Citations in Virginia
Statistics, citations and compliance trends for long-term care facilities in Virginia.
Statistics for Virginia (Last 12 Months)
Financial Impact (Last 12 Months)
Latest citations in Virginia
A resident with chronic pain, polyneuropathy, a sacral pressure ulcer, and polyarthritis did not have ordered Morphine sulfate available for administration. The eMAR showed the scheduled morphine dose was held because the pharmacy had not delivered it, while the resident received PRN oxycodone for severe pain. Staff interviews confirmed the medication was not in the Omnicell, and the resident stated the medicine was not available when admitted and was later received during the night.
Missed ADL Care and Poor Grooming for Dependent Residents: Multiple dependent residents with significant cognitive and physical impairments had missing documentation and observed gaps in bathing, incontinence care, dressing, oral care, personal hygiene, grooming, and showers. Staff interviews linked the missed care to blanks in the record and short staffing, and one resident was sent to an outside appointment improperly groomed and dressed, while others were observed with soiled clothing, long dirty nails, facial hair, and call bells out of reach.
A resident with multiple chronic conditions and moderately impaired cognition was sent to an outside appointment via stretcher without being appropriately groomed or dressed. The resident was documented as dependent for personal hygiene, and an LPN and the Unit 2 Nursing Manager stated the overnight shift failed to get the resident ready, resulting in the resident going to the appointment in a gown and in an undignified manner.
A resident with an indwelling Foley catheter and severe cognitive impairment had the catheter collection bag observed resting on the floor on two occasions. The unit manager acknowledged the bag should be kept off the floor for infection control purposes, and the facility policy stated drainage bags are not to touch the floor.
Failure to Provide Ordered Pain Medication: A resident prescribed scheduled MS Contin for pain did not receive the medication for 48 hours because it was unavailable from the pharmacy, and staff substituted one-time oxycodone doses. The resident reported inadequate pain relief and withdrawal symptoms, and the NP documented an acute opioid withdrawal episode with diaphoresis when the scheduled opioid supply was interrupted.
Laundry Lint Trap Not Maintained as Required: The facility failed to keep dryer lint traps cleaned at the required interval. During a laundry room fire event, smoke was seen coming from dryer #3, and the Maintenance Director found embers of lint in the lint trap. Interviews showed the lint trap had not been emptied as required, and the cleaning log had been completed for an entire shift before the shift was over.
Medication Not Available for Pain Management
Penalty
Summary
The facility failed to ensure Morphine sulfate was available for administration for one resident. The resident had diagnoses including polyneuropathy, a sacral pressure ulcer, and polyarthritis, and the MDS indicated the resident was cognitively intact with a BIMS score of 15 out of 15. The care plan identified the resident as at risk for complications related to opioid use and included administering medications as ordered. The physician’s orders included Morphine Sulfate Oral Tablet 15 mg, 1 tablet by mouth three times a day for pain, and oxycodone HCl Oral Tablet 10 mg every 4 hours as needed for pain. The eMAR showed the morphine dose scheduled for 2200 was coded as hold/see progress notes, and the oxycodone PRN dose was administered at 2050 with a pain level of 9 out of 10. Progress notes documented that the morphine dose was held because the pharmacy had not yet delivered the night dose, and the order was entered as a hold due to nondelivery from the pharmacy. The resident stated the medication was not available when admitted and was later received during the night. Staff interviews showed differing procedures for unavailable medications, including checking the Omnicell, calling the pharmacy, contacting the physician, and requesting stat delivery. The surveyor found that Morphine sulfate 15 mg tablets were not available in the Omnicell.
