Cherrydale Health & Rehabilitation Center

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

investigation and interviews, we are substantiating an allegation of neglect. According to the facility synopsis, CNA #1 was noted prior to the incident to be at the nursing station and not responding to resident's requests for assistance/call lights. Review of CNA #1's personnel file, revealed termination of employment was effective 4/17/25. The facility policy titled, Administrative Reference Guide, with an effective date of 1/23/20, was reviewed. The policy read in part, . b. Neglect means a repeated or willful failure to provide timely and consistent services, treatment or care to a patient which are necessary to obtain or maintain a patient's health, safety or comfort; or a repeated or willful failure to provide timely and consistent goods and services necessary to avoid physical harm, mental anguish, or emotional distress, including but not limited to acts that cause, or could cause, pain or injury to a patient or death of a patient; acts that substantially disregard a Center's duties and obligations to a patient; acts that cause or could significantly or likely be expected to cause, mental or emotional damage to a patient. Examples include but are not limited to: . iii. Disregard of physical needs including, but not limited to, toileting and bathing, or continued omission in providing daily care and/or failure to address the omission. On 11/14/25 at 12:30 PM,

the above findings were reviewed with the facility Administrator, Assistant Administrator, Director of nursing and Regional Director of Clinical Services. No additional information was provided.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/13/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Cherrydale Health & Rehabilitation Center

3710 Lee Highway Arlington, VA 22207

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0607 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

During the above interview, the HRD was shown CNA #1's personnel file and confirmed that a criminal background check was not in the file and there was no evidence of a license verification in the personnel file. The HRD stated she would go look and see what she could find. On 11/13/25 at 12:20 PM, the HRD returned and reported that CNA #1 had previously worked for the facility from 9/5/23-11/1/24. With respect to the criminal background check, the HRD said, I'm not sure what happened here. With the license verification, the HRD stated that because she had worked at the facility previously and her license was still active, they did not pull it again. On 11/13/25 at 12:25 PM, the facility administrator confirmed that despite

the fact that CNA #1 had previously worked for the facility and they had evidence at the time of her termination that her license remained active at the time of re-hire, they should have checked it again to ensure there were no adverse actions against the license and that it had not been suspended for any reason. According to the facility's policy titled, Prevention/Screening/Training, which read in part, 1. Criminal background and reference checks are performed on all employees. On 11/13/25 at 12:30 PM, the above findings were reviewed with the facility's administrator, assistant administrator, director of nursing and regional director of clinical services. No additional information was provided.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/13/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Cherrydale Health & Rehabilitation Center

3710 Lee Highway Arlington, VA 22207

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

attention to resident care, Resident R4's concern which resulted in her calling the police, who responded but took no measures to remove CNA #1. Review of CNA #1's personnel file and timecard revealed that following the incident on 4/9/25, she was permitted to work a full shift on 4/10/25 from 7:05 AM until 3:34 PM, providing direct resident care. The facility policies titled, Prevention/Screening/Training, Reporting Requirements/Investigations, and Administrative Reference Guide, were reviewed. None of the policies addressed protection of residents from alleged perpetrators during an investigation regarding allegations of abuse or neglect. On 11/14/25 at 12:30 PM, the above findings were reviewed with the facility Administrator, Assistant Administrator, Director of nursing and Regional Director of Clinical Services. The administrator confirmed that OS #7 should have left the facility when the allegation was made and not permitted to work

the remainder of the shift. On 11/14/25 at 1 PM, the facility administrator confirmed that nurses are the unit supervisors and responsible for the supervision of CNA's and should be taking measures to protect residents when allegations of abuse/neglect are made. No additional information was provided.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/13/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Cherrydale Health & Rehabilitation Center

3710 Lee Highway Arlington, VA 22207

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Services. No additional information was provided. 2. For Resident R5 and Resident R6, the facility staff failed to follow physician orders and implement the use of a anchor for the feeding tube. On 11/13/25 at 8:21 AM, licensed practical nurse #2 (LPN #2) accompanied the surveyor to the room of Resident R6, so that observations of the peg tube (percutaneous endoscopic gastrostomy tube) (tube used for delivering nutrition to patient) could be made. Observations revealed that no anchor to secure the tube was in place. When LPN #2 was questioned about the use of an anchor, LPN #2 stated that the facility only uses anchors for foley/urinary catheters. On 11/13/25 at 8:40 AM, registered nurse #1 (RN #1) accompanied the surveyor to the room of Resident R5. Observations of Resident R5's peg tube revealed that no anchor/securing device was in place. No other concerns were noted. On 11/13/25, a clinical record review was conducted of Resident R5 and Resident R6's physician orders. Resident R5 had an active order dated 11/3/25 that read, Anchor feeding tube every shift for tx [treatment]. Resident R5 also had a prior physician order from 6/2/25-11/2/25, that read, Anchor feeding tube every shift for tx.

