Based on staff interviews, and facility documentation reviews, the facility staff failed to ensure that residents were protected during an allegation of abuse investigation and failed to investigate an allegation of verbal abuse involving one resident (Resident #1) in a survey sample of 10 residents. Resident #1 (R1) was the victim of two different abuse allegations and during the investigations on 5/30/25 and 10/30/25 the perpetrator was allowed to work to the end of their shift and worked their schedule days following, and while the investigation was being conducted. …
F610 citations in Virginia
Investigating alleged violations · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Respond appropriately to all alleged violations.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Virginia cites F610 more often than its own record predicts
1.01 times the share F610 takes of citations nationally.
Of every deficiency written in Virginia in 2025, this is the portion that was F610.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Virginia surveyors wrote
F610 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 Resident interview, staff interview, clinical record review, facility documentation review, and in the course of a complaint investigation, the facility staff failed to investigate allegations of abuse, exploitation and mistreatment, and failed to take measures to protect residents, and failed to make corrections affecting 4 Residents (Resident #35, 368, 52, and 317) in a survey sample of 60 Residents. The failure to make corrections resulted in harm for Residents #35 and #368. The findings included: 1. For Residents #35 and #368, who were married and victims of financial misappropriation and were exploited for an excess of $50,000, the facility staff failed to make corrections/restitution, which resulted in fear of economic hardship and mistrust, which constituted harm. …
Based on staff interview, clinical record review, and facility record review, the facility failed to have evidence that alleged violations were investigated thoroughly for 1 of 28 residents in the sample, Resident #117 (R117).The findings include:For R117 the facility failed to thoroughly investigate all allegations regarding alleged abuse.Diagnoses for R117 include schizophrenia and osteoarthritis. On the most recent applicable Minimum Data Set (MDS) assessment, a quarterly assessment with an Assessment Reference Date (ARD) of 12/5/2024, R117 scored a 9 out of 15 on the Brief Interview for Mental Status (BIMS) indicating moderate cognitive impairment.A progress note in the clinical record dated 4/29/2024 stated that R117 made facility staff aware of allegations of abuse. …
The short window
Recent years
| Year | Share of Virginia citations | vs expected |
|---|---|---|
| 2023 | 0.40% | 0.31× |
| 2024 | 0.85% | 0.60× |
| 2025 | 1.53% | 1.01× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Virginia surveyors cite →
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