Alleghany Health And Rehab

F-F742. On 1/27/25 at approximately 4 p.m., the facility presented the survey team with a revised IJ removal plan that had a completion date of 1/27/25 at 4:45 p.m.

On 1/28/25, the survey team again compared the list of residents identified with behaviors, diagnosis of PTSD, history of trauma, and/or mental disorders were referred to psych services. The previously identified residents who had not been interviewed were interviewed by facility staff and the omitted residents had been referred to psych services.

Thus, verifying full implementation of the abatement plan and that the risk for serious injury, serious harm, serious impairment, or death had been eliminated, IJ was removed on 1/28/25 at 9:15 a.m., with the scope and severity of the remaining noncompliance lowered to a Level Three, Isolated.

According to the facility assessment provided to the survey team, the facility plan read in part, [Facility name redacted] has a Psychiatric FNP who provides services in the facility a minimum of once weekly and provides on-call services when not in the building . If the resident's needs exceed what the facility can provide, [hospital name redacted] has a psychiatric wing that can provide hospitalization and stabilization for

the resident. A Counselor provides services in the facility weekly

On 1/28/25, the facility administrator and Regional [NAME] President of Operations (RVPO) reported that

they had routine psychiatric services until their provider resigned around mid-October of 2024. They presented a typed document that read, [facility name redacted] entered into an agreement with [psychiatric provider name redacted] on 1/24/24. They provided psychiatric services through 10/14/24, at which time the provider resigned. From 10/14/24 until 1/23/25 [company name redacted] provided telehealth psychiatric services for acute needs and managed day to day by the primary care medical team. They also stated, a new provider visited the facility for the first time on 1/24/25.

No further information was provided.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 45 of 57 495141 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 495141 B. Wing 01/28/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Alleghany Health and Rehab 1725 Main Street Clifton Forge, VA 24422

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 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Level of Harm - Minimal harm or 49456 potential for actual harm Based on observation, staff interviews, resident interviews, and facility documentation, the facility staff failed Residents Affected - Few to provide meals at an appetizing temperature for residents on one of three units.

The findings included:

The staff failed to serve residents food that reached an appropriate temperature to be appetizing.

On 1/21/25 at 11:45 a.m., a tour of the kitchen was conducted. During the tour the temperature logs were reviewed and the steam table where the food was being served. No issues were noted during the tour.

On 1/21/25 at 12:15 p.m., the lunchtime meal was observed. The meal cart reached the A-wing at 12:20 p.m.

The surveyor had requested a test tray be placed on the meal cart, and the test tray was obtained at 12:35 p. m., as the last resident tray was being served. The meal served was a cheeseburger, mashed potatoes, cole slaw, and a fruit bowl. The regional dietary manager was present, and temperatures were obtained. The hot foods were observed as not reaching the proper temperatures. The cheeseburger temperature was 90 degrees, and mashed potatoes were 120 degrees. The temperatures were obtained of the cold foods and no concerns were noted. The surveyor and regional dietary manager both took bites of each of the food items and the regional dietary manager agreed, the meal was not appetizing in appearance, taste, or temperature.

The cheeseburger and mashed potatoes were cold, observing that the cheese was not melted on the burger.

On 1/21/25 at 12:45 p.m., an interview was conducted with the district dietary manager. The district dietary manager said, The meal is not appetizing, and we need to change how they plate the food.

On 1/22/25 at 10:15 a.m., an interview was conducted with Resident #3 (Resident R3). Resident R3 said, The food is lousy and lukewarm a lot of the times, that's the way they serve the food.

On 1/22/25 at 10:32 a.m., an interview was conducted with Resident #1 (Resident R1). Resident R1 said, Food is cold when served. Menus are not followed, and a lot of people don't eat the food.

On 1/22/25 at approximately 2:00 p.m. a review of facility documentation was conducted. The facility document titled, Serving Food, read in part, .serve food at the proper temperatures, attractively and under sanitary conditions. Foods should be maintained on serving line outside the danger zone (below 41 degrees Fahrenheit or above 135 degrees or 140 degrees Fahrenheit per state guidelines).

