Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Staunton Health And Rehab Ctr during CMS and state inspections, most recent first.
Failure to Maintain Fall Interventions and Safe Transfers: The facility did not consistently implement fall precautions or perform safe transfers for multiple high-risk residents. A resident with a history of falls and fractures was observed without ordered fall interventions in place and was transferred with a mechanical lift while the w/c was unlocked. Another resident with poor balance had repeated falls from bed while ordered floor mats were not in place. A third resident with cognitive impairment and prior bed falls reported not having the ordered non-slip support under the mattress, and a fourth resident was not safely held during a transfer.
Call Light Not Kept Within Reach: A resident with MS and quadriplegia, dependent on staff for all ADLs and using a blow call light, was observed with the device placed too far away to activate. On another occasion, staff left the resident lying flat in bed and he had to yell for help because his call light was out of reach; the resident stated his low voice made it hard for staff to hear him and that this left him frightened, frustrated, embarrassed, and helpless.
Failure to identify, treat, and prevent pressure ulcers affected three residents with significant risk factors such as immobility, incontinence, malnutrition, diabetes, and dependence on staff. Staff observed new or worsening skin breakdown, including open areas on the heel, foot, buttock, sacrum, and coccyx, but the wounds were not consistently reported, documented, or treated as ordered. In one case, the wound nurse stated a resident had gone from one wound to five wounds because new skin issues were not communicated, and in another, wound care orders were not followed as written.
The facility failed to maintain an operational call light system for most residents, leaving many without a functioning way to summon assistance from their rooms and bathrooms. Several residents reported that their call lights did not work and that tabletop bells provided by the facility were either not heard by staff or not available at the bedside. Surveyor observations confirmed the presence of bells in some rooms and the absence of a bell in at least one room. Facility records documented a family grievance about the call light system being down and a testing log showing that numerous call lights failed during checks, despite facility policy requiring that activated call lights illuminate in the room, outside the room, and on a central panel.
The facility failed to revise and update fall care plans with progressive interventions for two residents after multiple documented falls. One resident with systemic lupus, epilepsy, altered mental status, tremors, a BIMS score of 9, and extensive ADL assistance needs had a fall from a wheelchair while washing her face and later a witnessed fall forward from a wheelchair, both resulting in head impact; fall investigations identified intent to get out of the wheelchair and poor safety awareness, yet no new care plan interventions were added. Another resident with Parkinson’s disease, confusion, an indwelling catheter, and dependence for mobility was found on the bathroom floor with a detached catheter and blood present, and later found on a floor mat next to the bed with a facial reddened area; investigations cited confusion, poor safety awareness, and attempts to get out of bed without assistance, but the care plan did not reflect specific new interventions after these events, despite facility policy requiring investigation and implementation of appropriate interventions.
Two residents with cognitive impairment, significant mobility limitations, and known fall risks experienced multiple falls, including unwitnessed falls from wheelchairs and falls from bed to the floor, resulting in head impact and catheter trauma. Although both residents had existing fall-risk care plans with general interventions such as low beds, non-skid footwear, floor mats, and alarms, the facility did not document new or revised care plan interventions after each fall, despite fall investigations identifying behaviors such as leaning forward, attempting to get out of the w/c, confusion, and poor safety awareness as contributing factors. This lack of progressive, individualized interventions occurred even though facility policy requires immediate investigation, IDT review, determination of root cause, and implementation of appropriate interventions to prevent further falls.
Surveyors found that expired and discontinued medications, including insulin pens and suppositories, remained in medication storage areas after they should have been removed and destroyed. An LPN and the DON confirmed that these medications, some belonging to deceased or discharged residents, were not properly discarded as required by facility policy.
Surveyors found that several residents receiving oxygen therapy or nebulizer treatments did not have their respiratory equipment, such as nasal cannulas, humidification containers, and nebulizer parts, properly dated or changed as required by physician orders and facility policy. Staff interviews confirmed that equipment should be changed and dated weekly, but this was not consistently done or documented.
A CNA was observed repeatedly touching her hair, face, glasses, clothing, and cell phone, then serving coffee and passing meal trays to multiple residents without performing hand hygiene, despite the availability of alcohol-based hand rub and facility policy requiring hand hygiene before and after assisting with meals.
