Staunton Post Acute & Rehabilitation

Penalty

No penalty information released

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 deficiency involves the facility’s failure to ensure that a resident who was assessed as requiring supervision for smoking followed established safe smoking protocols. One resident with diagnoses including major depressive disorder, COPD, anemia, dementia, anxiety, insomnia, and protein-calorie malnutrition, and assessed on the MDS as having moderately impaired cognitive skills, was observed by surveyors actively smoking alone in the designated outdoor smoking courtyard. At the time of observation, the resident was holding a lit cigarette that had not been provided or lit by staff, and no staff were present in the courtyard, despite posted smoking times indicating that smoking was to occur at specific supervised times. The resident’s smoking assessment documented the resident as low risk for safety concerns but explicitly required supervision while smoking. The assessment noted no visual impairment, range of motion or balance issues, fine motor difficulty, lethargy, history of burns, or difficulty safely lighting, holding, or extinguishing a cigarette, and stated the resident was safe to smoke with supervision and did not require adaptive or protective equipment. The care plan, revised earlier in the year, also documented that the resident was deemed a safe smoker only with staff supervision, with interventions including supervision during smoking, education on the facility’s smoking policy (location, times, and safety precautions), and smoking assessments as needed. Interviews and record reviews showed that the facility’s policy prohibited residents from keeping smoking materials on their person or in their rooms and required that residents needing supervision be within eyesight of staff while smoking. The resident reported that smoking was usually supervised at designated times and denied having cigarettes or a lighter in their possession or room, stating that nursing kept supplies locked in the medication room. Staff confirmed that all smoking materials were kept locked and that residents were supervised at set times, but two CNAs acknowledged they were late taking smokers out on the afternoon in question and were not present in the courtyard at the time the resident was observed smoking. Both CNAs stated that when they arrived later with the smoking box, no residents were smoking, and they did not know how the resident had obtained a cigarette or lighter prior to their arrival. The administrator and DON confirmed that all resident smoking required supervision and were unable to explain how the resident obtained smoking materials for the unsupervised smoking observed by surveyors.

Penalty

Inspection fine: $24,413

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 deficiency involves the facility’s failure to protect multiple residents from physical and verbal abuse by another resident with known aggressive behaviors. One resident with severe cognitive impairment and diagnoses including heart failure, diabetes, dementia, hemiplegia, and seizure disorder repeatedly exhibited aggression toward other residents and staff. Behavior notes documented frequent verbal outbursts with expletives, yelling, and threatening behavior, as well as physical aggression such as ramming another resident’s wheelchair, attempting to strike a resident using a walker, and kicking and punching a nurse. These behaviors were noted to occur multiple times per week or daily, and staff documented that separating the resident from others and moving him to a quiet location were not effective interventions. The aggressive resident’s behaviors were directed toward several specific residents. On one occasion, when another resident came downstairs to visit friends, the aggressive resident yelled profanities and ordered him to leave. On another date in the dining room, the aggressive resident stared and ground his teeth, yelled loudly, frightened two female residents, rammed one resident’s wheelchair as she tried to leave, and lunged toward another resident with a walker, swinging his arms in an attempt to hit her before a male nurse intervened. During the same incident, the aggressive resident kicked and punched a nurse, causing bruising and a knot on the shin and bruising on the chest. On a later date at the elevator, when the aggressive resident encountered another resident he disliked, he began screaming profanities, kicked the other resident, and swung at him, causing the other resident to back into the wall and yell. Additional behavior notes described the aggressive resident yelling repetitively, grinding his teeth, shaking with anger, and attempting to attack a female resident after she asked him to stop yelling, with staff intervening to block him. Staff interviews confirmed that this resident’s behaviors were sporadic, unpredictable, and could be directed at anyone, and that he became aggressive when his wants were not met immediately. Staff reported that another resident was a known trigger and had been moved to another unit, but the aggressive behaviors toward other residents and staff continued. Psychiatric documentation indicated that the aggressive behavior was possibly related to vascular dementia and a mood disorder, and the treatment plan called for identifying triggers, redirection, one-to-one staffing, and psychosocial interventions; however, staff described their responses as largely reactive, focused on separation and occasional one-to-one, and behavior notes repeatedly documented that these interventions were ineffective. The facility also failed to produce an incident summary or investigation for the incident involving two residents in the dining room, despite documentation that they were involved and upset at the time. Interviews with the affected residents showed that they experienced the aggressive resident as loud, hateful, rude, and a bully. One resident reported that the aggressive resident had been physically aggressive toward him in the elevator but that he did not sustain injuries. Two female roommates reported that the aggressive resident had not physically contacted them but had come toward one of them aggressively and was stopped, and they described him as hateful, loud, and believing he should get everything he wants. Another resident stated that the aggressive resident had been aggressive toward her and that she tried to stay to herself. Staff, including CNAs, LPNs, the unit manager, social services, and the facility NP, consistently described the aggressive resident as unpredictable, easily escalated when his demands were not met, and requiring separation when angry. Despite ongoing, documented aggressive behaviors toward multiple residents and staff over an extended period, the facility did not implement and sustain effective interventions to prevent further abuse, and did not consistently investigate all incidents, resulting in a failure to ensure residents’ right to be free from abuse.

