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
Unclean Resident Rooms and Evidence of Pest Activity: Two residents were found in rooms that were not maintained in a clean, homelike condition. One resident with severe cognitive impairment had a strong urine odor in the room and closet, while another resident with intact cognition reported mice coming out of the closet at night; the closet contained clutter and debris that appeared to be mouse droppings, and a pest control report documented two mice in the employee break room.
The facility failed to timely notify the provider of significant changes in condition for two residents. One resident with a complex cardiac history had a pulse of 131 bpm documented, but the elevated HR was not reported or reassessed for hours before the resident was later sent to the hospital with SOB and chest pain and died there. Another resident with ESRD on dialysis and cirrhosis with ascites had a 28.6-lb weight gain, but the record did not show provider notification of the significant change.
Staff failed to prevent significant medication errors for multiple residents. A resident with moderate cognitive impairment had Eliquis discontinued but the supply was not removed from the cart, 12 tablets were unaccounted for, and the resident later had severe bleeding with critically abnormal labs before dying in the facility. Other residents experienced repeated missed or incorrect insulin administrations, and one resident with bacteremia had delayed IV penicillin doses while awaiting medication from the infusion center.
Missed Ordered Laboratory Testing: The facility failed to obtain multiple ordered labs for several residents, including PT/INR monitoring for a resident transitioning from Eliquis to Coumadin with a Lovenox bridge, urinalyses for residents with suspected UTI/CAUTI, CBC/CMP testing, anticonvulsant levels, blood cultures, and an ammonia level. One resident developed active bleeding with critically abnormal lab values and died in the facility while bleeding from multiple sites. The record also showed several ordered tests were not found or were not completed as ordered.
Failure to Protect Resident from Sexual and Physical Abuse: A resident with dementia, PTSD, and a trauma history was involved in two separate incidents with other residents. In one event, a cognitively intact resident was observed on the resident’s bed with his penis exposed while the resident was holding his penis; the resident later had no recollection of the incident. In another altercation, two residents were seen fighting in the dining room, and the resident was left with scratches, bruising, and a fracture of the right 4th metatarsal after a wheelchair-related injury.
A resident with significant cardiac history had a documented HR of 131 and low BP, but an LPN did not notify a provider or document a repeat assessment for hours. The resident later developed SOB, chest pain, and low O2 sat, was sent to the hospital, and died there the same evening. The report also found an RN competency assessment with multiple below-standard scores that lacked required reassessment and completion documentation.
Unclean Resident Rooms and Evidence of Pest Activity
Penalty
Summary
The facility failed to provide a clean and homelike environment for two residents. One resident had a most recent MDS annual assessment showing a BIMS score of 6, indicating severe cognitive impairment for daily decision-making. During an environmental tour, the resident’s room had a strong urine odor, and when the closet door was opened the odor became significantly stronger and was concentrated within the closet. The Director of Housekeeping stated that residents’ rooms are cleaned daily and the resident’s clothing is laundered twice weekly, but the odor remained present during later observations. The facility also failed to ensure a clean homelike environment for another resident who had a quarterly assessment with a BIMS score of 14 out of 15, indicating orientation to person, place, and time with unimpaired immediate recall. During an interview, the resident stated that mice were present and had been seen coming out of the closet at night. Observation of the closet showed clothing hanging up, boxes on the floor, clothing items between the boxes, and small black debris that appeared to be mouse droppings throughout the closet. The facility’s pest control report also documented two mice found on a sticky pad trap in the employee break room.
Failure to Timely Report Significant Changes in Condition
Penalty
Summary
The facility failed to notify the medical provider of a significant change in condition for two residents. For one resident, staff did not timely report a heart rate of 131 beats per minute and did not document any provider notification or further assessment for approximately seven hours. The resident had a history that included atrial fibrillation, acute diastolic congestive heart failure, takotsubo syndrome, a prosthetic heart valve, and bacteremia, and the record showed the resident had recently been hospitalized and returned to the facility before this event. For that resident, a nursing note documented tachycardia, new leg swelling, altered mental status, and later transfer to the hospital after complaints of shortness of breath and chest pain. The on-call provider note documented shortness of breath, chest pain, and low oxygen saturation, but there was no documentation that the provider had been informed earlier that day of the elevated heart rate or the resident’s cardiac history. The resident was admitted to the hospital with atrial fibrillation with rapid ventricular response and a heart rate in the 150s, and the record states the resident expired at the hospital later that evening. For the second resident, the facility did not notify the medical provider of a significant 28.6-pound weight gain over five weeks. The resident had end stage renal disease with dialysis, alcoholic cirrhosis with ascites, type 2 diabetes mellitus, portal hypertension, and congestive heart failure. The record showed an admission weight of 164.4 pounds and a later weight of 193.0 pounds, and a dietary note identified the gain as significant. The clinical record did not show documentation that the provider was notified of the weight change.
