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 (F) can lead to third degree burns in 15 seconds. Resident #19 was bathed in 134 degrees (F) water. Resident #19 sustained second degree burns to the left hand, bilateral lower extremeties, bilateral buttocks, and scrotum. The staff responsible for monitoring water temperatures and maintaining equipment knew the hot water had measured more than 110 degrees (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. …
F921 citations in West Virginia
Safe, clean, comfortable environment · Environmental Deficiencies
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
West Virginia cites F921 less often than its own record predicts
0.75 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 F921.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What West Virginia surveyors wrote
F921 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 interview, staff interview, the facility failed to ensure they had maintained a safe and functional envrionment for residents who wanted to go outside to the patio area. This practice had the potential to affect more than an isolated number of residents. Facility census: 101.a) During an interview on 07/22/26 at approximately 9:25 AM the Maintenance director stated that the door to the patio was a sometimes issue. This meant the door sometimes worked and sometimes did not. He continued to state that he would have to contact the vendor to come and fix it. During an interview on 07/22/26 at 9:37 AM the Administrator stated that the door to the patio was not working correctly during their previous annual survey in February 2026. …
Based on observation and staff interview, the facility failed to ensure a safe, functional, sanitary, and comfortable environment for residents, staff and the public. This has the potential to affect more than a limited number of residents residing at the facility. This was a random opportunity for discovery. Facility census: 65. Findings included: a) Observations of the facility On 03/07/23 at 10:00 AM, a tour of the facility with the maintenance supervisor #56 found the corridor leading to the kitchen (accessible to residents, visitors, and staff) had a locked door at the end of the corridor which opened to the outside. The door had missing paint, was scratched, scraped, and had a buildup of grease and grime. The glass in the door was broken with spider web cracks. …
The short window
Recent years
| Year | Share of West Virginia citations | vs expected |
|---|---|---|
| 2023 | 0.93% | 1.08× |
| 2024 | 0.45% | 0.56× |
| 2025 | 0.64% | 0.75× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else West Virginia surveyors cite →
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