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
The facility failed to prevent accident hazards and adequately supervise residents when two residents obtained cannabis gummies and CBD products via DoorDash, kept them in a bedside box with vape pens and OTC medications, and offered gummies to another resident, resulting in altered mental status, red eyes, paranoia, and ER transfers without a documented thorough investigation by administration. In a separate incident, a resident with decision-making capacity reportedly used a vape in a room with an active oxygen concentrator and refused a room search, leaving a potential fire hazard unresolved. Additional observations showed that a resident care planned for bilateral fall mats was in bed with one mat propped against the wall instead of on the floor, and another high-fall-risk resident was in bed with the bed not in the lowest position as required by the care plan, with staff confirming these fall-prevention interventions were not in place.
Two residents were not protected from neglect when one was left overnight in a soiled brief despite requests for incontinence care, resulting in raw, excoriated skin to the sacrum and scrotum, and another was served a grilled cheese sandwich despite an order for a mechanical soft diet, causing coughing before the tray was replaced. Staff interviews and documentation confirmed that the first resident had not been changed during the night and that prior skin assessments showed no issues, while the second resident’s diet order and the facility’s nutrition manual identified grilled sandwiches as inappropriate for a mechanical soft diet; neither incident was entered into the facility’s reportables or grievance systems.
The facility failed to accurately post daily nurse staffing information, with incorrect dates, unclear corrections, and mismatched total hours worked on most reviewed days. The daily staffing sheet was not readily visible on entry and, when located, contained multiple discrepancies between posted staffing and actual time-punch records. During one night shift, the posted sheet listed more LPNs and NAs than were actually present, with one NA found sleeping and another conducting personal business on a laptop in the breakroom, while one NA was assigned 1:1 to a resident, leaving two NAs to care for the remaining residents. These issues were confirmed through record review, observation, and staff interviews.
The facility failed to ensure adequate nursing staff on all shifts, leading to prolonged call light response times and unmet care needs. Multiple residents reported waiting from 45 minutes to several hours for assistance, including toileting and incontinence care, and described staff leaving the floor during smoke breaks and meal tray pass, leaving minimal coverage. Staffing records showed nursing HPPD below required minimums on at least one reviewed day, and an external report flagged low weekend staffing. One resident reported being left overnight in a soiled brief while having diarrhea, later found with raw, red skin to the sacral and scrotal areas, and this incident was not documented as a grievance or reportable event. A night-shift observation also revealed fewer staff on duty than posted, with one NA sleeping and another conducting personal business, while only two NAs were left to care for more than fifty residents.
Surveyors found that residents were not provided a way to file anonymous grievances and reported fear of retaliation for making complaints. During a Resident Council meeting, multiple residents stated they had no anonymous grievance option and felt their concerns raised in council were not taken seriously. The Social Worker confirmed there was no anonymous grievance mechanism and that residents and families had to request grievance forms from nursing or department heads, despite a written policy stating that residents and representatives have the right to file grievances orally or in writing and that staff will make prompt efforts to resolve them.
Two residents did not receive care according to physician orders and professional standards. One resident with a documented right hand contracture had orders and a care plan directing splinting of the left, functional hand, and surveyors observed the contracted right hand tightly fisted without a splint in place; the OT and DON later confirmed the order should have been for the right hand. Another resident with an order for Humalog Kwikpen requiring the provider to be called for blood sugar (BS) readings over 400 had multiple BS values above 400 documented on the MAR, but there was no documentation that the provider was notified on those occasions, which was confirmed by an RN consultant.
Surveyors identified multiple failures to follow food safety and sanitation policies, including soiled food service equipment, outdated and improperly labeled food items, and inadequate documentation of manual ware washing procedures. Personal items such as employee coats were stored on bread racks, and trash bins were placed on the same shelves as milk containers on beverage carts used for residents. These observations showed that staff did not consistently maintain clean food preparation areas, properly label and date TCS foods, or separate trash and personal belongings from food and food-contact surfaces.