On 1/22/25 at 4:30 p.m., an end of day meeting was conducted with the administrator, director of nursing, and regional vice president of operations, during which the above concerns were discussed.

No additional information was provided prior to exit conference.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 46 of 57 495141 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 495141 B. Wing 01/28/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Alleghany Health and Rehab 1725 Main Street Clifton Forge, VA 24422

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 0835 Administer the facility in a manner that enables it to use its resources effectively and efficiently.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 41449 potential for actual harm Based on resident interview, staff interview, clinical record review, and facility documentation review, the Residents Affected - Many facility staff failed to effectively administer the facility to ensure residents are free from abuse and fully implement their abuse policy, having the potential to affect residents on 2 of 3 nursing units.

The findings included:

1. For Residents #8, who suffered psychosocial harm, the facility administrator, who is the facility's abuse coordinator and was aware of Resident R16's on-going behaviors resulting in mental abuse, verbal abuse, and sexual abuse, failed to implement effective corrective measures to protect all the residents sharing the same common areas with Resident #16, who was the alleged perpetrator.

On 1/22/24 at approximately 9:30 a.m., during an interview with resident #8 (Resident R8), the resident verbalized to

the surveyor and facility administrator that Resident #16 (Resident R16) had told Resident R8 to Suck my di*k. Resident R8 went on to state that she had been molested three times in the past and I just can't handle this. The administrator was observed making notes during this interview.

A comprehensive review of Resident R8's chart documented that facility staff had been aware of Resident R8's history of abuse and trauma according to a Trauma Informed Care Screen dated 4/21/24 and another dated 5/22/24. In those assessments Resident R8 reported having been a victim of physical abuse, verbal abuse, emotional neglect, having a family member who was an alcoholic/addict, and sexual violence. The most recent trauma screen noted that Resident R8 answered Yes to the following questions: Have you had a nightmare about event(s) or thought about the event (s) when you did not want to? Have you tried hard not to think about the event(s) or went out of your way to avoid situations that reminded you of the event(s)? Have you been constantly on guard, watchful, or easily startled? Have you ever felt numb or detached from people, activities, or your surroundings? According to the screening form Resident R8 was asked, What if any mental health treatment have you had in the past? Resident R8's response was recorded as, I see a doctor. However, no triggers were identified or interventions to implement trauma informed care, as well no recent psych services to support Resident R8's mental health needs.

According to Resident R8's nursing progress notes, multiple entries were noted that documented that Resident R8 had been a victim of abuse by Resident R16. On 6/10/23 at 8:20 p.m., an entry was noted in Resident R16's chart that documented that it took three persons to restrain Resident R16 from physically attacking Resident R8, while cursing and threatening to kill her. The note also documented, Resident continued with threatening behaviors and began to threaten his family . Squad was called, and resident was sent to ER [emergency room ].

According to Resident R8's chart, a note dated 6/25/23 documented that Resident R8 was found in her room crying, indicating that Resident R16 had rolled over her foot with his wheelchair. This nurses' note indicated that Resident R8 had reported that Resident R16 had threatened her life and that she didn't feel safe, which was reported to the RN Supervisor, who came into the facility to access the altercation.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 47 of 57 495141 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 495141 B. Wing 01/28/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Alleghany Health and Rehab 1725 Main Street Clifton Forge, VA 24422

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 0835 Resident R16's chart documented a note on 6/25/23, which read, Resident kicked resident [Resident R8's medical record number redacted] rolling walker in the dining room after [Resident R8's medical record number redacted] did not move Level of Harm - Minimal harm or it out of his way. Resident was also threatening to kill everyone and blow up the building when asked to potential for actual harm leave the dining room RN supervisor was called in to help with the situation between the two residents. Will continue to observe resident. Residents Affected - Many

On 10/22/23, a nursing entry in Resident R16's documented that Resident R16 had thrown coffee on Resident R8 and that both the on-call nurse and administrator had been notified of the altercation.

