Based on record review and resident and staff interview, the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident by failing to take actions related to allegations of abuse/neglect, when reported by staff. This had the potential to adversely affect all residents residing in the facility. The State Agency (SA) determined these failures caused Resident #97 to suffer sexual abuse and psychosocial harm. Due to the facility's failure to act on the allegation of sexual abuse when they were made aware not only placed Resident #97 at risk for sexual abuse and psychosocial harm but also placed the remaining 110 residents. …
F835 citations in West Virginia
Administration · Administration Deficiencies
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
West Virginia cites F835 less often than its own record predicts
0.93 times the national share — cited less often here than elsewhere.
Of every deficiency written in West Virginia in 2025, this is the portion that was F835.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What West Virginia surveyors wrote
F835 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 staff interview and record review, the facility administration failed to ensure the facility was administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Administration including the facility administrator and director of nursing (DON) was aware of resident to resident sexual abuse going on in the facility and failed to take appropriate action(s) to protect vulnerable residents. This was a random opportunity for discovery throughout the complaint survey process. The lack of action on the part of the administration created a problem for all seventeen (17) female residents living on the dementia unit. …
Based on record review, resident interviews, staff interviews, observations, the facility administration failed to effectively operate the facility in a manner that ensured residents attained or maintained their highest practicable physical, mental, and psychosocial well-being. The facility failed to provide administrative oversight to ensure adequate staffing, resident protection systems, abuse/neglect reporting and investigation, and a person-centered activity program were implemented and monitored. These systemic failures resulted in repeat deficient practices and had the potential to affect all residents residing in the facility. …
The short window
Recent years
| Year | Share of West Virginia citations | vs expected |
|---|---|---|
| 2023 | 0.08% | 0.29× |
| 2024 | 0.30% | 0.91× |
| 2025 | 0.27% | 0.93× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else West Virginia surveyors cite →
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