Based on observation, staff interviews, facility documentation review, and clinical record review, the facility staff failed to implement their infection control policy and procedures with regards to COVID-19, including maintaining an accurate record of staff's COVID-19 vaccination status, conducting COVID-19 testing, wearing proper PPE (personal protective equipment). In addition, the facility had a COVID-19 outbreak, which resulted in 14 Residents testing positive for COVID-19 and one Resident (Resident #3) being hospitalized , which is harm. This noncompliance affected Residents on all 5 halls/units within the facility. Specifically, the facility staff failed to implement their infection control policies and procedures with regards to COVID-19, as evidenced by: 1. …
F888 citations in Virginia
Infection Control Deficiencies
Ensure staff are vaccinated for COVID-19
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2023
Virginia cites F888 more often than its own record predicts
1.32 times the share F888 takes of citations nationally.
Of every deficiency written in Virginia in 2023, this is the portion that was F888.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Virginia surveyors wrote
F888 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 facility document review, the facility staff failed to meet staff vaccination requirements, 15 residents tested positive for COVID-19, and the facility staff failed implement their policy for COVID-19 vaccination for 11 of 166 employee records reviewed. The facility records documented that 15 residents had tested positive for COVID-19 during the previous four weeks but did not require hospitalization ; and the facility staff failed to provide evidence of approval of the employee's vaccination exemption as a condition of employment according to the facility's policy. The findings include: On 05/17/2022 the facility provided a document listing residents who tested positive for COVID-19 from 04/19/2022 through 05/13/2022 as requested. …
Based on staff interview and facility document review, the facility staff failed to implement their policy for ensuring that all staff were fully vaccinated for COVID-19, or who have been granted exemptions for three of 79 employee records reviewed. The findings include: The facility COVID-19 records documented that 3 staff were partially vaccinated, however there was no follow up information documented. An interview was conducted on 4/17/23 with ASM #2, the director of clinical services, who was filling in for the Infection Preventionist who had been out of the building for approximately one month. …
What else Virginia surveyors cite →
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