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.
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 2024-11-19Record 495237-20241011-F686
F697Provide safe, appropriate pain management for a resident who requires such services.Scope/severity GHarm
Care planning
Isolated; actual harm that is not immediate jeopardy.Corrected 2025-01-15Record 495237-20241011-F697
F554Allow residents to self-administer drugs if determined clinically appropriate.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-11-19Record 495237-20241011-F554
F558Reasonably accommodate the needs and preferences of each resident.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-11-19Record 495237-20241011-F558
F565Honor the resident's right to organize and participate in resident/family groups in the facility.Scope/severity EStandard
Dignity & rights
Pattern; no actual harm, potential for more than minimal harm.Corrected 2024-11-19Record 495237-20241011-F565
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 2024-11-19Record 495237-20241011-F580
F584Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.Scope/severity FStandard
Dignity & rights
Widespread; no actual harm, potential for more than minimal harm.Corrected 2024-11-19Record 495237-20241011-F584
F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Scope/severity EStandard
Abuse & neglect
Pattern; no actual harm, potential for more than minimal harm.Corrected 2024-11-19Record 495237-20241011-F600
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 2024-11-19Record 495237-20241011-F607
F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Scope/severity EStandard
Abuse & neglect
Pattern; no actual harm, potential for more than minimal harm.Corrected 2025-03-06Record 495237-20241011-F609
F610Respond appropriately to all alleged violations.Scope/severity EStandard
Abuse & neglect
Pattern; no actual harm, potential for more than minimal harm.Corrected 2024-11-19Record 495237-20241011-F610
F645PASARR screening for Mental disorders or Intellectual DisabilitiesScope/severity DStandard
Care planningRecords
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-11-19Record 495237-20241011-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 EStandard
Care planningRecords
Pattern; no actual harm, potential for more than minimal harm.Corrected 2025-01-15Record 495237-20241011-F656
F658Ensure services provided by the nursing facility meet professional standards of quality.Scope/severity EStandard
Care planningRecords
Pattern; no actual harm, potential for more than minimal harm.Corrected 2024-11-19Record 495237-20241011-F658
F660Plan the resident's discharge to meet the resident's goals and needs.Scope/severity DStandard
Care planningRecords
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-01-15Record 495237-20241011-F660
F661Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.Scope/severity DStandard
Care planningRecords
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-11-19Record 495237-20241011-F661
F677Provide care and assistance to perform activities of daily living for any resident who is unable.Scope/severity EStandard
Care planning
Pattern; no actual harm, potential for more than minimal harm.Corrected 2024-11-19Record 495237-20241011-F677
F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Scope/severity DStandard
Care planningFalls
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-03-06Record 495237-20241011-F689
F691Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-01-15Record 495237-20241011-F691
F692Provide enough food/fluids to maintain a resident's health.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-11-19Record 495237-20241011-F692
F725Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.Scope/severity DStandard
Staffing
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-11-19Record 495237-20241011-F725
F727Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.Scope/severity DStandard
Staffing
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-01-15Record 495237-20241011-F727
F740Ensure each resident must receive and the facility must provide necessary behavioral health care and services.Scope/severity EStandard
Care planning
Pattern; no actual harm, potential for more than minimal harm.Corrected 2024-11-19Record 495237-20241011-F740
F742Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-01-15Record 495237-20241011-F742
F745Provide medically-related social services to help each resident achieve the highest possible quality of life.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-11-19Record 495237-20241011-F745
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 2024-11-19Record 495237-20241011-F755
F760Ensure that residents are free from significant medication errors.Scope/severity EStandard
Medication
Pattern; no actual harm, potential for more than minimal harm.Corrected 2025-01-15Record 495237-20241011-F760
F761Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.Scope/severity EStandard
Medication
Pattern; no actual harm, potential for more than minimal harm.Corrected 2024-11-19Record 495237-20241011-F761
F804Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.Scope/severity FStandard
Food & nutrition
Widespread; no actual harm, potential for more than minimal harm.Corrected 2024-11-19Record 495237-20241011-F804
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 2025-01-15Record 495237-20241011-F812
F835Administer the facility in a manner that enables it to use its resources effectively and efficiently.Scope/severity FStandard
Records
Widespread; no actual harm, potential for more than minimal harm.Corrected 2024-11-19Record 495237-20241011-F835
F838Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.Scope/severity FStandard
Records
Widespread; no actual harm, potential for more than minimal harm.Corrected 2025-01-15Record 495237-20241011-F838
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 2024-11-19Record 495237-20241011-F842
F880Provide and implement an infection prevention and control program.Scope/severity FStandard
Infection control
Widespread; no actual harm, potential for more than minimal harm.Corrected 2024-11-19Record 495237-20241011-F880
F908Keep all essential equipment working safely.Scope/severity DStandard
Environment
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-11-19Record 495237-20241011-F908
F921Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.Scope/severity FStandard
Environment
Widespread; no actual harm, potential for more than minimal harm.Corrected 2024-11-19Record 495237-20241011-F921
F925Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.Scope/severity EStandard
Environment
Pattern; no actual harm, potential for more than minimal harm.Corrected 2024-11-19Record 495237-20241011-F925
F940Develop, implement, and/or maintain an effective training program for all new and existing staff members.Scope/severity EStandard
Records
Pattern; no actual harm, potential for more than minimal harm.Corrected 2024-11-19Record 495237-20241011-F940
F942Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents.Scope/severity EStandard
Dignity & rights
Pattern; no actual harm, potential for more than minimal harm.Corrected 2024-11-19Record 495237-20241011-F942
