Ashland Nursing and Rehabilitation: Care Plan Failures - VA
The care plan on file for the resident, identified in inspection records only as R25, was dated August 14, 2023. Federal inspectors reviewing his clinical record in August 2025 found it had not been revised following the January 24 assault or the March 21 assault. Nearly two years old, the plan sat unchanged while the resident accumulated a documented history of striking his neighbors.
The first incident happened at around 3:45 in the afternoon on January 24. A certified nursing assistant walked in and found R25 on top of another resident, hitting him in the face. The CNA separated them. A nurse assessed the man who had been hit and noted no new skin injuries. When asked why he had been hitting the other resident, R25 said the man had been in his room.
The nurse practitioner was called. The resident's sister was called. No revision was made to the care plan.
Eight weeks later, on March 21, a CNA told a nurse that R25 had slapped another resident in the face. The nurse asked R25 what happened. He said she had been trying to take his juice. The responsible party was called. The nurse practitioner was called again. The notes recorded that no new orders were given at the moment.
The care plan still was not updated.
The care plan is the document that is supposed to tell staff, shift after shift, what a resident needs and how to respond to him. It captures the interventions in place, the risks identified, the approaches that work. When it goes stale, the people caring for a resident are working without the full picture.
A licensed practical nurse at the facility told inspectors on August 20 exactly what should have happened. The purpose of a care plan, LPN #4 said, is to specialize in the needs of the resident. When a resident hits another resident, she said, the care plan should be updated, and it should include whatever interventions were put in place.
Those interventions, whatever they were, never made it into the document.
Inspectors flagged the deficiency under federal tag F0657, which covers care plan revision. The violation was categorized as minimal harm or potential for actual harm, and listed as affecting some residents.
By 5:00 in the afternoon on August 20, the executive director and the director of clinical services had been told about the finding. Inspectors noted that no further information was presented before they left the building.
What the record does not show is whether any new interventions were actually put in place after the January incident, or after the March one. It does not show whether staff working the floor in the months between the two assaults knew about the first one. It does not show what, if anything, changed for the woman who was slapped, or for the man who was punched while lying in his bed.
R25 gave a reason each time. Someone was in his room. Someone was trying to take his juice. Whether those explanations pointed toward something that could be anticipated and addressed, something that could be built into a plan, was a question the facility's paperwork left unanswered.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Ashland Nursing and Rehabilitation from 2025-08-21 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: July 3, 2026 · Our methodology
ASHLAND NURSING AND REHABILITATION in ASHLAND, VA was cited for violations during a health inspection on August 21, 2025.
The care plan on file for the resident, identified in inspection records only as R25, was dated August 14, 2023.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.