According to facility documentation, a facility investigation was initiated on 1/16/25, regarding Resident R8 reporting that Resident R16 had made sexually inappropriate comments to her.

On 1/21/25, a note was entered that read, During this time SSD (social services director) spoke with [Resident R8's name redacted] after hearing her yell at another Resident [Resident R16's medical record number redacted] to shut up across the hallway from her room. SSD let [Resident R8's name redacted] know that she needed to be respectful of other Residents. The issue resolved following discussion. No further exploration of what preceded the outburst was documented.

Starting 1/22/25 at 10:09 a.m., staff interviews conducted by the survey team included the facility social worker, five CNA's, three nurses, the activities director, and the maintenance director had all been aware of and verbalized that Resident R16 has long standing behaviors of saying he is going to blow this place up and shouting, Suck my d*ck. All 11 of the staff interviewed expressed being aware of Resident R16 making targeted sexual comments to Resident R8 repeatedly. When asked about interventions implemented to address these inappropriate behaviors, staff stated that 15 min checks were done, but mostly offering snacks works, and that sometimes Resident R16's escalating behaviors required the removal of the other residents from the dining room, which is where

he likes to sit the most. Some of the staff reported that the prior Administrator, who was in that role until just

a month ago, would go to [NAME] and buy Resident R16 chicken to calm him down. was conducted with the facility's social worker (SW). When asked if she had any knowledge about Resident R8 being a victim of sexual abuse, the SW said, I do recall her mentioning she had an ex-significant other that she had issues with.

On 1/22/25-1/23/25, a clinical record review was conducted of Resident R16's chart. This review revealed numerous entries notating behaviors that occurred in the presence of, or directed at other residents, in addition to almost daily refusals of treatment and medications. The notes were dated, 4/16/23, 4/17/23, 4/25/23, 5/6/23, 5/10/23, 5/14/23, 5/19/23, 6/8/23, 6/9/23, 6/10/23, 6/11/23, 6/12/23, 6/17/23, 6/22/23, 6/23/23, 6/25/23, 6/26/23, 6/29/23, 7/22/23, 7/23/23, 7/27/23, 7/28/23, 9/5/23, 9/29/23, 9/30/23, 10/2/23, and 10/11/23. On 10/23/23, 11/3/23, 11/6/23, 11/8/23, 12/2/23, 12/6/23, 1/5/24, 2/3/24, and on 3/22/24, scissors were removed from Resident R16's possession. Additional entries regarding Resident R16's behaviors were dated 3/24/24, 6/8/24, 7/6/24, 10/2/24, 11/9/24, and 11/25/24. A note dated 12/9/24 documented that Resident R16 threw his oxygen tank, knocked over his dresser, and rammed his wheelchair into his neighbor's door, including that residents were complaining about his verbal abuse. No evidence was found that the facility had taken any action to implement safeguards to protect the targeted residents or to adequately investigate the documented resident to resident incidents.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 48 of 57 495141 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 495141 B. Wing 01/28/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Alleghany Health and Rehab 1725 Main Street Clifton Forge, VA 24422

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 0835 At the time of the survey being conducted in January 2025, there was no evidence that Resident R16 had not seen a psychiatrist since hospitalization in early December 2024. According to the hospital discharge summary and Level of Harm - Minimal harm or psychiatry consultation dated 12/7/24, both documents directed that Resident R16's Seroquel dose return to the prior potential for actual harm dosage of 250 mg twice daily. According to Resident R16's physician orders and medication administration records, upon readmission to the nursing facility Resident R16 was receiving 50 mg three times daily from 12/8/24-12/27/24. Residents Affected - Many On 12/27/24, the Seroquel dose was increased to 100 mg three times daily.

On 1/23/25 at approximately 10 a.m., an interview was conducted with the facility administrator and Regional [NAME] President of Operations (RVPO). The administrator was asked, can you tell me what abuse is? The administrator said, Not off the top of my head, I would like to refer to my policy. The administrator was asked

the same question regarding neglect and gave the same response, wanting to refer to the policy. When asked the same questions, the RVPO defined abuse as willful intent causing harm and neglect as willful intent to not provide something. When asked if a resident had to suffer harm for it to be considered abuse,

the RVPO stated, No.