F944Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.Scope/severity EStandard
Records
Pattern; no actual harm, potential for more than minimal harm.Corrected 2025-01-15Record 495237-20241011-F944
F946Provide training in compliance and ethics.Scope/severity EStandard
Records
Pattern; no actual harm, potential for more than minimal harm.Corrected 2024-11-19Record 495237-20241011-F946
F947Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.Scope/severity EStandard
Staffing
Pattern; no actual harm, potential for more than minimal harm.Corrected 2024-11-19Record 495237-20241011-F947
F949Provide behavior health training consistent with the requirements and as determined by a facility assessment.Scope/severity EStandard
Records
Pattern; no actual harm, potential for more than minimal harm.Corrected 2025-01-15Record 495237-20241011-F949
F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-07-17Record 495237-20240529-F550
F553Allow resident to participate in the development and implementation of his or her person-centered plan of care.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-07-17Record 495237-20240529-F553
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 2024-07-17Record 495237-20240529-F580
F658Ensure services provided by the nursing facility meet professional standards of quality.Scope/severity EStandard
Care planningRecords
Pattern; no actual harm, potential for more than minimal harm.Corrected 2024-07-17Record 495237-20240529-F658
F677Provide care and assistance to perform activities of daily living for any resident who is unable.Scope/severity EStandard
Care planning
Pattern; no actual harm, potential for more than minimal harm.Corrected 2024-07-17Record 495237-20240529-F677
F690Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.Scope/severity EStandard
Care planning
Pattern; no actual harm, potential for more than minimal harm.Corrected 2024-07-17Record 495237-20240529-F690
F692Provide enough food/fluids to maintain a resident's health.Scope/severity EStandard
Care planning
Pattern; no actual harm, potential for more than minimal harm.Corrected 2024-07-17Record 495237-20240529-F692
F725Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.Scope/severity EStandard
Staffing
Pattern; no actual harm, potential for more than minimal harm.Corrected 2024-07-17Record 495237-20240529-F725
F809Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.Scope/severity EStandard
Food & nutrition
Pattern; no actual harm, potential for more than minimal harm.Corrected 2024-07-17Record 495237-20240529-F809
F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2022-02-07Record 495237-20211230-F550
F554Allow residents to self-administer drugs if determined clinically appropriate.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2022-02-07Record 495237-20211230-F554
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 EStandard
Dignity & rights
Pattern; no actual harm, potential for more than minimal harm.Corrected 2022-02-07Record 495237-20211230-F578
F645PASARR screening for Mental disorders or Intellectual DisabilitiesScope/severity DStandard
Care planningRecords
Isolated; no actual harm, potential for more than minimal harm.Corrected 2022-02-07Record 495237-20211230-F645
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 2022-02-07Record 495237-20211230-F655
F660Plan the resident's discharge to meet the resident's goals and needs.Scope/severity DStandard
Care planningRecords
Isolated; no actual harm, potential for more than minimal harm.Corrected 2022-02-07Record 495237-20211230-F660
F679Provide activities to meet all resident's needs.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2022-02-07Record 495237-20211230-F679
F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2022-02-07Record 495237-20211230-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 2022-02-07Record 495237-20211230-F686
F688Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2022-02-07Record 495237-20211230-F688
F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Scope/severity DStandard
Care planningFalls
Isolated; no actual harm, potential for more than minimal harm.Corrected 2022-02-07Record 495237-20211230-F689
F690Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2022-02-07Record 495237-20211230-F690
F698Provide safe, appropriate dialysis care/services for a resident who requires such services.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2022-02-07Record 495237-20211230-F698
F806Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.Scope/severity DStandard
Food & nutrition
Isolated; no actual harm, potential for more than minimal harm.Corrected 2022-02-07Record 495237-20211230-F806
F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Scope/severity EStandard
Food & nutrition
Pattern; no actual harm, potential for more than minimal harm.Corrected 2022-02-07Record 495237-20211230-F812
F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.Scope/severity EStandard
Care planningRecords
Pattern; no actual harm, potential for more than minimal harm.Corrected 2022-02-07Record 495237-20211230-F842
F880Provide and implement an infection prevention and control program.Scope/severity EStandard
Infection control
Pattern; no actual harm, potential for more than minimal harm.Corrected 2022-02-07Record 495237-20211230-F880
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 2019-04-26Record 495237-20190314-F578
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 2019-04-26Record 495237-20190314-F580
F583Keep residents' personal and medical records private and confidential.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2019-04-26Record 495237-20190314-F583
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 2019-04-26Record 495237-20190314-F657
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 2019-04-26Record 495237-20190314-F684
F697Provide safe, appropriate pain management for a resident who requires such services.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2019-04-26Record 495237-20190314-F697
F698Provide safe, appropriate dialysis care/services for a resident who requires such services.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2019-04-26Record 495237-20190314-F698
F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Scope/severity EStandard
Medication
Pattern; no actual harm, potential for more than minimal harm.Corrected 2019-04-26Record 495237-20190314-F755
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 2019-04-26Record 495237-20190314-F756
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 2019-04-26Record 495237-20190314-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 2019-04-26Record 495237-20190314-F760
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 2019-04-26Record 495237-20190314-F842
F849Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.Scope/severity DStandard
Records
Isolated; no actual harm, potential for more than minimal harm.Corrected 2019-04-26Record 495237-20190314-F849
F921Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.Scope/severity DStandard
Environment
Isolated; no actual harm, potential for more than minimal harm.Corrected 2019-04-26Record 495237-20190314-F921