Roane General Hospital: Abuse Probe Failures - WV
SPENCER, WV. When something happened to Resident #38 at Roane General Hospital in June 2024, the facility reported it, opened an investigation, and closed it as inconclusive. What it did not do was ask the other residents whether they had been hurt too.
That omission sat buried in the facility's own records for more than a year before a state complaint inspection in September 2025 pulled it into the open.
The incident was reported to the Director of Nursing on June 16, 2024, at 9:58 in the evening. By the following afternoon, Social Worker #150 had filed the required initial report with the Office of Health Facility Licensure and Certification. A five-day follow-up arrived at the state office on June 20. The investigation's conclusion: inconclusive.
The facility did not leave the matter entirely unaddressed. The Director of Nursing announced plans to implement mandatory competencies for staff, covering how to conduct transfers, how to use lifts, how to hand off reports when a resident is being moved, and where to find transfer order instructions in the electronic medical record. In-service training was held. A sign-in sheet documented who attended.
But when inspectors arrived on September 24, 2025, and began working through the records, a more uncomfortable picture emerged. The two nursing assistants involved, NA #151 and NA #152, were no longer employed at the facility. Social Worker #150, who had filed both state reports, was also gone. LPN #25, who had worked the night shift at the time, was unavailable for interview. NA #153, who had since become a registered nurse, was working night shifts at the hospital and also could not be reached.
Every staff member with direct knowledge of what happened to Resident #38 was either gone or unreachable.
The Director of Nursing sat for an interview at approximately 3:00 in the afternoon on September 24. She confirmed that staff had been questioned about Resident #38's care at the time of the incident. She also confirmed that no other dependent residents had been interviewed, and that none had been assessed for injury in the period after the incident was reported.
That is the center of what inspectors cited. The question in any investigation of this kind is not only what happened to the resident at the center of the report, but whether the same thing happened to anyone else. Dependent residents cannot always report what has been done to them. They may not have the language, the cognition, or the opportunity. A facility's obligation, when an incident surfaces, is to look beyond the single case that triggered the report.
Roane General looked at Resident #38. It did not look further.
The inspection was triggered by a complaint, not a routine survey. The violation was cited at a level of minimal harm or potential for actual harm, affecting few residents. Federal inspectors assigned it to F0610, the tag covering a facility's duty to investigate and report allegations of abuse, neglect, and exploitation, and to protect residents during that process.
What the record does not show is whether any other resident was harmed. The investigation closed before that question was asked. The staff who could have answered it are gone. The social worker who filed the paperwork is gone. The nursing assistants are gone. What remains is a sign-in sheet from a training session, a five-day follow-up marked inconclusive, and a Director of Nursing who, more than fifteen months after the incident, confirmed to inspectors that no one had thought to check.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Roane General Hospital from 2025-09-25 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 13, 2026 · Our methodology
ROANE GENERAL HOSPITAL in SPENCER, WV was cited for abuse-related violations during a health inspection on September 25, 2025.
What it did not do was ask the other residents whether they had been hurt too.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.