CMS · Virginia Office of Licensure and Certification publishes each citation’s tag, official description and scope/severity letter. The surveyor’s written findings are in the Statement of Deficiencies (CMS-2567) for each survey, linked above.
F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Scope/severity JHarm
Care planning
Isolated; immediate jeopardy to resident health or safety.Corrected 2024-12-19Record 495200-20240821-F684
F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Scope/severity GHarm
Care planningFalls
Isolated; actual harm that is not immediate jeopardy.Corrected 2024-11-13Record 495200-20240821-F689
F578Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-11-13Record 495200-20240821-F578
F623Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.Scope/severity EStandard
Dignity & rights
Pattern; no actual harm, potential for more than minimal harm.Corrected 2024-11-13Record 495200-20240821-F623
F625Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.Scope/severity EStandard
Dignity & rights
Pattern; no actual harm, potential for more than minimal harm.Corrected 2024-11-13Record 495200-20240821-F625
F641Ensure each resident receives an accurate assessment.Scope/severity DStandard
Care planningRecords
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-11-13Record 495200-20240821-F641
F645PASARR screening for Mental disorders or Intellectual DisabilitiesScope/severity DStandard
Care planningRecords
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-11-13Record 495200-20240821-F645
F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Scope/severity DStandard
Care planningRecords
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-11-13Record 495200-20240821-F656
F657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.Scope/severity DStandard
Care planningRecords
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-11-13Record 495200-20240821-F657
F677Provide care and assistance to perform activities of daily living for any resident who is unable.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-11-13Record 495200-20240821-F677
F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-11-13Record 495200-20240821-F686
F695Provide safe and appropriate respiratory care for a resident when needed.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-11-13Record 495200-20240821-F695
F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Scope/severity DStandard
Medication
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-11-13Record 495200-20240821-F755
F757Ensure each resident’s drug regimen must be free from unnecessary drugs.Scope/severity DStandard
Medication
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-12-19Record 495200-20240821-F757
F758Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.Scope/severity DStandard
Medication
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-11-13Record 495200-20240821-F758
F760Ensure that residents are free from significant medication errors.Scope/severity DStandard
Medication
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-12-20Record 495200-20240821-F760
F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Scope/severity DStandard
Food & nutrition
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-11-13Record 495200-20240821-F812
F814Dispose of garbage and refuse properly.Scope/severity FStandard
Food & nutrition
Widespread; no actual harm, potential for more than minimal harm.Corrected 2024-11-13Record 495200-20240821-F814
F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Scope/severity KHarm
Care planning
Pattern; immediate jeopardy to resident health or safety.Corrected 2023-05-12Record 495200-20230320-F684
F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Scope/severity GHarm
Care planning
Isolated; actual harm that is not immediate jeopardy.Corrected 2023-05-12Record 495200-20230320-F686
F582Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-05-12Record 495200-20230320-F582
F635Provide doctor's orders for the resident's immediate care at the time the resident was admitted.Scope/severity DStandard
Care planningRecords
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-05-12Record 495200-20230320-F635
F641Ensure each resident receives an accurate assessment.Scope/severity DStandard
Care planningRecords
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-05-12Record 495200-20230320-F641
F655Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admittedScope/severity DStandard
Care planningRecords
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-05-12Record 495200-20230320-F655
F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Scope/severity DStandard
Care planningRecords
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-05-12Record 495200-20230320-F656
F657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.Scope/severity DStandard
Care planningRecords
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-05-12Record 495200-20230320-F657
F658Ensure services provided by the nursing facility meet professional standards of quality.Scope/severity DStandard
Care planningRecords
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-05-30Record 495200-20230320-F658
F693Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-05-30Record 495200-20230320-F693
F695Provide safe and appropriate respiratory care for a resident when needed.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-05-12Record 495200-20230320-F695
F756Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.Scope/severity DStandard
Medication
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-05-12Record 495200-20230320-F756
F760Ensure that residents are free from significant medication errors.Scope/severity DStandard
Medication
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-05-30Record 495200-20230320-F760
F770Provide timely, quality laboratory services/tests to meet the needs of residents.Scope/severity EStandard
Records
Pattern; no actual harm, potential for more than minimal harm.Corrected 2023-05-12Record 495200-20230320-F770
F773Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.Scope/severity DStandard
Records
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-05-12Record 495200-20230320-F773
F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Scope/severity DStandard
Food & nutrition
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-05-12Record 495200-20230320-F812
F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.Scope/severity DStandard
Care planningRecords
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-05-30Record 495200-20230320-F842
F865Have a plan that describes the process for conducting QAPI and QAA activities.Scope/severity DStandard
Records
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-05-12Record 495200-20230320-F865
F880Provide and implement an infection prevention and control program.Scope/severity DStandard
Infection control
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-05-12Record 495200-20230320-F880
F580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2021-07-14Record 495200-20210520-F580
F607Develop and implement policies and procedures to prevent abuse, neglect, and theft.Scope/severity EStandard
Abuse & neglect
Pattern; no actual harm, potential for more than minimal harm.Corrected 2021-07-14Record 495200-20210520-F607
F637Assess the resident when there is a significant change in conditionScope/severity DStandard
Care planningRecords
Isolated; no actual harm, potential for more than minimal harm.Corrected 2021-07-14Record 495200-20210520-F637
F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Scope/severity EStandard
Care planning
Pattern; no actual harm, potential for more than minimal harm.Corrected 2021-07-14Record 495200-20210520-F684
F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2021-07-14Record 495200-20210520-F686
F695Provide safe and appropriate respiratory care for a resident when needed.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2021-07-14Record 495200-20210520-F695
F726Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.Scope/severity DStandard
Staffing
Isolated; no actual harm, potential for more than minimal harm.Corrected 2021-07-14Record 495200-20210520-F726