Every finding on record at Berkeley Springs Healthcare Center

Based on record review and staff interviews, the facility failed to include all the relevant diagnoses for residents on their Pre-admission Screen (PASARR). Out of the thirty four (34) residents in the initial pool, four (4) residents had incorrect or missing diagnoses. Resident identifiers #8, #11, #12 and #68. Facility census: 101. Findings include: a) Resident #8 On 07/06/26, during a record review of Resident #8's chart, their Pre-admission Screening (PAS) in section thirty (30) has option K (affective bipolar disorder) marked. This does not match the current active diagnosis on chart of Bipolar disorder, unspecified (F31.9), and it is missing a diagnosis of Unspecified dementia, unspecified severity without behavioral disturbances (F03.90). In a follow-up interview with the DON, she stated that the facility is conducting a house wide audit on admission paperwork and will ensure they capture all the admission and any new diagnoses a resident may have on the PAS. b) Resident #12 On 07/06/26, during a record review of Resident #12's chart, their Pre-admission Screening (PAS) in section thirty (30) has option A (none) marked. Nothing is listed in section N (other) to allow for any diagnosis that may not fit into other listed areas to be added to this form. The resident has F31.81 BIPOLAR II DISORDER, F33.1 MAJOR DEPRESSIVE DISORDER, and F41.1 GENERALIZED ANXIETY DISORDER all listed under their active diagnoses in their chart. These diagnoses were all required to be listed on the PASARR but were missing. In a follow-up interview with the DON, she stated that the facility was conducting a house wide audit on admission paperwork and will ensure they capture all the admission and any new diagnoses a resident may have on the PASARR. c) Resident #11: On 07/07/26 at 9:30 AM, during a record review of Resident #11's chart, their Pre-admission Screening (PAS) in section thirty (30) option K was marked NONE. This does not match the current active diagnoses on the chart: Schizophrenic Disorder(20.9), Vascular Dementia with Anxiety (F01.B4), and it is missing a diagnosis of Major Depressive Disorder recurrent, moderate(F31.9). d) Resident #68: On 07/07/26 at 2:35 PM, during a record review of Resident #68's chart, their Pre-admission Screening (PAS) in section thirty (30) option K was marked NONE. This does not match the current active diagnosis on chart of Bipolar Disorder, unspecified (F33.0), and it is missing a diagnosis of Generalized Anxiety disorder recurrent, mild(F41.1). In a follow up interview with the Corporate RN on 07/07/26 at 2:45 PM, she confirmed the missing diagnoses on Resident #11 and #68 then stated the facility was doing a house wide audit on admission paperwork and will ensure they capture all the admission and any new diagnosis a resident may have on the PASARR.

Based on record review and staff interview, the facility failed to ensure resident care plans were revised for one (1) resident. The issues included the residents diet being changed twice and her weekly weight orders not being included. This failed practice had the potential to affect more than a limited number of residents. Resident Identifiers: #14. Facility Census: 101.a) CommuniCare policy titled Plan of Care Overview states: Plan of Care: for the purpose of this policy, the Plan of Care, also Care Plan is the written treatment provided for a resident that is resident focused and provides for optimal personalized care. It is the policy of this facility to provide resident centered care that meets the psychosocial, physical and emotional needs and concerns of the residents. Safety is a primary concern for our residents, staff and visitors. The purpose of the policy is to provide guidance to the facility to support the inclusion of the resident or resident representative in all aspects of person centered care planning, and that this planning includes the provision of services to enable the resident to live with dignity and supports the resident's goals, choices, and preferences including, but not limited to, goals related to their daily routines and goals to potentially return to a community setting. The facility will review care plans quarterly and / or with significant changes in care. The Minimum Data Set (MDS) Coordinator will oversee and coordinate the care team and Plan of Care (POC). Nurses are expected to participate in the resident plan of care for reviewing and revising the care plan of residents they provide care for as the resident's condition warrants. Care plan documents are resident specific / resident focused and reflect resident / representative opportunities for participation and preferences. b) Resident #14 Resident #14 care plan was not revised when her diet was changed from a therapeutic diet to a regular diet on 03/31/26. Resident #14 care plan was not revised, when her weight order was changed to weekly weights every Thursday starting on 06/18/26, due to weight loss. Resident #14 care plan was not revised when her order for finger foods with meals as available was discontinued on 06/29/26. During an interview with the Regional Director of Clinical Operations (RDCO) on 07/07/26 at 1:35 PM the surveyor showed her the care plan had not been updated for Resident #14 on three (3) separate occasions and she stated I will contact the Registered Dietitian (RD) and I will start an audit for care plan revision. We did miss these revisions.

Based on observation and staff interview, the facility failed to provide a safe, clean, comfortable, and homelike environment for residents on the 300 hall. This was a random opportunity for discovery. Room Numbers: #307, #308, #309, and #312. Facility census: 101. Findings included: room [ROOM NUMBER]Upon survey entrance and resident interviews on 07/06/26 at 11:50AM, the following was observed in room [ROOM NUMBER]The window sills had dust and cobwebs in the corners with a buildup of blackish debris. a) room [ROOM NUMBER]-During resident interviews on 07/06/26 at approximately 12:10 PM, the following was observed in room [ROOM NUMBER]The window sill had dust and cobwebs with a buildup of blackish debris. b) room [ROOM NUMBER]-During resident interviews on 07/06/26 at approximately 12:25 PM, the following was observed in room [ROOM NUMBER]The window sill had dust and cobwebs with a buildup of blackish debris. c) room [ROOM NUMBER]:-During resident interviews on 07/07/26 at approximately 2:25 PM, the follwoing was observed in room [ROOM NUMBER]The window sill had dust and cobwebs with a buildup of blackish debris. Further observation found a brownish smeared substance on the floor in the bathroom in front of the toilet. - A recheck of room [ROOM NUMBER]'s bathroom on 07/08/26 at 10:25 AM found the brownish smeared substance was still on the floor in front of the toilet base During a facility walk through with the administrator on 07/08/26 at 10:25 AM, he confirmed the black debris build up and dusty cobwebs on the above listed window sills. He also confirmed the brown smears in room [ROOM NUMBER]'s bathroom floor in from of the toilet base.

Based on medical record review, observation, and staff interview, the facility failed to ensure Resident's received treatment and care in accordance with professional standards of practice. Specifically, physician's orders were not followed in regards to G-tube (gastrostomy tube) placement and significant weight loss Resident #100 and #14. Facility census: 101. Findings Included: An observation on Medication administration for Resident #100 found Licensed Practical Nurse (LPN) # 74 administering medication and feeding through a G-tube. Eternal tube placement was not checked prior to administrating medications or feeding. During an interview on 07/08/26 at approximately 8:10 AM with LPN #74 she verified placement was not checked prior to medication administration and feeding. A medical record review found a physician orders: - Enteral Feed, every shift check for resin 100cc hold feeding for one hour and recheck if residual remains greater than 100 ml notify physician with a start date 07/14/2025. - Enteral Feed, every shift verify enteral tube placement before feedings, flushes, and medication passes by checking gastric contents are not visualized 07/14/2025. During an interview on 07/08/26 at approximately 8:30 AM the Director of Nursing verified placement should have been checked prior to administration of medication or feeding. b) CommuniCare policy titled Resident Height and Weight states: Weight: the number of pounds / ounces that an individual weighs. This important vital is used for medication, nutrition and other treatments and must be managed correctly. Weights will be obtained monthly or as ordered by the physician or practitioner. Unless a compelling reason exists, obtain weight in the morning before meals and post voiding to obtain the most accurate body weight. Compare weight to previous weight obtained. If a variance of five (5) pounds or more is noted, reweigh resident to verify weight. Unstable residents will be reviewed by IDT team to determine frequency of obtaining weight. Update Interdisciplinary Care Plan as needed. Weight loss concerns are reported to the practitioner and discussed at the weekly clinical meetings. c) Resident #14 07/07/2026 10:18 AM Resident #14 has a significant weight loss. Her Body Mass Index (BMI) is classified as underweight at 17.3. Resident #14 care plan was not revised, when her weight order was changed to weekly weights every Thursday starting on 06/18/26, due to weight loss. 07/08/26 11:30 AM Resident #14 had a significant weight loss on 06/01/26, her weight was 88.8 pounds (#). She was reweighed by the facility on 06/03/26, and her weight was 88.6#. The Registered Dietitian completed a nutritional assessment on 06/15/26 and recommended weekly weights for Resident #14. The Physician approved this recommendation and the order was written to obtain weekly weights every Thursday starting on 06/18/26. There was no weekly weight attempted by the facility on 06/18/26. Interview with the Director of Nursing (DON) and the Regional Director of Clinical Operations (RDCO) today at 11:00 AM. I asked them why the weekly weight that the Physician ordered to start on 06/18/26 was not attempted by the facility, and the DON stated the order was not put in correctly by the nurse, so it did not show up the the Medication Administration Record (MAR) correctly. That is why it was missed.

