Based on observation, resident interview, staff interview, facility document review, and clinical record review, the facility staff failed to notify the physician of a change in condition for one of 24 residents, Resident #14. This resulted in harm. An unknown staff member identified a wound on Resident #14's left leg stump, and placed a dressing over the wound without a physician's orders [REDACTED]. The dressing remained in place for an unknown length of time and when removed on 09/06/2017 the wound was an unstageable pressure ulcer. Findings were: Resident #14 was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. The most recent MDS (minimum data set) was a quarterly assessment with an ARD (assessment reference date) of 07/27/2017. …
F157 citations in Virginia
Resident Rights Deficiencies
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
No F157 citations were recorded in Virginia for 2025. That means none appear in the CMS file for that year — not that the requirement does not apply.
In the surveyor’s words
What Virginia surveyors wrote
F157 findings written in Virginia, one from each severity band recorded here, most serious first.
Severity is as the surveyor wrote it. Some findings had already been corrected before the survey.
Based on observation, staff interviews, clinical recorded review and facility documentation, the facility staff failed to follow physician orders [REDACTED].#1) in the survey sample. The facility staff failed to notify the physician that the following medications were not administered as ordered: *Phoslo 667 capsule for Resident #1. The findings included: Resident #1 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED].*End Stage [MEDICAL CONDITIONS] and Right *Femur Fracture. The current Minimum Data Set (MDS) a 30-day assessment with an Assessment Reference Date (ARD) of 09/15/17 coded the resident with a 08 of a total possible score of 15 on the Brief Interview for Mental Status (BIMS), indicating moderate cognitive impairment. …
Based on the investigation of a complaint, clinical record review and staff interview it was determined for Resident #3, one of 17 residents in the survey sample that the facility staff failed to notify her responsible party when she was diagnosed with [REDACTED]. The findings included: Resident #3 was diagnosed with [REDACTED]. Shingles is a blistering rash caused by the [MEDICAL CONDITION] that causes chicken pox. The rash is tingling, itchy and burning and develops along a nerve path usually on the torso. …
What else Virginia surveyors cite →
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