Based on staff interview, clinical record review, and facility document review, the facility staff failed to notify the medical provider of a significant change in condition in a timely manner for two (2) of 51 residents in the survey sample, Resident #95 and Resident #6.The facility's failure to recognize, act upon, and report a heart rate of 131 beats per minute to a medical provider for approximately six hours, likely caused and/or hastened the resident's death which occurred one to two hours after being sent out to the hospital with complaints of shortness of breath and chest pain.This resulted in the identification of Immediate Jeopardy for Resident #95. The survey team informed the facility on [DATE] at 3:28 PM of the Immediate Jeopardy situation regarding Resident #95. …
F580 citations in Virginia
Notifying of changes · 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.
Against expectation — 2025
Virginia cites F580 more often than its own record predicts
1.96 times the share F580 takes of citations nationally.
Of every deficiency written in Virginia in 2025, this is the portion that was F580.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Virginia surveyors wrote
F580 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 family interview, staff interview, facility documentation review, and clinical record review, the facility staff failed to inform the the resident's representative and Nurse Practitioner of a change in condition for 2 of 10 residents (Resident #4, and #2) which resulted in harm at Past Non-Compliance, for Resident #4 in the survey sample.The findings included: 1.Resident #2 was admitted to the facility on [DATE] with diagnoses including nephrostomy tubes for urine excretion, chronic heart failure and chronic heart disease with 3 cardiac arterial bypass grafts, an artificial heart valve, and a left ventricular ejection fraction of only 26% revealing a severely weakened heart muscle. …
Based on staff interview, clinical record review and facility document review, the facility staff failed to notify the resident's responsible party of significant weight loss for one of 43 residents, Resident #118. The findings included:A facility policy entitled, Weight Monitoring and Tracking with an effective date of 1/29/2024 was reviewed. The document read in part, The Center has a system in place to weigh, monitor, and track patient's weights. Weights are tracked, monitored, and analyzed by the interdisciplinary team. Under item #8 the document stated, The team will notify the provider and responsible party (RP) of significant weight changes, investigate possible causes of the weight change, discuss interventions, and document a progress note. …
The short window
Recent years
| Year | Share of Virginia citations | vs expected |
|---|---|---|
| 2023 | 2.57% | 1.79× |
| 2024 | 2.35% | 1.54× |
| 2025 | 2.91% | 1.96× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Virginia surveyors cite →
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