Based on record review, observations, and staff interview. The facility failed to ensure physician orders were being followed for treatment services to prevent pressure ulcers. This affected one(1) of three (3) residents reviewed. Resident identifier: #101. Facility census : 101. Findings include- a) Resident #101 Review of physician order.-Reads in part, resident to have heel boot to right/left hell at all times except for bathing. Review of care plan.-Reads in part, Focus-Resident #101 is at risk for pressure ulcers/injuries related to decreased mobility, poor nutritional intake, and favors right side.Intervention reads in part.-Resident to have heel boot on the right/left heel at all times except bathing. Date initiated: 01/17/23Date revised: 02/19/2023 -On 07/06/26 at around 12:30 PM during observation with Resident #101, both heel protectors were laying in chair not on. Resident was on the right side facing window. Reviewed physician order, which reads in part: to have heel protectors on at all times except for showers. -On 07/06/26 at around 3:20 PM Observed resident remains laying on right side facing the window, heel protectors not in place, remain one in chair and one on floor, resident also remains laying on right side. Spoke with nurse #124, she verified the heel protectors need to be on when in bed and they were not and that resident has been laying on the right side. She then placed the heel protectors on the resident. -On 07/07/26 at around 9:30AM. During observations, the resident had heel protectors lying in the chair and not on the heels per orders. -On 07/07/26 at around 12:30 PM. Residents heel protectors remained in the chair. Nurse #89 was in residents room to assist with meal, verified these were to be kept on at all times. She then placed them on the resident.

Based on observation and staff interviews, the facility failed to ensure the resident environment remains as free of accident hazards as is possible r/t med cart left unlocked and unattended. This failed practice was a random opportunity for discovery. Facility Census:101Findings Included: a) On 07/06/26 approximately 3:10 PM It was observed in the 200 hallway, the med-cart was found unattended and left unlocked. Employee #148 was also in the 200 hall at the time the med cart was found unattended and unlocked, confirmed she had witnessed surveyor able to walk up and pull open the top drawer of the med cart. She then closed it and locked it to ensure the safety of residents until the nurse returned. In an interview with Licensed Practical Nurse, Employee #140 on 07/06/26 at 3:15PM she confirmed the med-cart was left unlocked while she went to get some ice for the cart and stated I am sorry I didn't realize it was unlocked. During an interview with the Facility Administrator on 7/6/26 at 3:35 PM, he acknowledged the med cart was left unlocked and stated thank you for letting me know.

Based on observation and interviews, the facility failed to ensure the resident environment over which they had control was as free from accident hazards as possible in regards to bed safety. This was a random opportunity for discovery. Resident Identifiers: 101. Facility census: 101.Findings Include: a) Resident #101 During an initial tour of the facility an observation, completed on 07/06/26 at 1:16 PM, revealed Resident #101 was lying in bed with an approximate 12-inch gap between the mattress and foot rail. The bed was extended with a small suffer in place leaving about a 10 inch gap deep. During an interview on 07/06/26 at 1:20 PM, the Assistant Director of Nursing verified the gaps between the mattress and foot boards for Residents #101. He continued to say that he would have the maintenance director evaluate and fix the gap at this time.

Based on observation and staff interviews the facility failed to ensure Resident #71 had a dignified dining experience during the lunch meal on 07/06/26 and 07/07/26. The facility failed to serve Resident #71 at the time his roommate was served. Resident #71 was not served for 35 minutes after the roommate was served his meal. This failed practice was a random opportunity for discovery. Resident Identifiers: #45 and #71. Facility Census: 101.Findings Included: a) During an observation of the lunch meal at 12:10 PM on 07/06/26 Resident #45 was observed eating his meal while his roommate Resident #71 still had not received his tray. In an interview with Resident #45, about his lunch, he stated he was on vacation and was eating in his room this week. When asked of Resident #71 if he had already eaten his meal, he reported he had not received his tray yet. My tray always comes after the dining room gets theirs. It was further noted that Resident #71's meal arrived at 12:35PM. It was observed on 7/7/26 at 12:15 that Resident #45 received his tray in his room at 12:15PM but Resident #71 did not receive his noontime meal until 12:40PM. On 07/07/26 at 12:45PM Licensed Practical Nurse Employee #116 was interviewed. She confirmed she was aware that Resident #45 had decided to eat in his room this week, calling it his vacation. His meals arrive before his roommate and explained that (roommate)Resident #71 prefers to receive his meals in his room, which is served after the dining room while Resident #45 usually prefers to eat in the dining room. She also reported that due to resident #45's diagnosis of explosive disorder, he would be upset and have explosive behaviors if his food is not where he at his time to eat. Due to this issue, she stated she could not see a way to accommodate both residents to receive their meals at the same time. During an interview with the Administrator on 7/7/26, at 3:00pm He acknowledged that trays are delivered to the floors after meals are served in the dining room which causes conflicts in tray arrival times if a resident chooses to eat in his room instead. He stated this was unacceptable and that he would look into it.

Based upon Record review and staff interviews, the facility failed to ensure that care plans were person centered and had measurable goals. Resident identifiers #8. Census: 101.Findings include:a) Resident #8On 07/08/2026 during routine chart review for Resident #8, it was determined that their care plan was not specific to the resident and did not have measurable goals associated with it. Page one (1) of their care plan in the goal section stated, resident will not experience any increase in signs and symptoms of mood disturbance through review period. The target date listed is 09/09/26. There was no mention of what types of disturbances or behaviors this resident has had in the past, or what ones that the staff should be on the look out for. In the intervention area on page one (1) it states observe and document s/sx of effectiveness and side effects. There is no mention of what sign, symptoms, or side effects to look out for or document. That section also states Honor residents preferred choices. The choices are not listed for anyone to know what the resident likes or dislikes. Page fourteen (14) in the goal section states resident will have fewer episodes of behaviors through review date. There is no mention of how many episodes are currently happening and there are missing signs and symptoms for the medications that the staff is to observe and document.Without this necessary information the staff is unable to provide the full care for this resident and ensure the care they are providing is working. There must be resident specific and measurable goals for each.In a follow up interview with the Administrator that same day, they stated that care plans are done when the resident admits to the facility as well as quarterly. They also update them as needed if a resident's status changes.

Based on observation, staff interview and policy review the facility failed store food and wear hair net in accordance with professional standards for food service. This practice had the potential to affect more than an isolated number of residents. Facility census: 99. Finding included: a) Upon initial tour of the kitchen on 03/24/25 at 12:00 PM, the following foods were found: -Two (2), five (5) pound tubs of United Dairy Sour Cream dated Best By 03/05/25 in stand-up cooler. -A box labeled crustables with random, unlabeled popsicles and no dates in walk in freezer. -A zip lock bag containing eight (8) Sub Rolls labeled 12-11- 3-11-25 in the walk-in freezer. -A container of prepared spaghetti for puree dated 8-6-2/6 in the walk-in freezer. The Kitchen Account Manager (KAM) accompanied the initial tour on 03/24/25 at 12:00 PM and acknowledged these foods were not stored in accordance with professional standards. She stated that foods were usually thrown away after best by dates and that the popsicles were for staff use only for hydration. On 03/26/25 a review of policy titled Healthcare Services Group Policy 019, Procedure number five (5.) stated All foods will be stored, wrapped or in covered containers, labeled and dated, and arranged in a manner to prevent cross contamination. b)On 3/25/25 at 11:20 AM Culinary Aide # 95 observed with hair not properly contained in hair net. KAM acknowledged and asked staff to re-tuck her hair and replace her gloves. On 03/26/25 a review of policy titled Healthcare Services Group Policy 024, Procedure number one (1.) stated All staff members will have their hair off the shoulders, confined in a hair net or cap, and facial hair properly restrained.

Based on resident interview and observation the facility failed to provide palatable, attractive, and appetizing food. This practice had the potential to affect more than an isolated number of residents who received their nutrition from the facility dietary department. Facility Census 99. Findings included: a) Resident #94 An interview was held with Resident #94 on 03/24/25 at 01:36 PM who reported the food is served cold and is not served in a timely manner. On 03/25/25 at 12:50 PM a test tray temperature was measured after the last tray was served to residents in the facility. The serving temperatures we as follows: Hamburger 104 degrees Tator Tots 107 degrees Pureed Vegetable Salad 33 degrees Mixed fruit 30 degrees Milk 33 degrees Slaw 40 degrees coffee 146 degrees

