Based on staff interview, facility document review, and clinical record review, the facility staff failed to provide care in a timely manner to prevent serious injury and/or death to two of 12 residents in the survey sample, Residents #1 and #2, resulting in the identification of immediate jeopardy.The findings include:1. For Resident #1 (R1), on [DATE], the facility staff failed to assess and accurately identify signs and symptoms of sepsis (1) and to transfer the resident to the hospital in a timely manner. The resident's significant change of condition was identified on [DATE] at 7:30 a.m., the resident was not transferred to the local hospital for treatment until approximately 12:30 p.m., and the resident died at the hospital at 3:37 p.m. from sepsis. …
F684 citations in Virginia
Quality of care · Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Virginia cites F684 more often than its own record predicts
1.16 times the share F684 takes of citations nationally.
Of every deficiency written in Virginia in 2025, this is the portion that was F684.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Virginia surveyors wrote
F684 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.
Based on observation, interview and clinical record review the facility staff failed to ensure receive treatment and care in accordance with physician orders for two residents (Resident #7-R7 and Resident #74-R74) in a survey sample of 37 residents. The failure to follow physician orders resulted in a delay in identification and treatment for a fracture, which resulted in harm for R7.The findings included:1. For Resident #7 (R7) the facility staff failed to ensure physician orders were followed/carried out for a post-fall x-ray of the pelvis and left hip, which resulted in a delay in treatment of a fractured left hip and caused the resident pain, which constituted harm. …
Based on staff interview, clinical record review and facility document review, the facility staff failed to follow medical provider orders for (11) eleven of (51) fifty-one sampled residents, Resident #9, Resident #10, Resident #13, Resident #43, Resident #8, Resident #48, Resident #33, Resident #69, Resident #42, Resident #55, and Resident #79. Findings included: 1. For Resident #9, the facility staff failed to obtain a pulse ox reading (a quick, painless measurement of the percentage of oxygen in the blood and pulse rate) as ordered by a medical provider. …
The short window
Recent years
| Year | Share of Virginia citations | vs expected |
|---|---|---|
| 2023 | 3.95% | 1.09× |
| 2024 | 4.22% | 1.06× |
| 2025 | 4.97% | 1.16× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Virginia surveyors cite →
Deficiency Index is independent and is not affiliated with, endorsed by, or approved by CMS, Medicare, or any government agency. About this data · Report a correction