On 1/23/25 at approximately 11:30 a.m., during an interview with certified nursing assistant #15 (CNA #15) and CNA #16, both reported Resident R16 took the oxygen tank out to throw at us, we ran up the hall. CNA #15 stated

they got the administrator to intervene, as they were both scared that Resident R16 would throw the oxygen tank, but neither CNA #15 & CNA #16 could recall specifically when the incident occurred. On 1/23/25, during a later

interview with the facility administration, the administrator, and director of nursing discussed that a daily meeting is held with the management team and interdisciplinary team, during which progress notes and grievances are reviewed. On 1/23/25, during a follow-up interview, Resident R8 reported being afraid of Resident R16 and gets another resident, identified as Resident #2, to accompany her because .she watches out for me. During this interview, Resident R8 was observed breaking eye contact, tucking her head downwards while speaking, with hands slightly trembling. He said, 'Come on Baby, suck my d-ck!' He would say we need to go to bed in his room . I told him No! and he said, Ok, B-tch, I will just f-ck the hell out of you then! Sometimes I'm afraid to go to sleep. I've gotten so afraid at night, that he is gonna come in here.

On 1/23/25, an interview was conducted with Resident #2 (Resident R2), who reported that she has witnessed Resident R16 threaten to hit Resident R8, This can happen daily, [Resident R8] cries and gets upset about it. I have to calm her down. [Resident R8] is scared of him. At times, he says hateful things to her, sometimes he approaches her and intimidates her, and her hands start shaking. She said he makes her very nervous. I try to help and break it up. He says, Suck my d-ck b-tch, I will blow this place up. Resident R2 went on to report that Resident R8 would wake her to go with her to the dining/activity room. Resident R2 reported she is not personally afraid of Resident R16, and that he used to say that stuff to her, .but Resident R8 gets so upset her hands shake.

On 1/23/25 at approximately 6 p.m., the survey team met with the facility administrator, director of nursing, and corporate level staff. When questioned about facility actions regarding Resident R16's abusive behaviors, the administrator, DON, regional vice-president of operations, and the regional clinical director all stated that

they had not been aware that the behaviors had been to the level of severity as shared by the survey team and indicated that Resident R16 would be put on 1:1 supervision immediately.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 49 of 57 495141 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 495141 B. Wing 01/28/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Alleghany Health and Rehab 1725 Main Street Clifton Forge, VA 24422

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 0835 On 1/23/25, the facility administrator provided the survey team with a copy of a facility incident summary and investigation initiated on 1/16/25, which was completed on 1/22/25. Review of this documentation revealed Level of Harm - Minimal harm or that during the investigation, the facility had not interviewed other residents to determine if they had been potential for actual harm affected by Resident R16's behaviors. The facility had also not interviewed facility staff or reviewed Resident R16's chart to determine the severity of Resident R16's behaviors. When questioned about facility actions regarding Resident R16's Residents Affected - Many aggressive behaviors, the administrator, DON, the regional vice-president of operations, and the regional clinical director all stated that they had not been aware that the behaviors had been to this severity and involved prior incidents with other residents, but indicated that Resident R16 would be put on 1:1 supervision immediately. When requested, the facility administration had no evidence that measures had been implemented to protect residents, that interventions had been implemented to prevent or prohibit further abuse violations, or that all allegations of abuse had been reported or investigated as required.

On 1/24/25 at 2:30 p.m., an interview was conducted with the nurse practitioner (NP). The NP was asked about Resident R16's behaviors and Seroquel dosing. The NP stated she was not aware of the order/recommendation from the hospital for Resident R16's Seroquel to return to the dose of 250 mg twice daily and stated had she seen the addendum with that recommendation she would have followed it because, I do follow what is on the hospital discharge summary. The NP also stated she was aware of Resident R16 having some behaviors, but it had been reported the behaviors were related to his pain management and had just increased his Gabapentin. The NP said, We have not had an on-site psych provider since I started in December. We have only had 1 telehealth psych visit; from what I am told we now have a psych provider starting. The NP went on to state that she was not aware of Resident R16 making abusive sexual comments to other residents or the instances of Resident R16 attempting to throw his oxygen cylinder.

