2. For R454, the facility staff failed to appropriately assess and treat a hospice patient with a history of trauma, by involving the family in the comprehensive admission assessment and administering medications ordered by the provider for paranoia and agitation. R454's diagnoses according to the facility diagnoses sheet, included but were not limited to, other seizures, chronic obstructive pulmonary disease, hypertension, anxiety, heart failure, personal history of suicidal behavior, traumatic brain injury, major depressive disorder, and vascular dementia with psychotic disturbance. R454's minimum data set (MDS) assessment with an assessment reference date of [DATE] assigned the resident a brief interview for mental status score of 11 out of 15 indicating moderate cognitive impairment. …
F742 citations in Virginia
Quality of Life and Care Deficiencies
Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Virginia cites F742 more often than its own record predicts
1.90 times the share F742 takes of citations nationally.
Of every deficiency written in Virginia in 2025, this is the portion that was F742.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Virginia surveyors wrote
F742 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, clinical record review, and facility documentation, the facility staff failed to ensure residents who display or are diagnosed with mental disorder, or history of Post-traumatic Stress Disorder (PTSD) receives appropriate treatment and services to attain the highest practical mental and psychosocial well-being for 1 resident (Resident #53) in a survey sample of 48 residents. The findings included: For Resident #53, the facility staff failed to ensure the resident received appropriate services post sexual assault by a staff member at the facility. …
Based on staff interview, facility document review and clinical record review, the facility staff failed to develop a comprehensive care plan regarding post-traumatic stress disorder for one of twenty-eight residents in the survey sample (Resident #11). The findings include:Resident #11 had no care plan developed regarding post-traumatic stress disorder. Resident #11 (R11) was admitted to the facility with diagnoses that included asthma, collapsed vertebra, cervical fracture, dysphagia, polyneuropathy, anxiety, neurogenic bladder, chronic post-traumatic stress disorder (PTSD), major depressive disorder and delusional disorder. The minimum data set (MDS) dated [DATE] assessed R11 with severely impaired cognitive skills. …
The short window
Recent years
| Year | Share of Virginia citations | vs expected |
|---|---|---|
| 2023 | 0.26% | 2.38× |
| 2024 | 0.11% | 0.85× |
| 2025 | 0.23% | 1.90× |
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