37324 Based on observation, record review, and staff interview the licensee failed to maintain hot water mechanical equipment in safe operating condition. According to CMS guidelines exposure at water temperature of 133 degrees Fahrenheit can lead to third degree burns in 15 seconds. Resident #19 was bathed in 134 degrees Fahrenheit water. Resident #19 sustained second degree burns to his feet, legs, thigh, and hand. The staff responsible for monitoring water temperatures and maintaining equipment knew the hot water had measured more than 110 degrees Fahrenheit (F) since January 2023. This caused an immediate jeopardy situation that began on 01/03/23 and ended on 01/07/24. This practice had the potential to affect all facility residents. Resident identifier: #19. …
F908 citations in West Virginia
Equipment in safe condition · Environmental Deficiencies
Keep all essential equipment working safely.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
West Virginia cites F908 more often than its own record predicts
1.40 times the share F908 takes of citations nationally.
Of every deficiency written in West Virginia in 2025, this is the portion that was F908.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What West Virginia surveyors wrote
F908 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, resident/family interviews, and record review, the facility failed to ensure patient care equipment, specifically mechanical lifts with frayed, taped wires, was maintained in safe operating condition. Resident identifiers: #21, #31, #9, #17, #75, #44, #45, #47, #13, #79, #29, #66, #105, #73, #82, #83, #16, #33, #63, #64, #68, and #84. Facility Census: 88. Findings included:a) On 04/29/26 at approximately 4:30 PM, a resident's family member spoke with the state survey team concerning an issue with the mechanical lifts. The Joerns' Hoyer Lifts, model [NAME]-PRESENCE-S) were an issue per the discussion. The family member stated the resident lifts were dirty and had electrical tape on them. …
The short window
Recent years
| Year | Share of West Virginia citations | vs expected |
|---|---|---|
| 2023 | 0.93% | 1.99× |
| 2024 | 0.45% | 1.01× |
| 2025 | 0.64% | 1.40× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else West Virginia surveyors cite →
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