On 1/28/25, the RVPO stated, in the review of Resident R16's clinical chart, they had identified multiple instances of behaviors that rose to the level of being reported as abuse and would be preparing a report to cover each of

the occurrences.

2. For Resident R17, who reported an allegation of abuse and neglect by which certified nursing assistant #1 (CNA #1), which resulted in psychosocial harm, the facility administrator reviewed and signed off on the grievance without effectively responding to the allegations.

On 1/22/25, during a review of facility documentation, it was noted that on 1/19/25, Resident R17 reported an allegation of verbal abuse and neglect by CNA #1 to the nurse, who completed a grievance form. Within the grievance documentation it read, CNA [CNA #1's name redacted] became very smart and rude with resident when she asked to have her shower. Resident shower days are designated to Monday and Thursday. However, resident wanted one due to feeling unsanitary. Resident was very upset and even called her husband wanting to go home . resident became very emotional . Resident became hesitant on using her call light as well, because she didn't want any more attitude.

According to a document dated 1/20/25, where the social worker interviewed Resident R17, it was noted, Resident reports that when the aide came in and spoke to her about getting a shower Saturday the aide was very rude and told her 'Absolutely not tonight' and continued to state that 'Saturday was not her day' for a scheduled shower. [Resident R17's name redacted] also reported that later that night she had an accident and needed to be changed she said that the other aide came in and told her that she was passing snacks and would have to come back after doing that to assist her. I don't want her in here if she's going to talk to me like that. Resident is concerned other people are being talked to that way.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 50 of 57 495141 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 495141 B. Wing 01/28/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Alleghany Health and Rehab 1725 Main Street Clifton Forge, VA 24422

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 0835 On 1/22/25 at 3:25 p.m., during a meeting with the facility administrator, director of nursing, and Regional [NAME] President of Operations, they were asked to explain the protocol when an allegation of abuse is Level of Harm - Minimal harm or brought forward. The administrator explained that it goes on a facility reported incident form, We start an potential for actual harm investigation and report the incident.

Residents Affected - Many On 1/23/25 at 8:45 a.m., an interview was conducted with Resident R17. Resident R17 was very complimentary of the care she has received at the facility. When asked about the incident involving CNA #1, Resident R17 said, I was told when I came that Wednesday and Saturdays were my shower days. I was so excited and told my husband I was going to get a shower. It was about 8:15 p.m., I rang to see when I would get the shower. She [CNA #1] came in and said, 'absolutely not, no ma'am, I'm not giving you a shower tonight. Tuesday and Fridays was your shower day and tomorrow, Sunday is the makeup day. I called my husband crying and told him to come get me. Thank God they had me medicated. This girl needs to know if I have to deal with her, I will slap her. If she talks to me like this, how is she talking to other residents. The next day my husband called and said I had 2 choices; I could tell them, or he would be down here Monday morning. The next morning [nurse's name redacted, identified as registered nurse #2- RN #2] came in and knew something was wrong. I burst out crying. Sunday when [certified nursing assistant #4's name redacted] got her stuff done, she gave me a shower.

On 1/23/25, the facility social worker said during an interview that she felt the allegation rose to the level of abuse and neglect. She said when this happens, she takes the grievance to the administrator and in this case took Resident R17's grievance to the administrator, who was the abuse coordinator. However, the facility administrator failed to respond to the incident as an allegation of abuse and treated it as a grievance. When asked about Resident R17's abuse allegations, the facility administrator reported that he considered it a poor customer service issue, indicating that he had not reported or investigated the allegations. The administrator said, I may be wrong, but I will have to live with that. A review of CNA#1's timecard revealed that she continued to work, without any suspension, and was not restricted from having access to Resident R17 and other residents.

