River Oaks Healthcare Center: Infection Control Failures - WV
The soda cans were one of three infection control problems inspectors documented during an October 16 complaint inspection at the 116-bed facility. None of the findings were complex. All of them were visible to anyone walking the hallways.
Outside another room, three lift pads had been left sitting on top of a clean linen cart, uncovered and exposed. An employee, identified in the inspection report only as employee number 105, told inspectors the pads should not be there. "They definitely should not be on top of that cart," the employee said. "They should be at least inside under the cover. I'll make sure they are taken care of."
That an employee knew exactly where the pads belonged, and said so without hesitation, made the lapse harder to explain away. The pads had not been placed there by someone who didn't know better.
The third problem was broader and, in some ways, harder to fix quickly. Throughout the building, inspectors found infection precaution signs posted on resident room doors that did not identify which resident the precaution applied to. In rooms where two people live, that distinction matters. A nurse or aide entering a double-occupancy room needs to know whether they're suiting up for one resident, the other, or both.
Staff did not know. An employee identified as number 213 told inspectors they "just assume both residents are covered by the sign and not sure how they mark them honestly."
The director of nursing gave a different answer. She told inspectors the signs were supposed to include a number, either a 1 or a 2, and sometimes a blue dot, to indicate which resident the precaution covered. She said she would let the infection prevention person know the signs needed to be addressed.
Two employees, two different understandings of the same system. One of them was guessing.
Inspectors cited the facility under F880, the federal infection control tag, noting the findings represented "random opportunities for discovery, with the ability to affect more than a single person." The level of harm was classified as minimal harm or potential for actual harm.
Infection precaution signs exist for a reason. When a resident is placed on contact precautions, droplet precautions, or another form of enhanced barrier protection, the sign on the door tells everyone who enters what they need to wear and how to move. A sign that doesn't say which of two roommates it applies to is a sign that staff may read incorrectly, or not read carefully at all. The employee who assumes both residents are covered is not necessarily wrong, but they are guessing, and guessing in an infection control context is how precautions break down.
River Oaks had 116 residents at the time of inspection. The report does not specify how many rooms had the unmarked signs, only that they appeared on "multiple doors" throughout the building.
The lift pads and the soda cans speak to a different kind of problem. Lift pads are used to reposition or transfer residents, and they come into contact with residents' skin and clothing. Leaving them on top of a clean linen cart creates a pathway for contamination to move from one resident's room to another, through the linens used to make beds and cover bodies. It is not a theoretical risk. It is the specific thing infection control procedures are designed to prevent.
The soda cans are easier to dismiss. Open beverage containers on a cart used to hold gloves, masks, and gowns is not the same category of violation as an unmarked isolation sign. But it is the kind of thing that happens when a hallway cart becomes a convenient surface, when the space where protective equipment is stored is treated as common space. Inspectors noted it. It was there to be noted.
The report does not describe any resident who was harmed. It does not name any resident. It records what inspectors saw on a single afternoon in Clarksburg, and what two employees said when asked about it, and what the director of nursing said she planned to do.
The employee who left the lift pads on the linen cart knew they shouldn't be there. The employee reading the door signs was guessing which resident was under precautions and had been for long enough that they no longer thought to ask.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for River Oaks Healthcare Center from 2025-10-16 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 9, 2026 · Our methodology
RIVER OAKS HEALTHCARE CENTER in CLARKSBURG, WV was cited for violations during a health inspection on October 16, 2025.
The soda cans were one of three infection control problems inspectors documented during an October 16 complaint inspection at the 116-bed facility.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.