Based on observations, resident interviews, staff interviews, clinical record review, and facility document review, the facility staff failed to provide a safe, clean, homelike environment for 1 of 3 sampled residents, Resident #1. This failure resulted in Resident #1 sustaining several injuries from a rodent, which required emergent treatment and constituted harm.The findings included: For Resident #1, the facility staff failed to provide a safe, clean, homelike environment that was free of a rodent in the resident's bed. A mouse was found to be in Resident #1's bed that resulted in compromised skin to the resident's left lower leg, resulting in being transferred to a higher level of care, antibiotics, tetanus vaccine, and rabies vaccinations. …
F584 citations in Virginia
Safe, clean, homelike environment · Resident Rights Deficiencies
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Virginia cites F584 more often than its own record predicts
1.09 times the share F584 takes of citations nationally.
Of every deficiency written in Virginia in 2025, this is the portion that was F584.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Virginia surveyors wrote
F584 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, resident interview, staff interview, clinical record review and facility document review, it was determined that the facility staff failed to provide a clean and homelike environment for 2 of 36 residents in the survey sample, Residents #14,& 27. 1. For Resident #14 (R14), the facility staff failed to provide a clean and homelike environment. On the most recent minimum data set (MDS), an annual assessment with an assessment reference date (ARD) of 7/7/2026, the resident scored 6 on the brief interview for mental status (BIMS) assessment, indicating they were severely cognitively impaired for making daily decisions. On 7/28/26 at 7:27 AM during the environmental tour, an observation was made of R14's room. Upon entering the room, a strong urine odor was detected. …
Based on observation and staff interview, the facility staff failed to ensure the wall in one of sixteen rooms was in good repair promoting a homelike environment. The wall in room 169 had two areas of white dry wall patch beside the resident's bed. The rest of the wall and room were painted yellow. Findings were: On 07/27/2021 at approximately 8:00 a.m., Room 169 was observed. The bed beside the door was against the wall with the head of the bed facing the doorway. The wall beside the bed was yellow except for two separate areas of dry wall patches that were white. The resident residing in that room was not interviewable and when asked what had happened to his wall, his response was not understandable, as he pointed at the television. …
The short window
Recent years
| Year | Share of Virginia citations | vs expected |
|---|---|---|
| 2023 | 1.78% | 0.80× |
| 2024 | 1.65% | 0.78× |
| 2025 | 2.30% | 1.09× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Virginia surveyors cite →
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