Staunton Post Acute & Rehabilitation

Inspectors wroteBased on observation, resident interview, staff interview, facility document review and clinical record review, the facility staff failed to ensure one of seven residents (Resident #107) followed protocols for safe smoking.

Inspectors wroteBased on resident interviews, staff interviews, clinical record review, and facility document review the facility failed to protect the residents' rights to be free from abuse, including physical and verbal abuse for four of eleven residents in the survey sample, (resident #'s 2, 3, 4, 5) resulting in immediate jeopardy (IJ) and substandard quality of care. After accepting the plan for removal of Immediate Jeopardy from the Administrator, and determining that the Immediate Jeopardy was removed, the deficiency was assigned a Scope and Severity level of level 2, pattern. The Findings Include:For Resident #1 (R1) who had repeated aggressive behaviors towards multiple residents including R2, R3, R4, and R5, the facility staff failed to implement interventions to respond to and intervene in R1's continued abuse towards others. [...]

Inspectors wroteBased on staff interview, clinical record review, and facility document review the facility failed to report incidents of resident-to-resident abuse involving three of eleven residents in the survey sample (Resident #1, Resident #3, and Resident #4). The Findings Include: The facility did not report resident to resident abuse between Resident #1 (R1), R3, and R4. Diagnoses for R1 included heart failure, diabetes, dementia, hemiplegia, and seizure disorder. The most current MDS (minimum data set) was a quarterly assessment with an ARD (assessment reference date) of 12/16/2025. R1 was assessed with a cognitive score of 5 indicating severely cognitively impaired. Diagnoses for R3 include heart failure, kidney disease, dysphagia, and cognitive communication deficit. The most current MDS (minimum data set) was a quarterly assessment with an ARD (assessment reference date) of 1/28/2026. [...]

Inspectors wroteBased on staff interview, clinical record review, and facility document review, the facility failed to investigate an incident of resident-to-resident abuse involving three of eleven residents in the survey sample (Resident #1, Resident #3, and Resident #4). The Findings Include: The facility did not investigate resident to resident abuse between Resident #1 (R1), R3, and R4. Diagnoses for R1 included heart failure, diabetes, dementia, hemiplegia, and seizure disorder. The most current MDS (minimum data set) was a quarterly assessment with an ARD (assessment reference date) of 12/16/2025. R1 was assessed with a cognitive score of 5 indicating severely cognitively impaired. Diagnoses for R3 include heart failure, kidney disease, dysphagia, and cognitive communication deficit. [...]

Inspectors wroteBased on staff interview and clinical record review, the facility staff failed to develop and implement a comprehensive care plan regarding behaviors for one of eleven residents, Resident #1.

Inspectors wroteBased on observation, resident interview, staff interview, facility document review and clinical record review, the facility staff failed to ensure one of seven residents (Resident #107) followed protocols for safe smoking.

Inspectors wroteBased on observation, resident interview, staff interview, facility document review, and clinical record review, the facility failed to provide medically related social services for psychosocial well-being for four of eleven residents in the survey sample. Resident 's 7, 8, 9, and 10 were not assessed by the social worker after a resident-to resident altercation.

Inspectors wroteBased on staff interview, facility document review and clinical record review, the facility staff failed to follow abuse prevention policies for two of eleven residents in the survey sample (Residents #1 and #11).

Inspectors wroteBased on staff interview, facility document review and clinical record review, the facility staff failed to report to the state agency, adult protective services and law enforcement of a positive test result for illicit drugs for one of eleven residents in the survey sample (Resident #1).

Inspectors wroteBased on staff interview, facility document review, and clinical record review, the facility failed to ensure a complete and thorough investigation of an allegation of abuse and/or unusual event for two of eleven residents (Residents #1 and #11).

Inspectors wroteBased on observation, staff interview and facility document review, the facility staff failed to follow professional standard of care for medication administration on two of four units (2NW and 2NS).

Inspectors wroteBased on staff interview, facility document review and clinical record review, the facility staff failed to promote a safe, drug free environment for one of eleven residents in the survey sample (Resident #1).

Inspectors wroteBased on staff interview and clinical record review, the facility staff failed to ensure a complete and accurate clinical record for two of eleven residents in the survey sample (Residents #6 and #10).

Inspectors wroteBased on observation, staff interview, clinical record review, and facility document review, the facility failed to ensure a resident's room was free of an accident hazard for one of 25 residents, resulting in harm at past noncompliance. Resident #210 received a second degree burn from a heating element with a missing heat guard. The Findings Include: Diagnoses for Resident #210 included: Dementia, anemia, brain injury, and seizure disorder. The most current MDS (minimum data set) was an annual assessment with an ARD (assessment reference date) of 9/28/22. Resident #210 was assessed with moderate cognitive impairment. [...]

