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.
F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Scope/severity KHarm
Care planningFalls
Pattern; immediate jeopardy to resident health or safety.Corrected 2025-03-20Record 495327-20250205-F689
F835Administer the facility in a manner that enables it to use its resources effectively and efficiently.Scope/severity KHarm
Records
Pattern; immediate jeopardy to resident health or safety.Corrected 2025-03-20Record 495327-20250205-F835
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 2025-05-26Record 495327-20250205-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 2025-03-20Record 495327-20250205-F554
F558Reasonably accommodate the needs and preferences of each resident.Scope/severity EStandard
Dignity & rights
Pattern; no actual harm, potential for more than minimal harm.Corrected 2025-05-26Record 495327-20250205-F558
F567Honor the resident's right to manage his or her financial affairs.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-05-26Record 495327-20250205-F567
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 2025-03-20Record 495327-20250205-F578
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 2025-03-20Record 495327-20250205-F582
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 2025-03-20Record 495327-20250205-F583
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 2025-03-20Record 495327-20250205-F584
F586Not prohibit or in any way discourage a resident from communicating with federal, state, or local officials.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-03-20Record 495327-20250205-F586
F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Scope/severity DStandard
Abuse & neglect
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-03-20Record 495327-20250205-F600
F602Protect each resident from the wrongful use of the resident's belongings or money.Scope/severity EStandard
Abuse & neglect
Pattern; no actual harm, potential for more than minimal harm.Corrected 2025-03-20Record 495327-20250205-F602
F607Develop and implement policies and procedures to prevent abuse, neglect, and theft.Scope/severity DStandard
Abuse & neglect
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-03-20Record 495327-20250205-F607
F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Scope/severity DStandard
Abuse & neglect
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-03-20Record 495327-20250205-F609
F610Respond appropriately to all alleged violations.Scope/severity DStandard
Abuse & neglect
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-03-20Record 495327-20250205-F610
F623Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-03-20Record 495327-20250205-F623
F641Ensure each resident receives an accurate assessment.Scope/severity DStandard
Care planningRecords
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-03-20Record 495327-20250205-F641
F645PASARR screening for Mental disorders or Intellectual DisabilitiesScope/severity DStandard
Care planningRecords
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-03-20Record 495327-20250205-F645
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 EStandard
Care planningRecords
Pattern; no actual harm, potential for more than minimal harm.Corrected 2025-03-20Record 495327-20250205-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 2025-05-26Record 495327-20250205-F658
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 2025-03-20Record 495327-20250205-F677
F685Assist a resident in gaining access to vision and hearing services.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-05-26Record 495327-20250205-F685
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 2025-03-20Record 495327-20250205-F686
F687Provide appropriate foot care.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-05-26Record 495327-20250205-F687
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 EStandard
Care planning
Pattern; no actual harm, potential for more than minimal harm.Corrected 2025-03-20Record 495327-20250205-F688
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 2025-05-26Record 495327-20250205-F690
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 2025-03-20Record 495327-20250205-F692
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 2025-03-20Record 495327-20250205-F755
F760Ensure that residents are free from significant medication errors.Scope/severity DStandard
Medication
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-05-26Record 495327-20250205-F760
F791Provide or obtain dental services for each resident.Scope/severity EStandard
Care planning
Pattern; no actual harm, potential for more than minimal harm.Corrected 2025-03-20Record 495327-20250205-F791
F803Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.Scope/severity DStandard
Food & nutrition
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-03-20Record 495327-20250205-F803
F804Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.Scope/severity DStandard
Food & nutrition
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-05-26Record 495327-20250205-F804
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 2025-05-26Record 495327-20250205-F880
F914Provide bedrooms that don't allow residents to see each other when privacy is needed.Scope/severity DStandard
Environment
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-03-20Record 495327-20250205-F914
F925Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.Scope/severity FStandard
Environment
Widespread; no actual harm, potential for more than minimal harm.Corrected 2025-03-20Record 495327-20250205-F925
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 2025-03-20Record 495327-20250205-F947
F559Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-05-10Record 495327-20240328-F559
F563Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-05-10Record 495327-20240328-F563
F573Let each resident or the resident's legal representative access or purchase copies of all the resident's records.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-05-10Record 495327-20240328-F573
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 DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-05-10Record 495327-20240328-F584
F624Prepare residents for a safe transfer or discharge from the nursing home.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-05-10Record 495327-20240328-F624
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 2024-05-10Record 495327-20240328-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 2024-05-10Record 495327-20240328-F657
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 2024-05-10Record 495327-20240328-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 2024-05-10Record 495327-20240328-F660
F675Honor each resident's preferences, choices, values and beliefs.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-05-10Record 495327-20240328-F675
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 2024-05-10Record 495327-20240328-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 2024-05-10Record 495327-20240328-F686
