Based on clinical record review, family interview, staff interviews, and review of facility documentation, the facility's staff failed to identify, address, and obtain necessary psychiatric services for the behavioral health care needs of 1 of 15 residents (Resident #1), in the survey sample who had self-harming behaviors that ultimately caused the resident's death and identification of Immediate Jeopardy. The findings included: The facility's staff failure resulted in Resident #1 self-harming behavior on [DATE] by putting her hands around her neck until bruising and bleeding occurred, throwing herself on the floor multiple times and sustaining a left periorbital subcutaneous hematoma on [DATE] and finally on [DATE] the resident swallowed a wooden object which lodged in her throat,… …
F740 citations in Virginia
Behavioral health services · Quality of Life and Care Deficiencies
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Virginia cites F740 less often than its own record predicts
0.87 times the national share — cited less often here than elsewhere.
Of every deficiency written in Virginia in 2025, this is the portion that was F740.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Virginia surveyors wrote
F740 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 resident interview, staff interview, and clinical record review, the facility staff failed to coordinate necessary behavioral health care services to attain the highest practicable physical, mental, and psychological well-being for 1 of 27 residents, Resident #121. The finding included: For Resident #121, facility staff failed coordinate behavioral health care services between the resident's guardian, facility staff, physician, and behavioral health care services following [CONDITION(S)] resulting in three separate suicide attempts. In one of the attempts, The resident was found in room laying in bed with eyes closed with call light tied tightly around neck. The resident was turning blue and when released and untied call light cord, resident stated (he/she) wished to die. …
Based on staff interview, facility document review, and clinical record review, the facility staff failed to provide behavioral health services for one of eight residents in the survey sample, Resident #6.The findings include:For Resident #6 (R6), the facility staff failed to offer behavioral health services related to his substance use disorder (SUD) following two episodes of intoxication in [DATE].R6 was admitted to the facility on [DATE]. One of the resident's diagnoses on admission was alcohol abuse.A review of R6's clinical record revealed the following progress notes: [DATE] 22:54 (10:54 p.m.) Resident came down from upstairs visually intoxicated. Writer witnessed resident pull a bottle out from inside his pants in the groin area. …
The short window
Recent years
| Year | Share of Virginia citations | vs expected |
|---|---|---|
| 2023 | 0.07% | 0.25× |
| 2024 | 0.37% | 1.51× |
| 2025 | 0.23% | 0.87× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Virginia surveyors cite →
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