Inspectors wroteBased on review of facility's records, interviews, and policy review, the facility failed to maintain a legionella prevention program to protect residents from contracting water-borne pathogens as part of the facility's infection prevention and control program. This failure had the potential to affect all residents residing in the facility. Additionally, the facility failed to ensure staff follow infection prevention practices for hand hygiene during dining observation. This has the potential for facility wide spread of infection and/or contamination.

Inspectors wroteBased on observation, facility document review, resident interview and staff interview, the facility staff failed to provide a clean, homelike environment on three of four living units.

Inspectors wroteBased on observation, facility document review, and staff interview, the facility staff failed to store, prepare and distribute food in a sanitary manner.

Inspectors wroteBased on observation and staff interview, the facility staff failed to ensure proper function of the freezer in the main kitchen.

Inspectors wroteBased on interview and record review, the facility failed to ensure Power of Attorney (POA) for healthcare document was located in the medical record for one sampled resident reviewed for advance directives (Resident (R)11). This failure had the potential for an unauthorized person to enter a Do Not Resuscitate (DNR) directive for the resident.

Inspectors wroteBased on staff interview and clinical record review, the facility failed to ensure a significant change assessment was completed for one of 25 residents. Resident #61 did not have a significant change assessment completed, after a functional decline in ADL's (Activities of Daily Living). The Findings Include: Diagnoses for Resident #61 included: Dementia, schizophrenia, anxiety, Alzheimer's disease and malignant neoplasm. The most current MDS (minimum data set) was an annual assessment with an ARD (assessment reference date) of 5/31/23. Resident #61 was assessed with short and long-term memory problems and as severely cognitively impaired. On 6/13/23, a comparison of Resident #61's quarterly MDS dated [DATE] and an annual MDS dated [DATE] indicated (in section G) Resident #61 had a decline in the following: [...]

Inspectors wroteBased on record review, interview, and review of facility policy, the facility failed to ensure the required Level II Preadmission Screening and Resident Review (PASRR) was completed for one of 24 residents (Resident (R) 4). Potentially, this impedes R4 from receiving the appropriate treatments/services for mental illness.

Inspectors wroteBased on interviews, record review, and review of facility policy, the facility failed to revise the comprehensive care plan to ensure accuracy for two of 21 residents (Resident (R) 89 and R54) reviewed for care plan revision. Specifically, the facility failed to revise R89's care plan to address weight loss and failed to revise R54's care plan to identify use of a catheter safety strap.

Inspectors wroteBased on observations, interview, record review, and review of facility policy, the facility failed to ensure one of one resident (Resident (R)54) reviewed for catheter care was wearing a securement device. This failure increased the potential for the catheter to become dislodged or cause injury.

Inspectors wroteBased on observation, facility document review and staff interview, the facility staff failed to properly dispose of garbage/refuse.

Inspectors wroteBased on staff interview and facility document review, the facility staff failed to ensure a registered nurse was onsite at the facility for 8 consecutive hours on 06/05/2022.

Inspectors wroteBased on review of employee files, facility policy review, and staff interview, the facility failed to implement their policy for Abuse, neglect, and Exploitation. Six of 25 employee files reviewed did not contain either a criminal record check, a sworn statement, or references

Inspectors wroteBased on observation, staff interview and clinical record review, the facility staff failed to provide gastrostomy care as ordered for one of thirty-one residents in the survey sample, Resident #23. A physician's order to cleanse and apply a daily dressing to Resident #23's gastrostomy site was not implemented for over three months.

Inspectors wroteBased on complaint investigation, clinical record review, facility document review, and staff interview, the facility failed to ensure three of 31 residents in the survey sample, Residents # 169, 24, and 168 were free from abuse. Resident # 169 was physically abused and Residents # 24 and 168 were verbally abused by a facility staff member.

Inspectors wroteBased on observation, staff interview and clinical record review, the facility staff failed to develop a comprehensive care plan for one of thirty-one residents in the survey sample, Resident #23. Resident #23 had no care plan regarding care of a gastrostomy.

Inspectors wroteBased on staff interview and clinical record review, the facility staff failed to follow physician orders for one of thirty-one residents in the survey sample, Resident #72. Notification was not made to the provider regarding weight gain for Resident #72 as ordered by the physician.

Inspectors wroteBased on observation, staff interview and clinical record review the facility staff failed to implement interventions to prevent weight loss for one of 31 residents in the survey sample, Resident #117.

