Based on family interview, staff interview, clinical record review, and facility document review, the facility staff failed to ensure residents were free of significant medication errors for 6 of 51 sampled residents, Resident #94, Resident #2, Resident #33, Resident #95, Resident #29, and Resident #43. For Resident #94, the facility staff failed to remove the anticoagulant, Eliquis from the resident's active medication supply when discontinued on [DATE]. 12 Eliquis tablets were missing from Resident #94's Eliquis supply and were unaccounted for. Lab results obtained on [DATE] revealed a critically low hemoglobin of 6.7, a low hematocrit of 20.9, and PT/INR levels that were unable to be determined due to no clotting endpoint on the lab instrument. …
F760 citations in Virginia
Significant medication errors · Pharmacy Service Deficiencies
Ensure that residents are free from significant medication errors.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Virginia cites F760 more often than its own record predicts
1.35 times the share F760 takes of citations nationally.
Of every deficiency written in Virginia in 2025, this is the portion that was F760.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Virginia surveyors wrote
F760 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 interviews, clinical record review, and facility documentation review, the facility staff failed to ensure resident #2 (R2) was free from significant medication error, which resulted in harm for one of ten residents in the survey sample.The findings included:The facility staff failed to ensure that R2 was administered the correct dosage of his medication daily. On 4/27/26 at 10:15 AM, a clinical record review was conducted. On 6/9/25 the nurse practitioner/Doctor of Nursing Practice (DNP) wrote a progress note that read in part, . the reason for visit was resident was having muscle weakness. A different nurse practitioner (NP) wrote a progress note dated 6/18/25 and 6/19/25 that the reason for the visit was that R2 was having weakness. …
Based on clinical record review, staff interview and facility document review, it was determined that the facility staff failed to ensure one of 52 residents were free of a significant medication error, Resident #13. The findings include:For Resident #13 (R13), the facility staff failed to ensure correct dosing of Dialudid (1) and Methadone (2) on 1/27/2026. R13 was admitted to the facility with diagnoses that included but were not limited to Cauda Equina syndrome (3) and chronic pain syndrome (4). On the most recent minimum data set (MDS), a significant change assessment with an assessment reference date (ARD) of 5/11/2026, the resident was assessed as receiving scheduled and as needed pain medications, having occasional pain, and receiving an opioid medication. …
The short window
Recent years
| Year | Share of Virginia citations | vs expected |
|---|---|---|
| 2023 | 1.98% | 1.78× |
| 2024 | 2.19% | 1.88× |
| 2025 | 1.76% | 1.35× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Virginia surveyors cite →
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