Removal Plan

• Resident #1 was placed on 1 to 1 supervision and will remain on 1 to 1 supervision while out of bed until discharge or a significant change in condition limits the resident's physical ability to encounter another resident; while in bed the resident is not considered a risk because the resident cannot transfer independently.
• Residents #2, #3, #4, and #5 will receive follow-up psychosocial support from facility staff.
• The facility will continue attempts to find alternative placement for Resident #1.
• All residents in the facility will be screened for evidence of abuse and neglect (interviewable residents with BIMS ≥ 8 interviewed using an abuse questionnaire; non-verbal residents and residents with BIMS ≤ 7 assessed head-to-toe to validate absence of signs of physical abuse).
• Any identified concerns from the screening will be addressed according to the facility Abuse Policy.
• All residents will be assessed/reviewed for similar behaviors as exhibited by Resident #1 by reviewing all Facility Reportable Incidents (FRIs), and care plans will be reviewed and revised with interventions for any identified residents.
• All facility and agency staff will be reeducated on the facility Abuse Policy, including abuse prevention, types of abuse, and abuse reporting.
• Staff not present will be required to complete mandatory abuse-policy education prior to the start of their next shift.
• No staff member will be allowed to return to work until the mandatory abuse-policy education has been completed.
• New hire orientation will include abuse-policy training as part of the new hire process.
• All agency staff will be required to complete abuse-policy education prior to starting work in the facility.
• Facility leadership will be reeducated by the Regional Director of Clinical Operations and Regional Director of Operations on assessing triggers, root causes, and escalation patterns and developing an effective and sustained supervision and separation intervention for residents with behavioral disturbances.
• The Medical Director was notified of the situation.
• The facility conducted an Ad Hoc QAPI committee meeting to accept the IJ Removal Plan.

Penalty

Inspection fine: $24,413

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 deficiency involves the facility’s failure to report and investigate resident-to-resident abuse incidents involving three residents. One resident with heart failure, diabetes, dementia, hemiplegia, seizure disorder, and a severely impaired cognitive score of 5 was involved in an altercation in the dining area with two other residents. One of the other residents had heart failure, kidney disease, dysphagia, a cognitive communication deficit, and a mildly impaired cognitive score of 12, while the third resident had cerebral palsy, anxiety, bipolar disorder, a psychotic disorder, and was cognitively intact with a score of 15. Progress notes showed that during the dining incident, the cognitively impaired resident began yelling "No" to another resident nearby, after which one of the female residents told the resident to stop. The cognitively impaired resident then rammed the wheelchair of one of the female residents and started swinging and trying to attack the other female resident, requiring staff to separate all residents. Staff interviews and record review confirmed that the residents were separated and skin assessments were completed, with no injuries identified, although the two female residents were upset at the time. The RN who documented the behavior reported that the DON was informed of the involvement of the two female residents. When surveyors requested all investigations and incident summaries related to the aggressive resident’s behavior toward others, the facility produced documentation only for a separate altercation involving a different resident, and there was no evidence of an investigation or incident synopsis for the dining room altercation involving the two female residents. The DON stated that no incident synopsis or report was completed because there was no actual physical abuse due to staff separating the residents. Later review of a progress note showed that one of the female residents had been pushed by the aggressive resident, and the administrator acknowledged that no investigation or incident summary was found and that one should have been reported. This failure occurred despite the facility’s abuse policy requiring all alleged violations involving abuse to be reported immediately, but no later than two hours after the allegation is made.