The job description of the facility administrator was reviewed. It read in part, General Purpose: To lead and direct the overall operations of the facility in accordance with customer needs, government regulations and company policies, with focus on maintaining excelling care for the residents while achieving the facility's business objectives. Oversee regular rounds to monitor delivery of nursing care, operation of support departments, cleanliness and appearance of the facility; morale of the staff; and ensure resident needs are being addressed . Protect residents from neglect, mistreatment, and abuse .

According to the facility's abuse policy, it noted in section 2. Types of Abuse: . G. Mental Abuse is the use of verbal or nonverbal conduct which causes or has the potential to cause the resident to experience humiliation, intimidation, fear, shame, agitation, or degradation. H. Verbal abuse may be considered to be a type of mental abuse. Verbal abuse includes the use of oral, written, or gestured communication, or sounds, to residents within hearing distance, regardless of age, ability to comprehend, or disability .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 51 of 57 495141 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 495141 B. Wing 01/28/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Alleghany Health and Rehab 1725 Main Street Clifton Forge, VA 24422

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 0835 The facility's abuse policy went on to read in part, . G. Procedure for Reporting Abuse. i. All incidents of resident abuse are to be reported immediately to the licensed nurse in charge, Director of nursing, or the Level of Harm - Minimal harm or Administrator. Once reported to one of those three officials, the prescribed forms are to be completed and potential for actual harm delivered to the Abuse Coordinator or his/her designee for an investigation. ii. The facility shall report to the state agency and one or more law enforcement entities any reasonable suspicion of a crime against any Residents Affected - Many individual who is a resident of, or is receiving care from, the facility. iii. And if the events that caused the suspicion resulted in serious bodily injury the facility must report within 2 hours after forming the suspicion. If

the events that caused the suspicion did NOT result in serious bodily injury the facility shall report within 24 hours

The facility administration was or should have been aware of Resident R16's ongoing behavioral issues, that Resident R8 being

a target of his behaviors on numerous occasions, and that other residents were being subjected to frequent abusive behaviors, particularly if the facilty's abuse policies and procedures had been fully implemented to conduct thorough investigations, to report alleged violations as required, and to implement safeguards to protect all residents from further potential abuse/neglect. The administrator was also aware of Resident R17's allegations as indicated by his signature on the grievance form. Despite the knowledge of these allegations,

the facility administrator failed to administer the facility in a manner to ensure abuse policies and procedures were fully implemented, to ensure residents were free from abuse, protected from alleged perpetrators, and that residents received appropriate services for their conditions/behaviors.

On 1/28/25, mid-morning, the facility's administrator, director of nursing, and corporate staff was made aware of the concern that the facility was not being effectively administered.

No additional information was provided.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 52 of 57 495141 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 495141 B. Wing 01/28/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Alleghany Health and Rehab 1725 Main Street Clifton Forge, VA 24422

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 0838 Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies. Level of Harm - Minimal harm or potential for actual harm 41449

Residents Affected - Many Based on staff interview and facility documentation review, the facility staff failed to have credible evidence that the facility assessment was reveiwed at least annually and failed to ensure that the facility assessment involved the appropriate participants, which had the potential to affect all operations and residents residing

on 3 of 3 nursing units.

The findings included:

The facility staff failed to have credible evidence of the active involvement of direct care staff and solicit input from residents, resident representatives, and family members in the development of the facility assessment and that it was reviewed annually.

On 1/27/25, a review of the facility assessment was conducted. This review revealed no evidence of when

the facility assessment had been last reviewed and who had been involved in that process. Within the facility assessment the data listed included Quality Measure reports dated December 2018-February 2019, and August 2023-October 2023. The facility Administrator and Regional [NAME] President of Operations (RVPO) were asked to provide the survey team with the details of when it was reviewed and who was involved.