Based on interviews, observation and review of documentation the facility failed to provide Activities of Daily Living (ADL) care for dependent residents in the area of bathing. This was true for four (4) of four (4) residents reviewed in this area. Resident identifiers: #66, #94, and #49. Facility census: 99. Finding included: a) Resident #66 On 03/24/25 at 01:33 PM an interview with Resident #66 revealed she bathed herself and would prefer to have someone bath her to wash her back and hair. Resident was observed to have unkempt hair. On 03/26/25 at approximately 12:20 PM resident's shower log was reviewed from date of admission on 03/06/25 to 03/26/25 which revealed that resident had a Shower on 3/20/2025 2:15 PM. No further documentation was presented. On 03/26/25 at 12:30 PM an interview with Director of Clinical Operations # 161 was conducted and she acknowledged that the facility had no further documentation to prove that resident had more showers than listed. b) Resident #94 03/24/25 01:39 PM would prefer to have a shower at least one time per week. She reports that she had only been given one since her admission. Wants her head washed and said she had not been getting assistance with that and had been getting only bed baths. She had asked and been told she will be on the list but has not had one. She stated that her hair was dirty. Resident was observed to have uncombed, unkempt. oily hair. On 03/26/25 at approximately 12:20 PM resident's shower log was reviewed from date of admission on 02/17/25 to 03/26/25 which revealed that resident had a Bed Bath on 3/10/2025 1:28 PM. No further documentation was presented. On 03/26/25 at 12:30 PM an interview with Director of Clinical Operations # 161 was conducted and she acknowledged that the facility had no further documentation to prove that resident had more showers than listed. 42120 d) Resident #49 An observation of Resident #49 sitting in a resident sitting area 3/24/25 11:45 AM with disheveled oily hair. A second observation on 03/25/25 at 9:24 AM found Resident #49 with oily hair. Medical record review revealed, Resident #49 shower schedule and preference are two (2) times weekly. A continued review of Resident #49s ADL documentation found: Two (2) showers given, one (1) bed bath, and no refusals documented in 30 days. On 03/27/25 at 12:30 PM the Regional Director of Operations verified the facility could not provide any other documentation for Resident #49's showers. 50795 c) Resident #86 During a brief interview of Resident #86 on 03/24/25 at approximately 3:11 PM, the resident was observed in a wheelchair. Resident #86 appeared unkempt, and her hair appeared greasy. Resident #86's Brief Interview for Mental Status (BIMS) revealed a score of 10. The resident stated that she had not been offered a shower. However, the resident was unable to state the date of her last shower. Record review on 03/25/25 at approximately 2:45 PM revealed that the resident had not received showers or baths for the following periods: 02/11/24 to 02/23/24 - 12 days 03/11/25 to 03/23/25 - 12 days A review of the shower log for Resident #86 on 03/25/25 at approximately 1:10 PM verified this finding: 02/03/25 13:59 Type Bath/Shower Shower 02/06/25 12:19 Type Bath Shower Bed Bath 02/10/25 13:21 Type Bath/Shower Shower 02/13/25 13:14 Type Bath/Shower Response Not Required 02/17/25 13:31 Type Bath/Shower Response Not Required 02/20/25 13:42 Type Bath/Shower Response Not Required 02/24/25 13:09 Type Bath/Shower Refused 03/03/25 13:53 Type Bath Shower Bed Bath 03/06/25 13:27 Type Bath Shower Shower 03/10/25 13:59 Type Bath Shower Bed Bath 03/13/25 13:59 Type Bath/Shower Response Not Required 03/17/25 13:59 Type Bath/Shower Response Not Required 03/20/25 13:24 Type Bath/Shower Response Not Required 03/24/25 9:55 Type Bath Shower Bed Bath During an interview with the Director of Nursing (DON) on 03/25/25 at 3:52 PM, the DON stated that the documentation should state if the resident was not available or had refused a bath or shower. DON confirmed that Response Not Required meant that no shower, or bath, had been performed.

Based on observation and staff interview, the facility failed to provide a safe, clean, comfortable, and homelike environment for residents on the two (2) of four (4) hallways. Resident rooms affected were on the 100 and 300 halls. Room Numbers: #112, #114, #117, #301, #104, and #103. Resident identifier: #82. Facility census: 99. Findings included: a) room [ROOM NUMBER] Upon survey entrance on 03/24/25 at 11:30AM, the following issues were observed in room [ROOM NUMBER]: -black scuff marks on right wall inside the door - window missing curtains, - broken blinds During a walk through with the Infection Prevention Manager, on 03/25/25 at 3:50 PM, she acknowledged the scuffs and black marks, missing curtains, and broken window blinds and stated she would make sure the room repair would be placed on the list with the maintenance department. b) room [ROOM NUMBER] Upon survey entrance, on 03/24/25 at 11:30AM, the following issues were observed in room [ROOM NUMBER]: -rips and tears in the dry wall from the chair rail to the floor and chips in the wood of the chair rail behind head of resident's bed - missing a Window curtain - yellow stains on the floor behind the toilet and stains on the toilet seat. - cracked bathroom caulking around the sink - loose and hanging Baseboard trim on the back wall under the window c) Resident #82 On 03/24/25 at 03:34 PM, during an interview with Resident # 82 She stated she would like to have a curtain for her window because it is hard to sleep during the day with no way to block out the sunlight. She stated she had asked for a curtain about a month ago, but hasn't gotten one yet. During a walk through with the Infection Prevention Manager, on 03/25/25 at 3:50 PM, she acknowledged the loose baseboards missing curtains, bathroom floor stains and stained toilet seat, and cracked caulking around the bathroom sink and stated she would make sure the room repair would be placed on the list with the maintenance department. d) room [ROOM NUMBER] Upon survey entrance on 03/24/25 at 11:30AM, the following issues were observed in room [ROOM NUMBER]: - broken window blinds - missing window curtain - loose and hanging baseboard trim on the left wall e) room [ROOM NUMBER] Upon survey entrance on 03/24/25 at 11:30AM, the following issues were observed in room [ROOM NUMBER]: - black scuff marks and tears in the drywall behind resident's bed During a walk through with the Infection Prevention Manager, on 03/25/25 at 3:50 PM, she acknowledged the scuffs and black marks as well as the tears in the drywall behind resident's bed and stated she would make sure the room repair would be placed on the list with the maintenance department. 43340 f) room [ROOM NUMBER] During a walk-through of the facility, completed on 03/24/25 at 1:00 PM, it was identified that room [ROOM NUMBER] had window blinds that had slots that were broken and/or missing. On 03/26/25 at 10:50 AM, LPN #71 verified one (1) blind slat was partially missing on the left, three (3) blinds slats were partially missing on the right side, and one (1) blind slat was missing altogether. LPN #71 agreed the blinds were not in good repair and did not afford visual privacy. g) room [ROOM NUMBER] During a walk-thru of the facility, completed on 03/24/25 at 1:00 PM, it was identified that room [ROOM NUMBER] had window blinds that were bent with dangling slats. On 03/26/25 at 10:55 AM, LPN #71 was unable to lower the blinds in the room successfully. She confirmed the two (2) bottom window slats were bowing. LPN #71 agreed the blinds were not in good repair and did not afford visual privacy.

Based on resident interview, record review, and staff interview, the facility failed to accommodate resident food preferences. This was true for one (1) of 28 residents reviewed in the Long-Term Care Survey Process. Resident identifier: 19. Facility census: 99. Findings included: a) Resident #19 During an interview on 03/25/25 at 11:03 AM, Resident #19 reported he disliked fish, and it was listed as a dislike in his dietary record. The resident reported he was served fried fish on 03/10/25 and 03/24/25. The resident then showed Surveyor pictures of the fried fish on his tray beside his tray tickets for 03/10/25 and 03/24/25. During a medical record review, completed on 03/25/25 at 7:30 PM, the Diet History / Food Preferences assessment reflected resident disliked fish. On 03/26/25 at 8:40 AM, the Culinary Director confirmed that Resident #19 was erroneously served fried fish on 03/10/25 and 03/24/25. The Culinary Director stated it had been an oversight and immediately revised resident's dislike information to prevent the error from occurring again.

Based on observation and staff interview, the facility failed to post an updated staffing report sheet for 03/24/25. This was a random opportunity for discovery. Facility census: 99. Findings included: a) Nurse Staffing Information On 03/03/25 at 12:56 PM, upon entrance to the facility, the facility census on the posted daily staffing report sheet had not been updated that morning. The daily staffing report sheet stated the facility census was 98 which was not accurate. The correct census was 99. b) Administrator Interview On 03/24/25 at 12:51 PM, in an interview with the Administrator, he acknowledged that the Daily Staffing report sheet posted the census was incorrect at 98. A resident had been admitted the previous evening. The system updates everyday between 10am and 12 PM the posted report was not updated until after surveyors arrived.

Based on record review and staff interview, the facility failed to follow a physician's order for administration of an antibiotic. This was true for one (1) of five (5) residents reviewed under the unnecessary medications pathway. Resident identifier: #32. Facility census: 99. Findings included: a) Resident #32 A record review, completed on 03/25/25 at 3:40 PM, found a physician order for Amoxicillin-Pot Clavulanate tablet 875-125 MG. The order directed, give one (1) tablet by mouth every 12 hours for bacterial infection - PNA [pneumonia] for seven (7) days. A review of the February 2025 Medication Administration Record (MAR) revealed Resident #32 began taking the antibiotic on 02/08/25 and the resident only received 12 of the 14 ordered doses: -02/08/24 at 8:00 AM -02/08/25 at 8:00 PM -02/09/25 at 8:00 AM -02/09/25 at 8:00 PM -02/10/25 at 8:00 AM -02/10/25 at 8:00 PM -02/11/25 at 8:00 AM -02/11/25 at 8:00 PM -02/12/25 at 8:00 AM -02/12/25 at 8:00 PM -02/13/25 at 8:00 AM -02/13/25 at 8:00 PM -03/09/23 at 8:00 AM The Medication Administration Record (MAR) provided no evidence Resident #32 received the full ordered course of the antibiotic. Further record review revealed the medical record lacked evidence that the physician had been contacted about the missed doses. During an interview on 03/26/25 at 10:05 AM, the Director of Nursing (DON) reported Resident #32 had not finished the full 14 doses of the antibiotic and that the physician's order had not been followed correctly. 50795

Based on record review and staff interviews, the facility failed to ensure Professional standards care and services were provided according to accepted standards of clinical practice in regard to medications left at bedside. This practice has the potential to affect a limited number of residents. Resident identifier: #79. Facility census: 99. An observation on 03/26/25 at 8:08 AM found, Resident #79 taking medications from a medication cup, unattended. During an interview on 03/26/25 at 8:10 AM, Licensed Practical Nurse (LPN) #59 verified, she should not have left the room before Resident 49 took her medication. Medical record review revealed Resident #49 did not have physician's order for medication self-administration.