According to the treatment administration record (TAR), facility staff had signed off each shift three times daily from 11/7/25-11/12/25, that the anchor device was in place. According to Resident R6's physician orders, an order was entered 10/30/25 and remained an active order at the time of review that read, Anchor feeding tube every shift for tx. According to Resident R6's TAR, the anchor device was signed off three times daily, at each shift for the month of November, except for first shift on 11/6/25. The review revealed that on 11/11/25 and 11/12/25, LPN #2 had signed off as the anchor device having been in place. On 11/13/25 at 10:42 AM, an

interview was conducted with the director of nursing (DON). When asked about the use of anchor devices for peg tubes, the DON said, we don't use an anchor, we clean it daily and use tape to secure the gauze [gauze dressing placed between the skin and tube bumper]. The surveyor notified the DON of Resident R5 and Resident R6 of having orders for anchor devices to be used and observations that morning revealed they were not in place,

the DON stated she would have to get with central supply about an anchor device and if they could order them. The DON stated she was not aware of the physician's order, but if an order was present, they should be following the order. On 11/13/25 at 11:15 AM, a follow-up interview was conducted with LPN #2. LPN #2 was made aware of the physician order for the anchor device for the PEG tube and was asked about her signing off the two days prior that the device was in place. LPN #2 reported that she thought she was signing off that the yankauer [plastic suction tip used to suction a patient] was present in the drawer.

According to the facility policy titled, Enteral Feeding Tubes with an effective date of 1/29/24, it did not address the use of an anchor device. On 11/13/25 at 12:30 PM, the facility Administrator, Assistant Administrator, DON and Regional Director of Clinical Services were made aware of the above findings. No additional information was provided.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/13/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Cherrydale Health & Rehabilitation Center

3710 Lee Highway Arlington, VA 22207

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0760 Level of Harm - Minimal harm or potential for actual harm

1. 4. Right route. 5. Right time. 6. Include diagnosis/reason for use. On 11/13/25 at 12:30 PM, the above

findings were again reviewed with the facility Administrator, Assistant Administrator, DON, and Regional Director of Clinical Services. No additional information was provided.

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/13/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Cherrydale Health & Rehabilitation Center

3710 Lee Highway Arlington, VA 22207

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

resident left or returned to the facility. On 11/13/25 at 12:30 PM, during a meeting with the facility's Administrator, Assistant Administrator, Director of Nursing, and Regional Director of Clinical Services, the above concerns was discussed. The Administrator confirmed that he would expect there to be documentation within Resident R8's clinical record of when the resident left and returned. Review of the facility policy titled, Hemodialysis with an effective date of 1/29/24, was conducted. The policy read in part, . 1. The Dialysis Communication Form will be initiated prior to sending patient for dialysis. A dialysis center's designated form may be used in place of the center's Dialysis Communication Form. 2. Patient reports received from dialysis center will be uploaded to the medical record. A follow-up review of Resident R8's clinical

record revealed that no Dialysis Communication Forms had been uploaded into the clinical record for the month of November. No additional information was provided.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/13/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Cherrydale Health & Rehabilitation Center

3710 Lee Highway Arlington, VA 22207

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

resident in the hallway. The nurse then removed her gloves, performed no hand hygiene and began using

the computer and then handled medication cards that were on top of the medication cart and returned the medication cards to a drawer within the cart. Upon closing the drawer, the nurse then used hand sanitizer.

On 11/13/25 an interview was conducted with LPN #3. LPN #3 explained that PPE is important to protect yourself and also protect the patient whose immune system has been compromised, and we don't want to spread infection around. On 11/13/25 at 10:42 AM, an interview was conducted with the Director of Nursing (DON). The DON was asked to explain the use of PPE with enhance barrier precautions and contact isolation. The DON said, on contact-based precautions you have to put on gloves, mask, and gown up

before entering the room. She explained with enhanced barrier precautions, If you provide care you have to wear a gown. When asked if changing bed linen would require use of an isolation gown, the DON said, yes.

During the interview, the DON was made aware of the above findings. When asked about the RT who entered the hallway in full PPE and then re-entered the patient's room, she said, We have plenty of PPE to get a new set if you exit and re-enter the room. It still puts the patient at risk. I always tell them no gloves or gowns in the hall. Regarding the administration of eye drops in the hallway, the DON said, No, they shouldn't be administering medications in the hallway. The facility policy titled, Enhanced Barrier Precautions (EBPs), which had an effective date of 3/26/24, was reviewed. The policy read in part, . 3.

EBPs require the use of gown and gloves by staff during high-contact patient care activities as defined below: a. Dressing, b. bathing/showering, c. transferring, d. changing linen, e. providing hygiene, f. changing briefs or assisting with toileting, g. device care or use, h. wound care for chronic wounds. 4. Post Enhanced Barrier Precaution signage on the wall outside the patient(s) room. 5. Ensure PPE is available. The facility policy titled, Transmission Based Precautions- General Practice, with an effective date of 12/1/21, was reviewed. The policy read in part, 1. Standard precautions combine the major features of universal precautions and body substance isolation and are based on the principle that all blood, body fluids, secretions, excretions, (except sweat), non-intact skin, and mucous membranes may contain transmissible infectious agents. Standard precautions are to be used during the care of all patients . 4. a. TBPs will be instituted when it is necessary to be especially wary of protecting select patients from infections. b. TBPs will be instituted if there is a risk of spreading infection. e. The health care team and visitors will be instructed on the importance and necessity of maintaining TBPs before entering the patient's room. 5.

Fundamental protective measures must be maintained. a. Hand Hygiene and Gloving. 6. Masks, Respiratory Protection, Eye Protection, Face Shields. 7. Gowns and Protective Apparel. On 11/13/25 at 12:30 PM, the above findings were reviewed with the facility's administrator, assistant administrator, director of nursing and regional director of clinical services. No additional information was provided.

Event ID:

Facility ID:

If continuation sheet