Inspectors wroteBased on observation, staff interview, and facility document review, the facility staff failed to ensure drugs and biological's were labeled appropriately on one of two nursing units. The facility failed to appropriately label a multi- dose vial of Tuberculin on unit 3 New West.

Inspectors wroteBased on observation, staff interview, facility document review and clinical record review, the facility staff failed to assess and implement care for treatment of a blister for one of 34 residents (Resident #122) resulting in the development of an infected, necrotic pressure ulcer and failed to provide pressure ulcer dressing changes in a manner to prevent infection for two of 34 residents (Residents #122 and #112).

Inspectors wroteBased on record review, staff interview and facility document review, the facility staff failed to prevent a significant medication error for one of 34 Residents. Resident #147 was given an extra dose of Methadone (classified as an opioid) which resulted in harm. The Findings Include: Resident #147 was admitted to the facility on [DATE] with a readmission of 2/7/20. Diagnoses for Resident #147 included; Osteoporosis, dementia, seizure disorder, and chronic pain. The most current MDS (minimum data set) was a significant change assessment with an ARD (assessment reference date) of 1/27/20. Resident #147 was assessed with a cognitive score of 7 indicating severe cognitive impairment. On 2/09/20 Resident #147's medical record was reviewed and evidenced a physician's progress note dated 1/20/20 that read [AGE] year old male who I am seeing today because of medication error. [...]

Inspectors wroteBased on observation, staff interview, and facility document review, facility staff failed to store drugs and biologicals appropriately on two of four units in the facility.

Inspectors wroteBased on staff interview, facility document review and clinical record review, the facility staff failed to complete a valid Durable Do Not Resuscitate Order (DDNR) for one of 34 residents in the survey sample. No resident representative signed the state approved DDNR form for Resident #122.

Inspectors wroteBased on staff interview and clinical record review, the facility staff failed to ensure a CCP (comprehensive care plan) was reviewed and revised for two of 34 residents in the survey sample, Resident #66 and Resident #86.

Inspectors wroteBased on observation, staff interview and clinical record review, the facility staff failed to follow physician orders for the use of compression stockings for one of 34 in the survey sample, Resident #86.

Inspectors wroteBased on observation, staff interview, and clinical record review, the facility staff failed to ensure proper treatment and assistive devices to maintain vision for one of 34 residents, Resident #66. Resident #66 was assessed and care planned for needing glasses, but the resident was not provided visual aids to assist and/or maintain vision.

Inspectors wroteBased on resident interview, staff interview, and clinical record review, the facility staff failed to provide supervision to prevent accidents for one of 34 residents, Resident #51. Kitchen staff opened a locked door giving Resident #51 access to the outside. The door locked behind her and she was unable to reenter the building.

Inspectors wroteBased on observation, staff interview and clinical record review, the facility staff failed to ensure interventions were implemented to prevent weight loss for one of 34 residents in the survey sample, Resident #22. Resident #22 was not weighed for three months by facility staff. A weight was obtained on 02/11/20 and the resident had lost 5.45 % since the last weight completed in November 2019 (3 months).

Inspectors wroteBased on staff interview, family interview, clinical record review, facility document review, and in the course of a complaint investigation, the facility staff failed to ensure that medication (Methadone) was available for administration for one of 34 residents, Resident #48.

Inspectors wroteBased on a medication pass and pour observation, clinical record reviewed, staff interview and facility document review, the facility staff failed to ensure a medication error rate of less than 5% (five percent). The medication pass and pour observation consisted of 25 (twenty- five) medication opportunities with four medication errors, resulting in a medication error rate of 16% (sixteen percent).

Inspectors wroteBased on observations, clinical record review, resident interview, staff interview, the facility staff failed, for two of 34 residents in the survey sample (Residents # 59 and 137), to provide routine and emergency dental services. Resident # 137 lost a natural tooth and was not provided with emergency dental services to treat the loss. Resident # 59 was not provided routine dental care for tooth decay and a broken partial plate.

Inspectors wroteBased on observation, facility document review and staff interview, the facility staff failed to store food in a sanitary manner. Two large pans of plain cake were stored in the walk-refrigerator uncovered.

Inspectors wroteBased on observations, clinical record review, resident interview, and staff interview, the facility staff failed, for one of 34 residents in the survey sample (Resident # 137), to maintain a complete and accurate clinical record. Facility staff failed to document Resident # 137's loss of a natural tooth in the clinical record.

Inspectors wroteBased on observation, facility document review, staff interview and clinical record review, the facility staff failed to follow infection control practices during dressing changes for two of 34 residents in the survey sample (Residents #122 and #112).