Based on record review and staff interview, the facility failed to have a comprehensive and individualized care plan in discharge planning for one (1) of 28 residents reviewed in the Long-Term Care Survey Process. Resident identifier: 98. Facility census: 99. Findings included: a) Resident #98 During a record review, completed on 03/26/25 at 10:18 PM, the following details were identified: -A Pre-Admission Screening (PAS), dated 10/09/24, reflected Resident #98's expected length of stay was less than three (3) months. -A physician encounter note, dated 10/09/24, stated, Prior to her ground-level fall the patient had been dwelling with her husband at the [Name of Facility] memory unit and she had been ambulatory with some assistance. -An Activities Progress Note, dated 10/10/24 at 12:28 PM, stated, She is here for short term rehab and goal to return to [Name of Assisted Living Facility] where she resides on their Memory Unit. -A social service note, dated 12/23/24 at 2:39 PM, stated that the Director of Social Work (DOSW) had spoken to staff at the assisted living facility and discussed what information the assisted living facility would need to assess if they could accommodate resident's needs in their facility. The Director of Social Work completed her section of the necessary information and then passed the form on to nursing to complete the necessary medical details. During an interview, on 03/27/25 at 10:40 AM, the DOSW reviewed Resident #98's care plan and did not find evidence that the care plan reflected discharge goals. DOSW stated she would look at the situation closer and get back to Surveyor after attending a care plan meeting. No further information was given prior to the end of the survey.

Based on record review and staff interviews, the facility failed to ensure that the resident's newly mental disorder was referred to the appropriate state-designated authority for review or one (1) of three (3) residents reviewed for the category of PASARR, during the long-term care survey. Resident identifier: #49. Facility census: 99. Findings include: a) Resident #49. A Review of Resident #49's medical record revealed a physician's order: --Risperidone 2 MG one time a day for schizophrenia. On 03/25/25, a record review of the resident's electronic medical record (EMR), the resident's most recent PAS, dated 09/02/20, indicated no level II not required. Section lll #30 MI/MR Assessment indicated current diagnosis of Major Depression. The record also revealed the resident had a diagnosis of schizophrenia on admission 06/27/24 but did not receive a new PAS to address whether specialized services were needed. An interview on 03/26/25 at 12:30 PM with the Regional Director of Operations verified Resident #49's PAS did not reveal his diagnosis of schizophrenia and confirmed a new PAS was not completed.

Based on staff interview and documentation review the facility failed to implement the Abuse / Neglect policy of reported incidents of abuse to the appropriate agencies. Resident identifier: #31. Facility census: 99. Findings included: a) Resident #31 Review of an incident report for Resident #31 dated 08/22/24 revealed an incident of abuse by staff was reported to the Nurse Aide Registry and Adult Protective Services with no evidence that the incident was reported to Office of Health Facility Licensure and Certification (OHFLAC). A review of the facility form titled Policies and Standard Procedures, Subject: [NAME] Virginia Abuse, Neglect and Misappropriation revealed the following: Page 13, number two (2.) A Suspected Abuse (c.) The Executive Director, Director of Nursing, or designee will report immediately to the appropriate agencies, and document the time and date of that report on the investigation form. Page 15, number VII. Reporting of Incidents and Facility Response. Number two (2.) The Executive Director/designee will report appropriate incidents to Office of Health Facility Licensure and Certification (OHFLAC), Adult Protective Services (APS), the Regional Ombudsman, and other local authorities, including but not limited to local law enforcement (if appropriate), as required by State law. c) During an interview with the Facility Administrator on 3/26/25 at approximately 3:30 PM regarding incident reported filed on 08/22/24. He acknowledged that he did not report to OHFLAC because he had reported the incident to the Nurse Aide Registry, and he did not believe that he had to report to both.

Based on observation, record review, and staff interview, the facility failed to ensure a resident who received enteral feeding was provided that feeding in accordance with professional standards of being in a semi-Fowler's position during the tube feeding administration. This deficient practice was identified in one (1) of one (1) resident reviewed who received enteral feedings. Resident identifier: Resident #41. Census: 102. On 03/28/23 at 5:26 PM, the State Agency determined these failures placed Resident #41 and six (6) other residents receiving enteral feeding in an immediate jeopardy situation due to potential complications from improper positioning. On 03/28/23 at 5:27 PM, the State Agency notified the Nursing Home Administrator of the immediate jeopardy. The facility submitted a Plan of Correction (POC) on 03/28/23 at 6:51 PM. The State Agency requested changes and a revised POC was submitted at 8:14 PM. At 8:25 PM, the POC was accepted by the State Agency. The State Agency verified the POC was implemented by reviewing training and audit documentation and conducting staff interviews. The immediate jeopardy was abated at 10:34 AM on 03/29/23. Once the immediate jeopardy was abated, deficient practices remained and the scope and severity was decreased from a J to an D. Findings included: a) Resident #41 The facility's policy titled Enteral General Nutritional Guidelines with no implementation date on the policy defined bolus enteral feeding as delivered using a syringe or gravity that provides for a single dose or preparation delivered all at one time. A review of physician's orders for Resident #41 showed an order for enteral feedings, Jevity 1.5 bolus, 247 ml, every four (4) hours, related to dysphagia following a cerebral Infarction, beginning 02/20/23. The resident had a gastrostomy tube (G-tube). The resident also had an order to flush the G-tube with at least 30 cc of water before and after feeding. Further review of previous physician's orders revealed on 02/20/23, an order for Jevity 130 ml/hour for 12 hours a day was discontinued due to a history of aspiration pneumonia while the resident resided at the facility. A record review noted on 11/29/22, Resident #41 was transferred to the hospital with a diagnosis of most likely aspiration pneumonia and returned 12/22/22. On 02/11/23, Resident #41 was transferred to the hospital for vomiting, crackles in the lungs, oxygen saturation of 93%, heart rate of 138, and clamminess. Resident #41 returned on 02/19/23 with a diagnosis of suspected aspiration for the second time. Resident #41 also had an order related to the enteral feeding for the head of bed (HOB) to be elevated at least 30 degrees or higher while receiving enteral feeding. A sign was observed above the resident's bed which stated, REMINDER: Please keep resident in semi- fowler's position or higher while G-tube feeding infused and after flushes and medication administration. Semi-Fowlers 15 degrees to Fowlers 60 degrees. On 03/28/23 at 3:45 PM, Licensed Practical Nurse (LPN) #116 was observed administering Resident #41's enteral feeding. LPN #116 checked the resident's G-tube for placement by aspiration and auscultation and flushed the tube with 30 cc of water without ensuring Resident #41 was positioned in a semi-Fowler's position. LPN #116 then began the feeding without ensuring Resident #41 was positioned in a semi-Fowler's position. The resident had slid down in bed. His head was on the lower edge of the pillow, and his torso was flat in bed. The resident's feet reached the foot board. The resident was repositioned after surveyor intervention. Additionally, the enteral feeding was administered via an enteral feeding pump at 247 cc/hr for an hour instead of by bolus by syringe or gravity. A staff interview with LPN #116 on 03/28/23 at 03:51 PM, revealed LPN #116 confirmed the resident did need to be repositioned prior to the feeding administration but failed to do so before surveyor intervention. LPN #116 also stated Resident #41's enteral feeding was administered by pump over an hour because the resident tended to grab at the nurse's hands when feeding was administered by bolus syringe. On 03/28/23 at 8:14 PM, the facility submitted the following final Plan of Correction to abate the Immediate Jeopardy (typed as written): 1. The tube feeding for resident #41 was stopped and resident #41 repositioned according to physician order and the tube feeding was restarted. a) Nurse #116 was educated on proper positioning and elevation of bed was completed on 03/28/23 6:00 p.m. b) A Licensed Nurse has been placed at bedside during the tube feed and 1 hour after. 2. ADON and Unit Manager rounded on like patients. a) [Resident #32] b) [Resident #8] c) [Resident #29] d) [Resident #1] e) [Resident #20] 3. Retraining and education will be provided to all Licensed Nurses and Certified Nurse Aides following proper policy and procedure for residents receiving tube feedings for proper positioning and elevation of bed. a) Licensed Nurses and Certified Nurse Aides will be required to complete a test post education. b) Education will be provided prior to start of next shift, 3/28/23 10:00 p.m. shift, for oncoming Licensed Nurses and Certified Nurse Aides. c) Education will be completed by 4/4/23 with current staff any new staff will be educated during orientation afterwards. 4) Resident #41 will be observed every meal x 5 days, 2 meals per day for 5 days, then 1 meal per day for 5 days, and PRN afterwards by professional nurse for proper positioning to reduce potential aspiration risk. a) Like residents identified will be audited daily for 1 meal x 5 days by nursing staff. i) Duration will be reviewed after 5 days for continued auditing. 5) Education and audits will be submitted to QAPI for review weekly for the first 3 weeks and then PRN afterwards based on findings. On 09/30/23 at 9:40 AM, the Director of Nursing (DON) stated the facility had no reference source to define semi-Fowler's positioning. The DON presented Internet research showing semi-Fowler's positioning was 30 degree elevation. On 03/29/23, the Nurse Practitioner wrote an order to administer Resident #41's enteral feeding by pump infusion.

