Based on observation, resident interview, staff interview, clinical record review, and facility document review, the facility staff failed to administer the building in a manner that uses its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being for four (4) residents (R#42, #106, #124 and #130) and each Long-Term Care Resident which resulted in Immediate Jeopardy. The findings included: For all facility residents, the Administration failed to act on the residents found to be using illicit drugs and alcohol in the building, failed to ensure all residents were protected from those substances being brought into the building, and failed to act on one (1) Resident creating sharp stabbing-like weapons from dining room… …
F835 citations in Virginia
Administration · Administration Deficiencies
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Virginia cites F835 more often than its own record predicts
1.56 times the share F835 takes of citations nationally.
Of every deficiency written in Virginia in 2025, this is the portion that was F835.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Virginia surveyors wrote
F835 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, resident interviews, and facility documentation the facility staff failed to be administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident which resulted in harm to several residents, who had untreated pain, residing on one unit out of three units. The findings includedThe facility administration failed to ensure a licensed nurse was present on an entire unit for approximately a 12-hour period to administer scheduled medications, assess for changes in condition, communicate with the doctor, receive new orders, initiate life-saving measures in the event of an emergency, and provide any skilled nursing care such as enteral… …
Based on staff interviews and facility documentation review, the facility staff failed to effectively administer the facility by failure of the administrator, who was the abuse coordinator to effectively implement the facility's abuse policy to ensure measures were taken to protect residents when an allegation of abuse and/or neglect is being investigated and failure to conduct thorough investigations into allegations for one resident, Resident #1 (R1) out of a survey sample of 10 residents.The findings included:The facility's Abuse Coordinator, who was the administrator, failed to follow the abuse policy, protect the residents when an allegations of abuse was alleged, and initiate a thorough investigation into the allegations. …
The short window
Recent years
| Year | Share of Virginia citations | vs expected |
|---|---|---|
| 2023 | 0.07% | 0.23× |
| 2024 | 0.43% | 1.31× |
| 2025 | 0.46% | 1.56× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Virginia surveyors cite →
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