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 dementia and a history of aggression assaulted another resident in a hallway, pushing him from a chair onto the floor and then attempting to strike him with a chair while a third resident was nearby. Staff on constant observation and another observer did not intervene until after the resident had already been pushed down, despite the resident being on enhanced supervision for prior resident-to-resident altercations. Both residents had severe cognitive impairment, and interviews showed the assigned aide did not understand the urgency of the constant observation role.
Failure to Notify RP/MD of Change in Condition and Missed Meds A resident with dementia, aphasia, dysphagia, malnutrition, and pressure injuries had documented lethargy, decreased alertness, poor intake, pocketing of food/meds, weight loss, and worsening LFTs, but the RP was not promptly notified of the change in condition and end-of-life planning concerns. Another resident on dialysis had repeated missed scheduled doses of multiple meds, including pain, BP, anticoagulant, COPD, psych, and ESRD-related therapies, when out of the facility, and the chart did not show MD notification of the missed doses.
Stale Urine Odor in Hallway: Surveyors observed a strong stale urine odor in the 300 hallway between rooms 303-306 on multiple occasions, and the odor was still present the next day. The DOH said she was new to the facility, described the odor-control products used by housekeeping, and noted problem areas at the end of the hallway, including one resident room with urine saturation from a leaking urine collection bag. The facility policy stated the environment should be clean, sanitary, orderly, and homelike.
A resident with dementia, aphasia, dysphagia, and malnutrition had documented decline, low O2 saturation, and ongoing SOB despite oxygen and nebulizer treatments, yet remained in the facility until family chose hospital transfer; the resident was later transitioned to hospice. In a separate case, staff administered Midodrine without evidence in the eMAR of the required BP checks before the dose and one hour after, despite the physician order requiring both monitoring points.
Failure to Clean and Monitor a Pressure Injury: The facility failed to promote healing of a resident’s unstageable DTI to the right ischium. During wound care, the DON applied treatment without cleaning the wound first, despite staff and the wound physician stating that cleansing with saline or wound cleanser was appropriate. The record also lacked weekly nursing assessments documenting the wound’s location, stage, size, and description, and the facility relied on intermittent wound physician visits that were missed when the resident was at dialysis or out of the facility.
Failure to Follow Dietician Weight Monitoring and Feeding Recommendations: A resident with AD, aphasia, dysphagia, and protein-calorie malnutrition had a care plan and physician orders addressing nutrition and feeding support, but the facility did not complete the ordered weekly weights to establish a baseline after readmission. Records showed significant weight fluctuation, poor PO intake, pocketing of food and meds, and dependence on staff for feeding and fluids, while CNAs described the resident as weak, lethargic, and needing supervision, prompting, and redirection.
Failure to Prevent Resident-to-Resident Abuse During Constant Observation
Penalty
Summary
The facility failed to protect a resident from abuse when a resident with severe cognitive impairment and a history of aggressive behavior assaulted another resident in the hallway. Resident #1 had diagnoses including unspecified dementia with behavioral disturbance, COPD, muscle weakness, and major depressive disorder, and his MDS coded him with a BIMS score of 3 out of 15. Resident #2 also had severe cognitive impairment, with diagnoses including Alzheimer’s disease with early onset, unspecified dementia without behavioral disturbance, hypertension, and muscle wasting and atrophy, and his MDS also coded a BIMS score of 3 out of 15. During the incident, staff heard a chair flip over and a thud, then found Resident #2 on the floor. A video reviewed by the facility showed Resident #1 standing in front of Resident #2 and pushing him out of a chair and onto the floor. The video also showed Resident #1 picking up a chair and attempting to strike Resident #2 with it while Resident #3 was in close proximity. An OSM sitting nearby observed the incident and did not intervene until after Resident #2 had been pushed to the floor, and the chair was only stopped when the OSM placed a hand on it. The record and interviews showed that Resident #1 had been on constant supervision because of prior aggressive behavior and resident-to-resident altercations. The care plan documented behaviors related to aggression during care and a history of pushing another resident. Staff interviews indicated that the Activities Aide assigned to constant observation was watching the incident but did not intervene quickly, and the aide stated she did not think the situation would become physical and did not know what the constant observation was for. The facility’s policy required staff on constant observation to remain within close proximity to intervene immediately if necessary, but that did not occur during the altercation.