Based on observation, medical record review, staff interview, and review of staffing schedules, the facility failed to provide sufficient nursing staff to provide needed care and supervision to all residents residing on the 500 hall/memory care unit. Deployed staffing was not adequate for monitoring the resident population which included residents with dementia, and residents that wandered and were at risk of eloping. Seven (7) residents with dementia-related [DIAGNOSES REDACTED]. The T shaped department was staffed every shift by two (2) people, a nurse and a nurse aide (NA), and contained multiple unsecured, out of sight areas for the residents to wander into unobserved. In addition to the [DIAGNOSES REDACTED].#61, #93, and #75) of the seven (7) residents had care plans for wandering. The front door, an alarmed egress, malfunctioned intermittently, preventing anyone from exiting the building or turning off the alarm if it sounded. Additionally, staff had difficulty hearing the alarm. Observations on 03/29/16 at 10:03 a.m., found the main door at the front of the unit would not open. An incorrect exit code was entered and then the door locked and required maintenance to come and try to get it to open. A faint alarm sounded, but no staff approached in response. Therapy Staff #35 was able to get the door to open by pushing the red button near the door on the outside. According to the staff member, this had happened on other occasions, once just the week before. Therapy Staff #37 attempted to enter the unit by pushing the red button, but the door would not open. No staff were observed on the unit except the two therapy employees. The alarm sounded throughout the time. Therapy Staff #37 came in through the door at the end of that hall. When Maintenance Director #6 entered the unit by the back door, Therapy Staff #35 said to Maintenance Director #6, You need to look at the front door. It won't open, and the alarm won't turn off. This happened last week. After reviewing incident reports and medical records, conducting staff interviews, and multiple observations on the 500 hall/memory care unit, it was determined an immediate jeopardy (IJ) existed for seven (7) of seven (7) residents residing on the 500 hall. On 03/29/16 at 1:45 p.m. the Administrator was notified of the immediate jeopardy. A written notice of the findings and request for a plan to correct the immediacy of the findings was provided to the administrator at 1:45 p.m. p.m. on 03/29/16. At 2:30 p.m., the administrator provided a written corrective action plan for the immediate jeopardy situation. Two tours were conducted by the surveyors to verify corrective measures had been implemented as planned. Observations during the second tour of the unit on 03/29/16 at 3:09 p.m., Dietary Aide #101 walked up to the nurses' station and informed LPN #30 that a resident had walked past the dumbwaiter and entered room [ROOM NUMBER] (a closed room). LPN# 30 admitted she would have never known Resident #93 had left the unit during an interview on 03/29/16 at 3:13 p.m. The surveyor team met with the Administrator on 03/29/16 at 3:44 p.m. When advised of the incident for Resident #93's, the administrator prepared a second plan of abatement which stated All seven residents on 500 hall will be brought up to the 400 wing in main part of building. This was presented on 03/29/16 at 3:44 p.m. As of 4:17 p.m. on 03/29/16, all the residents were back in the main building. An abatement plan of correction was prepared and sent to the State Survey Agency Director. The State agency reviewed and accepted the facility's plan of correction. After all residents moved back to the main building, the immediate jeopardy was removed with no deficient practices remained. Resident identifiers: #61, #93, #94, #76, #54, #75, and #39. Facility census: 92. Findings include: a) During the initial tour of the memory care unit/500 hall with the Director of Nursing (DON) on 03/23/16 at 8:45 a.m., the DON reported the residents residing on the unit were considered appropriate for the future memory care unit. Surveyors were informed plans were in place to renovate this wing in anticipation of licensure for an Alzheimer's unit. Entrance to the unit was made by exiting the main building to the outdoors, walking down a paved sloping roadway and entering through the front door. The DON reported there was no internal access to this unit. The seven (7) residents were residing in rooms 501 through 508, in the main hall between the front door of the unit and the television lounge. A follow up observation of the memory care unit/500 hall on 03/29/16 at 12:00 p.m. found several unsecured and vacant resident rooms located beyond the unlocked and unalarmed fire doors past the television lounge and room [ROOM NUMBER]. An alarmed egress was located at the end of this hall between rooms [ROOM NUMBERS] and was found to not be visible from the nurses' desk because of the closed fire doors. Outside of this door was a small unsecured cement patio. The patio was surrounded by a three (3) foot fence with two (2) unlocked gates. Immediately in front of the patio was a water treatment pond surrounded by a six (6) foot locked fence. The left gate led to a grassy area between other sections of the building and the right unlocked gait had four (4) steps which led to a gravel road and construction zone. There was a ladder to the roof of the building, a dump truck, and a dumpster containing old roofing material. Beyond the gravel road was an unpopulated wooded area. A second unsecured hall was located between the nurses' station and the television lounge, across from room [ROOM NUMBER]. This hall was blocked with two (2) yellow and black cones with a detachable barrier strip between them and contained the laundry services, the food dumbwaiter, a beauty shop, a lounge, a storage area, and five (5) unsecured resident rooms. A secured exit door, not visible from the nurses' station was located at the end of this hall and exited into a grassy area between other sections of the main building. b) Residents residing on the 500 hall/memory care unit: 1) Resident #61 Review of the medical record on 03/29/16 at 10:19 a.m. revealed Resident #61 was transferred to the memory care unit/500 hall on 02/23/16. Her [DIAGNOSES REDACTED]. The quarterly minimum data set (MDS) with an assessment reference date (ARD) of 01/19/16, and the annual MDS with an ARD of 10/19/15, identified the resident wandered one (1) - three (3) days during the 7 day look back period for Item E0900. The care plan, with a revision date of 01/27/16, identified Resident #61's exit seeking behaviors related to her [DIAGNOSES REDACTED]. The interventions include wearing a Wanderguard bracelet and monitoring the resident when close to the door; avoid over stimulation, and removing the resident from the situation when agitated. An incident and accident report with a revision date of 02/28/16, stated Resident #61 exited through the back door onto the unlocked patio on 02/27/16 with the alarm sounding. A staff member from another department found the resident and notified the unit nurse, Licensed Practical Nurse (LPN) #74. The nursing progress notes, dated 03/26/16, stated LPN #74 observed the resident exit out the alarming front door onto the sidewalk. LPN #74 documented the resident returned to the unit after much encouragement and a third Wanderguard bracelet was applied to the resident. During an interview on 03/29/16 at 12:50 p.m. Nurse Aide (NA) #64 reported Resident #61 had three (3) Wanderguard bracelets on because they do not alarm if covered up, She likes to pull her socks up over them. These were two (2) separate incidents. Review of incident reports found the resident went out the back door on 02/27/16. On 03/2616, which was a Saturday, there was a progress note in the computer stating she had gotten out the front door, but no written incident report was filed. 2) Resident #93 Review of the medical record on 03/30/16 at 8:00 a.m. revealed Resident #93 was moved to the 500 hall/memory care unit on 02/23/16. Her [DIAGNOSES REDACTED]. The annual MDS with an ARD of 02/02/16, noted the resident wandered daily and had a Brief Interview for Mental Status (BIMS) of three (3) - indicating severe cognitive impairment. The care plan, with a revision date of 03/29/16, noted Resident #93's [DIAGNOSES REDACTED]. The interventions included a Wanderguard bracelet, redirect the resident when wandering towards the outside doors, and observe frequently and place in supervised area when out of bed. Observations during a second tour of the unit on 03/29/16 at 3:08 p.m. noted Resident #93 left her walker next to the yellow and black caution cones and detachable barrier and walked down the unsecured and unused short hall of the department; unobserved by either staff member working on the unit at that time. At 3:09 p.m. on 03/29/16, Dietary Aide #101 walked up to the nurse's station and informed LPN #30 that a resident had walked past the dumbwaiter and entered room [ROOM NUMBER] (a closed room). LPN #30 found a walker sitting next to the caution cones and detachable barrier strap; she walked down the closed hall past the dumbwaiter accompanied by Dietary Aide #101 opened the door to room [ROOM NUMBER] and found Resident #93 standing next to the wall. During an interview immediately after this observation, LPN #30 admitted she would not have known where the resident was if the Dietary Aide had not notified her. Registered Nurse (RN) #92, during an interview on 03/29/16 at 11:00 a.m., acknowledged that with dementia residents there was always a risk for elopement and two (2) staff members per shift was not enough. She said she takes her break on the unit, but some staff leave for smoke breaks and that leaves one (1) person on the unit with seven (7) residents. On 03/23/16 at 3:20 p.m., Nurse Aide (NA) #27 reported she planned care around the residents' activities. It was easier to shower a resident when the other residents were napping and the nurse could help monitor the other residents. 3) Resident #94 Resident #94's medical record, reviewed on 03/30/16 at 11:30 a.m., found this [AGE] year-old transferred to the 500 hall/memory care unit on 02/23/16. Her [DIAGNOSES REDACTED]. The quarterly MDS with an ARD of 03/11/13 noted the resident had inattention and disorganized thinking continuously present. The care plan, updated 01/14/16, addressed the resident's cognitive loss and risk for decline in activities of daily living related to dementia and [MEDICAL CONDITION]. Plans of action included consistent routines/caregivers, allow adequate time to respond, do not rush the resident, and check every two (2) hours for comfort, positioning, pain, and needs. 4) Resident #76 Review of the resident's medical record on 03/30/16 at 11:00 a.m., revealed this [AGE] year-old man transferred to the 500 hall/memory care unit on 02/23/16. His [DIAGNOSES REDACTED]. His care plan with a revision date of 03/29/16, identified his dementia with cognitive loss. He required verbal cues for names, room location, and activity reminders. 5) Resident #54 Review of the resident's medical record on 03/30/16 at 8:35 a.m., revealed this [AGE] year-old woman transferred to the 500 hall/memory care unit on 02/23/16. Her [DIAGNOSES REDACTED]. The MDS with an ARD of 02/09/16, assessed the Brief Interview for Mental Status (BIMS) as 99 (unable to determine mental status), with moderately impaired cognition, inattention and disorganized thinking. Her care plan, revised on 04/04/16, identified the resident was dependent on others for environmental stimuli. She needed encouragement to remain active and required hands on assistance to complete tasks. Resident #54 had hallucinations and could present with anger. She required assistance with activities of daily living (ADLS) because of muscle weakness, [MEDICAL CONDITION], and dementia. 6) Resident #75 The resident's medical record, reviewed on 04/06/16 at 12:00 p.m., revealed this [AGE] year-old woman transferred to the 500 hall/memory care unit on 02/23/16. Her [DIAGNOSES REDACTED]. The significant change MDS with an ARD of 01/17/16, identified the resident's BIMS score as one (1) - indicating severe cognitive impairment with inattention and disorganized thinking and rejection of care at times. The current care plan, with a revision date of 03/24/16, identified the use of a Wanderguard bracelet, short and long-term memory problems with decision-making impairment related to [MEDICAL CONDITION] and dementia. 7) Resident #39 Review of the resident's medical record on 04/06/16 at 12:30 p.m., revealed this [AGE] year-old woman's [DIAGNOSES REDACTED]. She was transferred to the memory care unit/500 hall on 02/23/16. Her quarterly MDS, with an ARD of 02/09/16, identified the resident required supervision to minimal assistance with ADLS. Her care plan, updated 03/29/16, identified her history of a [MEDICAL CONDITION], mildly impaired cognition, and TIAs. She required some assistance with ADLS related to TIAs, muscle weakness, and walking difficulties. c) Staffing schedules On 03/30/16 at 11:45 a.m., review of the nursing schedules for March and April 2016 verified the unit was staffed every shift with two (2) people, a nurse and a nurse aide. d) Staff interviews During an interview on 03/23/16 at 12:00 p.m. Licensed Practical Nurse (LPN) #124 reported the 500 hall was currently staffed with two (2) people every shift and in an emergency the unit would have to call upstairs for assistance. There were no plans put into place. No certain number to call to guarantee someone would answer and provide assistance. The future unit director, RN #100, the current MDS nurse, was working on these plans. Registered Nurse (RN) #92, during an interview on 03/29/16 at 11:00 a.m., acknowledged that with dementia residents there was always a risk for elopement and two (2) staff members per shift was not enough. She said she took her break on the unit, but some staff left for smoke breaks and that left one (1) person on the unit with seven (7) residents. On 03/23/16 at 3:20 p.m., Nurse Aide (NA) #27 reported she planned care around the residents' activities. It was easier to shower a resident when the other residents were napping and the nurse could help monitor the other residents. During an interview on 03/29/16 at 1:15 p.m., the unit director, RN #100, reported the facility had a staffing plan in place when the residents were moved to the 500 hall/memory care unit. The plan did not work and the 500 hall staff was maintained with two (2) people per shift. She stated the corporation deemed two (2) staff members per shift was adequate for the unit. RN #100 remained silent when asked if she thought this was adequate staffing for the seven (7) residents currently residing on the 500 hall/memory care unit.