The facility did not follow its own food safety and sanitation policies requiring trash to be contained in covered, leak-proof containers. During a kitchen walkthrough with the Director of Dining Services (DDS), a surveyor observed an uncovered trash can next to the juice machine and another uncovered trash can in the dish room. The DDS confirmed that these trash receptacles lacked lids, contrary to Healthcare Services Group (HCSG) policies that require the DDS to ensure appropriate lids are provided for all containers.
Two residents reported and staff observed sexually inappropriate behavior by a male resident, including entering a resident’s room uninvited while naked from the waist down and pulling on her in bed, and placing his hands under another resident’s blanket and rubbing near and on her private area. Both residents described the contact as unwanted, and one was documented as cognitively intact with capacity. Despite staff corroboration and resident statements to clinical providers, the facility’s investigations concluded that sexual abuse was not substantiated, citing lack of physical harm and inconsistent statements, and failed to adequately assess or address whether the residents felt safe or to alleviate their expressed anxiety.
The facility failed to ensure food was palatable, attractive, and maintained at a safe and appetizing temperature, as shown by tray temperature checks and interviews with several residents and staff. At lunchtime, kitchen staff were not taking or recording temperatures for items on the always-available menu, including beef patties, hotdogs, and brown gravy, before meal service began. The DDS acknowledged that temperatures for these always-available menu items were not being monitored or documented.
Failure to Control Resident Access to Non-Prescribed Substances and Implement Fall-Prevention Measures
Penalty
Summary
The facility failed to maintain an environment as free from accident hazards as possible and did not provide adequate supervision to prevent accidents, particularly related to resident access to non-prescribed substances and implementation of fall-prevention measures. An anonymous resident reported that two female residents purchased cannabis gummies via DoorDash and offered them to another resident, who refused. These two residents were later sent to the hospital after one was noticeably impaired. Record review showed no investigation documented in the facility’s reportable or grievance logs regarding these residents’ changes in condition due to cannabis gummies being brought into the facility and offered to other residents. Nursing documentation for one of the involved residents described a change in condition with altered mental status, suspicion of substance abuse, and tachycardia, leading to transfer to the ER for evaluation and toxicology screening. A late-entry note indicated the resident was educated on facility policies prohibiting OTC medications and CBD products in the room. Another nursing note detailed that a CNA reported a resident had consumed a gummy given by another resident, then discarded the second gummy, which the CNA retrieved from the trash. On assessment, the resident was found lying in bed with reddened eyes, reporting feeling tired, and vital signs were obtained. The resident stated she had consumed “pot gummies” and allowed the nurse to inspect a wooden box at the bedside, which contained several red sugar-coated gummies, three vape pens (including a suspected CBD vape pen), a bottle of Benadryl, and several Imodium tablets. The resident reported purchasing the gummies and CBD vape pen from DoorDash, and the items were removed with her consent. Further documentation showed that another nurse was informed that two residents had consumed an unknown gummy-like substance. On assessment, one resident had very red eyes and reported feeling paranoid, with vital signs recorded. This resident stated she had received two gummies from another resident and that a third resident knew about the gummies. The nurse interviewed the third resident, who reported that the resident supplying the gummies had told her she had gummies and THC pens and planned to give gummies to another resident. The nurse also noted that as staff were going to check on the resident who supplied the gummies, a DoorDash delivery person arrived and handed a bag to the nurse containing a pack of cigarettes and a receipt showing two CBD purchases. Facility administration had no evidence that a thorough investigation into this incident had been completed, and only limited action was taken following the event, leading surveyors to identify an immediate jeopardy situation due to residents being susceptible to drug abuse from other residents. The facility also failed to address other accident hazards and fall-prevention interventions for additional residents. One resident, who had capacity to make her own medical decisions, was involved in an incident where she reportedly used a vape in her room while an oxygen concentrator was present and turned on. The resident was verbally educated by the Administrator about the dangers of vaping near oxygen equipment, the smoking policy requiring smoking paraphernalia to be stored by nursing staff, and the prohibition of vaping inside the facility. However, during the survey period it remained unknown whether the resident still had vape pens in her possession, and she refused a room search, leaving a possible serious fire hazard unresolved at the time of review. In separate observations related to fall prevention, one resident was observed lying in bed with a fall mat that was supposed to be in place on the floor instead leaned against the wall behind the headboard. Record review confirmed the care plan required fall mats on both sides of the bed while the resident was in bed, and an LPN acknowledged that the floor mat was not in place. Another resident, care planned as at risk for falls due to multiple factors including muscle weakness, cognitive impairment, incontinence, psychoactive medication use, recent hospitalizations, visual impairment, and a history of traumatic brain injury and multiple CVAs, was observed lying in bed with the bed not in the low position despite a care plan intervention specifying that the bed should be in the lowest position. A RN consultant confirmed that the bed was not in the lowest position while the resident was in bed.
