Alleghany Health And Rehab

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, staff interview, clinical record review, facility documentation reviews the facility staff failed to give notification of a room change to one resident, Resident #1(Resident R1) out of a survey sample of eight residents. The findings included: The facility failed to provide a room change consent form, obtain the resident's signature on such a form, or notify the resident or their representative regarding the room change.On 9/9/25 at 11:25 a.m., an interview was conducted with Resident R1 regarding her room change. She stated that she initially did not want to move and did not understand the reason for the change. Staff then explained that the move was for her safety due to the possibility of another incident. After this explanation,

she agreed to relocate.On 9/10/25 at 8:40 a.m., an interview was conducted with the Social Worker Director. She explained that the standard process for a room change includes obtaining permission from

the resident or their representative, contacting the representative, escorting the resident to the new room, and having a consent form signed. Room changes are also discussed during the morning meeting. She said, that no paperwork was completed for Resident R1 room change by me.On 9/10/25 at 8:50 a.m., the Administrator was interviewed regarding the room change for Resident R1. She stated that she had assumed the social worker completed the paperwork for the room change. She stated that a meeting was held with Resident R1,

during which staff explained that the move was for her safety and would be beneficial. Resident R1 agreed to the room change.On 9/10/25 at 2:45 p.m., the director of nursing (DON) stated that Resident R1 requested the room change because she wanted a private room due to not getting along with roommates.On 9/10/25 a clinical

record review was conducted. The record contained no signed consent form or documentation that the resident or their representative was notified of the room change. The only note in the chart, dated 7/9/25, indicated that Resident R1's personal belongings were moved to the new room.On 9/10/25 a facility document was reviewed. The document titled, Room changes, read in part, .2. Prior to the room change, we will give the resident's legal representative twenty-four-hour notice to all the resident's legal representative time to prepare for the room change.4. All room changes will be documented in the resident's chart. The documentation will include a. reason for the change b. notification of resident, family, and their assent. c. the resident's reaction. d. the roommate's reaction. e. follows up on resident and roommate adjustment to the change by visiting within forty-eight hours. Room [NAME] notice Consent to room transfer.On 9/10/25 a meeting was held with the DON, administrator, regional director of clinical services and the vice president of operations. They were made aware of the above concerns.No additional information was provided.

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date

these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

TITLE

(X6) DATE

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

Facility ID:

If continuation sheet

Event ID:

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

09/11/2025

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

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

resident denied feeling uncomfortable during their interaction and reported feeling safe in her room if Resident R2 is not nearby. The residents were placed in separate areas to prevent contact. The Nurse Practitioner (NP) recommended visual aid materials to help address Resident R2's sexual behaviors. She noted that the incident did not appear to affect Resident R1's psychosocial well-being. This information from the NP was not included in the investigation.On 9/10/25, the investigation of the incident for 7/6/25 involving Resident R1 and Resident R3 was reviewed. The 7/6/25 investigation inaccurately documented the incident regarding where Resident R1 touched Resident R2. Additionally, the original investigation did not include a statement from the CNA1 who witnessed the incident; however, the Administrator was able to provide the CNA1's statement later in the day. The investigation did not have witness statements from the residents involved in the incident. On 9/10/25 at 2:45 PM, a meeting was held with the Administrator, the Director of Nursing (DON), the Regional Director of Clinical Services, and the [NAME] President of Operations. During the meeting, they were informed of the above concerns. On 9/10/25, two facility documents were reviewed. The first, titled. Resident Abuse, outlines that the Abuse Coordinator and/or Director of Nursing is responsible for obtaining written statements from the victim, the alleged perpetrator, and all possible witnesses, including other employees in the area. They are also responsible for securing all physical evidence. Upon completion of the investigation, a detailed report must be prepared.The second document, titled, Resident Abuse - Resident-to-Resident, states that the Administrator must notify the Regional [NAME] President of Operations and the Director of Clinical Services of any alleged or actual incidents of abuse under ongoing investigation. The Administrator or Director of Nursing (or their designee) must notify Adult Protective Services, the local Ombudsman, and the State Department of Health of any alleged abuse per state-specific protocols. The Administrator must also notify local law enforcement authorities when applicable. Additionally, the facility must develop measures to prevent recurrence of abuse and document these measures in the resident's medical record, including updates to the care plan. On 9/10/25 at 2:45 PM, a meeting was held with the Administrator, the Director of Nursing (DON), the Regional Director of Clinical Services, and the [NAME] President of Operations. During

the meeting, they were informed of the above concerns.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

09/11/2025

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 0658

president of operations. They were made aware of the above concerns.No additional information was provided.