Based on observation, record review and staff interview the facility failed to ensure the resident environment remained as free of accident hazards as possible and that each resident received adequate supervision to prevent accidents. Seven (7) residents resided on the 500 hall/Memory Care Unit (MCU), a separate unit isolated from other parts of the building. The T shaped department was staffed every shift by two (2) people, a nurse and a nurse aide (NA), and contained multiple unsecured, out of sight areas for the residents to wander into unobserved. Three (3) (Residents #61, #93, and #75) of the seven (7) residents had care plans for wandering. The front door, an alarmed egress, malfunctioned intermittently, preventing anyone from exiting the building or turning off the alarm if it sounded. Additionally, staff had difficulty hearing the alarm. Observations on 03/29/16 at 10:03 a.m., found the main door at the front of the unit would not open. An incorrect exit code was entered and then the door locked and required maintenance to come and try to get it to open. A faint alarm sounded, but no staff approached in response. Therapy Staff #35 was able to get the door to open by pushing the red button near the door on the outside. According to the staff member, this had happened on other occasions, once just the week before. Therapy Staff #37 attempted to enter the unit by pushing the red button, but the door would not open. No staff were observed on the unit except the two therapy employees. The alarm sounded throughout the time. Therapy Staff #37 came in through the door at the end of that hall. When Maintenance Director #6 entered the unit by the back door, Therapy Staff #35 said to Maintenance Director #6, You need to look at the front door. It won't open, and the alarm won't turn off. This happened last week. After reviewing incident reports and medical records, conducting staff interviews, and multiple observations on the 500 hall/memory care unit, it was determined an immediate jeopardy (IJ) existed for seven (7) of seven (7) residents residing on the 500 hall. On 03/29/16 at 1:45 p.m. the Administrator was notified of the immediate jeopardy. A written notice of the findings and request for a plan to correct the immediacy of the findings was provided to the administrator at 1:45 p.m. p.m. on 03/29/16. At 2:30 p.m., the administrator provided a written corrective action plan for the immediate jeopardy situation. Two tours were conducted by the surveyors to verify corrective measures had been implemented as planned. Observations during the second tour of the unit on 03/29/16 at 3:09 p.m., Dietary Aide #101 walked up to the nurses' station and informed LPN #30 that a resident had walked past the dumbwaiter and entered room #524 (a closed room). LPN# 30 admitted she would have never known Resident #93 had left the unit during an interview on 03/29/16 at 3:13 p.m. The surveyor team met with the Administrator on 03/29/16 at 3:44 p.m. When advised of the incident for Resident #93's, the administrator prepared a second plan of abatement which stated All seven residents on 500 hall will be brought up to the 400 wing in main part of building. This was presented on 03/29/16 at 3:44 p.m. As of 4:17 p.m. on 03/29/16, all the residents were back in the main building. An abatement plan of correction was prepared and sent to the State Survey Agency Director. The State agency reviewed and accepted the facility ' s plan of correction. After all residents moved back to the main building, the immediate jeopardy was removed with no deficient practices remained. Resident identifiers: #61, #93, #76, #94, #75, #39, and #54. Facility census: 92. Findings include: a) Memory care unit/500 hall During the initial tour of the Memory Care Unit (MCU)/500 hall with the Director of Nursing (DON) on 03/23/16 at 8:45 a.m., the DON said they closed the assisted living unit and plans were in place to renovate this wing in anticipation of licensure for an Alzheimer's unit. To gain entrance to the unit from the main part of the building required exiting the main building to the outdoors, walking down a paved hill and entering through the front door. The DON reported there was no internal access to this unit. The seven (7) residents resided in rooms 501 through 508, in the main hall between the front door of the unit and the television lounge. A follow up observation of the MCU/500 hall on 03/29/16 at 12:00 p.m. found the following: 1. Main hall -- Several unsecured and unused resident rooms located beyond the unlocked and unalarmed fire doors past the television lounge and room 508. -- An alarmed egress was located at the end of this hall between rooms 515 and 516, which was not visible from the nurses' desk because of the closed fire doors, -- Outside of this door was a small-unsecured cement patio. A three (3) foot high fence with two (2) unlocked gates surrounded the patio. -- Immediately in front of the patio was a water treatment pond surrounded by a six (6) foot high locked fence. -- The left unlocked gate in the fence around the patio led to a grassy area between other sections of the building and the right unlocked gait had four (4) steps that led to a gravel road and construction zone. -- In the construction zone, there was a ladder to the roof of the building, a dump truck, and a dumpster containing old roofing material. -- Beyond the gravel road was an unpopulated wooded area. 2. Second hall -- A second unsecured hall, located between the nurses' station and the television lounge, across from room 506, had two (2) yellow and black cones with a detachable barrier strip between them blocking the hall. -- This hall contained the laundry services, the food dumbwaiter, a beauty shop, a lounge, a storage area, and five (5) unsecured resident rooms. -- There was a secured exit door, not visible from the nurses' station, located at the end of this hall. The door exited to a grassy area between other sections of the main building. On 03/30/16 at 11:45 a.m., review of the nursing schedules for March and April 2016 verified the unit was staffed every shift with two (2) staff members, a nurse and a nurse aide. Observations on 03/29/16 at 10:03 a.m., found the main door at the front of the unit would not open. An incorrect exit code was entered and then the door locked and required maintenance to come and try to get it to open. The door had a doorknob and a metal latch at the top. The door had a sign that said there was no push bar, but one was ordered. A faint alarm sounded, but no staff approached in response. Then at 10:05 a.m., Therapy Staff #35 came to the front door from outside and was able to get it to open by pushing the red button near the door on the outside. According to the staff member, this had happened on other occasions, once just the week before. At 10:08 a.m., Therapy Staff #37 approached the door. She was told to push the red button. She did, but the door would not open. At 10:13 a.m., she was told to go around the back way. Observations during this time, found no staff except the two therapy employees. The alarm sounded throughout the time. Therapy Staff #37 came through the hall that had barriers up saying Caution with two black and yellow cones and barrier tape stretched between them. Therapy Staff #37 said he/she came in through the door at the end of that hall. Then Maintenance Director #6 entered the unit by that door. Therapy Staff #35 said to Maintenance Director #6, You need to look at the front door. It won't open, and the alarm won't turn off. This happened last week. A second observation from 11:00 a.m. until 12:01 p.m., found the main entrance door would open, but the alarm system was not functioning. Registered Nurse #92, during an interview at 11:00 a.m., acknowledged there was a risk of elopement, but said there had never been any elopements. When advised Resident #61 had eloped on 03/26/16 and found outside by a nurse, she said she was unaware of any elopements and acknowledged that staffing of two (2) persons for the unit was not sufficient to permit adequate monitoring of all residents. While conducting additional interviews and observations at 11:29 a.m., Housekeeper #28 said, the door hasn't been broken long, only a week or two. Observations at that time found the doorknob to go out had been removed and the door opened with a push. The alarms were turned off. Some residents were at lunch, and some were sitting in their rooms. No staff were monitoring the exit. Unit Director RN #100, in an interview on 03/29/15 at 1:15 p.m., acknowledged the front door had been an issue since the residents were moved to the unit. Staff could not hear the alarm and they had been asking for it to be repaired. c) Immediate Jeopardy After reviewing incident reports and medical records, conducting staff interviews, and multiple observations on the 500 hall/memory care unit, it was determined an immediate jeopardy (IJ) existed for seven (7) of seven (7) residents residing on the 500 hall. On 03/29/16 at 12:26 p.m., the findings were relayed to the Office of Health Facility Licensure and Certification (OHFLAC) for review and the decision was made to identify this as an Immediate Jeopardy (IJ). On 03/29/16 at 1:45 p.m., the Administrator was notified of the immediate jeopardy. A written notice of the findings and request for a plan to correct the immediacy of the findings was provided to the administrator at 1:45 p.m. p.m. on 03/29/16. At 2:30 p.m., the administrator provided a written corrective action plan for the immediate jeopardy situation. There corrective actions were for an employee to monitor the front door for a 24 hour watch until the door was fixed, and an additional nurse aide or staff member would be added to each shift for all three shifts. Two (2) tours were conducted by the surveyors to verify corrective measures had been implemented as planned. Observations during the second tour of the unit on 03/29/16 at 3:08 p.m., found Dietary Supervisor #81 sitting at the front of the building with a resident monitoring the front door, Licensed Practical Nurse (LPN) #30 sitting in the nurses' station charting on the computer. Nurse Aide (NA) #27 sitting in the TV lounge with a few of the residents. At 3:09 p.m. on 03/29/16, Dietary Aide #101 walked up to the nurse's station and informed LPN#30 that a resident had walked past the dumbwaiter and entered room #524 (a closed room). LPN#30 found a walker sitting next to the caution cones and detachable barrier strap; she walked down the closed hall past the dumb waiter accompanied by Dietary Aide #101, opened the door to room #524 and found Resident #93 standing next to the wall. LPN# 30 admitted she would have never known Resident #93 had left the unit during an interview on 03/29/16 at 3:13 p.m. The surveyor team met with the Administrator on 03/29/16 at 3:44 p.m. When advised of this, the administrator prepared a second plan of abatement, which stated All seven residents on 500 hall will be brought up to the 400 wing in main part of building. This was presented on 03/29/16 at 3:44 p.m. As of 4:17 p.m. on 03/29/16, all the residents were back in the main building. An abatement plan of correction was prepared and sent to the State Survey Agency Director. The State agency reviewed and accepted the facility's plan of correction. After all residents moved back to the main building, the immediate jeopardy was removed with no deficient practices remained. b) Wandering residents residing on the 500/Memory Care Unit These three (3) resident were not provided with supervision to prevent accidents. 1. Resident #61 Review of the resident's medical record on 03/29/16 at 10:19 a.m., revealed Resident #61 transferred to the memory care unit/500 hall on 02/23/16. The resident's [DIAGNOSES REDACTED]. The quarterly minimum data set (MDS) with an assessment reference date (ARD) of 01/19/16, and the annual MDS with an ARD of 10/19/15, identified the resident wandered one (1) - three (3) days during the 7 day look back period in E0900. The resident's care plan, with a revision date of 01/27/16, identified Resident #61's exit seeking behaviors were related to her [DIAGNOSES REDACTED]. The interventions include wearing three (3) Wanderguard bracelets and monitoring the resident when close to the door; avoid over stimulation, and removing the resident from the situation when agitated. Two separate incidents were found regarding Resident #61's wandering. An incident report, dated 02/27/16 documented the resident went out the back door. On 03/2616, which was a Saturday, there was a progress note in the computer stating she had gotten out the front door. The incident report with a revision date of 02/28/16, stated Resident #61 exited through the back door onto the unlocked patio on 02/27/16 with the alarm sounding. A staff member from another department found the resident and notified the unit nurse, Licensed Practical Nurse (LPN) #74. The nursing progress note dated 03/26/16 stated LPN #74 observed the resident exit out the alarming front door onto the sidewalk. LPN #74 documented the resident returned to the unit after much encouragement and a third Wanderguard bracelet was applied to the resident. During an interview on 03/29/16 at 12:50 p.m., Nurse Aide (NA) #64 reported Resident #61 had three (3) Wanderguard bracelets on because they do not alarm if covered up, She likes to pull her socks up over them. 2. Resident #93 Review of the resident's medical record on 03/30/16 at 8:00 a.m., revealed Resident #93 moved to the 500 hall/memory care unit on 02/23/16. Her [DIAGNOSES REDACTED]. The annual MDS, with an ARD of 02/02/16, noted the resident wandered daily and had a Brief Interview for Mental Status (BIMS) of three (3), indicating severe cognitive impairment. The care plan, with a revision date of 03/29/16, noted Resident #93's [DIAGNOSES REDACTED]. The interventions include a Wanderguard bracelet, redirect the resident when wandering towards the outside doors, and, Observe frequently and place in supervised area when out of bed. Observations during a second tour of the unit on 03/29/16 at 3:08 p.m. noted Resident #93 left her walker next to the yellow and black caution cones and detachable barrier and walked down the unsecured and unused short hall of the department; unobserved by either staff member working on the unit at that time. At 3:09 p.m. on 03/29/16, Dietary Aide #101 walked up to the nurses' station and informed LPN #30 that a resident had walked past the dumbwaiter and entered room #524 (a closed room). LPN #30 found a walker sitting next to the caution cones and detachable barrier strap; she walked down the closed hall past the dumbwaiter accompanied by Dietary Aide #101, opened the door to room #524 and found Resident #93 standing next to the wall. During an interview immediately after this observation, LPN #30 admitted she would not have known where the resident was if the Dietary Aide had not notified her. 3. Resident #75 Review of the medical record on 04/06/16 at 12:00 p.m. revealed Resident #75, a [AGE] year-old woman, transferred to the 500 hall/memory care unit on 02/23/16. Her [DIAGNOSES REDACTED]. The significant change MDS, with an ARD of 01/17/16, noted the resident's BIMS score was one (1), indicating severe cognitive impairment with inattention and disorganized thinking and rejection of care at times. The current care plan, with a revision date of 03/24/16, identified the use of a Wanderguard bracelet, and that the resident had short and long-term memory problems with decision-making impairment related to Alzheimer's disease and dementia. Registered Nurse (RN) #92, during an on 03/29/16 at 11:00 a.m., acknowledged that with dementia residents there was always a risk for elopement and two (2) staff members per shift was not enough. She said she took her breaks on the unit, but some staff left for smoke breaks and that left one (1) person on the unit with seven (7) residents. On 03/23/16 at 3:20 p.m., Nurse Aide (NA) #27 reported she planned care around the residents' activities. It was easier to shower a resident when the other residents were napping and the nurse could help monitor the other residents.