Failure to Notify Physician or Responsible Party of Change in Condition and Missed Medications
Penalty
Summary
The facility failed to notify the responsible party of a change in condition for one resident with multiple serious diagnoses, including Alzheimer’s disease, aphasia, dysphagia, and protein-calorie malnutrition. The resident’s record showed moderate impairment in daily decision making, significant recent weight loss, and unhealed pressure injuries. Progress notes documented lethargy, decreased alertness from baseline, non-verbal status, poor oral intake, pocketing of food and medications, worsening liver function tests, declining albumin, and progressive functional decline after hospitalization for acute clinical deterioration. A provider note stated that the resident’s overall clinical decline, poor nutritional status, and worsening hepatic synthetic dysfunction warranted notification of the responsible party to discuss goals of care, with recommendations for palliative care consultation and hospice transition. A later note documented that the responsible party was notified by voice message. During interview, the NP stated there was nutritional decline and that a voice message had been left for the responsible party to recommend hospice, but the responsible party did not return the call. The attending physician stated that they usually try to talk with the responsible party about a change in condition, but because the resident was doing better they did not speak with the responsible party about end-of-life planning. The facility also failed to notify the physician of medications not administered for another resident who was out of the facility for dialysis or appointments on multiple dates. The resident’s orders included multiple scheduled medications for pain, hypertension, ESRD, constipation, anticoagulation, COPD, schizophrenia, chronic pain, hypotension, pulmonary hypertension, supplementation, and depression. Review of the eMAR for two months showed repeated missed doses of several medications, including acetaminophen, amlodipine, calcium acetate, cetirizine, docusate, Eliquis, ipratropium-albuterol, lactobacillus, lidocaine patch, lurasidone, methocarbamol, metoprolol, midodrine, Revatio, renal capsule, and sertraline. Nursing staff documented that the resident was out at dialysis or out of the facility, but the record did not evidence physician notification of the multiple missed medications. Staff interviews confirmed that the resident left early for dialysis, did not receive morning medications before leaving, and that missed doses were simply documented as the resident being out.
Stale Urine Odor in Hallway
Penalty
Summary
The facility failed to maintain a homelike environment on the 300's hallway between rooms 303-306. During multiple observations on 6/30/2026, surveyors noted a strong stale urine odor in the hallway, and the same odor was still present on 7/1/2026. At one observation, a wet floor sign was present and a faint deodorizing scent was noted, but the stale urine odor remained in the area. The director of housekeeping stated she was new to the facility and still learning the processes. She reported that housekeeping used Virex disinfectant, Odoban odor eliminator, and spray air freshener to control odors, and that staff tried to identify hot spot rooms so odors could be addressed right away. She acknowledged problem areas at the end of the 300 hallway and said a mattress had been changed in one resident room due to urine saturation from a leaking urine collection bag, but the odor lingered and the source could not be detected. The facility policy on Homelike Environment stated that staff and management maximize characteristics of the facility that reflect a personalized, homelike setting, including a clean, sanitary, and orderly environment.
