Based on facility documentation and staff interviews, the facility failed to have/keep the required documentation for Quality Assessment meetings (QAA). Additionally, the facility did not have required attendees present or sign in at the Quality Assessment and Assurance (QAA) meeting logs. This failed practice had the potential to affect all residents residing at the facility. Facility Census: 76. Findings included: During an interview with both the Director Of Nursing and Regional Director Clinical Operations (RDCO) on 01/14/26 at approximately 8:50 AM, both stated they had been looking for the Quality Assurance (QAPI/QAA) books or records since the survey team entered the facility. Unfortunately, they were unable to locate documentation to show their meetings and what was discussed. …
F865 citations in West Virginia
QAPI program · Administration Deficiencies
Have a plan that describes the process for conducting QAPI and QAA activities.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
West Virginia cites F865 less often than its own record predicts
0.76 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 F865.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What West Virginia surveyors wrote
F865 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 | 0.08% | 0.49× |
| 2024 | 0.22% | 1.20× |
| 2025 | 0.18% | 0.76× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else West Virginia surveyors cite →
Deficiency Index is independent and is not affiliated with, endorsed by, or approved by CMS, Medicare, or any government agency. About this data · Report a correction