3_F578-IJ Based on interview, record review, and review of the facility's policy, the facility failed to ensure a resident's advance directive was executed per the resident's wishes related to code status for one of 47 sampled residents (Resident (R) 24). R24 formulated an advance directive prior to being admitted to the facility; however, the resident's family member signed a Do Not Resuscitate (DNR) form without being educated about the form or it's implications. This failure had the potential to affect all residents of the facility who had, or who wished to formulate an advance directive. On [DATE] at 3:55 PM, the facility's Assistant Administrator was notified and issued an Immediate Jeopardy at F578, the right to formulate an Advance Directive. …
F578 citations in Virginia
Advance directives · Resident Rights Deficiencies
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Virginia cites F578 less often than its own record predicts
0.65 times the national share — cited less often here than elsewhere.
Of every deficiency written in Virginia in 2025, this is the portion that was F578.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Virginia surveyors wrote
F578 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, facility documentation review and clinical record review the facility staff failed to honor one Resident's desires on an Advance directive for one Resident (Resident 4) in a survey sample of 7 Residents. The findings include: For Resident # 4, the facility staff failed to verify and honor the signed Advance Directive and Do not Resuscitate paperwork documented in the clinical record. Because the nurse did not see proper documentation of a DNR, the order was changed to a Full Code. Resident # 4 was admitted to the facility on [DATE], and expired on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #4's most recent MDS (minimum data set) (an assessment tool) with an ARD (assessment reference date) of [DATE], was coded as an Admission assessment. …
Based on record review, interview and policy review, the facility failed to offer advanced directive information for one of five residents (Resident (R)13) reviewed for advanced directives in the sample of 31. The failure to discuss advanced directive information with the residents and resident representatives could potentially affect their ability to make informed decisions about their care. Findings include:Review of R13's electronic medical record (EMR) admission Record under the Profile tab identified that R13 was admitted to the facility on [DATE]. Review of R13's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) date of 06/30/25 with a Brief Interview Mental Status (BIMS) score of seven out of 15 indicated R13's cognition was significantly impaired. …
The short window
Recent years
| Year | Share of Virginia citations | vs expected |
|---|---|---|
| 2023 | 1.05% | 0.98× |
| 2024 | 0.64% | 0.65× |
| 2025 | 0.61% | 0.65× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Virginia surveyors cite →
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