical decisions and that a medical power of attorney representative or surrogate decision-maker may make medical decisions regarding life-prolonging intervention or mental health treatment. During surveyor review, the Nursing Home Administrator stated that the Director of Admissions oversaw POST forms, and the Director of Admissions acknowledged the error when shown the POST form and the physician’s capacity determination.
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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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