On 1/27/25, in the afternoon the facility Administrator and RVPO told the survey team that they had been unable to find any further information with regards to the facility assessment. The Administrator stated it had been uploaded online in July 2024, so they can only assume it was discussed around that time frame. However, they had no evidence of who was involved in the process and development/revision of the facility assessment.

On 1/28/25 at 11:20 a.m., the survey team met with the facility administrator, Director of Nursing and three corporate management staff to discuss that the facility had failed to provide credible evidence of direct care staff, residents, resident representatives or family members being involved and/or their input being solicited for the development of and/or review of the resident assessment and it being reviewed annually.

The facility policy titled, Facility Assessment was received and reviewed. The document read in part, . The facility will review and update the facility assessment, as necessary, and at least annually . II. Scheduling of assessment and on-going process requirements: The governing body will assist with completion of the facility assessment. Members of the governing body include, but are not limited to the regional and corporate team . There was additional pages titled, Facility Assessment Addendum, which read in part, . Facility Assessment Meeting Planning: Meeting #1- discuss the purpose of the facility assessment, what information you will need from each member, decide who will be included and plan how you will engage the residents, RR's [resident representatives] and families- discuss a timeframe to gather the information to discuss in meeting #2 .

No additional information was provided.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 53 of 57 495141 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 495141 B. Wing 01/28/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Alleghany Health and Rehab 1725 Main Street Clifton Forge, VA 24422

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 0840 Employ or obtain outside professional resources to provide services in the nursing home when the facility does not employ a qualified professional to furnish a required service. Level of Harm - Minimal harm or potential for actual harm 41449

Residents Affected - Some Based on resident interview, staff interview, clinical record review, and facility documentation review, the facility staff failed to utilize outside resources to ensure ongoing psychiatric services were available to residents needing such service, having the ability to affect residents on 3 of 3 nursing units.

The findings included:

The facility staff failed to provide outside resources to ensure ongoing and consistent psychiatric services were available to all residents who may have required mental health services, as they had no routine provider from October 2024 until 1/23/25.

On 1/24/25 at 2:30 p.m., an interview was conducted with the medical nurse practitioner, who is the primary provider at the facility. During this interview, the nurse practitioner said, We have not had an on-site psychiatric provider since I have been here and have only had 1 telehealth psych visit. From what I am told,

we now have a psych provider who will be coming.

According to the facility assessment provided to the survey team, the facility noted, Resident/Facility Data which noted, 66 residents with dementia, 9 with sundowners, 32 with a behavioral health diagnosis and 32 being seen by behavioral health services. The facility plan read in part, [Facility name redacted] has a Psychiatric FNP who provides services in the facility a minimum of once weekly and provides on-call services when not in the building . If the resident's needs exceed what the facility can provide, [hospital name redacted] has a psychiatric wing that can provide hospitalization and stabilization for the resident. A Counselor provides services in the facility weekly

On 1/28/25, the facility administrator and Regional [NAME] President of Operations (RVPO) reported that

they had routine psychiatric services until their provider resigned around mid-October of 2024. A new provider visited the facility for the first time on 1/24/25. During the time from mid-October through January 23, 2025, the facility only had telehealth visits and management of mental health issues by the medical providers.

No further information was provided.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 54 of 57 495141 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 495141 B. Wing 01/28/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Alleghany Health and Rehab 1725 Main Street Clifton Forge, VA 24422

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 0843 Have an agreement with at least one or more hospitals certified by Medicare or Medicaid to make sure residents can be moved quickly to the hospital when they need medical care. Level of Harm - Minimal harm or potential for actual harm 41449

Residents Affected - Many Based on staff interview, the facility staff failed to maintain an active transfer agreement with a hospital, having the potential to affect residents on 3 of 3 nursing units.

The findings included:

On 1/27/25 at approximately 9 a.m., the facility administrator was asked to provide the survey team with a copy of their transfer agreement.

On 1/27/25 in the mid-morning, the survey team was asked to provide clarification to the Administrator and corporate staff regarding the transfer agreement requested. The surveyor explained that the hospital transfer agreement as required in federal regulation

F-F843 was being reviewed as part of the extended survey and was requested for review to determine compliance.