Penalty

Inspection fine: $24,413

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 investigate an incident of resident-to-resident abuse involving three residents. One resident with diagnoses including heart failure, diabetes, dementia, hemiplegia, and seizure disorder, and a severely impaired cognitive score of 5 on the most recent MDS, was involved in an altercation in the dining area with two cognitively intact residents whose diagnoses included heart failure, kidney disease, dysphagia, cognitive communication deficit, cerebral palsy, anxiety, bipolar disorder, and psychotic disorder. Progress notes documented that during the incident, the cognitively impaired resident began yelling "No" to another resident near the dining area, after which one of the female residents told this resident to stop. The cognitively impaired resident then rammed one resident’s wheelchair and started swinging and trying to attack the other resident, and staff separated all residents involved. During interviews, the RN who wrote the behavior note confirmed that the residents were separated, the DON was informed, and skin assessments were completed on the two cognitively intact residents, which showed no injuries, though both were upset at the time. When surveyors requested all investigations and incident summaries related to the aggressive resident’s behavior toward others, the facility produced documentation only for a separate altercation involving a different resident, and there was no evidence of an investigation or incident summary for the dining room altercation involving the two cognitively intact residents. The DON stated there was no incident synopsis or investigation because there was no actual physical abuse due to staff separating the residents. Later review of a progress note indicating that one resident had been pushed did not yield any additional documentation, and the administrator acknowledged that an investigation and incident summary should have been completed. The facility’s abuse policy required designated staff to immediately review and investigate all allegations or observations of abuse and to communicate results to the administrator and appropriate officials within five working days, but no such investigation was completed for this incident.

Penalty

Inspection fine: $24,413

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

Facility staff failed to develop and implement a comprehensive, measurable behavior care plan for one resident requiring 1:1 supervision. The resident had diagnoses including heart failure, diabetes, dementia, hemiplegia, and seizure disorder, and a recent MDS with a cognitive score of 5 indicating severe cognitive impairment. Review of the resident’s behavior care plan showed an intervention initiated on 12/30/25 that stated "1:1 supervision as indicated" without specifying parameters such as timeframe, whether the supervision was continuous or behavior-based, what specific behaviors would trigger its use, or the duration of the intervention. During an interview on 3/19/26 at 12:15 p.m., the DON stated that the resident is placed on 1:1 when he becomes aggressive toward another resident and remains on 1:1 until he deescalates, and acknowledged that the care plan should be more specific regarding 1:1 supervision. This lack of detailed parameters and measurable actions in the written care plan for 1:1 supervision constituted the deficiency identified by surveyors for failure to develop and implement a complete care plan that met all of the resident’s needs with clear timetables and measurable interventions.

Penalty

Inspection fine: $24,413

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 ensure that one resident followed the facility’s safe smoking protocols. The resident had diagnoses including major depressive disorder, COPD, anemia, dementia, anxiety, insomnia, and protein-calorie malnutrition, and the MDS assessed moderately impaired cognitive skills. The resident’s smoking assessment identified the resident as a low risk for smoking safety concerns but still required supervision while smoking, and the care plan also directed staff supervision and education on the facility smoking policy. On 4/27/26, the resident was observed in the outdoor courtyard, which was designated as the smoking area, actively smoking a lighted cigarette without staff present. The resident stated a staff member had been in the courtyard and had just gone back inside, and the resident extinguished the cigarette on the concrete surface. The courtyard had posted smoking times of 10:30 a.m., 2:30 p.m., and 7:30 p.m. The resident later stated that smoking was usually supervised and that staff had allowed the resident to finish the last couple of puffs. Staff interviews showed that smoking supplies were kept locked in the medication room and that residents were not allowed to keep cigarettes or lighters in their possession. Two CNAs stated they were late taking smokers out that afternoon and did not arrive in the courtyard until about 2:45 p.m., after the resident had already been observed smoking at 2:40 p.m. Both CNAs stated the resident was not smoking when they arrived and that they hand out cigarettes one at a time and light them for residents. The administrator and DON stated all resident smoking required supervision and that they were unsure where the resident got the cigarette and/or lighter.

