F659 in Virginia. Pick another state for the same tag.
No F659 citations were recorded in Virginia for 2025. That means none appear in the CMS file for that year — not that the requirement does not apply.
In the surveyor’s words
What Virginia surveyors wrote
F659 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.
D · No harm, potential for more than minimal, isolatedApril 8, 2021
Based on observation, staff interview, facility document review and clinical record review, it was determined the facility staff failed to ensure respiratory services were provided by qualified persons in accordance with the written plan of care for one of 33 current residents in the survey sample, Resident #128.
Resident #128 was removed from her oxygen concentrator by CNA (certified nursing assistant) #10, who then switched and connected the resident to a new oxygen concentrator and turned on the machine, which had a flow rate of 3 LPM (liters per minute) and not the physician ordered 2 LPM. …
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