Every finding on record at The Villa Rehab

Based on interview and record review, the facility failed to protect 1 of 4 residents (Resident #1) from verbal abuse by a Licensed Nursing Assistant (LNA). Findings include:Per interview on 5/26/26 at 12:48 PM with a Licensed Practical Nurse (LPN), she reported that she was the nurse on duty on 2/16/26 at approximately 1 to 2 AM, who witnessed and reported an LNA for abuse against Resident #1. The LPN stated that the LNA came up close to her when she was at the med cart and cursed saying that the LPN better go get Resident #1 and then cursed again stating Resident #1 had just urinated in their face. The LPN then walked into Resident #1's room and saw that s/he was standing there naked, with urine on the floor, and that s/he looked terrified. The LPN reported that while assisting Resident #1 with care, the LNA then came in the room and cursed at Resident #1 about how s/he urinated in the LNA's face.Per record review of Resident #1's progress notes, there is a note titled Incident Note dated 2/17/26 that states that an LNA went into Resident #1's room and cursed at the resident about how they urinated in the LNA's face. The note then mentions that the Resident looked startled and terrified.Per review of the facility investigation titled Complaint Investigation with the date of the complaint as 2/16/26, it states that the Employee was seen yelling at and using profanity at a resident after urine accidentally splashed on his face. This employee then stated he wanted to punch [him/her] (resident) in the face because he was so mad.Per review of Resident #1's medical diagnosis, they have a diagnosis of dementia.Per review of the reasonable person concept, a person with intact mental status (without a diagnosis of dementia or disease process that affects a person's response) would have experienced mental anguish as a result of being left undressed and then sworn and yelled at by a staff member.Per review of the facility policy titled Abuse, Suspicious Crimes & Resident to Resident Incident Investigating/Reporting reviewed on 1/7/26 it states Our Facility will not permit our residents to be subject to abuse by anyone, including staff members, other residents, family members, legal guardians, friends, consultants, volunteers, sponsors, staff of other agencies serving the residents or other individuals. The policy then defines verbal abuse; is defined as any use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance, regardless of their age, ability to comprehend or disability. Examples would be, but are not limited to: threats of harm, saying things to frighten a resident, telling a resident they will never see their family again, etc.

Based on interview and record review, the facility failed to submit their five-day investigative report to the Division of Licensing and Protection within the allotted time. Findings include:Per interview on 5/26/26 at 12:48 PM with a Licensed Practical Nurse (LPN), she reported that she was the nurse on duty on 2/16/26 at approximately 1 to 2 AM, who witnessed and reported a Licensed Nursing Assistant (LNA) for abuse against Resident #1. The LPN stated that the LNA came up close to her when she was at the med cart and cursed saying that the LPN better go get Resident #1 and then cursed again stating Resident #1 had just urinated in their face. The LPN then walked into Resident #1's room and saw that s/he was standing there naked, with urine on the floor, and that s/he looked terrified. The LPN reported that while assisting Resident #1 with care, the LNA then came in the room and cursed at Resident #1 about how s/he urinated in the LNA's face. Refer to F600 for more information.Per interview on 5/26/26 at 1:18 PM with the Director of Nursing and Administrator, the Administrator stated she could not find the five-day investigative report for this incident and was unable to provide evidence that they had submitted the required five-day investigative report in a timely manner.Per review of the facility policy titled Compliance with Reporting Allegations of Abuse/Neglect/Exploitation reviewed 1/7/26, it states that the facility will report all alleged and substantiated incidents to the state agency and other agencies as required and that the Administrator will follow up with the appropriate agencies, and Within 5 working days of the incident, report sufficient information to describe the results of the investigation, and indicate any corrective actions taken, if the allegation was verified.Per review of the facility policy titled Abuse, Suspicious Crimes & Resident to Resident Incident Investigating/Reporting reviewed on 1/7/26 it states that Within 5 working days the Social Worker, Director of Nursing Services and/or Administrator, will complete a thorough investigation of the reported abuse, suspicious crime or resident to resident incident. This person will complete the Facility Reported Incidents-Investigative Summary Form. These results will be sent to the Division of Licensing and Protection, Adult Protective Services, and the Local Law Enforcement Office when being used.

