Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
F838 in West Virginia. Pick another state for the same tag.
Against expectation — 2025
West Virginia cites F838 less often than its own record predicts
Versus expected share0.36×
0.36 times the national share — cited less often here than elsewhere.
Share of West Virginia citations0.09%
Of every deficiency written in West Virginia in 2025, this is the portion that was F838.
West Virginia0.09%
National0.25%
Share of all citations that were F838.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What West Virginia surveyors wrote
F838 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.
J · Immediate jeopardy, isolatedNovember 15, 2018
Based on staff interview and Facility Assessment review, the facility identified providing services to residents receiving Intravenous (IV) therapy via a peripheral IV and peripherally inserted central catheter (PICC); however, failed to ensure staff were competent to provide the care needed for this resident population resulting in Immediate Jeopardy. This affected two (Resident #48 and #32) of two sampled residents receiving Intravenous (IV) therapy via a PICC. The facility census was 87.
On 11/13/18 at 7:56 PM, the Administrator and Director of Nursing were notified verbally that Immediate Jeopardy began on 10/05/18 when Resident #48 was admitted to the facility with a PICC and receiving IV antibiotics. …
E · No harm, potential for more than minimal, patternMarch 18, 2026
Based on record review and staff interview the facility assessment failed to state the break down of staffing needed to care for the residents based on their acuity levels. This failed practice had the potential to affect more than a limited number of residents. Facility census: 62. Findings include: a) A review of the facility assessment with a review date of 02/16/26 found no staffing levels were identified in regards to the number of direct care staff needed to care for the residents based on the acuity level of the residents housed at the facility. In fact the facility assessment contained no break down to reflect the acuity level of the residents housed in the facility to base staffing off of. …
C · No harm, potential for minimal, widespreadJanuary 26, 2023
Based on facility documentation and interview, the facility failed to have accurate direct staffing levels / direct overall number of staff for the resident acuity in the Facility Assessment. This has the potential to affect all resident in the facility. Facility census 194.
Findings included:
a) Facility Assessment
The facility assessment, dated 01/10/23, stated that based on the facility resident population and their needs for care and support, the facility would utilize the following staffing plan for direct care Certified Nursing Assistants (CNAs) to ensure they had sufficient staff to meet the needs of residents at any given time:
7:00 AM - 3:00 PM - 1:X Ratio on Days
[would require 20 CNAs]
3:00 PM - 11:00 PM - 1:X Ratio on Evenings
[would require 16 CNAs]
11:00 PM - 7:00 AM - 1:1… …
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