Failure to Prevent Neglect in Incontinence Care and Diet Texture Management
Penalty
Summary
The deficiency involves failure to protect residents from neglect by not providing timely incontinence care and by not providing the correct diet texture. One resident reported during interview that he had been left overnight without his brief being changed while experiencing diarrhea, despite requesting to be changed. Two CNAs separately stated that when they saw the resident the following morning, he reported not having been changed all night, that aides had come in only to change his roommate and then left, and that his skin was "raw," "pretty bad," and red. Both CNAs reported the condition of his skin to an LPN, and an order was written later that day for wound care to excoriated sacrum and scrotum every shift. Prior skin assessments from earlier in the month documented no issues to the sacrum or scrotum, and the incident was not found in the facility’s reportables or grievances. The Administrator confirmed that, if accurate, this situation would constitute neglect under the facility’s abuse policy, which defines neglect as failure to provide necessary goods and services to avoid physical harm, pain, mental anguish, or emotional distress. A second deficiency concerns failure to provide the correct food texture to another resident who had an active diet order for mechanical soft texture. Progress notes document that this resident was served a grilled cheese sandwich on a dinner tray, which she began to eat before an NA noticed and removed the tray. The resident coughed a few times and then was fine, and the NA obtained another tray with food the resident could eat without problem. The resident’s diet order specified mechanical soft foods, and the facility’s Diet and Nutrition Care Manual lists grilled sandwiches as foods to avoid on a mechanical soft diet. A nurse consultant later confirmed that this incident occurred as documented and that it was not reported.
Failure to Accurately Post Daily Nurse Staffing Information
Penalty
Summary
The deficiency involves the facility’s failure to accurately post daily nurse staffing information in a prominent, accurate manner as required, with inaccuracies identified on 22 of 23 reviewed days. Upon surveyor entrance, the daily nurse staffing sheet was not readily visible and was ultimately located on a wall near the nurse’s station. Review of posted staffing sheets and time punch detail reports revealed multiple discrepancies, including incorrect dates on several postings and numerous errors in the total hours worked for various dates. On some days, corrections were written over original entries, making it impossible to clearly determine the actual number of nurse aides working or the correct total hours. In several instances, the posted total hours did not match the actual hours worked as shown on time detail reports, with both understatements and overstatements of staffing hours documented. During a nighttime observation, the posted staffing sheet listed two LPNs, three NAs, and zero RNs on duty, but a visual count showed only one LPN and two NAs actually present, with no RN. One NA was found sleeping on duty upon arrival, and another NA was in the breakroom with a makeshift office setup using a table, laptop, battery charger, and large rolling briefcase. It was later learned that one NA was assigned 1:1 to a resident, leaving two NAs to cover the remaining 56 residents. When questioned, an LPN stated that another LPN listed on the staffing sheet had called in sick due to pregnancy. These observations and documentation reviews were discussed with the Regional Director of Operations and an RN consultant, confirming that the posted staffing information did not accurately reflect the actual staffing levels and hours worked on multiple dates.