Level of Harm - Minimal harm or potential for actual harm 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

09/11/2025

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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Based on staff interview, clinical record review, facility documentation reviews the facility staff failed to implement fall interventions for two residents, Resident #2 (Resident R2) and Resident #3 (Resident R3) out of a survey sample of eight residents. The findings included:1.The facility failed to implement interventions for several falls on Resident R2's care plan.The Director of Nursing (DON) was interviewed on 09/10/25 at 9:40 a.m. The DON stated, I know interventions need to be on the care plan, I get that, but sometimes we have other things.

The DON was unable to provide any evidence that fall-related interventions had been placed on the care plan.A clinical record review conducted on 09/10/25 revealed Resident R2 had documented falls on 7/17/25. Review of the care plan showed that no new fall interventions were added following this fall. The facility failed to implement interventions on the resident's care plan after a fall, as required to address ongoing risk and ensure resident safety.2.The facility staff failed to implement interventions for a fall on Resident R3's care plan. The Director of Nursing (DON) was interviewed on 09/10/25 at 9:40 a.m. The DON stated, I know interventions need to be on the care plan, I get that, but sometimes we have other things. The DON was unable to provide any evidence that fall-related interventions had been placed on the care plan.A clinical record

review conducted on 09/10/25 revealed Resident R3 had documented falls on 05/17/25, 05/21/25, 08/23/25, and 08/29/25. Review of the care plan showed that no new fall interventions were added following these falls.

The facility failed to implement interventions on the resident's care plan after multiple falls, as required to address ongoing risk and ensure resident safety. A facility document titled, Steps to Follow When a Fall Occurs, (reviewed on 09/10/25) states staff must: hold an immediate team meeting with current staff to determine interventions to prevent further falls, establish new interventions and place them on the care plan, and implement interventions on the care plan. The facility failed to follow its own procedure and ensure Resident R3's care plan was updated with interventions following multiple falls.A meeting was held with the administrator, DON, regional director of clinical services, and vice president of operations. They were made aware of the above concerns.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

09/11/2025

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 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and

the public.

Based on observations, resident interview, staff interview, facility documentation reviews the facility staff failed to maintain a sanitary environment on two of three units. The findings included:The facility failed to maintain a sanitary environment for one bathroom on B wing and one resident's room on A wing.On 9/9/25 at 10:30 a.m., an observation was made on the B wing in room B6 revealed dried brownish material consistent with feces on the base of the commode, on the floor around the commode, and down the side of

the commode. On 9/9/25 at 10:45 a.m., an interview was conducted with the housekeeper. She stated that when cleaning resident rooms, staff are responsible for dusting the blinds, cleaning the sink, cleaning the bathroom, dusting surfaces and above the lights, mopping and sweeping the floors, and removing the trash.She further said, there are times I feel like the rooms are not cleaned like they should be, and we could do a better job. The housekeeper observed the bathroom in room B6 and said, that is feces, and I feel like it's getting up under the floor tiles. I don't have a scrubber to scrub with, so I just do the best I can with a rag and mop.She also said, I feel like the facility could be cleaner, but we're contracted. We're not allowed to touch personal belongings, and sometimes it's a struggle to get the nursing staff to remove the belongings so we can clean.On 9/9/25 at 11:45 a.m., observation of the resident room on the A wing in room A6 revealed wallpaper that was puckered and moist. An odor resembling cat urine was noted in the room.On 9/9/25 at 11:45 a.m., an interview was conducted with Resident #4 (Resident R4). She stated that her room had been painted, but the wallpaper was puckered and the room smelled like cat urine. She said, it was hard to sleep. She stated when she asked the staff about it, they told me the roof leaks, and that maybe an animal or person peed in the corner, Resident R4 stated that she has difficulty sleeping with the odor, said, I sleep turned toward the window, and it makes it hard to rest.On 9/10/25 at 10:00 a.m., an interview was conducted with

the Maintenance Director. He observed the wall in room A6 and agreed that the wallpaper was puckered.

He said, There's a drain right outside that window where it's puckered, and it could be sweating and causing the wallpaper to pucker.The maintenance director further stated that he did not notice an odor at

the time of observation but said, if there is an odor, it might be coming from that wallpaper. He also stated that no worker had been submitted for this concern.On 9/10/25 at 10:20 a.m., an interview and observation were conducted with the Administrator, the Director of Nursing (DON), and the regional director of clinical services (RDCS). Upon entering room A6, the DON and RDCS stated that they smelled the odor. All three individuals observed the wallpaper, felt the wall and stated it was moist. The Administrator stated she did not smell an odor.On 9/10/25 a facility policy was requested for room sanitation and cleanliness. The administrator provided a form titled, Job to be done. Complete room cleaning. No policy was provided.On 9/10/25 at 2:45 p.m., a meeting was held with the administrator, DON, RDCS and [NAME] president of operations and they were made aware of the above concerns.No additional information was provided.

Event ID:

Facility ID:

If continuation sheet