Missed ADL Care and Poor Grooming for Dependent Residents
Penalty
Summary
Facility staff failed to provide activities of daily living care for multiple dependent residents, with missing documentation and observations showing unmet needs for bathing, incontinence care, dressing, oral hygiene, personal hygiene, grooming, and showering. The report identified seven residents affected, each with care plans and MDS assessments showing significant dependence for ADLs and, for several residents, severe cognitive impairment. In multiple instances, staff interviews stated that blanks in the documentation meant the care was not provided, and several staff members attributed missed care to short staffing and heavy assignment loads. For one resident with diabetes, CKD, bipolar disorder, severe cognitive impairment, and dependence for locomotion, transfer, dressing, toileting, hygiene, and meals, the record lacked evidence of bathing, incontinence care, dressing, oral hygiene, and personal hygiene on numerous dates across March, April, and May 2026. The resident’s care plan called for toileting hygiene as needed for incontinent episodes and lift-sheet use for turning and repositioning. The resident’s RP stated that briefs were not changed often enough and attributed this to short staffing. CNA interviews confirmed that missing documentation meant the care was not done. Another resident with diabetes, CVA, dementia, severe cognitive impairment, and dependence for locomotion, transfer, dressing, toileting, hygiene, and meals also had missing ADL documentation for bathing, incontinence care, dressing, oral hygiene, and personal hygiene across November and December 2025. The care plan directed staff to provide toileting hygiene, check and change briefs frequently, and assist with feeding. Additional residents had similar failures: one resident had repeated missed showers and incontinence care across February through May 2026, with family reporting the resident was left soiled and staff describing inability to complete care because of staffing levels; another resident had long, dirty fingernails with debris underneath and no evidence of nail care despite dependence for personal hygiene; another resident missed scheduled showers in September and October 2025; one resident was transported to an outside appointment in a gown and without proper grooming; and one resident was observed with a call bell out of reach, facial hair, dirty chipped fingernails, and food on clothing and bedding while dependent for eating, oral care, toileting hygiene, showers, personal hygiene, and dressing.
Failure to Provide Dignified Grooming and Clothing Before Outside Appointment
Penalty
Summary
The facility failed to maintain dignity for a resident by not providing appropriate grooming or clothing before a scheduled outside appointment. The resident had diagnoses including Type 2 diabetes mellitus with diabetic chronic kidney disease, anemia, heart failure, and peripheral vascular disease. The quarterly MDS dated 4/16/26 coded the resident as scoring 12 out of 15 on the BIMS, indicating moderately impaired cognitive abilities for daily decision making, and coded the resident as dependent for personal hygiene. A synopsis of the event dated 4/22/26 stated the resident had a morning outside appointment and was transported by stretcher, but was not appropriately groomed or dressed and went to the appointment in an undignified manner. The nurse's note documented the resident left the facility at approximately 7:10 a.m. and returned at approximately 1:30 p.m. via stretcher transport. During interviews, an LPN stated the 11 PM to 7 AM shift did not get the resident ready for the appointment and confirmed the resident was not dressed or groomed appropriately, and the Unit 2 Nursing Manager stated the resident should have been appropriately groomed and dressed and that it was the responsibility of the 11 PM to 7 AM shift to have the resident ready.
Catheter drainage bag left on the floor
Penalty
Summary
Facility staff failed to provide appropriate catheter care for Resident #136, who was admitted with diagnoses including obstructive uropathy and was assessed as severely cognitively impaired with an indwelling catheter. The resident’s most recent MDS coded the resident as having an indwelling catheter, and the physician’s order documented a Foley catheter 16 French with a 10 cc balloon. During observations on two occasions, the bottom of the resident’s catheter collection bag was found resting on the floor. The unit manager stated that the bag should be kept off the floor for infection control purposes and acknowledged that the collection bag should not have been resting on the floor. The facility policy on urinary catheterizations also stated to ensure drainage bags are not touching the floor.
Failure to Provide Ordered Pain Medication
Penalty
Summary
The facility failed to provide effective pain management for one resident who was prescribed MS Contin 15 mg twice daily for pain. The resident stated that his morphine was not available, that oxycodone was ordered one time in place of the morphine, and that the oxycodone did not relieve his pain like the morphine did. He also stated that he experienced withdrawal symptoms because he went without the morphine. Clinical record review showed the resident’s care plan directed staff to administer analgesia as ordered and to observe for effectiveness and signs and symptoms of side effects. Progress notes documented that the resident’s morphine extended release medication was interrupted when the supply was not available, and that he was given oxycodone as a substitute. A nurse practitioner note later stated that the resident experienced an acute opioid withdrawal episode when his MS Contin supply was interrupted and he went without medication for 44 hours, with diaphoresis and withdrawal symptoms, and that he was bridged with oxycodone until the refill arrived. The medication administration record showed the resident was not administered MS Contin on two consecutive days and missed four doses, leaving him without the medication for 48 hours. During that time, the NP issued a one-time order for oxycodone 10 mg for pain. The DON stated the morphine extended release was on back order and that there was a gap when the medication could not be obtained. The NP stated she expected residents on scheduled pain medication not to go without it and that staff should ensure medications were available.