The facility did not provide required Medicare non-coverage notices to three residents, as confirmed by the inability of staff to locate the necessary documentation when requested by surveyors. Facility policy requires that the NOMNC be delivered at least two days before Medicare-covered services end, but this was not done for the affected individuals.
A resident with Alzheimer's and other conditions had a rash that was not treated as per physician's orders due to a communication lapse. The prescribed medications, Triamcinolone and Clotrimazole, were not documented or administered, despite the facility's policies requiring clear processing of such orders.
The facility failed to maintain and sanitize the ice machine properly, leading to water damage and potential mold growth. The drainage pipe lacked an air gap, risking backflow. Staff were unaware of the issue's cause, and the problem persisted for weeks, affecting all 45 residents.
The facility failed to develop an ongoing infection control program that effectively collected and analyzed infection data. The infection control logs were incomplete, and the newly hired DON admitted to lacking comprehensive surveillance data. The facility did not adhere to its Infection Control Program Policy, potentially affecting all 45 residents.
The facility failed to ensure correct antibiotic use for residents, administering antibiotics without proper lab confirmation of infections. This led to inappropriate antibiotic use, increasing the risk of resistance and adverse effects. The Director of Nursing acknowledged systemic issues in obtaining necessary lab results.
The facility failed to supervise two residents to prevent wandering and did not respond to a pressure alarm for a high-risk fall resident. One resident with Alzheimer's frequently wandered into female residents' rooms, causing distress, while another resident with a recent hip fracture was observed getting up unassisted without staff responding to the alarm.
A resident with a history of chronic UTIs and severe cognitive impairment was left in saturated pants and a wet wheelchair seat for over four and a half hours. CNAs admitted to being behind schedule but acknowledged the resident should have been checked and changed every two hours as per facility policy. The DON confirmed this expectation.
Failure to Maintain Fall Interventions and Safe Transfers
Penalty
Summary
The facility failed to maintain resident safety by not consistently implementing fall interventions and by not performing safe transfers for residents identified as high fall risk. The report states that 4 of 6 residents reviewed for resident safety were affected: R4, R5, R13, and R500. The deficiency involved missed or absent interventions such as fall mats, non-slip pads, scoop mattresses, and proper transfer practices, despite care plans and assessments identifying these residents as at risk for falls and injuries. R4 had a history of falls, multiple fractures, moderate cognitive impairment, and dependence on staff for all ADLs and transfers. The care plan called for interventions including a mat to bedside, a non-slip pad to the wheelchair, and a scoop mattress, and also documented that mechanical lift assistance was required for transfers. During observation, these interventions were not in place: no fall mat was seen, no non-slip pad was seen in the wheelchair, and no scoop mattress was on the bed. Staff transferred R4 using a full body mechanical lift while the wheelchair was unlocked. The record also shows R4 had previously fallen from bed and was later hospitalized with lumbar fractures and a right femur fracture. R13 was documented as alert to person, place, and time with an unsteady gait, poor balance, and a history of falls. The care plan included interventions such as adequate lighting, a reacher at bedside, a pressure relieving mattress, and a mat at bedside when in bed. However, observations showed no floor mat in place on multiple occasions, and staff stated they were unsure why the mats were not in place. R13 had an unwitnessed fall from bed and was found with the head and upper body on the floor and the feet on the bed. The resident stated she was trying to reach something on the floor and slipped out of bed, and the record notes a head injury and transfer to the hospital. R5 was moderately cognitively impaired, required substantial to maximal assistance to roll in bed, had a history of falls, and had a care plan that included bed positioning and use of dycem between the mattress and sheet. Records show prior falls from bed and sliding from the mattress. During interview, R5 stated he did not have dycem or a non-slip pad beneath him when he fell and did not have one at the time of the interview. The report also includes R500, for whom the facility failed to perform a safe transfer, and states that V29 could not have held onto R500, prevented the fall, or transferred R500 safely. The report identifies the deficiency as failure to ensure resident safety through proper fall interventions and safe transfers.