Failure to Promptly Address Decline and Monitor Ordered BP Parameters
Penalty
Summary
The facility failed to promote the highest level of well-being for two residents. For one resident with Alzheimer’s disease, aphasia, dysphagia, and protein-calorie malnutrition, staff did not promptly transition care despite documented decline. The resident’s most recent MDS noted impaired decision-making, significant weight loss, and unhealed pressure injuries. On the day of the event, the resident was nonverbal and aphasic at baseline, had oxygen saturation of 88% on room air, and was placed on 2 liters of oxygen with improvement to 92%. Nursing documented shortness of breath, respiratory rate of 25, and continued distress despite oxygen and nebulizer treatments. The record shows the resident remained symptomatic after repeated interventions and physician notification. Nursing documented that the on-call service was informed, oxygen and nebulizer treatments were continued, and diagnostic testing was ordered. The resident still had shortness of breath with oxygen saturation only reaching 91-92%, and the family ultimately decided to send the resident to the hospital. Interviews with the NP and attending physician indicated that the resident had functional decline, significant weight loss, and was later transitioned to hospice after hospital transfer. The DON stated the resident had gone to the hospital twice between May and June and continued to decline after returning to the facility. For the second resident, the facility failed to document blood pressure monitoring before and one hour after administration of Midodrine as ordered. The physician order required BP checks prior to each dose and one hour post-dose, with hold parameters based on systolic and diastolic readings. Review of the eMAR for two months showed no evidence of the required pre-administration or post-administration BP documentation. During interview, the administering RN stated she checked the BP before giving the medication and rechecked it afterward, but was unsure whether it was documented. The regional director of clinical services stated there was no evidence of the required BP readings available.
Failure to Clean and Monitor a Pressure Injury
Penalty
Summary
The facility failed to provide care and services to promote healing of a pressure injury for one resident with an unstageable deep tissue injury to the right ischium. The resident was cognitively intact on the most recent MDS, with a BIMS score of 14 out of 15, and the assessment documented one unstageable deep tissue injury that was not present on admission. The resident told surveyors that staff had been applying cream to a diaper rash wound on the buttocks and said it had been there for a while. During wound care observation, the DON performed treatment to the right ischium wound but did not clean the wound before applying the dressing. The DON stated she did not clean it because the physician order did not specify cleaning with anything, and said she would have used normal saline or wound cleanser if it had been ordered. The wound physician later stated that nursing staff should use their judgment for cleaning the pressure injury and could generally use wound cleanser or house stock saline. An RN also stated that she cleansed the wound with normal saline or wound cleanser because a wound should always be cleaned before treatment. The record also failed to show weekly monitoring of the wound with the required location, staging, sizing, and description. The wound physician notes showed assessments on some dates, but several visits were rescheduled because the resident was at dialysis or out of the facility, and one refusal was documented. The clinical record did not contain additional assessments or refusals to account for weekly monitoring. Facility policy required weekly evaluation and documentation of the pressure injury by a licensed nurse and/or practitioner, including wound location, stage, measurements, tissue type, drainage, surrounding tissue, pain, and interventions to promote healing.
Failure to Follow Dietician Weight Monitoring and Feeding Recommendations
Penalty
Summary
The facility failed to implement dietician recommendations for a resident with Alzheimer’s disease, aphasia, dysphagia, and protein-calorie malnutrition. The resident’s care plan identified risk for dehydration, weight loss, or malnutrition, and physician orders included use of a maroon spoon for all meals to control oral intake and a mechanical soft diet with thin liquids. The most recent MDS also documented impaired daily decision-making, significant recent weight loss, and unhealed pressure injuries. A nutritional assessment documented weekly weights times four to re-establish a baseline weight after readmission, but the weight summary showed those weekly weights were not completed. The resident’s weights fluctuated significantly over the months reviewed, including a drop from 171.0 lbs to 141.5 lbs. The record also showed poor intake, with the resident dependent or requiring maximum assistance with eating on multiple days and consuming only 25-50% of meals during the period reviewed. Progress notes documented that the resident was eating less than 25% of meals, pocketing food and medications, and needing escalation of nutritional interventions. CNA interviews described the resident as weak, lethargic, not feeding self consistently, requiring supervision, redirection, prompting for fluids, and often eating only 25-30% of meals. The RDCS stated there were no weights per the dietician recommendations, and the dietician stated the weekly weights were ordered to establish a baseline after readmission.
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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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