Based on staff interviews, clinical record review, and facility document review, the facility staff failed to ensure a resident's medication needs were addressed as part of admission orders for one (1) of 55 sampled residents (Resident #153). The findings include: The facility staff failed to ensure Resident #153's admission documentation/orders addressed the medications included as part of Resident #153's hospital discharge information. Resident #153's admission minimum data set (MDS) assessment was not due and had yet to be submitted prior to the surveyor's review of the resident's clinical record. A medical provider assessment indicated Resident #153 was alert and oriented times three (3). Resident #153 was documented as having adequate vision. …
F635 citations in Virginia
Resident Assessment and Care Planning Deficiencies
Provide doctor's orders for the resident's immediate care at the time the resident was admitted.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Virginia cites F635 more often than its own record predicts
1.38 times the share F635 takes of citations nationally.
Of every deficiency written in Virginia in 2025, this is the portion that was F635.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Virginia surveyors wrote
F635 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.
The short window
Recent years
| Year | Share of Virginia citations | vs expected |
|---|---|---|
| 2023 | 0.26% | 4.11× |
| 2024 | 0.16% | 3.30× |
| 2025 | 0.08% | 1.38× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Virginia surveyors cite →
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