Call Light Not Kept Within Reach
Penalty
Summary
The facility failed to ensure a call light was within reach and that a resident had a means to call for help for one resident reviewed for accommodation of needs. The resident had diagnoses of Multiple Sclerosis and quadriplegia, was documented as cognitively intact, and was dependent on staff for all ADLs. The care plan noted that the resident required assistance with all ADLs and was at increased risk for needs not being met. The facility’s call light guidance policy stated that a call light activation device shall be kept within resident reach while in resident rooms and bathrooms. On observation, the resident was found lying in bed with a blow call light placed in front of his mouth, but it was too far away for him to reach with his lips and he had to use his tongue to move it closer before he could activate it. On another observation, the resident was lying flat in bed and yelling for help after staff had left the room; he stated he had been left flat for about 15 minutes and was starting to taste his feeding, which scared him. The resident stated multiple times that his call light was not in reach, that he sometimes had to yell for help because staff could not hear his low voice, and that this made him feel frightened, frustrated, embarrassed, helpless, and disposed of. The Administrator, an LPN, and a CNA all stated that the resident’s call light needed to be in reach.
Failure to Identify, Treat, and Prevent Pressure Ulcers
Penalty
Summary
The facility failed to identify, treat, and prevent pressure ulcers for 3 of 5 residents reviewed for pressure ulcers. The deficiency involved residents with significant risk factors and existing skin issues, including impaired mobility, incontinence, cognitive impairment, malnutrition, diabetes, and dependence on staff for ADLs and transfers. The record showed that staff did not consistently identify new skin breakdown, did not communicate new wounds to the wound nurse or provider, and did not ensure ordered wound care was carried out as documented. For one resident, the record showed multiple skin concerns that were not recognized or treated when observed. The resident had diagnoses including fractures, malnutrition, CKD, anemia, hypertension, atrial fibrillation, and was documented as always incontinent and dependent on staff. During observation, an obvious pressure wound was seen on the heel without a dressing, another pressure sore was noted on the lateral foot without a dressing, and a small open area was later found on the buttock during incontinent care. The wound nurse stated the buttock wound was new and that she had not been told about the foot wounds, and the NP stated the resident had gone from one wound to five wounds because no one notified the wound nurse or provider. For another resident, the care plan documented a pressure ulcer to the sacrum and high risk for pressure ulcers related to decreased mobility, incontinence, and poor nutritional intake. The resident’s Braden Scale indicated high risk. During wound care observation, a small red and open area to the coccyx was seen, and no treatment was performed. The wound nurse stated the wound was open and new. For the third resident, the record documented a stage four pressure ulcer to the left buttock and a current pressure ulcer care plan with dressing checks. Hospice and facility wound orders required scheduled dressing changes, but during observation the left buttock wound had no dressing in place and the right hip dressing was old and dated several days earlier. Hospice staff stated the facility was supposed to complete wound care on the days hospice was not present, and the wound nurse stated the orders entered did not match the intended schedule.
Failure to Maintain Operational Call Light System for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide residents with a working call light system in resident bathrooms and bathing areas for 22 of 23 residents reviewed for physical environment. Multiple residents reported that their call lights did not work, including one resident who stated that neither her room nor bathroom call lights functioned and that a tabletop bell provided by the facility was not heard by staff, and another resident who reported her call light did not work and that she could not locate her bell. Surveyor observations confirmed the presence of tabletop bells in some residents’ rooms and the absence of a bell in at least one resident’s room. Facility documentation showed that a grievance had been filed by a resident’s daughter-in-law regarding the call light system being down, and a Call Light Testing Log indicated that 22 residents’ call lights failed during testing. The facility’s own Call Light Guidance Policy stated that when initiated, the system should light up in the room, outside the room, and on a central panel, but interviews with the Maintenance Supervisor and Administrator confirmed that the existing call light system was not functioning and that parts for the old system were unavailable, necessitating full replacement. These findings collectively show that the facility did not maintain an operational call light system as required by its policy, instead relying on tabletop bells that were inconsistently available and reportedly ineffective for alerting staff, resulting in residents lacking a reliable means to summon assistance from their rooms and bathrooms.
