Based on record review and staff interview the facility failed to ensure it had a Quality Assessment and Assurance (QAA) committee to meet at least quarterly with the required minimum staff. This failed practice was a random opportunity for discovery during the Long-Term Care Survey Process. Facility census: 106. Findings Include: a) QAA meetings A review on 02/11/26 at 9:49 PM, of the QAA sign in sheets from 01/25 to 01/26 revealed, that The Director of Nursing (DON) did not attend the 2nd quarter or 3rd quarter meetings as required. During an interview on 02/12/26 at 8:40 AM, The Administrator stated, We had the Assistant Director of Nursing (ADON), filling in as our Director of Nursing (DON) for the facility because we were in between DON's. …
F868 citations in West Virginia
Quality assurance committee · Administration Deficiencies
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
West Virginia cites F868 more often than its own record predicts
1.57 times the share F868 takes of citations nationally.
Of every deficiency written in West Virginia in 2025, this is the portion that was F868.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What West Virginia surveyors wrote
F868 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 record review and staff interview, the facility failed to ensure Quality assessment and assurance (QAA) meetings were completed at minimum quarterly. This failed practice has the potential to affect more than a minimal number of residents residing in the long term care facility. Facility Census: 91Findings included: a) Record review completed on 06/03/26 revealed the QAA meeting for Quarter Two (2) was held on 10/29/25 along with the Quarter Three (3) meeting. During an interview on 06/03/26 at approximately 11:30 AM the Administrator stated they normally hold meetings the month following the end of the quarter to discuss all items for that quarter. …
The short window
Recent years
| Year | Share of West Virginia citations | vs expected |
|---|---|---|
| 2023 | 1.51% | 5.91× |
| 2024 | 0.67% | 2.75× |
| 2025 | 0.36% | 1.57× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else West Virginia surveyors cite →
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