Penalty

No penalty information released

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.

Penalty

No penalty information released

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

Facility staff failed to follow established abuse prevention policies in two separate incidents involving residents. In the first case, a resident with a history of traumatic brain injury, epilepsy, dementia, and substance abuse tested positive for marijuana and methamphetamine after being sent to the emergency room for seizure-like activity. Prior to this, staff had noted unusual behavior, a chemical smell in the room, and the discovery of drug paraphernalia and prohibited items in the roommate's possession. Despite these findings and the positive drug test, the facility did not report the incident to the state agency, adult protective services, or law enforcement, nor did they conduct a documented investigation into the resident's positive drug test as required by facility policy. The facility's own policies mandate immediate review, investigation, and reporting of all allegations or observations of abuse, neglect, or exploitation, including injuries of unknown origin and misappropriation of property. These policies also require written reports to be submitted to appropriate agencies and individuals within specified timeframes. However, in this instance, the administrator did not initiate a formal facility reported incident (FRI) regarding the drug findings, focusing instead on the roommate's aggressive behaviors. The only FRI submitted pertained to the roommate's verbal aggression and subsequent transfer, with no mention of the drug-related findings or the affected resident's positive drug test. In a separate incident, the facility did not fully implement its abuse policy regarding documentation of a resident-to-resident altercation. An investigation into inappropriate touching by one resident toward three others was missing required written witness statements. The director of nursing was unable to locate these statements, and interviews with staff revealed that at least one witness did not recall providing a statement. Facility policy specifically requires that witness reports be obtained in writing, signed, and dated, but this was not completed or documented in the investigation.

Penalty

No penalty information released

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

Facility staff failed to report a positive drug test for a resident to the state agency, adult protective services, and law enforcement as required. The resident, who had a history of traumatic brain injury, epilepsy, dementia, and substance abuse, was found to have tested positive for marijuana and methamphetamines after experiencing seizure-like activity. The positive drug test was discovered following an incident where staff noted a chemical smell in the resident's room, leading to a search of the roommate's belongings and the discovery of multiple prohibited items, including vape devices, glass smoking devices, and containers of THC-a smoking material. Despite these findings and the resident's positive drug screen, the facility did not submit a Facility Reported Incident (FRI) form to the state agency or notify adult protective services or law enforcement about the drug use and related paraphernalia. The administrator confirmed during interviews that no formal notification or FRI was made regarding the positive drug test, although actions were taken in response to the roommate's possession of prohibited items and aggressive behavior. The facility's policy required immediate reporting of all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of property, to the appropriate authorities. The deficiency was identified through staff interviews, facility document review, and clinical record review, which confirmed that the required notifications were not made following the discovery of illicit drug use and related items. The administrator acknowledged the omission and stated that the focus of the investigation was on the roommate's behaviors rather than the positive drug test, resulting in a failure to comply with the facility's abuse investigation and reporting policy.