Insufficient Staffing Leading to Delayed Care and Resident Neglect
Penalty
Summary
The deficiency involves the facility’s failure to provide sufficient nursing staff on all shifts to meet residents’ needs, resulting in delayed responses to call lights and inadequate incontinence care. During a resident council meeting, multiple residents reported waiting 1–3 hours for call lights to be answered, with staff sometimes stating they would return but not coming back for hours, and some residents reporting staff said they had been outside smoking with a resident. Individual resident interviews corroborated these concerns, with residents stating that night shift took a long time to answer call lights, that it could take 45 minutes to an hour or more to receive assistance, and that staff would delay changing residents during meal tray pass or after a scheduled smoke break when most aides and a nurse accompanied residents outside, leaving only one nurse to cover the floor. Staffing record reviews for specific dates showed Hours Per Patient Day (HPPD) below the minimum required 2.25 on at least one day, and the facility’s CASPER report triggered for low weekend staffing. A specific incident of neglect was identified for one resident who reported being left overnight in a soiled brief while experiencing diarrhea, despite requesting to be changed. Two CNAs independently stated that when they saw this resident the following morning, he reported not having been changed all night, and both described his skin as raw, bad, and red; one CNA stated she had changed him the previous day and that he reported no changes overnight, and both CNAs reported the condition to an LPN, who then notified an RN, leading to a wound care order for excoriation to the sacrum and scrotum. Prior skin assessments earlier in the month showed no issues in those areas, and the incident was not documented in reportables or grievances. Additionally, a night-shift observation found a discrepancy between the posted staffing sheet and actual staff present: the sheet listed two LPNs, three NAs, and no RNs, but only one LPN and two NAs were observed, with one NA found sleeping on duty and another engaged in personal business on a laptop, while a third NA was assigned 1:1 to a resident, leaving two NAs to cover 56 other residents. The administrator confirmed that the described incontinence incident would constitute neglect if accurate.
Failure to Provide Anonymous Grievance Process and Protect Residents From Fear of Retaliation
Penalty
Summary
Surveyors identified that the facility failed to honor residents’ rights to voice grievances without fear of reprisal and to provide a method for anonymous grievance submission. During a Resident Council meeting attended by 11 residents, residents reported they had no way to file an anonymous grievance, did not want to report complaints due to fear of retaliation, and felt that concerns raised in Resident Council were not taken seriously. An interview with the Social Worker confirmed there was no method for anonymous grievances and that residents and family members had to request a grievance form from a nurse or department head. Review of the facility’s Grievances/Complaints policy showed that residents and their representatives have the right to file grievances orally or in writing with facility staff or the designated agency, and that the Administrator and staff will make prompt efforts to resolve grievances, but the facility’s actual practice did not provide an anonymous option or alleviate residents’ fear of retaliation. This deficiency involved at least one identified resident (Resident #22) and the broader resident group, who reported barriers to exercising their grievance rights and lack of confidence that their concerns raised in Resident Council would be addressed, in contrast to the facility’s written grievance policy.
Failure to Follow Splinting and Blood Glucose Notification Orders
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care in accordance with professional standards and physician orders for two residents. For one resident with a documented right hand contracture, surveyors observed that the right hand was tightly fisted and that no splinting device was in place. Record review showed active orders to apply and remove a splint to the left hand every night shift for mobility, and the care plan directed left hand splinting as ordered, despite the medical record listing a diagnosis of a right hand contracture. During interviews, the occupational therapist confirmed the splinting order should have been for the right hand, and the Director of Nursing confirmed that both the orders and care plan were written to place a splint on the resident’s functional hand instead of the contracted hand. For another resident with an order for Humalog Kwikpen, the physician’s order specified to hold the medication for blood sugar (BS) less than 100 and to call the provider for BS over 400. Review of the Medication Administration Record for March and April showed multiple dates on which the resident’s blood sugar exceeded 400. The facility was unable to provide documentation that the provider was contacted on those dates when the blood sugar was over 400, as required by the order. A registered nurse consultant confirmed that, according to the documentation, the provider was not notified when the resident’s blood sugar readings were over 400 on the identified dates.
