F657 in Virginia. Pick another state for the same tag.
Against expectation — 2025
Virginia cites F657 more often than its own record predicts
Versus expected share1.47×
1.47 times the share F657 takes of citations nationally.
Share of Virginia citations2.75%
Of every deficiency written in Virginia in 2025, this is the portion that was F657.
Virginia2.75%
National1.87%
Share of all citations that were F657.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Virginia surveyors wrote
F657 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.
G · Actual harm, isolatedJanuary 31, 2024
Based on staff interviews, clinical record review, and facility documentation review, the facility staff failed to conduct timely revisions of the comprehensive care plan for two residents (Resident #1 and Resident #5) in a survey sample of 14 residents. For Resident #1 (R1) the failure to revise the care plan and implement interventions that ensured R1 received the required dialysis treatments as ordered, resulted in R1 missing 3 dialysis sessions and 3 partial treatments, which resulted in four hospitalization s. This constituted four occurrences of harm.
The findings included:
1. …
D · No harm, potential for more than minimal, isolatedJuly 28, 2026
Based on staff interview, clinical record review, and facility document review, the facility staff failed to review and revise the comprehensive person-centered care plan for 3 of 51 sampled residents, Resident #94, Resident #2, and Resident #12.The findings included:
1. For Resident #94, the facility staff failed to revise the comprehensive person-centered care plan (CP) when hospice services were initiated.
A facility policy titled, Comprehensive Care Plans revised 11/14/25 specified The comprehensive care plan will describe, at a minimum, the following: a. …
B · No harm, potential for minimal, patternDecember 4, 2020
Based on observation, staff interview, facility documentation review, and clinical record review, the facility staff failed to review and revise the careplan for 2 Residents (Resident #10 and Resident #13) in a survey sample of 16 Residents.
1. For Resident #10, the facility staff failed to revise the careplan to remove the intervention of one on one observation, when this service was discontinued.
2. For Resident #13 the facility staff failed to review and revise careplan to reflect Resident #13's Foley catheter was removed on 12/4/19.
The findings included:
1. For Resident #10, the facility staff failed to revise the careplan to remove the intervention of one on one observation, once this service was discontinued.
Resident #10 was admitted to the facility on [DATE]. …
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