Based on resident interviews, facility staff interviews, clinical record review and facility documentation review, the facility staff failed to report allegations of abuse and sexual harassment by resident #10 (R10), affecting five residents and resulted in psychosocial harm for all five (resident #9, Resident #7, Resident #8, Resident #12 and Resident #13). This failure resulted in immediate jeopardy being identified. The findings included: 1. For resident #9 (R9), the facility staff failed to report the sexual behavior endured by R10, when R9's ability to consent had not been assessed. Failure to report to other regulatory and protective services did not afford R9 the opportunity to have other agencies which can provide protective services and conduct an investigation. …
F609 citations in Virginia
Reporting alleged violations · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Virginia cites F609 less often than its own record predicts
0.75 times the national share — cited less often here than elsewhere.
Of every deficiency written in Virginia in 2025, this is the portion that was F609.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Virginia surveyors wrote
F609 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, clinical record review and facility documentation review the facility staff failed for 1 resident (Resident #361) of 51 residents in the survey sample to report an allegation of Neglect to the state agency. Resident #361 did not receive treatments as ordered by the physician for two consecutive days 9/16/2017 and 9/17/2017. Maggots were found in the wounds on his heels. The nurse signed the Treatment Administration Record indicating the treatments were done. The nurse later admitted she did not do the treatments to the heels for those two days. A FRI (Facility Reported Incident ) was not submitted until a new administrator was hired in (MONTH) (YEAR). …
Based on record reviews and staff interview the facility failed to report the results of a facility reported incident investigation within 5 working days of the incident.The findings included: The facility staff failed to report the results of a facility reported incident investigation within 5 working days regarding Resident #1 abusing Resident #2 by pushing him out of a chair and onto the floor as well as attempting to hit Resident #2 with a chair while Resident #3 stood in close proximity to the incident. On 7/1/26 at 4:55 PM an interview was conducted with the Administrator. The Administrator stated that she had 5 (five) minutes to send the final investigation to the State Agency or she would be in violation of not reporting in the required amount of time. …
The short window
Recent years
| Year | Share of Virginia citations | vs expected |
|---|---|---|
| 2023 | 1.19% | 0.60× |
| 2024 | 1.28% | 0.56× |
| 2025 | 1.84% | 0.75× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Virginia surveyors cite →
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