Staunton Health and Rehab CTR

In the surveyor’s words

From the most serious findings on record at Staunton Health and Rehab CTR, in the surveyor’s own words.

• Actual harm, isolatedF689Jun 2, 2026

  Based on interview, observation, and record review, the facility failed to maintain resident safety by failing to implement fall interventions and performing safe transfers. for 4 of 6 residents (R4, R5, R13, R500) reviewed for resident safety in the sample of 31. This failure resulted in R4 being hospitalized for fractures resulting in surgery and R500 being hospitalized for subdural hematoma, and spinal fractures. The findings include: 1. R4's admission Record, dated 5/28/26, documents R4 was admitted to the facility on [DATE].R4's Medical Diagnosis include on 4/6/26: Periprosthetic fracture around internal prosthetic right hip joint, displaced subtrochanteric fracture of right femur, displaced fracture of lesser trochanter of right femur. […]

• Actual harm, isolatedF558Jun 1, 2026

  Based on observation, interview, and record review, the facility failed to ensure a call light was in reach and residents had a means to call for help for 1 of 3 (R11) residents reviewed for accommodation of needs in a sample of 31. This failure resulted in R11 unable to receive help. It also resulted in R11 feeling frightened, frustrated, embarrassed, helpless and disposed of.Findings include:1. R11's admission Record, not dated, documents that R11 was admitted on [DATE] with diagnosis of Multiple Sclerosis and Quadriplegia. R11's Care Plan, dated 7/1/2025, (R11) has Quadriplegia. He requires assist with all of his ADL's (Activities of daily living). It also documents 8/4/2025 (R11) have Multiple Sclerosis. He is dependent on all ADLs. […]

• Actual harm, isolatedF686Jun 1, 2026

  Based on interview, observation, and record review, the facility failed to identify, treat, and prevent pressure ulcers for 3 of 5 residents (R4, R9, R13) reviewed for pressure ulcers in the sample of 31. This failure resulted in R4 and R13 having new pressure sores that were not discovered or treated. The findings include:1. R4's admission Record, dated 5/28/26, documents R4 was admitted to the facility on [DATE]. R4's Electronic Medical Record, under Medical Diagnosis, documents R4's diagnosis dated 4/6/26: Periprosthetic fracture around internal prosthetic right hip joint, displaced subtrochanteric fracture of right femur, displaced fracture of lesser trochanter of right femur. […]

• No harm, potential for more than minimal, widespreadF761Apr 17, 2025

  Based on observation, interview,and record review, the facility failed to properly store and discard expired medication. This failure has the potential to effect all 48 residents residing in the facility. Findings include: On [DATE] at 9:40 AM the facility's 100 Hall Medication Cart was inspected. The medication cart contained the following: R19's opened and labeled multi dose Aspart insulin Pen. The multi-dose vial was labeled with open date of [DATE]. R19's open and labeled multi dose Glargine insulin pen. The multi-dose vial was labeled with open date of [DATE]. On [DATE] at 9:45 AM V5, Licensed Practical Nurse, verified that the multi dose vials were open and in use. V5 stated that when opening an insulin pen the resident's last name and open date is placed on the multi dose pen. […]

• No harm, potential for more than minimal, widespreadF812May 3, 2024

  Based on observation, interviews and record reviews, the facility failed to ensure there was an air gap in the ice machine between the floor sewage drain and the ice machine and there were no signs of water damage from sewage lines and or/pipelines. This has the potential to affect all 45 residents living in the facility. Findings include: On 5/1/2024 at 8:33 AM, the ice machine was in the dining area. Behind the ice machine there was water present on the floor. Behind the machine there were also 2 orange cones with the words wet floor that were placed behind the machine. On 5/1/2024 at 8:39 AM, Behind the ice machine there was a white pipe that went into another pipe into a drain. The pipe was going directly into the drain, and no air gap was observed. […]