Based on staff interviews, resident interviews, and facility documentation reviews, the facility staff failed to ensure sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident affecting 39 residents on the [NAME] Wing. Specifically, the facility failed to ensure licensed nurse coverage on the west wing, resulting in one of the three nursing units operating without a licensed nurse available to administer medications or provide nursing oversight for approximately 12 hours. This deficient practice resulted in the identification of immediate jeopardy (IJ), and subsequent substandard care. …
F725 citations in Virginia
Sufficient nursing staff · Nursing and Physician Services Deficiencies
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Virginia cites F725 more often than its own record predicts
1.19 times the share F725 takes of citations nationally.
Of every deficiency written in Virginia in 2025, this is the portion that was F725.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Virginia surveyors wrote
F725 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, resident interview, staff interviews, clinical record review, and facility documentation review, the facility staff failed to have sufficient nursing staff to meet the resident care needs on 2 of 3 nursing units, which affected many residents and resulted in psychological harm for one resident (Resident #44). The findings included: 1. For Resident #44 (R44), the facility staff failed to provide incontinence care for an extended period of time due to insufficient staffing, which resulted in psychological harm for the resident. R44 was admitted to the facility on [DATE]. Diagnoses for R44 included but were not limited to multiple sclerosis, chronic obstructive pulmonary disease, muscle weakness, history of falling, and abnormal posture. …
Based on resident interview, staff interview, clinical record review, and facility document review, the facility staff failed to maintain adequate staffing levels to consistently meet resident needs. The findings include: The facility staff failed to ensure consistent adequate staffing levels to meet individual resident needs. Review of payroll-based journal (PBJ) staffing data for quarter one 2026 (October 1-December 1, 2025) revealed the facility triggered for one star staffing and excessively low weekend staffing. This data is collected and reported to The Centers for Medicare & Medicaid Services (CMS) by the facility staff on a quarterly basis. During the survey process, interviews were conducted with cognitively intact residents and resident representatives. …
The short window
Recent years
| Year | Share of Virginia citations | vs expected |
|---|---|---|
| 2023 | 0.53% | 0.66× |
| 2024 | 0.69% | 0.87× |
| 2025 | 0.92% | 1.19× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Virginia surveyors cite →
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