Based upon observation, record review, staff interview, and policy review, the facility was not administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. The facility failed to make an appropriate corrective response to concerns identified by the consultant pharmacist, failed to operationalize its policies and procedures for the prevention, reporting, and investigation of abuse/neglect, and was cited for immediate jeopardy for insufficient monitoring and supervision to ensure residents' safety. These deficient practices had the potential to affect all residents. Facility census: 92. Findings include: a) The facility was cited for failure to recognize and implement corrective measures for pharmacy reviews that identified blank signature/initial areas for reconciliation of the shift to shift controlled substances counts for five (5) of five (5) hallways/units. b) The facility failed to implement and operationalize its policies to prevent neglect. Written reports of incidents or accidents in which a resident was involved were not consistently completed, and injuries of unknown origin were not reported or investigated. c) An immediate jeopardy was identified related to the failure of the facility to ensure the residents' environment remained as free of accident hazards as possible and each resident received adequate supervision to prevent accidents. The citations related to elopements and injuries of unknown origin on the 500 wing. d) The review found Administration should have been aware of the concerns reported by the consultant pharmacist and working to ensure those concerns were addressed. Administration should also have been aware of the concerns regarding abuse/neglect including injuries of unknown origin, and the concerns regarding incidents/accidents including elopements, falls, and injuries of unknown origin. Systemic failures such as the failure to consistently complete a written report of any incident or accident involving a resident and to investigate all injuries of unknown origin caused some of the usual means of communication to management to miss critical information, including instances resulting in actual harm to residents. There was evidence staff were oriented and received education on abuse/neglect reporting, investigation, and prevention, review facility policies and incidents reported to the appropriate State agencies and investigated, found although each staff member was a mandatory reporter, there was a failure to consistently recognize, report, and investigate injuries of unknown origin. There was also a failure to consistently recognize the critical system need to complete Written reports for resident elopements, falls, and injuries of unknown origin.

