Based on record review, staff interview and observations, the facility failed to ensure residents were served food in the correct consistency according to the facility's diet description for puree consistency solids. It was determined that this failed practice placed all (5) five residents currently on a puree diet in an immediate jeopardy situation. Providing a resident with the wrong consistency of food could result in choking, and/or aspiration pneumonia which can lead to serious harm and/or death. This failed practice was found to be true for five (5) of five (5) residents reviewed for diet consistency during the Long-Term Care Survey Process. Resident Identifiers: #12, #21, #33, #38, and #53. …
F805 citations in West Virginia
Food in a form residents can eat · Nutrition and Dietary Deficiencies
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
West Virginia cites F805 more often than its own record predicts
2.38 times the share F805 takes of citations nationally.
Of every deficiency written in West Virginia in 2025, this is the portion that was F805.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What West Virginia surveyors wrote
F805 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.
Based on observation, record review, and staff interviews, the facility failed to provide liquids in a form that met each resident's individual dietary needs. This failed practice was true for one (1) of eight (8) residents receiving thickened liquids during the Long-Term Care Survey Process. Resident identifier: #114. Facility Census: 112. Findings include: a) Resident #114 A record review, completed on 08/19/26 at 9:00 AM, revealed an order for Resident #114, dated 08/13/26, for a Dysphagia Puree diet texture with Honey-Thick liquids. An observation on 08/19/26 at 9:15 AM revealed a water pitcher at the bedside of Resident #114 containing approximately 1/4 cup of remaining liquid. The liquid was observed to be thin water. …
The short window
Recent years
| Year | Share of West Virginia citations | vs expected |
|---|---|---|
| 2024 | 0.15% | 0.41× |
| 2025 | 0.73% | 2.38× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else West Virginia surveyors cite →
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