Based on staff interview, clinical record review and facility document review, the facility staff failed to ensure that one of 16 residents, Resident #7, was free from a significant medication error. During a hospital admission in July 2017, it was determined that Resident #7 who had a history of [REDACTED]. This resulted in altered mental status and hospitalized from [DATE] through 07/11/2017. Resident #7 received IV (intravenous) [MEDICATION NAME] (a medication to replace [MEDICAL CONDITION] hormones) upon admission to the hospital and had improvement in her mental status by the following morning. …
F333 citations in Virginia
Pharmacy Service Deficiencies
Ensure that residents are safe from serious medication errors.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
No F333 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
F333 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 staff interview and clinical record review, the facility staff failed to ensure 1 of 25 residents (Resident #25) was free of a significant medication error. The findings included: The facility staff failed to ensure Resident # 25's blood sugar was checked prior to breakfast. Resident #25 was admitted to the facility 10/06/16 and readmitted [DATE] with [DIAGNOSES REDACTED]. Resident #25's admission minimum data set (MDS) assessment with an assessment reference date (ARD) of 9/11/16 coded the resident with a cognitive summary score of 13 out of 15 in Section C Cognitive Patterns. …
What else Virginia surveyors cite →
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