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 2024-05-10Record 495327-20240328-F698
F804Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.Scope/severity DStandard
Food & nutrition
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-05-10Record 495327-20240328-F804
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 2024-05-10Record 495327-20240328-F842
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 2024-05-10Record 495327-20240328-F921
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 2022-08-25Record 495327-20220714-F686
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 2022-08-25Record 495327-20220714-F550
F561Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2022-08-25Record 495327-20220714-F561
F563Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2022-08-25Record 495327-20220714-F563
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 EStandard
Dignity & rights
Pattern; no actual harm, potential for more than minimal harm.Corrected 2022-08-25Record 495327-20220714-F584
F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Scope/severity DStandard
Abuse & neglect
Isolated; no actual harm, potential for more than minimal harm.Corrected 2022-08-25Record 495327-20220714-F609
F645PASARR screening for Mental disorders or Intellectual DisabilitiesScope/severity DStandard
Care planningRecords
Isolated; no actual harm, potential for more than minimal harm.Corrected 2022-08-25Record 495327-20220714-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 2022-08-25Record 495327-20220714-F655
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 EStandard
Care planningRecords
Pattern; no actual harm, potential for more than minimal harm.Corrected 2022-08-25Record 495327-20220714-F657
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 2022-08-25Record 495327-20220714-F658
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 2022-08-25Record 495327-20220714-F689
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 2022-08-25Record 495327-20220714-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 2022-08-25Record 495327-20220714-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 EStandard
Staffing
Pattern; no actual harm, potential for more than minimal harm.Corrected 2022-08-25Record 495327-20220714-F727
F730Observe each nurse aide's job performance and give regular training.Scope/severity EStandard
Staffing
Pattern; no actual harm, potential for more than minimal harm.Corrected 2022-08-25Record 495327-20220714-F730
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 2022-08-25Record 495327-20220714-F745
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 2022-08-25Record 495327-20220714-F761
F802Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.Scope/severity EStandard
Food & nutrition
Pattern; no actual harm, potential for more than minimal harm.Corrected 2022-08-25Record 495327-20220714-F802
F803Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.Scope/severity DStandard
Food & nutrition
Isolated; no actual harm, potential for more than minimal harm.Corrected 2022-08-25Record 495327-20220714-F803
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 2022-08-25Record 495327-20220714-F835
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 2022-08-25Record 495327-20220714-F842
F850Hire a qualified full-time social worker in a facility with more than 120 beds.Scope/severity FStandard
Records
Widespread; no actual harm, potential for more than minimal harm.Corrected 2022-08-25Record 495327-20220714-F850
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 2022-08-25Record 495327-20220714-F880
F881Implement a program that monitors antibiotic use.Scope/severity EStandard
Infection control
Pattern; no actual harm, potential for more than minimal harm.Corrected 2022-08-25Record 495327-20220714-F881
F882Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.Scope/severity FStandard
Infection control
Widespread; no actual harm, potential for more than minimal harm.Corrected 2022-08-25Record 495327-20220714-F882
F883Develop and implement policies and procedures for flu and pneumonia vaccinations.Scope/severity EStandard
Infection control
Pattern; no actual harm, potential for more than minimal harm.Corrected 2022-08-25Record 495327-20220714-F883
F885Report COVID19 data to residents and families.Scope/severity FStandard
Infection control
Widespread; no actual harm, potential for more than minimal harm.Corrected 2022-08-25Record 495327-20220714-F885
F886Perform COVID19 testing on residents and staff.Scope/severity EStandard
Infection control
Pattern; no actual harm, potential for more than minimal harm.Corrected 2022-08-25Record 495327-20220714-F886
F887Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.Scope/severity EStandard
Infection control
Pattern; no actual harm, potential for more than minimal harm.Corrected 2022-08-25Record 495327-20220714-F887
F888Ensure staff are vaccinated for COVID-19Scope/severity EStandard
Infection control
Pattern; no actual harm, potential for more than minimal harm.Corrected 2022-08-25Record 495327-20220714-F888
F908Keep all essential equipment working safely.Scope/severity DStandard
Environment
Isolated; no actual harm, potential for more than minimal harm.Corrected 2022-08-25Record 495327-20220714-F908
F909Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.Scope/severity DStandard
Environment
Isolated; no actual harm, potential for more than minimal harm.Corrected 2022-08-25Record 495327-20220714-F909
F919Make sure that a working call system is available in each resident's bathroom and bathing area.Scope/severity DStandard
Environment
Isolated; no actual harm, potential for more than minimal harm.Corrected 2022-08-25Record 495327-20220714-F919
F943Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.Scope/severity EStandard
Abuse & neglect
Pattern; no actual harm, potential for more than minimal harm.Corrected 2022-08-25Record 495327-20220714-F943
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 EStandard
Dignity & rights
Pattern; no actual harm, potential for more than minimal harm.Corrected 2021-05-04Record 495327-20210408-F584
F602Protect each resident from the wrongful use of the resident's belongings or money.Scope/severity DStandard
Abuse & neglect
Isolated; no actual harm, potential for more than minimal harm.Corrected 2021-05-04Record 495327-20210408-F602
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 2021-05-04Record 495327-20210408-F607
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 2021-05-04Record 495327-20210408-F727
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 2021-05-04Record 495327-20210408-F755
F791Provide or obtain dental services for each resident.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2021-05-04Record 495327-20210408-F791
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 2021-05-04Record 495327-20210408-F880
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 2021-05-04Record 495327-20210408-F921