Failure to Revise Fall Care Plans With Progressive Interventions After Multiple Resident Falls
Penalty
Summary
The deficiency involves the facility’s failure to revise and update fall care plans with progressive interventions for two residents after multiple falls, despite facility policy requiring immediate investigation and implementation of appropriate interventions following accidents and incidents. For one resident with systemic lupus erythematosus, epilepsy, altered mental status, and a BIMS score of 9, the care plan identified fall risk related to medications, tremors, and a history of falls with head injuries and a displaced dens fracture. The care plan listed several fall-prevention interventions such as keeping the bed in the lowest position, ensuring proper footwear, instructing the resident to avoid sudden position changes, orienting the resident to the room, providing adequate lighting, encouraging sitting on the side of the bed before standing, use of assistive devices, non-skid footwear and socks in bed, and Dycem in the wheelchair. However, after subsequent falls, no new or revised interventions were added to the care plan. This resident experienced an unwitnessed fall on one occasion when a CNA found her on the floor at 7:15 AM. She reported that she had been washing her face and attempting to place a towel on the dresser when her wheelchair slid out from under her, causing her to hit the right side of her head, with blood noted on her hand, the floor, and the towel. Vital signs were documented, she was noted to be alert and oriented x2, and she was transferred to bed and then sent to the ED for further evaluation. The facility’s fall investigation documented that the fall occurred in the resident’s room while sitting, with the cause and root cause identified as the resident attempting to get out of the wheelchair. Despite this, there was no care plan intervention documented for this fall. Later, another fall occurred when the resident was observed leaning forward in the wheelchair and falling forward out of the chair, hitting her head on the leg of a sit-to-stand device. The fall investigation again identified the cause and root cause as the resident’s intent to get out of the wheelchair, with poor safety awareness and a BIMS score of 9, but again no new care plan interventions were documented. The second resident involved had diagnoses including Parkinson’s disease, was on palliative/hospice care, had an indwelling catheter, and was dependent for several mobility tasks. His care plan identified fall risk related to psychotropic and opioid medications, Parkinson’s disease, involuntary movements, and a history of falls, including sliding out of bed. Interventions included keeping the bed in the lowest position, encouraging call light use, placing a floor mat at bedside, keeping the environment free of clutter, keeping personal belongings within reach, providing adequate lighting, adding a bolster on the mattress, and using a personal alarm. Despite these measures, the resident was later found on the bathroom floor on his right side during midnight rounding, with his indwelling catheter detached and a large amount of blood on the floor and penis. The fall investigation documented confusion, poor safety awareness, and attempts to get out of bed without assistance as the problem and root cause, but although it stated the care plan was updated, no specific new interventions were documented in the care plan. On another occasion, this same resident was found lying on the floor mat next to the bed and window, on his stomach with arms at his side and legs extended, with a small red area to the left cheekbone and an indwelling catheter still patent. He was transferred back to bed via full mechanical lift and neuro checks were initiated. The fall investigation documented that the fall occurred in the resident’s room, with the resident found on the floor mat and no injuries noted. Again, no new or revised care plan interventions were documented following this fall. The DON later stated that some of the falls occurred before she was hired and that the care plan coordinator was new and learning. The facility’s Accidents & Incidents policy required the charge nurse to conduct an immediate investigation and implement appropriate interventions, and required the DON and IDT to review the incident, determine root cause, and implement appropriate interventions to attempt to prevent further falls, but the record review showed that progressive care plan interventions were not added after these falls for the two residents.
Failure to Implement Progressive Fall-Prevention Interventions After Repeated Resident Falls
Penalty
Summary
The deficiency involves the facility’s failure to provide progressive fall-prevention interventions for two residents with known fall risks and repeated falls. For one resident with systemic lupus erythematosus, epilepsy, altered mental status, a BIMS score of 9/15, and a need for substantial/maximal assistance with bed mobility and transfers, the care plan identified fall risk related to medications, tremors, and a history of falls with head injuries and a displaced dens fracture. The care plan listed general interventions such as keeping the bed in the lowest position, ensuring proper footwear, instructing the resident to avoid sudden position changes, orienting the resident to the room, providing adequate lighting, reinforcing sitting on the side of the bed before standing, and use of assistive devices, as well as non-skid footwear and Dycem in the wheelchair. However, after subsequent falls, no new or revised care plan interventions were documented. This same resident experienced an unwitnessed fall from the wheelchair in the resident room while washing her face and reaching to place a towel on the dresser, during which the wheelchair reportedly slid