Laundry Lint Trap Not Maintained as Required
Penalty
Summary
The facility failed to maintain laundry equipment in safe operating condition when lint traps on the dryers were not cleaned as required. The facility policy for Personal Laundry Handling and Processing stated lint traps should be checked, brushed, and cleaned at least every hour unless more frequent attention was required, and that cleanings should be documented on the Lint Trap Cleaning Log. During the incident review, the facility stated that on Thursday, January 22, 2026, the fire alarm activated at about 9:22 AM and smoke was seen coming from dryer #3 in the laundry room. The Maintenance Director reported opening the lint trap doors and seeing embers of lint, which were extinguished, and the facility later determined there had been excess lint buildup. Facility interviews showed the lint trap had not been cleaned as required. The Maintenance Director stated the lint trap had not been cleaned like it was supposed to and that laundry staff were supposed to empty it every hour. The Director of Environmental Services stated the lint trap was supposed to be emptied every hour, but the staff member working that morning did not do it, and the log had been filled out for the entire shift even though it was only 9:40 AM. The District Manager stated new employees were educated on checking lint traps during orientation and that, after the fire, laundry staff received corrective actions. The survey team reviewed the concern with facility leadership, and no further information was provided before exit.
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Compliance trends in Virginia
Data through Apr 2026Comparisons below measure the most recent period May 2025 – Apr 2026 against the prior period May 2024 – Apr 2025 (two equal 12-month windows). The most recent 1 months are excluded because CMS is still publishing them.
Top tags by month · last 24 months
dashed = still reportingMonthly citation counts for the 5 most-cited tags. The dashed tail is the 1-month reporting lag.
Frequency movers
Biggest change in how often each tag is cited, as a rate per 100 inspections (so it isn't skewed by survey volume): May 2025 – Apr 2026 vs the prior period May 2024 – Apr 2025. Only tags with at least 20 citations in both periods are shown.
Severity movers
Tags whose average scope/severity shifted the most: May 2025 – Apr 2026 vs the prior period May 2024 – Apr 2025. The number is the average severity on the A–L scale (A=0…L=11); the letter is the band it falls in. A rise means the same tag is being cited at a more serious level — note the average can move enough to rank here while staying within the same letter. Same 20-citation minimum applies.
Care domain movers
Citations grouped into CFR care domains — F-tags by their §483 regulatory section (CMS State Operations Manual, Appendix PP) — measured as a rate per 100 inspections: May 2025 – Apr 2026 vs the prior period May 2024 – Apr 2025. Share is the domain's portion of citations this period; avg severity is the mean scope/severity letter and immediate jeopardy the percentage cited at J–L, both over the current period. Domains with at least 20 citations in both periods are shown; the sparkline tracks the last 12 months (left = oldest).
Immediate jeopardies · this period
Citations at the most serious scope/severity — J–L, immediate jeopardy, residents placed at risk of serious harm or death — over May 2025 – Apr 2026 vs the prior period May 2024 – Apr 2025. "Surveys with an IJ" counts distinct health inspections that had at least one.
Survey activity · by month
faded/dashed = still reportingCitations each month split into complaint-driven (unscheduled, triggered by grievances) vs standard surveys — bars, left axis — with the number of inspections as a line on the right axis. Rising inspections signal more scrutiny; a rising complaint share means more off-cycle surveys. The most recent 1 months are still being reported.
Deficiency-free survey rate
Share of health surveys that found zero deficiencies — the odds of a clean survey. May 2025 – Apr 2026 vs the prior period May 2024 – Apr 2025; the most recent 1 months are still being reported (dashed).
Penalties · by month
faded = still reportingTotal civil money penalty dollars imposed on the state's facilities each month — how hard the state is enforcing. The most recent 1 months are still being reported, and penalties often lag citations by several months.
Emerging tags
Tags that weren't established last period but surged — an early warning, distinct from movers (which track already-common tags). Criteria: fewer than 20 citations in the prior period, but at least 10 this period and 2.5× their prior volume. The sparkline shows monthly counts over the last 12 months (left = oldest).
Trusted data from CMS and state health departments
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