CLIFTON FORGE, VA - Federal inspectors have identified significant violations at Alleghany Health and Rehab related to the facility's failure to protect residents from abuse and maintain basic care standards during a January 2025 inspection.
Administrative Failures Create Risk for Vulnerable Residents
The most serious findings centered on the facility's administration failing to effectively prevent and address resident-to-resident abuse, despite having documented evidence of ongoing problems. Inspectors discovered that facility leadership had been aware of repeated incidents involving sexually explicit comments, threats, and physical aggression from one resident toward others, particularly targeting a female resident with a documented history of trauma.
According to the inspection report, Resident #8 had experienced multiple instances of sexual harassment from another resident who made explicit comments such as demanding sexual acts and threatening violence. The targeted resident, who had previously reported being "molested three times in the past," told inspectors she was afraid to sleep at night, fearing the aggressive resident would enter her room.
The facility's own documentation revealed a pattern of incidents dating back to June 2023, including instances where the aggressive resident physically attacked others, threw objects, and made threats to "blow up the building." Despite these documented behaviors, facility administrators failed to implement adequate protective measures or properly investigate the incidents as required by federal regulations.
Medical records showed that eleven staff members were aware of the ongoing abusive behaviors but had only implemented minimal interventions such as 15-minute checks and offering snacks to calm the resident. Some staff reported that previous administrators would purchase food to pacify the aggressive resident rather than addressing the underlying behavioral issues.
Psychiatric Services Gap Compromises Mental Health Care
A critical contributing factor to the abuse situation was the facility's loss of psychiatric services for over three months. The inspection revealed that the facility's psychiatric provider resigned in mid-October 2024, leaving residents with mental health needs without adequate professional support until a new provider began in late January 2025.
This gap in psychiatric care was particularly problematic given that the facility serves 66 residents with dementia, 32 with behavioral health diagnoses, and 32 requiring behavioral health services. During the three-month period without proper psychiatric oversight, residents were managed only through telehealth visits and care from medical providers who lacked specialized mental health training.
The absence of psychiatric services directly impacted medication management for the aggressive resident, whose antipsychotic medication was not properly adjusted according to hospital discharge recommendations. The facility's nurse practitioner acknowledged being unaware of critical dosing instructions from the hospital, stating she would have followed the recommendations if she had seen them.
Mental health professionals recognize that consistent psychiatric care is essential for nursing home residents with behavioral disorders. Interruptions in psychiatric services can lead to medication non-compliance, increased agitation, and deteriorating mental health status. For residents with dementia and behavioral issues, regular psychiatric evaluation helps optimize medications, adjust treatment plans, and prevent behavioral escalations that can endanger other residents.
Staff Conduct Issues and Inadequate Investigations
The facility also failed to properly address allegations of verbal abuse by a certified nursing assistant. Resident #17 reported being spoken to rudely when requesting a shower outside her scheduled days, with the aide allegedly saying "absolutely not" in a harsh manner and providing conflicting information about shower schedules.
The incident left the resident emotionally distressed, calling her husband in tears and requesting to go home. She reported becoming hesitant to use her call light due to fear of receiving more hostile treatment. Despite the social worker acknowledging the incident constituted abuse and neglect, the facility administrator treated it as a customer service issue rather than an abuse allegation.
This response violated the facility's own abuse policies, which clearly define verbal abuse as conduct that causes humiliation, intimidation, or fear. Federal regulations require immediate reporting and investigation of abuse allegations, with appropriate protective measures implemented during the investigation process.
Food Service Temperature Control Problems
Inspectors also identified violations related to food temperature control that could pose health risks to residents. During lunch service observation, hot foods were served at dangerously low temperatures - cheeseburgers at 90 degrees and mashed potatoes at 120 degrees, well below the required minimum of 135-140 degrees Fahrenheit.
The district dietary manager acknowledged the meals were "not appetizing" and required changes to food preparation and serving procedures. Residents confirmed the ongoing problem, with one stating "The food is lousy and lukewarm a lot of the times" and another reporting "Food is cold when served."
Proper food temperature control is critical in nursing homes because many residents have compromised immune systems and are more susceptible to foodborne illnesses. Hot foods must be maintained at temperatures that prevent bacterial growth while remaining palatable and nutritious. Cold food service not only reduces nutritional value but can also lead to decreased appetite and malnutrition among elderly residents.
Medical Context: Why These Violations Matter
The interconnected nature of these violations creates significant health and safety risks for nursing home residents. Mental health issues, particularly in residents with dementia, require specialized care and consistent monitoring. When psychiatric services are interrupted, residents may experience increased agitation, depression, or behavioral problems that can escalate to dangerous levels.
Trauma-informed care is especially important for residents with histories of abuse or PTSD. These individuals require careful assessment and specialized interventions to prevent re-traumatization. Facilities must create safe environments and respond appropriately to triggers that may cause distress or behavioral reactions.
The failure to protect vulnerable residents from ongoing abuse can result in severe psychological harm, including increased anxiety, depression, and post-traumatic stress symptoms. For elderly residents with cognitive impairment, the impact of abuse can be particularly devastating and may accelerate cognitive decline.
Additional Issues Identified
The inspection also documented problems with facility assessment procedures, where administrators could not provide evidence that required annual reviews had been conducted with appropriate stakeholder input. The facility lacked documentation showing involvement of direct care staff, residents, or family members in assessment processes as required by federal regulations.
Additionally, the facility failed to maintain an active transfer agreement with a hospital, potentially delaying emergency medical care when residents require immediate hospitalization.
These administrative oversights reflect broader systemic problems in facility management and compliance with federal nursing home standards. Proper facility assessments help identify resource needs and quality improvement opportunities, while hospital transfer agreements ensure seamless emergency care coordination.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Alleghany Health and Rehab from 2025-01-28 including all violations, facility responses, and corrective action plans.
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