Based on observation, staff interview, clinical record review, and facility documentation review, the facility staff failed to maintain an available call bell system for multiple Residents which was identified initially for one Resident (Resident #117), and secondarily as the sample was expanded, for three other residents (#118, #119, and #120) in a sample of 22 residents resulting in a finding of immediate jeopardy (IJ). Following the removal of IJ, the scope and severity was lowered to a level two pattern. The findings included.For Resident #117 and others, the call bell system was inoperable and no alternative means to call for assistance was in place for them in the facility. Resident #117 was most recently readmitted to the facility on [DATE]. …
F919 citations in Virginia
Call system · Environmental Deficiencies
Make sure that a working call system is available in each resident's bathroom and bathing area.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Virginia cites F919 less often than its own record predicts
0.34 times the national share — cited less often here than elsewhere.
Of every deficiency written in Virginia in 2025, this is the portion that was F919.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Virginia surveyors wrote
F919 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 observation and interview, the facility failed to have adequate equipment to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area. Specifically, the call light system did not function in two of 24 resident (Resident (R) 82 and R129) and the facility did not provide residents in these rooms an adequate alternate means to communicate with nursing staff. Findings include: 1. During an interview on 07/08/26 at 12:45 PM R82 stated she had had her call light on since right after breakfast because she had a headache and needed some medication. R82 stated her outside light was not working and she had told staff several times, but no one had fixed it. …
The short window
Recent years
| Year | Share of Virginia citations | vs expected |
|---|---|---|
| 2023 | 0.40% | 0.91× |
| 2024 | 0.43% | 0.97× |
| 2025 | 0.15% | 0.34× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Virginia surveyors cite →
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