Significant medication errors involving anticoagulant, insulin, and IV antibiotic administration
Penalty
Summary
The facility failed to ensure residents were free from significant medication errors for 6 of 51 sampled residents. The most serious event involved a resident with atrial fibrillation, COPD, respiratory failure with hypoxia, type 2 diabetes mellitus, and bladder-neck obstruction whose anticoagulant Eliquis was discontinued, but the medication supply was not removed from the active cart. Twelve Eliquis tablets were missing and unaccounted for. The resident had a BIMS score of 9, indicating moderate cognitive impairment, and later developed bleeding from the nose, mouth, urinary tract, and rectum. Lab results showed a critically low hemoglobin of 6.7, hematocrit of 20.9, and PT/INR results that could not be calculated because there was no clotting endpoint. The resident died in the facility while actively bleeding. For another resident with type 2 diabetes mellitus and diabetic polyneuropathy, staff failed to administer sliding scale Insulin Lispro on 19 separate occasions despite blood sugar readings that met the ordered parameters for administration. The resident had severe cognitive impairment with a BIMS score of 1. For a third resident with type 2 diabetes mellitus and diabetic neuropathy, staff failed to administer Insulin Glargine on two occasions. One nursing note documented that the insulin was held because the blood sugar was 150, even though the order did not include a hold parameter based on that reading. That resident had intact cognition with a BIMS score of 15. The facility also failed to begin intravenous antibiotics as ordered for a resident admitted with acute and subacute endocarditis, streptococcal arthritis, and bacteremia. The resident’s discharge summary and history and physical documented continuous penicillin G therapy that was changed to intermittent IV dosing through a PICC line, but the MAR and nursing notes showed multiple held or missed doses while the medication was awaited from the infusion center. In addition, staff failed to follow insulin parameters for one resident whose order required holding Insulin Lispro if glucose was below 175, and staff administered the medication on multiple occasions when blood sugars were below that threshold. Staff also administered Insulin aspart to another resident when blood glucose values were below the ordered hold parameter of 150.
Missed Ordered Laboratory Testing
Penalty
Summary
The facility failed to obtain multiple laboratory tests as ordered by medical providers for 8 of 51 sampled residents, including PT/INR testing, urinalyses, CBC/CMP testing, anticonvulsant drug levels, blood cultures, and an ammonia level. The report states that these missed labs involved residents with significant medical histories such as atrial fibrillation, recurrent urinary tract infections, chronic kidney disease, epilepsy, cirrhosis, and cognitive impairment. Facility policy required the facility to provide or obtain laboratory services to meet resident needs. For one resident, the deficiency involved repeated failure to obtain PT/INR testing during a transition from Eliquis to Coumadin with a Lovenox bridge. PT/INR labs were ordered every 48 hours, but several were not obtained. Later testing showed a PT greater than 90 and an INR that could not be calculated because the result was greater than linearity. The resident then developed active bleeding, including bleeding from the nose, mouth, urinary tract, and rectum. Additional labs showed critically low hemoglobin and hematocrit, and PT/INR could not be determined because there was no clot endpoint. The resident died in the facility while actively bleeding. The report also describes missed ordered labs for other residents. One resident with altered mental status and a history of recurrent UTIs had urinalysis orders that were not found in the record, while another resident with suspected CAUTI had a urinalysis with culture and sensitivity ordered but no result located. A resident on warfarin had PT/INR orders that were not obtained as scheduled, and another resident had ordered CBC and CMP testing that was not found. Additional residents had missing anticonvulsant levels, missing infection workup labs including CBC, BMP, magnesium, blood culture, and missing ammonia testing. Surveyors discussed these missing tests with facility leadership, and the record reflects that the ordered laboratory services were not completed or could not be located in the clinical record.
