Based on staff interview, facility documentation review, clinical record review and in the course of a complaint investigation, it was determined the facility staff failed to develop a complete baseline care plan for one of 26 residents, Resident #8.The findings include:For Resident #8 (R8) the facility staff failed to complete the baseline care plan for PEG (1) (percutaneous endoscopic gastrostomy) tube care.On the most recent MDS (minimum data set) assessment, discharge assessment with a reference date of 4/24/2026, the resident was assessed as having a PEG (1) (percutaneous endoscopic gastrostomy) tube and receives 51% or more of calories from enteral feeding. …
F655 citations in Virginia
Baseline care plan · Resident Assessment and Care Planning Deficiencies
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Virginia cites F655 more often than its own record predicts
2.57 times the share F655 takes of citations nationally.
Of every deficiency written in Virginia in 2025, this is the portion that was F655.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Virginia surveyors wrote
F655 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 | 1.65% | 2.06× |
| 2024 | 1.07% | 1.55× |
| 2025 | 1.68% | 2.57× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Virginia surveyors cite →
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