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 orient one of seven residents (Resident #6) to ensure a safe and orderly discharge, resulting in Immediate Jeopardy. Immediate Jeopardy was called on 10/9/19 at 2:30 P.M. It was removed on 10/10/19 at 11:45 [NAME]M. After removal, it was lowered to a level 3 isolated. The Findings Included: 1. Resident #6 was discharged on [DATE] against his will in an unsafe manner to an unknown location with an unknown individual. The facility failed to give him education and a glucometer to manage his medication, which included sliding scale insulin. …
F624 citations in Virginia
Resident Rights Deficiencies
Prepare residents for a safe transfer or discharge from the nursing home.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Virginia cites F624 more often than its own record predicts
3.13 times the share F624 takes of citations nationally.
Of every deficiency written in Virginia in 2025, this is the portion that was F624.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Virginia surveyors wrote
F624 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 document review, the facility staff failed to provide and document sufficient preparation and orientation to the resident to ensure a safe and orderly transfer/discharge from the facility for (1) of (30) sampled residents, (Resident #65). The findings included: For Resident #65 the facility staff failed to provide and document sufficient preparation and orientation was provided to the resident in the clinical record to ensure a safe and orderly transfer/discharge to a higher level of care on 2/4/25. …
The short window
Recent years
| Year | Share of Virginia citations | vs expected |
|---|---|---|
| 2023 | 0.13% | 1.23× |
| 2024 | 0.05% | 0.45× |
| 2025 | 0.15% | 3.13× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Virginia surveyors cite →
Deficiency Index is independent and is not affiliated with, endorsed by, or approved by CMS, Medicare, or any government agency. About this data · Report a correction