out from under her and she hit the right side of her head, with blood noted on her hand, the floor, and the towel. The facility’s fall investigation documented that the fall occurred while the resident was sitting, that it was related to patient intent or behavior, and that the resident had just gotten out of bed and was sitting in the wheelchair. The problem statement and root cause both identified the resident’s attempt to get out of the wheelchair, but there is no documentation of any new care plan interventions being added in response to this fall. Later, the resident had another fall when she leaned forward in the wheelchair and fell forward out of the chair, hitting her head on the leg of a sit-to-stand device. The investigation again attributed the fall to patient intent or behavior, poor safety awareness, and the resident’s intention to get out of the wheelchair to get to bed, yet again no care plan interventions were documented for this fall. A second resident, with Parkinson’s disease, palliative care, malignant neoplasm of the renal pelvis, a BIMS score of 12/15, dependence for multiple mobility tasks, and an indwelling catheter, was also care planned as being at risk for falls due to psychotropic and opioid medications, Parkinson’s disease, involuntary movements, and a history of falls. The care plan noted that the resident had a low bed, double mattresses, a floor mat at bedside, and later a bolster on the mattress and a personal alarm. Despite these measures, the resident was found on the bathroom floor at night with the indwelling catheter detached and a large amount of blood on the floor and penis, and the fall investigation identified confusion, poor safety awareness, and attempts to get out of bed without assistance as the problem and root cause. Although the investigation form stated that the care plan was updated, there is no specific care plan intervention documented for this fall. The same resident was later found lying on the floor mat next to the bed and window, on his stomach with slow responsiveness and a small red area on the left cheekbone, and again no new care plan intervention was documented for this fall. The DON later stated that some of the falls occurred before she was hired and that the care plan coordinator was new and learning, while the facility’s accidents and incidents policy requires immediate investigation and implementation of appropriate interventions, with IDT review to determine root cause and implement appropriate interventions to attempt to prevent further falls.
Failure to Remove and Destroy Expired and Discontinued Medications
Penalty
Summary
Surveyors observed that the facility failed to properly store and discard expired and discontinued medications. During an inspection of the medication cart, opened and labeled multi-dose insulin pens for a resident were found, even though the medications had been discontinued in January. The LPN confirmed that these insulin pens should have been removed and destroyed after discontinuation. Additionally, in the medication room refrigerator, an opened box of Bisacodyl suppositories and a bottle of Glycerin suppositories belonging to a deceased resident were found, both past their appropriate use period. The LPN acknowledged that these medications should have been removed and destroyed following the resident's death. The Director of Nursing stated that expired, discontinued, or deceased residents' medications are expected to be removed from circulation and destroyed. The facility's own medication storage policy requires that discontinued, outdated, or deteriorated drugs be returned to the pharmacy or destroyed, and that medications be administered only prior to the manufacturer's expiration date. These observations and staff interviews confirm that the facility did not follow its policy or accepted professional standards regarding medication storage and disposal.
Failure to Date and Change Respiratory Equipment as Required
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care by not ensuring that nasal cannulas, oxygen humidification containers, and nebulizer administration equipment were properly dated for five residents who required respiratory support. Observations revealed that multiple residents had oxygen and nebulizer equipment in use without any date labels, despite physician orders and facility policy requiring weekly changes and dating of this equipment. In several cases, the care plans for residents receiving oxygen therapy did not include documentation of oxygen use, and treatment administration records did not reflect that equipment changes had occurred as ordered. For example, one resident with diagnoses including pulmonary hypertension and heart failure had orders for oxygen therapy and weekly tubing changes, but their oxygen tubing, humidification container, and nebulizer equipment were not dated during multiple observations. Another resident with chronic obstructive pulmonary disease and acute respiratory failure had a humidification bottle dated from a previous week and undated nasal cannula tubing. Additional residents were observed with undated oxygen tubing or equipment, and in one case, a nebulizer mouthpiece and tubing were dated over a month prior to the observation, with no documentation of recent changes as required by physician orders. Interviews with nursing staff, including LPNs and an RN, confirmed that the expectation was for all oxygen and nebulizer equipment to be changed and dated weekly, with the night shift responsible for this task. The DON also acknowledged that equipment for some residents was not dated as required. The facility's own policy specified that oxygen use should be care planned, humidifiers labeled with the date opened, and tubing changed and dated weekly, but these procedures were not consistently followed for the residents reviewed.
