F658 in Virginia. Pick another state for the same tag.
Against expectation — 2025
Virginia cites F658 more often than its own record predicts
Versus expected share1.93×
1.93 times the share F658 takes of citations nationally.
Share of Virginia citations3.44%
Of every deficiency written in Virginia in 2025, this is the portion that was F658.
Virginia3.44%
National1.78%
Share of all citations that were F658.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Virginia surveyors wrote
F658 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.
J · Immediate jeopardy, isolatedOctober 26, 2023
Based on staff interview, facility document review, and clinical record review, the facility staff failed to follow professional standards of care for one of twelve residents in the survey sample (Resident #1).
Facility staff failed to clarify with the provider a new order to administer 100 units of short-acting insulin at each meal, when Resident #1 was intended to receive 20 units with meals. Resident #1 received a total of 200 units of short-acting insulin in a 4-hour period leading to life-threatening hypoglycemia, requiring hospitalization in the intensive care unit for treatment of the insulin overdose (serious harm). …
Based on staff interview, clinical record review and facility policy review, the facility staff failed to provide care and services to meet professional standards of quality for 1 of 7 resident's in the survey sample, Resident #2. The findings included:The policy entitled Pain Management with a revised date of 09/24/2025 was reviewed and read in part, The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. Under the heading Recognition the document read, 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 meet professional standards of practice for the documentation of medication administration for 2 of 51 residents, Resident #12 and Resident #90. The findings included:1.For Resident #12 the facility staff documented the narcotic medication oxycodone as being administered, when no oxycodone was documented as removed from the narcotic supply.
Resident #12's clinical record listed diagnoses which included but not limited to rheumatoid arthritis, unspecified, contracture of muscle, right shoulder, and hemiplegia and hemiparesis following cerebral infarction affecting right non-dominant side. …
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