Based on medical record review and staff interview, the facility failed to ensure a resident was provided with the assistance she required as identified in her comprehensive plan of care. Resident #37 experienced pain and anxiety after falling out of bed when a staff member failed to provide care in accordance with the resident's assessed needs. This avoidable incident resulted in the actual harm to the resident. One (1) of twenty-seven (27) Stage 2 residents was affected. Resident identifier: #37. Facility census: 92. Findings include: a) Resident #37 Review of Resident #37's medical record on 03/28/16 at 1:20 p.m., found a nursing progress written by Licensed Practical Nurse (LPN) #130 on 03/04/16 stating, RNA (registered nurse aide) came out of resident's room to get this nurse. She stated that resident rolled out of bed and was on the floor. Resident assessed and noted to have c/o (complaints of) pain to her left shoulder, wrist, knee and hip. She had a slight nose bleed to left nares (nostril). The resident was urgently transferred to the hospital for evaluation. The nursing progress note dated 03/05/16 at 11:54 a.m. stated (typed as written), . Resident terrified whenever staff does personal care, and when repositioned. Resident reassured by having several staff members present when doing care. Given PRN (as needed) [MEDICATION NAME] for general pain . Requested to stay in bed due to being sore. Niece in to visit. After speaking with her and resident, call placed to MD (Medical Doctor) about increasing pain medication until she feels better from . Message left According to the minimum data set (MDS) assessment, with an assessment reference date (ARD) of 12/03/15, the resident required the extensive assistance of two (2) person for bed mobility and was totally dependent on two (2) people for transfers. The care plan, updated on 03/14/16, included a Focus of Resident requires extensive assist to remain clean, neat and free of body odors due to: history of falls, muscle weakness, depression, [MEDICAL CONDITIONS] and generalized pain. The interventions were, Plan of care per Kardex. The nursing Kardex stated under Transferring . 2 staff for bed mobility, 2 staff for repositioning and incontinence care. Review of incident reports on 03/29/16 at 9:00 a.m., revealed Resident #37 had rolled out of bed onto the floor on 03/04/16. The witness's statement was, RNA (registered nurse aide) states that she was turning resident to change her bedding and when she turned her on her side she just kept turning and rolled out of bed. She was on the opposite side of the bed. In an interview on 03/31/16 at 9:00 a.m., Nurse Aide (NA) #49 reported Resident #37 required assistance with all of her activities of daily living (ADLS) including transferring and repositioning. The resident's needs were listed on the computerized Kardex system (a system to communicate the care needs of the individual resident to direct care staff). Resident #37 had been a two (2) person reposition and lift since this NA started working in January 2016. Licensed Practical Nurse (LPN) #130 reported during an interview on 04/05/16 at 1:30 p.m., Resident #37, . is now scared to death of falling. The facility provided the resident with a wider bed to assist with her anxiety related to falling out of bed during care. This avoidable incident resulted in actual harm to the resident as she experienced pain, had to be sent to a hospital, and had persisting anxiety about falling out of bed.

Based on staff interview, resident interview, and record review, the facility failed to ensure four (4) of five (5) residents reviewed, who had pressure ulcers, were provided necessary treatment and services to prevent the development of avoidable pressure ulcers and/or the worsening of existing pressure ulcers. Residents developed Stage III pressure ulcers, suspected deep tissue injury (SDTI) or unstageable pressure ulcers before staff identified skin impairment. Additionally, staff failed to complete skin assessments and/or conduct accurate skin evaluations. Resident identifiers: Resident #81, #48, #22 and #32. Facility census: 85. Findings include: a) Resident #81 Review of the pressure ulcer list, provided by the director of nursing (DON), indicated Resident #81 had a Stage III pressure ulcer on her left buttocks, a Stage III pressure ulcer on her right buttocks, and a Stage III pressure ulcer on her coccyx. The list did not identify if the resident was admitted with the areas, or whether they were acquired in-house. During an observation and interview with Resident #81, at 9:07 a.m. on 12/02/14, she nodded "yes" she was admitted with a pressure ulcer, and indicated staff provided peri-care and assisted with repositioning in bed. She related she did not take showers. The resident related she experienced pain daily. Resident #81 related her "backside hurts." Although the resident was on a pressure relieving mattress, she indicated it was "not really comfortable." Observation revealed the resident resting in high Fowler's position, leaning to her right, with a wedge beneath her lower legs. Her heels were resting on the bed. Resident #81 related she did not get out of bed, related to personal choice. At the conclusion of the interview, Resident #81 requested staff be notified she needed something for pain in her back and buttocks. Observation of the wounds, at 9:58 a.m. on 12/02/14, revealed three (3) pressure ulcers. Licensed practical nurse (LPN) #66 related the pressure area on the coccyx was acquired in-house. She related she identified it during wound rounds. Observation of the coccyx wound revealed an elongated area with slough and dark brown/black tissue. Upon inquiry as to whether the facility utilized treatment nurses, LPN #66 related, "A lot of days nurses do their own treatments." During an interview with LPN #22, on 12/03/14 at 3:00 p.m., the nurse related the pressure ulcer on the coccyx started as a small abraded area. The LPN confirmed she did not note the area, report it, or complete an assessment at the time of discovery, "Because it was covered by the same dressing as other wounds." Further review of the electronic record, on 12/02/14 at 3:00 p.m., revealed a physician's orders [REDACTED].#81's left outer foot. An interview with LPN #66, on 12/03/14 at 1:45 p.m., revealed she found the blister while assisting Nurse Aide (NA) #36 to pull the resident up in bed and cover the resident's feet. LPN #66 said staff turned and positioned the resident every hour. The LPN related all staff should have been observant of the resident's skin and should have immediately reported any change in condition. The nurse related she reported it to LPN #22. An interview with NA #110, on 12/02/14 at 5:00 p.m., revealed the resident required assistance of two (2) for activities of daily living (ADL) care. She indicated the resident received a bed bath on the 2-10 shower shift. She also related the resident had a wedge to float her heels. NA #110 related she should report any changes in condition to the nurse, such as redness or any change, and the wound nurse would look at the area. An interview with the clinical care manager (CCC) #16, on 12/03/14 at 5:00 p.m., revealed he updated the care plan and sometimes discussed an issue with the nurse floor nurse, about appropriate interventions. He indicated the wound care nurse became involved. Upon inquiry, he related he did not recall when wounds were last discussed, but confirmed they were not discussed within the previous two (2) days. He reported he approved treatment plans and PUSH (pressure ulcer scale for healing) tools. He said he was not aware of a new pressure area acquired on 12/02/14. Upon inquiry, the clinical care supervisor related communication was relayed verbally, via 24 hour reports, and in skin audit records. Review of the 24 hour reports revealed no evidence of communication regarding the blister to the resident's left outer heel. Additionally, the CCC asked medical records staff to assist with finding skin audits completed on shower days. Medical records employee #100 reviewed the records and related she could find no skin observation reports for Resident #81 for the months of October, November, and December 2014. The facility's procedure was for nursing assistants to document skin observations, and for nurses to review them. Licensed nursing staff did not complete routine skin audits. b) Resident #48 Review of the pressure ulcer list, on 12/01/14, indicated Resident #48 had developed two (2) pressure ulcers. An interview with NA #43, on 12/03/14 at 9:45 a.m., revealed Resident #48 required total care with assistance of two (2) persons. She related he was "tough to roll" and staff "usually worked in pairs." She indicated the resident received a complete bed bath on Tuesdays and a shower on Fridays, affording staff a minimum of twice weekly skin audits. Review of the skin observation reports from October 2014 - December 2014, with Registered Nurse (RN) #16, revealed evidence of only one (1) observation, dated 10/31/14. At that time, staff noted the resident's skin as "normal." Employee #16 confirmed he had no evidence to indicate staff monitored and reported skin impairments in a timely manner. c) Resident # 22 Review of the weekly skin ulcer report revealed Resident #22 developed three (3) pressure ulcers identified as a Stage 3 at the time of discovery. Review of the resident's skin observation reports for November 2014 and December 2014 revealed skin observation reports were completed for only two (2) of nine (9) opportunities. Upon inquiry, RN #16 could provide no evidence staff completed and reported skin conditions in a timely manner. The interview with LPN #66 revealed there were standing orders for treatment orders, including physician notification for Stage 3 or Stage 4 wounds. The nurse related either nursing assistants were not reporting, or licensed staff were not completing a follow-up. The LPN related some wounds were identified when the dressings were changed. An interview with the administrator and director of nursing (DON), on 12/03/14 at 3:30 p.m., revealed quality assurance meetings were usually conducted monthly and risk management meetings were held weekly. They indicated facility acquired pressure ulcers which were first identified as a Stage III, suspected deep tissue injury (SDTI), or unstageable was an identified issue; however, the affected residents were viewed independently, and the in-house acquisition of these areas was not identified as a systems failure. Review of the weekly pressure ulcer reports revealed the facility acquired new or re-opened areas as follows: -- August 2014: (3) Stage III and one (1) SDTI -- September 2014: (4) Stage III -- October 2014: four (4) Stage III and one (1) SDTI -- November 2014: one (1) Stage III, two (2) SDTI, and one (1) stage IV reopened The DON and CCC were unable to provide evidence staff had been educated about pressure ulcers since February 2014. They confirmed the facility should have monitored skin, and identified and treated the pressure ulcers before they reached a Stage III, SDTI or unstageable status. . . d) Resident #32 On 12/03/14 at 9:00 a.m., review of Resident #32's medical record revealed the resident was identified with a new onset Stage III pressure ulcer to the right lower buttock on 10/27/14. The pressure ulcer measured 0.5 centimeters (cm) by 0.9 cm by 0.2 cm. New treatment orders included Santyl to debride the wound, and collagen border foam dressings. The area closed the week of 11/04/14. During an interview with LPN #66, on 12/03/14 at 11:50 a.m., she said a Stage III pressure ulcer on the ischial area of Resident #32 was first discovered on 10/27/14. Upon inquiry, Employee #66 clarified that on 10/27/14, she was alerted by a staff member to look at the resident's newly discovered wound. LPN #66 said she assessed the wound immediately, and found that it was already at a Stage III level. She said the wound contained slough at that time, but she could still see the wound bed. She said there was no known discoloration of the skin, or pressure ulcer treatment, prior to the wound's discovery at the Stage III level on 10/27/14. On 12/03/14 at 3:30 p.m., an interview was conducted with the administrator and with the director of nursing (DON). They acknowledged Resident #32 developed a pressure ulcer in October, 2014, which advanced to a Stage III pressure ulcer before it was initially discovered by facility staff. They said Resident #32 had decreased mobility, and the pressure ulcer came on quickly. They said the ulcer also healed quickly. The DON said she did not know why it was at a Stage III level when it was initially discovered. .