According to the facility assessment provided to the survey team, the facility noted, Resident/Facility Data which noted, 66 residents with dementia, 9 with sundowners, 32 with a behavioral health diagnosis and 32 being seen by behavioral health services. The facility plan read in part, . If the resident's needs exceed what

the facility can provide, [hospital name redacted] has a psychiatric wing that can provide hospitalization and stabilization for the resident

On the afternoon of 1/27/25, the administrator returned the paper, which listed the survey team's requested items and had noted beside transfer agreement don't have one, and verbally told the survey team they did not have an active transfer agreement, nor a policy related to the transfer agreement.

The facility had no evidence of having a transfer agreement with the said hospital for psychiatric services nor any other hospital for emergency medical services that may be needed by their resident population.

On 1/28/25 at 11:20 a.m., the survey team met with the facility Administrator, Director of Nursing and three corporate management staff to discuss the above findings.

No additional information was provided prior to conclusion of the survey.

On 1/30/25, the facility administrator submitted via email a transfer agreement between the facility's prior ownership and a local hospital that was executed July 2009. Also included was another agreement dated 2006 between the hopsital and the facilities owner before the most recent prior owner of the nursing facility.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 55 of 57 495141 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 495141 B. Wing 01/28/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Alleghany Health and Rehab 1725 Main Street Clifton Forge, VA 24422

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 0944 Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program. Level of Harm - Minimal harm or potential for actual harm 49456

Residents Affected - Few Based on staff interviews and facility documentation, the facility staff failed to provide Quality Assurance and Performance Improvement (QAPI) training for one employee (the director of nursing) in a survey sample of 10 employee records reviewed for training.

The findings included:

The facility staff failed to have the required QAPI training for one employee, the director of nursing.

On 1/27/25 at approximately 2:00 p.m., the surveyor requested 10 employee's files as part of the sufficient staffing and extended survey training review. The list of employees was given to the staff development coordinator, a registered nurse, RN#5 (RN5).

On 1/28/25 at 9:00 a.m., the employee files were obtained from Resident R5 and reviewed. During the review of the staff files for training, the director of nursing had not completed Quality Assurance and Performance Improvement training for the year 2024. She completed her training on the morning of 1/28/25, after the training records has been requested by the surveyor.

On 1/28/25 at 12:45 p.m., a meeting was held with the regional vice president of operations, administrator and the director of nursing. During this meeting they were made aware of the above concerns.

No additional information was provided prior to exit conference.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 56 of 57 495141 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 495141 B. Wing 01/28/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Alleghany Health and Rehab 1725 Main Street Clifton Forge, VA 24422

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 0945 Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program. Level of Harm - Minimal harm or potential for actual harm 49456

Residents Affected - Few Based on staff interviews and facility documentation, the facility staff failed to provide annual infection control training for one employee (the director of nursing) in a survey sample of 10 employee records reviewed.

The findings included:

The facility staff failed to have the required annual infection control training for one employee.

On 1/27/25 at approximately 2:00 p.m. the surveyor requested 10 employee's files for the sufficient staffing and extended survey training review. The list of employees was given to the staff development coordinator, a registered nurse, RN#5 (RN5).

On 1/28/25 at 9:00 a.m. the employee files were obtained from Resident R5 and were reviewed. During the review of

the staff files for training, the director of nursing, who was the infection preventionist for the facility had not completed her annual infection control training for 2024.

On 1/28/25 at 11:00 a.m. an interview was conducted with the director of nursing (DON). The director of nursing brought her infection control in long term care facilities certificate and stated that she was sure she had completed the annual infection control prevention training every year but was only able to show proof for

the year of 2023.

On 1/28/25 at 12:45 p.m. a meeting was held with the regional vice president of operations, administrator and the director of nursing. During this meeting they were made aware of the above concerns. The regional vice president of operations and director of nursing stated they would try to locate any prior training.

No additional information was provided prior to exit conference.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 57 of 57 495141