Based on record review and staff interview, the facility failed to ensure a care plan was revised and updated following two (2) resident-to-resident Facility Reported Incidents (FRIs) for abuse. This was true for one (1) out of four (4) residents sampled for abuse during the complaint survey process. Resident identifier: #46. Facility Census: 65.Findings included: a) The facility's policy and procedure for Abuse stated, The resident's plan of care will be revised to reflect interventions to minimize recurrence and to treat any injury or harm identified through assessment of the resident. The policy and procedure's original date was 10/01/21 and was revised on 10/20/22. …
F657 citations in West Virginia
Care plan timing and revision · Resident Assessment and Care Planning Deficiencies
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
West Virginia cites F657 more often than its own record predicts
1.75 times the share F657 takes of citations nationally.
Of every deficiency written in West Virginia in 2025, this is the portion that was F657.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What West Virginia surveyors wrote
F657 findings written in West Virginia, one from each severity band recorded here, most serious first.
Severity is as the surveyor wrote it. Some findings had already been corrected before the survey.
The short window
Recent years
| Year | Share of West Virginia citations | vs expected |
|---|---|---|
| 2023 | 3.11% | 1.45× |
| 2024 | 3.50% | 1.83× |
| 2025 | 3.27% | 1.75× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else West Virginia surveyors cite →
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