Based on observation, resident interview, staff interview, clinical record review, and review of facility documents, the facility failed to provide care that met the needs of residents with mental health disorders and/or behaviors requiring frequent monitoring. The facility staff failed to ensure sufficient staff was provided frequent safety checks with one-to-one supervision by staff to address the resident's behavioral health care needs and safety for 4 of 15 residents (Resident #1, Resident #3, Resident #5, and Resident #11) in the survey sample which resulted in immediate jeopardy. The findings include: 1. …
F741 citations in Virginia
Quality of Life and Care Deficiencies
Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2024
Virginia cites F741 more often than its own record predicts
1.06 times the share F741 takes of citations nationally.
Of every deficiency written in Virginia in 2024, this is the portion that was F741.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Virginia surveyors wrote
F741 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 staff interview, facility document review and clinical record review, it was determined that the facility staff failed to provide trauma informed care education for five of five staff reviewed. The findings include: During the course of an investigation of Resident #130's PTSD (post-traumatic stress disorder) / trauma informed care, five staff who were caring for Resident #130 were chosen to have their education files reviewed; RN (registered nurse) #1, LPN (licensed practical nurse) #5, LPN #11, CNA (certified nursing assistant) #5 and CNA #15. An interview was conducted on 10/25/23 at 3:00 PM with LPN #5. …
The short window
Recent years
| Year | Share of Virginia citations | vs expected |
|---|---|---|
| 2023 | 0.07% | 1.34× |
| 2024 | 0.05% | 1.06× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Virginia surveyors cite →
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