Alleghany Health and Rehab: Care Plan Failures - VA
The September 2025 complaint inspection documented two residents whose care plans failed them in concrete ways. The first involved a resident identified in inspection records as Resident 2, who was on one-to-one observation for inappropriate sexual behaviors, including touching both staff and other residents. The supervision didn't stop the behavior. Inspectors noted a psychiatry nurse practitioner had documented that despite continuous observation, the resident continued the conduct.
The nurse practitioner's plan was specific. She recommended allowing the resident private time to relieve sexual frustration, developing safety strategies for staff and other residents, considering visual aid materials, consulting psychiatry for further evaluation, increasing medication, continuing supervision, and implementing behavior charting each shift. She also spoke directly with the unit manager about the visual aid intervention.
None of it made it into the care plan.
When inspectors interviewed the nurse practitioner on September 10, she said she had recommended the visual aid materials back on July 17 and was unsure whether anyone had ever acted on the recommendation. The Director of Nursing confirmed they had not. The resident was never given any materials to watch or use.
What the DON described as standard practice made the gap worse, not better. She told inspectors that when nurse practitioners make recommendations, staff look at them and decide whether they seem workable — but the NP is not told when her recommendation has been set aside. The psychiatry NP who had been treating this resident, adjusting his medication, and documenting his behavior for months had no idea her intervention plan was sitting in a drawer somewhere while the behaviors continued.
The care plan that existed told staff to do 15-minute checks and call the physician if sexual behaviors continued. It said nothing about private time, visual aids, behavior charting, or any of the alternative interventions the NP had outlined. The facility's own policy required care plans to include measurable objectives addressing all identified problems, to be updated when circumstances change, and to be followed. It also required staff to notify the clinical nurse or MDS coordinator if any part of a care plan couldn't be implemented, so the record could be updated. That step never happened here.
The second finding involved a resident identified as Resident 3, who fell on August 29 without anyone witnessing it. After an unwitnessed fall, neurological checks are standard practice to catch delayed signs of head injury: changes in consciousness, pupil response, orientation, motor function. The facility initiated neuro checks. Then staff stopped completing them.
The DON, when interviewed, did not dispute what inspectors found. "Yes, you are correct that neuro checks were missing," she told them. She confirmed that documentation for neuro checks was absent on some of the required days following the fall.
The facility's own fall protocol listed what staff must do when a resident falls: assess for injury, provide treatment, notify the physician and family, complete an incident report, document in the medical record. Consistent neuro checks are part of that assessment. The protocol existed. The checks did not.
Inspectors held an end-of-day meeting on September 10 with the administrator, the Director of Nursing, a regional director of clinical services, and a vice president of operations. All four were informed of both findings. No additional information was provided in response.
The inspection covered eight residents. Two had care that fell short in documented, specific ways. One spent months under continuous supervision for behavior that harmed other residents, while the clinical intervention designed to address the root cause sat unimplemented and unreported back to the clinician who ordered it. The other fell, alone, and then went days without the monitoring that exists to catch the injuries a fall can hide.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Alleghany Health and Rehab from 2025-09-11 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 20, 2026 · Our methodology
ALLEGHANY HEALTH AND REHAB in CLIFTON FORGE, VA was cited for violations during a health inspection on September 11, 2025.
The September 2025 complaint inspection documented two residents whose care plans failed them in concrete ways.
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.