Failure to Protect Resident from Sexual and Physical Abuse
Penalty
Summary
The facility failed to protect a resident with Alzheimer’s disease, PTSD, generalized anxiety disorder, major depressive disorder, and moderate cognitive impairment from sexual abuse by another resident and from physical abuse during an altercation with another resident. The resident had a care plan noting a history of trauma, a potential for re-traumatization, and a history of stating she had been raped and abused, with interventions to avoid situations that reminded her of trauma. The resident also had a legal guardian in place. On one occasion, a staff member observed another resident lying on the resident’s bed with his penis exposed while the resident was sitting in her wheelchair holding his penis. The other resident had a BIMS score indicating he was cognitively intact, while the resident involved had no recollection of the incident. The medical provider later documented increased sexual behaviors in the context of impaired cognition and noted that the resident was alert but confused and had no recollection of the event. On another occasion, staff were alerted to two residents fighting in the dining room. Staff observed the resident and another resident in their wheelchairs intertwined, facing each other, with the other resident holding onto the resident’s wheelchair and not letting go. The resident was found with scratches and bruising on both arms, and later developed right foot swelling and toe discoloration. X-rays showed a closed fracture of the right fourth metatarsal neck, and the facility’s investigation linked the injury to a recent traumatic event involving a wheelchair rolling over the resident’s foot.
Failure to Recognize and Report Significant Change in Condition; Incomplete Nurse Competency Validation
Penalty
Summary
The facility failed to ensure nurses were competent to recognize and act on a significant change in condition for a resident with extensive cardiac history. The resident had diagnoses including atrial fibrillation, acute diastolic congestive heart failure, takotsubo syndrome, a prosthetic heart valve, and bacteremia. The resident’s care plan noted cognitive intactness, IV antibiotics, a diuretic, and an anticoagulant, with a goal of returning home. A nursing note documented a heart rate of 131 beats per minute and blood pressure of 98/53, but there was no documentation that a provider was notified or that the nurse further assessed the elevated heart rate. Approximately seven hours later, the next clinical entry was from an on-call provider documenting shortness of breath, chest pain, and not feeling well. The provider note included a pulse of 80 and oxygen saturation of 77, but there was no indication the nurse had informed the provider of the resident’s cardiac history, the recent hospitalization for atrial fibrillation with rapid ventricular response, or the earlier heart rate of 131. The record also did not show whether the resident remained stable during the intervening hours or whether the resident was checked during that period. The resident was later sent to the hospital and expired there the same evening. The nurse involved stated that after seeing the pulse of 131, she rechecked the resident and obtained 87, found the resident fine, and did not document the recheck. She stated that later in the evening the resident complained of shortness of breath and heart racing, at which time she assessed the resident and sent the resident out. The nurse’s file contained orientation documentation and a copy of the notification-of-changes policy, but there were no dates or signatures showing when it was reviewed and no evidence of hands-on skills validation. The report also identified that an RN’s competency assessment showed scores below expected standards in multiple skills areas, but the required reassessment and completion documentation were left blank and no further training records were found.
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Compliance trends in Virginia
Data through May 2026Comparisons below measure the most recent period Jun 2025 – May 2026 against the prior period Jun 2024 – May 2025 (two equal 12-month windows). The most recent 2 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 2-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): Jun 2025 – May 2026 vs the prior period Jun 2024 – May 2025. Only tags with at least 20 citations in both periods are shown.
Severity movers
Tags whose average scope/severity shifted the most: Jun 2025 – May 2026 vs the prior period Jun 2024 – May 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: Jun 2025 – May 2026 vs the prior period Jun 2024 – May 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 Jun 2025 – May 2026 vs the prior period Jun 2024 – May 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 2 months are still being reported.
Deficiency-free survey rate
Share of health surveys that found zero deficiencies — the odds of a clean survey. Jun 2025 – May 2026 vs the prior period Jun 2024 – May 2025; the most recent 2 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 2 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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