Failure to Perform Hand Hygiene During Meal Service
Penalty
Summary
A Certified Nurse Assistant (CNA) failed to perform hand hygiene during meal service for 18 residents. The CNA was observed repeatedly touching her hair, face, glasses, nose, clothing, and cellular phone with bare hands, and then serving coffee, passing meal trays, and assisting residents with their meals without using hand hygiene at any point during the entire meal service. The alcohol-based hand rub dispenser was operational and available at the kitchen opening, but was not used by the CNA. Interviews with other CNAs indicated that they were aware of the requirement to perform hand hygiene after touching hair, clothes, or cell phones and before and after assisting residents with meals. The facility's hand hygiene policy also documented the need for hand hygiene after contact with objects in the resident's vicinity and before and after assisting with meals. Despite this, the observed CNA did not follow these protocols, resulting in a failure to implement the infection prevention and control program as required.
Failure to Provide Medicare Non-Coverage Notices
Penalty
Summary
The facility failed to provide required notice of Medicare non-coverage to three residents who were reviewed for beneficiary notices. Surveyors requested the relevant documentation from the Director of Nurses and the Administrator, but the facility was unable to produce the Beneficiary Notices for these residents, only being able to locate one unrelated notice. According to the facility's own instructions, the Notice of Medicare Non-Coverage (NOMNC) must be delivered to beneficiaries at least two calendar days before the end of Medicare-covered services, but this process was not followed for the affected residents.
Failure to Administer Prescribed Medications for Rash
Penalty
Summary
The facility failed to follow physician's orders for a resident with a rash, identified as R3, who was admitted with diagnoses including Alzheimer's disease, aphasia, Parkinson's disease, and dementia. Despite a skin inspection assessment noting a rash on R3's bilateral upper and lower extremities and torso, and a physician's order to discontinue Clopidogrel and start Triamcinolone and Clotrimazole topically twice a day, these medications were not documented in the Physician's Order Sheet or administered according to the Treatment Administration Record from 11/18/2024 to 11/27/2024. The Director of Nurses (DON) acknowledged that the nurse had sought clarification on the dosage for the medications on 11/18/2024, but the communication was not completed, resulting in the medications not being ordered or administered. During an observation on 11/27/2024, a Certified Nurse Aide noted a red raised rash on R3's back, abdomen, and legs, and stated that only regular lotion was applied, with physician-prescribed lotion to be applied by the nurse. The facility's policies on physician and medication orders emphasize the need for clear documentation and processing of orders, which was not adhered to in this case.
Improper Maintenance and Sanitation of Ice Machine
Penalty
Summary
The facility failed to ensure proper maintenance and sanitation of the ice machine located in the dining area. Observations revealed water on the floor behind the ice machine, with two orange cones indicating a wet floor. The ice machine's drainage pipe was directly connected to the floor drain without an air gap, which could lead to backflow or back siphonage. Additionally, the pipe and surrounding area were covered with black spots and moisture, and the drywall behind the machine was damaged and puffy, indicating water damage and potential mold growth. Staff interviews confirmed that the wet floor condition had been ongoing for several weeks, and there was a lack of awareness and action to address the issue. The Dietary Manager and Environmental Health Director were unaware of the cause of the moisture and the presence of the cones. The President of Operations Maintenance acknowledged the water issue and the non-compliant air gap, attributing the moisture to temperature differences. The ice machine, which is the only one in the facility, is used for meal preparations and services, as well as for providing ice and water to residents. The facility did not have a specific policy on air gaps but claimed to follow state and local ordinances. The deficiency has the potential to affect all 45 residents in the facility.
Inadequate Infection Control Program
Penalty
Summary
The facility failed to adequately develop an ongoing infection control program that effectively collected data to calculate and analyze infection rates. The infection control log provided on 5/2/2024 did not have any dates or organisms listed or documented. The Director of Nursing (DON), who was newly hired and had just completed the Infection Control Preventionist (ICP) course, admitted that the provided surveillance was the only one available and lacked comprehensive data. A second infection control log was provided, but it was incomplete, with only two out of ten documented urinary tract infections having the organisms listed. The facility's Infection Control Program Policy, dated 09/15/2020, outlined the procedures for infection surveillance, including the collection, analysis, and reporting of infection data on a monthly, quarterly, and annual basis. However, the facility did not adhere to these guidelines, as evidenced by the incomplete and inadequate infection control logs. The policy also required the Infection Control Coordinator to track and trend infections, ensure proper staff training, and implement ongoing interventions to prevent the spread of infections, which was not effectively operationalized. This deficiency has the potential to affect all 45 residents living in the facility.