Food Storage and Sanitation Deficiencies in Dietary Services
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with its own food safety and sanitation policies and professional standards. During an initial kitchen walkthrough, the surveyor, accompanied by the Director of Dining Services, observed multiple sanitation and storage issues, including a juice machine top soiled with debris, crumbs in the toaster tray, and a soiled microwave in the pantry. In the dry storage room, there was an opened, outdated brownie mix past its use-by date, and employee coats were found hanging on the bread rack. In the walk-in cooler, a case of bacon lacked an open or use-by date, and the meat slicer, though covered, had old food debris on and around the blade. The three-compartment sink log for that morning’s breakfast lacked recorded water temperature and sanitizer concentration, contrary to policy requirements for monitoring and documenting manual ware washing. Additional observations showed improper handling and storage of food and related items outside the main kitchen. A beverage in the pantry refrigerator was not labeled or dated. During a dining observation, beverage carts for two halls had trash bins placed on the same shelf as milk containers intended for residents. On a subsequent day, an employee’s coat was again found hanging on the bread rack, despite prior identification of this issue. These findings demonstrated that staff did not consistently follow facility policies requiring clean, sanitary food preparation and service areas, proper labeling and dating of TCS foods, and appropriate separation of personal items and trash from food and food-contact surfaces.
Uncovered Trash Receptacles in Food Service Areas
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional food safety standards and did not follow proper sanitation practices for food preparation equipment, with the potential to affect all 60 residents. Healthcare Services Group (HCSG) Policy #28 requires all trash to be contained in covered, leak-proof containers to prevent cross-contamination, and HCSG Policy #30 requires the Dining Services Director to ensure appropriate lids are provided for all containers. During an initial kitchen walkthrough with the Director of Dining Services (DDS), the surveyor observed that the trash can beside the juice machine had no lid and that the trash can in the dish room also had no lid. The DDS confirmed both observations and acknowledged that there was no lid available for the dish room trash can.
Failure to Substantiate and Address Resident Sexual Abuse Allegations
Penalty
Summary
The deficiency involves the facility’s failure to appropriately use investigation results and residents’ reports to determine and substantiate sexual abuse allegations involving one male resident and two female residents. In the first incident, a cognitively intact resident reported that she awoke in her bed to find a male resident in her room, uninvited, naked from the waist down and pulling on her leg, and stated she thought he was going to try to rape her. Staff responding to her yelling found the male resident in her room wearing only a t‑shirt, with no brief or pants, and the resident told staff to remove him from her room. During examination by an NP, she again reported that a man came into her room and pulled her down in bed. Despite these observations and statements, the facility’s Five‑Day Follow‑Up report concluded that allegations of sexual abuse were not substantiated, and the facility’s position, as verified by the Administrator, was that no physical harm was done, which was the basis for not substantiating sexual abuse. The facility did not adequately evaluate whether this resident felt safe or address her expressed anxiety about the incident. In the second incident, another cognitively intact resident with a BIMS score of 14 and a physician determination of capacity reported sexual abuse by the same male resident. A CNA witnessed the male resident’s hands under this resident’s blanket, rubbing close to her private parts, and when staff intervened and asked if he had touched her private area, she stated yes. During the facility’s investigation, the resident told the Social Worker and Administrator that the male resident rubbed her private area and that she believed the contact was intentional, and she also told her attending physician that he had touched her private area. When later seen by a psychologist, she voiced no recollection of the event. The facility’s Five‑Day Follow‑Up report stated that sexual abuse could not be substantiated due to inconsistency in statements, and the Administrator confirmed that the male resident had touched her but asserted it was accidental while rubbing her leg under the blanket. The facility failed to recognize and address this resident’s expression of anxiety about the unwanted touching and did not adequately evaluate whether she felt safe, leaving her and other residents vulnerable during and after the investigative process.
Failure to Monitor and Record Food Temperatures for Always-Available Menu Items
Penalty
Summary
The facility failed to ensure that food and drink were palatable, attractive, and maintained at a safe and appetizing temperature, as evidenced by food tray temperatures, resident interviews, and staff interviews involving four identified residents (#47, #33, #42, and #9) out of a census of 60. On 4/28/26 at 12:00 PM, it was observed that kitchen staff were not taking and recording temperatures for items on the always-available menu prior to the start of the lunch meal service. Specifically, beef patties, hotdogs, and brown gravy did not have recorded temperatures before meal service began. The Director of Dining Services acknowledged that temperatures for always-available menu items were not being taken or recorded. No additional medical history or specific clinical conditions of the involved residents were provided in the report.
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