Based on resident, family and staff interviews, clinical record review and facility document review, the facility staff failed to promptly notify the provider of diagnostic results requiring urgent follow up for 1 of 55 residents in the survey sample, resident # 17 (R17). The findings included: R17's diagnoses included but were not limited to AV block complete, presence of cardiac pacemaker, essential hypertension, and asthma. The minimum data set (MDS) assessment with an assessment reference date of 2/14/25 assigned the resident a brief interview for mental status score (BIMS) of 15 out of 15 indicating intact cognition. On 3/31/25 at 1:30 PM this surveyor interviewed R 17 and a visiting family member. The family member asked if I had gotten their complaint. …
F777 citations in Virginia
Administration Deficiencies
Provide or obtain x-rays/tests when ordered and promptly tell the ordering practitioner of the results.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Virginia cites F777 more often than its own record predicts
3.07 times the share F777 takes of citations nationally.
Of every deficiency written in Virginia in 2025, this is the portion that was F777.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Virginia surveyors wrote
F777 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, the facility staff failed to obtain timely results of an X-ray for one of five residents in the survey sample, Resident #1. The findings include: For Resident #1 (R1), the facility staff failed to obtain timely results of an X-ray that was performed on 9/29/23. On the quarterly MDS (minimum data set) with an ARD (assessment reference date) of 9/7/23, R1 was coded as being severely impaired for making daily decisions. She was coded as sometimes able to understand others, and as sometimes understanding others. She was admitted to the facility with a diagnosis of dementia. …
The short window
Recent years
| Year | Share of Virginia citations | vs expected |
|---|---|---|
| 2023 | 0.07% | 2.81× |
| 2025 | 0.08% | 3.07× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Virginia surveyors cite →
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