Based on staff interview and facility documentation review, the facility staff failed to ensure QAPI (Quality Assurance Performance Improvement) meetings were conducted quarterly for 3 of 4 quarters sampled.The Findings included:Throughout the survey conducted 04/21/2026 - 04/28/2026, the survey team inspected and investigated the facility's systems and processes regarding correcting previously cited deficiencies and resident care concerns. It was noted the facility had failures and remained out of compliance in areas that had previously been cited as deficient during previous abbreviated surveys. The Maintenance logs and Pest control logs were reviewed by the survey team. …
F868 citations in Virginia
Quality assurance committee · Administration Deficiencies
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Virginia cites F868 less often than its own record predicts
0.99 times the national share — cited less often here than elsewhere.
Of every deficiency written in Virginia in 2025, this is the portion that was F868.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Virginia surveyors wrote
F868 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 and review of facility documents, the facility staff failed to maintain a quality assessment and assurance committee which meets at least quarterly. The findings included: On 3/3/22 at approximately 9:00 p.m., a Quality assessment and assurance (QA&A) interview was conducted with the Administrator. The Administrator stated there had been no QA&A meeting since she arrived 2/7/22 and she was unable to provide documentation of previous QA&A meetings because she was unable to locate the QA&A note book. The Administrator further stated a QA&A meeting had not not scheduled. The Administrator also stated staffing is a system failures and it hadn't been addressed with the Medical Director. …
The short window
Recent years
| Year | Share of Virginia citations | vs expected |
|---|---|---|
| 2023 | 0.26% | 1.03× |
| 2024 | 0.21% | 0.88× |
| 2025 | 0.23% | 0.99× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Virginia surveyors cite →
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