Penalty

No penalty information released

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 ensure a complete and thorough investigation of allegations of abuse and unusual events for two residents. In the first instance, a resident with Alzheimer's disease, dementia, anxiety, and depression was involved in a resident-to-resident altercation where three other residents were reportedly touched inappropriately. The facility's investigation listed three staff members as witnesses, but their written witness statements were missing from the investigation file. The DON was unable to locate these statements, and interviews with the staff revealed that at least one did not recall providing a statement, while another reported verbally to the DON. The facility's policy required written and signed witness statements, which were not present in this case. In the second instance, a resident with a history of traumatic brain injury, epilepsy, dementia, and substance abuse tested positive for marijuana and methamphetamine after being sent to the emergency room for seizure-like activity. The resident's room had been reported to have a chemical and marijuana smell, and a search of the roommate's belongings uncovered multiple prohibited items, including vape devices, glass smoking devices, and THC-a smoking material. Despite these findings and the positive drug test, there was no documented investigation into the source of the drugs, nor was a facility reported incident (FRI) submitted to the state agency or notifications made to other required agencies regarding the drug use. The administrator confirmed that no FRI was initiated for the positive drug test and that the investigation focused solely on the roommate's aggressive behaviors, not the drug incident. The facility's policy required all alleged violations involving abuse, neglect, exploitation, or injuries of unknown source to be thoroughly investigated and reported to appropriate agencies, but this was not done in the case of the resident's positive drug test. No documentation of a formal investigation into the drug incident was provided prior to the survey exit.

Penalty

No penalty information released

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

Facility staff failed to follow professional standards of care for medication administration on two skilled units (2NW and 2NS). Medications were observed left unattended in resident rooms on these units. The DON confirmed that, within the past three months, there were two separate incidents where medications were left unattended—one on each unit. These incidents were also corroborated by social media posts alleging that medications were left at bedside, which prompted internal audits and further investigation. The facility's policy requires that medications be administered at the time they are prepared and that residents are observed to ensure the dose is ingested, but these procedures were not followed in the cited incidents. The deficiency was identified through staff interviews, observation, and review of facility documentation. The DON and administrator acknowledged the incidents and confirmed that the nurses involved did not adhere to the established medication administration protocols. No specific residents or their medical conditions were identified in the report, and the incidents were not linked to any particular patient outcomes. The deficiency was cited as past non-compliance, with no unattended medications observed during the current survey.

Penalty

No penalty information released

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

Facility staff failed to promptly implement interventions after reports of marijuana and a chemical smell were noted in a resident's room. Despite documentation by nursing staff of these odors and a resident being found on the floor with glassy eyes and pinpoint pupils, no immediate action was taken to investigate or address the potential presence of illicit substances. The clinical records for both residents involved did not mention any interventions or follow-up regarding the reported smells until two days later. One resident, with a history of traumatic brain injury, epilepsy, and substance abuse, was found on the floor and later experienced seizure-like activity. During an emergency room visit, this resident tested positive for marijuana and methamphetamine. The roommate, who also had a history of substance abuse, was found in possession of multiple prohibited items, including vape devices, glass smoking devices, and empty THC containers, but this was only discovered after a delayed search of the room. Prior to this, there was no documentation of any investigation or search in response to the initial report of suspicious odors. The facility's inaction following the initial report of marijuana and chemical smells resulted in a lack of timely assessment and intervention to ensure a safe, drug-free environment. There was no documented investigation into how the resident tested positive for illicit drugs, and care plans for both residents did not reflect the risks or history of substance abuse at the time of the incident. The failure to act promptly on staff observations and to update care plans contributed to the deficiency in maintaining a safe environment free from accident hazards and illicit substances.

Penalty

No penalty information released

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

Facility staff failed to maintain complete and accurate clinical records for two residents. For one resident with severe cognitive impairment and multiple diagnoses, there was an unwitnessed fall resulting in a large hematoma and bruising. Although nursing notes indicated that neurological checks were initiated following the fall, no documentation of these checks was found in the clinical record. The director of nursing confirmed the absence of neuro check documentation, attributing it to a transition from electronic to paper records at the time. Paper copies of the neuro checks were later located but had not been scanned into the electronic health record, as the medical records clerk had not prioritized older documents. In a separate incident, another resident with severe cognitive impairment and multiple diagnoses was involved in a resident-to-resident altercation. The facility's investigation indicated that the resident was assessed for physical and emotional concerns, but there was no documentation of these assessments or any progress notes related to the incident in the clinical record. The director of nursing stated that assessments were performed at the time but should have been documented by nursing staff, in accordance with facility policy requiring documentation of incidents, findings, and corrective measures in the resident's medical record.