Based on clinical record review, interview, and facility documentation review, the facility failed to implement its abuse prevention and investigation policies to ensure the safety of two of three residents (Resident (R) 109 and R81) reviewed for abuse out of 29 sample residents. This had the potential to affect all residents in the facility who were at risk for abuse. The facility's Administrator was informed on 05/07/26 at 1:33 PM that Immediate Jeopardy existed which also constituted Substandard Quality of Care (SQC) related to the facility's failure to ensure R109 and R81 were free from sexual abuse by R15 and was determined to exist on 03/15/25. The facility provided an Immediate Jeopardy Removal Plan that was accepted on 05/07/26 at 5:42 PM. …
F607 citations in Virginia
Abuse-prevention policies · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Virginia cites F607 more often than its own record predicts
2.90 times the share F607 takes of citations nationally.
Of every deficiency written in Virginia in 2025, this is the portion that was F607.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Virginia surveyors wrote
F607 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 implement abuse policies on preventing neglect for one resident (Resident # 361) in a survey sample of 51 Residents resulting in harm. For Resident # 361, the facility staff failed to implement the policies on reporting abuse/neglect Findings: Resident #361 was admitted to the facility on [DATE] for skilled services in nursing and therapy related to altered mental status and [MEDICAL CONDITION]. [DIAGNOSES REDACTED]. Review of the Resident # 361's closed clinical record revealed the most recent MDS (Minimum Data Set) was an Admission Assessment with an ARD (Assessment Reference Date) of 8/9/2017. …
Based on facility document review and staff interview, it was determined that the facility staff failed to implement their abuse policy for protection of the resident during the investigation of an abuse allegation for one of 52 residents in the survey sample, Resident #162.The findings include:For Resident #162 (R162), the facility staff failed to implement their abuse policy for protection of a resident during the investigation of an abuse allegation reported on 11/11/2025.The facility policy Abuse documented in part, .When specific staff is identified as being allegedly involved in the abuse allegation, the staff may be re-assigned or suspended during the investigation .Review of the facility synopsis of events documented an initial report date of 11/11/2025 for the incident date… …
The short window
Recent years
| Year | Share of Virginia citations | vs expected |
|---|---|---|
| 2023 | 1.19% | 1.59× |
| 2024 | 1.39% | 1.84× |
| 2025 | 1.91% | 2.90× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Virginia surveyors cite →
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