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F0745
E

Failure to Provide Psychosocial Assessments After Resident-to-Resident Altercations

Staunton, Virginia Survey Completed on 07-31-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide medically related social services for psychosocial well-being to four residents following resident-to-resident altercations. Specifically, after an incident in which a newly admitted resident with dementia became aggressive and inappropriately touched three female residents in the dining area, there was no evidence that the social worker assessed the emotional or psychosocial status of the affected residents. The three female residents involved had diagnoses including dementia, schizophrenia, depression, cognitive communication deficit, and Alzheimer's disease, with assessments indicating moderate to severe cognitive impairment. Review of clinical records and facility documentation did not show that any psychosocial assessments were completed by social services after the incident, and the social worker could not provide evidence that such assessments had been done. In a separate incident, the same newly admitted resident became aggressive and struck another resident in the face. This resident also had diagnoses of dementia, depression, insomnia, and kidney disease, and was assessed as severely cognitively impaired. Again, there was no documentation or evidence that the social worker completed an emotional or psychosocial assessment following the altercation. Interviews with the social worker revealed awareness of the incidents but an inability to recall or provide evidence of completed assessments. Observations and interviews with staff and residents did not indicate any visible emotional distress, but the required assessments were not documented as completed.

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