Inappropriate Antibiotic Use Due to Lack of Proper Lab Confirmation
Penalty
Summary
The facility failed to ensure that residents were given the correct antibiotics for the organism causing infection. For Resident 25, a lab report indicated mixed genital flora, which is not indicative of a urinary tract infection (UTI), yet the resident was administered Nitrofurantoin for seven days without a culture and sensitivity (C&S) report. Similarly, Resident 150 was given cefdinir for a UTI without a documented C&S report to confirm the presence of an infection or the appropriateness of the antibiotic. The Director of Nursing acknowledged that the facility often does not receive C&S reports from hospitals and has to follow up, indicating a systemic issue in obtaining necessary lab results before administering antibiotics. Resident 8 was given Keflex daily for nearly a year without any documented diagnosis of a UTI or abnormal urinalysis, and the antibiotic was only discontinued after the Director of Nursing intervened. Resident 31 was administered Acyclovir and Cefdinir for a UTI despite a urinalysis culture showing mixed genital flora, which is not indicative of a UTI. The facility's antibiotic stewardship policy emphasizes the importance of using antibiotics appropriately to prevent resistance and adverse drug reactions. However, the facility's actions did not align with this policy, as antibiotics were frequently prescribed without proper lab confirmation of an infection. This led to the inappropriate use of antibiotics for multiple residents, increasing the risk of antibiotic resistance and other adverse effects. The Director of Nursing admitted to challenges in obtaining C&S reports from hospitals and mentioned issues with hospice care, further highlighting gaps in the facility's antibiotic stewardship practices.
Failure to Prevent Wandering and Respond to Fall Alarms
Penalty
Summary
The facility failed to ensure adequate supervision to prevent wandering for two residents. One resident with Alzheimer's and dementia, who has a history of wandering and aggressive behavior, was not properly monitored. Despite being on one-on-one supervision, the resident frequently wandered into female residents' rooms, causing distress and fear among them. The facility did not have any abuse investigations or incident reports for several documented incidents involving this resident, including physical altercations and inappropriate behavior in other residents' rooms. The facility also lacked a policy on supervision, as confirmed by the administrator. Another resident reported feeling unsafe due to the wandering resident entering her room multiple times. Despite the resident's complaints and a temporary measure of placing a banner in her doorway, the wandering resident continued to enter her room, causing further distress. The resident's progress notes and statements from her Power of Attorney confirmed that the issue was reported to the administrator, but no effective measures were taken to prevent the wandering resident from entering her room. Additionally, the facility failed to respond to a pressure alarm for a resident with a high risk of falling and a recent hip fracture. The resident was observed multiple times getting up unassisted, with the pressure alarm either not sounding or not being responded to by staff. The resident had a history of falls and was supposed to be monitored closely, but the facility's staff did not adequately check or maintain the pressure alarm. The Director of Nursing acknowledged the issue with the alarm and the need for staff to respond promptly, but the problem persisted, putting the resident at risk of further injury.
Failure to Provide Timely Incontinent Care
Penalty
Summary
The facility failed to provide timely incontinent care for a resident (R8) who was observed with saturated pants and a wet wheelchair seat. The incident occurred when a CNA transferred R8 to the toilet and found her adult incontinence brief soaked with urine, emitting a strong foul odor. The CNAs involved admitted that R8 had not been checked or changed since before 7:00 AM, which was over four and a half hours prior to the observation. The facility's policy mandates that incontinent residents should be checked and changed every two hours to keep their skin clean, dry, and free of irritation and odor. R8's medical records indicate a history of chronic urinary tract infections (UTIs) and severe cognitive impairment, making her always incontinent of bowel and bladder. The CNAs acknowledged that they were running behind schedule due to staffing issues but admitted that R8 should not have been left wet for such an extended period. The Director of Nursing confirmed that the expectation is for staff to make rounds at least every two hours and provide incontinent care as needed, regardless of staffing challenges.
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Illustrative
What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Illustrative
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Nursing homes near Staunton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Gillespie Health & Rehab Ctr | 6.6 mi | ★★★★★ | 1 | 0 |
| Alhambra Rehab & Healthcare | 9.3 mi | ★★★★★ | 0 | 0 |
| Hitz Memorial Home | 9.4 mi | ★★★★★ | 5 | 1 |
| Avenues At Litchfield | 13.1 mi | ★★★★★ | 2 | 0 |
| Litchfield Health & Rehab Center | 13.7 mi | ★★★★★ | 0 | 0 |
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