Based on interview and record review, the facility failed to ensure 1 of 3 residents sampled was provided with adequate supervision and assistance devices to prevent accidents (Resident #1), by failing to systematically evaluate the effectiveness of interventions or revise care plan interventions after falls occurred. As a result, Resident #1 suffered a fall and sustained significant fractures in both ankles. This is a repeat deficiency with the violation cited during a previous complaint survey dated 7/30/25. Findings include:Per record review, Resident #1 is assessed as having cognitive impairment, with diagnoses which include Alzheimer's Disease, osteoarthritis of the knee and muscle weakness. Resident #1 is dependent on staff for activities of daily living and hygiene and requires a mechanical lift for transfers. Per record review of a Fall Risk Evaluation on 12/30/25 scores the resident as an 11 out of 32 and is at risk for falls. Per record review of a Fall Risk Evaluation on 1/13/26 scores the resident as a 13 out of 32 and is at risk for falls.Per the facility's Fall risk, fall prevention and post-fall protocol policy [last revised 1/7/26] states, 3. For residents determined to be at risk for falls, prevention strategies and an At risk for Falls care plan will be implemented. Strategies will be based on results of the fall risk assessment resident's individualized care plans related to falls will include interventions, including adequate supervision, consistent with a resident's needs, goals, and current standards of practice in order to reduce the risk for falls.9. The interdisciplinary team will monitor the effectiveness of the care plan interventions, and modify the interventions as necessary, in accordance with current standards of practice.Per record review, Resident #1 has a care plan for being at risk for falls, which included interventions of: Assess presence of drugs that may cause falls, Encourage resident to get in bed when tired Involve in activity programs as tolerated, and Maintain safety (call bell within reach, bed in lowest position, proper lighting, appropriate footwear etc).Per review of physician notes, the resident fell on [DATE] out of their wheelchair in their room. The resident was found on the floor by staff and complained of severe knee pain. The resident's care plan was updated at this time only to record the fall with injury, stating the resident sustained a head hematoma [bruise with swelling and pain] and large bruise to their knee. The only update to his/her care plan was Follow facility fall policy.The resident's record states that the resident fell again on 1/16/26 while trying to self-transfer. The resident did not sustain injuries, and the care plan was updated at this time to record the fall and adds an intervention of will monitor closely, without timeframes or definition of what that meant for staff's responsibilities. The resident's record states that the resident fell on 2/5/26, again in their room and again involving the resident's wheelchair, with the resident being found on the floor after staff heard a thud. The resident was complaining of left leg pain. The resident's care plan addressing falls/safety was not updated after this fall to include any new interventions despite the pattern revealed with these 3 falls. Another fall occurred on 2/8/26 where staff responded to the resident screaming from their room and found the resident on the floor in front of their wheelchair. The resident was in pain and acute distress, holding their right knee and not moving their right leg. The resident was brought to the local emergency room and diagnosed with a fracture. Repeated imagery on 2/9/26 revealed bilateral [both sides] displaced severe ankle fractures.Per interview with a staff Licensed Practical Nurse (LPN #1) on 2/18/26 at 4:44 PM, she did not know how to access the care plan for Resident #1. When showed by the surveyor, the LPN confirmed there were no fall interventions implemented to specifically prevent falls from the wheelchair, and confirmed no interventions were added after the falls on 1/16/26 or 2/5/26.Per interview with the DON on 3/2/26 at 1:00 PM she stated that increased supervision was not implemented for Resident #1. At 2:21 PM the DON confirmed that the resident was on 2-hour checks and the facility did not formally increase any supervision. The DON confirmed the IDT notes were not in the resident's record. The DON confirmed that the only intervention added was a sleep hygiene assessment which is not noted in his/her care plan.

Based on interview and record review the facility failed to ensure care plans were updated with interventions after recurrent falls for 2 of 3 sampled residents (Resident #1 and Resident #2). Findings include:1.Per review of Resident #1's care plan dated 10/17/24 and revised 2/12/26, it states, [Resident #1] is at risk for falls related to decreased mobility, pain issues and cognitive deficits, and recent falls. Most recent fall with several fractures in [his/her] bilateral lower extremities.Per review of a provider's note dated 1/16/26, it states, Primary Chief Complaint: Fall without injury. Nurse called to report a fall without injury. Pt [Patient] was attempting to self-transfer when they lost their balance and fell onto the ground. Negative LOC [Loss of Consciousness] . The resident's care plan read, 1/16/25: fall out of [his/her] wheelchair in [his/her] bedroom.Will monitor closely.Per review of a health status note dated 2/5/26, it states, This writer heard a thud from the nurses' station at 0045. Upon entering the room, found [Resident #1] sitting on the floor in front of [his/her] wheelchair. [S/he was sitting between the wheelchair and the empty bed on the left side. denies hitting [his/her] head. [Resident #1] was transferred into bed to assist with the Hoyer. [Resident #1] is complaining of all over pain per [his/her] baseline especially to [his/her] LLE [left lower extremity]. VSS [vital signs] stable and neuro [neurological] vital signs stable. ROM [range of motion] within normal limits to all extremities.Per review of Resident #1's care plan, there were no interventions related to preventing the resident from falling from his/her wheelchair after falls on 1/16/26 and 2/5/26. Per review of the facility's Comprehensive care Plans policy [last revised 1/7/26] it states, 6. The comprehensive care plan will include measurable objectives and time frames to meet the resident's needs as identified in the resident's comprehensive assessment. The objectives will be utilized to monitor the resident's progress. Alternative interventions will be documented, as needed.8. Qualified staff responsible for carrying out interventions specified in the care plan will be notified of their roles and responsibilities for carrying out the interventions, initially and when changes are made.An interview was conducted with LPN#1 on 2/18/26 at 1:15 PM. LPN [Licensed Practical Nurse] #1 stated she did not know how to access the care plan for Resident #1 stating, You just showed me how to [access the care plan]. LPN#1 confirmed there were no interventions implemented in the care plan to prevent the resident falling from her wheelchair. She also confirmed there were no fall interventions added to the resident's care plan after falls on 1/15/26 and 2/5/26. An interview was conducted with the DON [Director of Nursing] on 2/18/26 at 1:10 PM. The DON confirmed Resident #1's care plan should have been updated with interventions for falls out of his/her wheelchair for the falls that occurred on 1/16/26 and 2/5/26.2.Per review of Resident #2's care plan dated 8/27/25 and revised on 1/23/26, it states, [Resident #2] is at risk for falls related to bilateral left knee amputation, decreased mobility/balance, and history of falls. Per a fall risk assessment on 12/27/25 scores Resident #2 at a 17 out of 32 and is at risk for falls.Per review of an incident note in Resident #2's EMR [Electronic Medical Record] dated 1/11/26, it states, LNA called to nurse saying resident is on the floor. Upon rooming in resident was found covered in feces sitting on [his/her] bottom with [his/her] back propped against the wall near beside [his/her] wheelchair. When asked what happened [s/he] said [s/he] was trying to get out of here, and then said [s/he] was just hanging around. Reside [sic] could not give a credible account of how [s/he] landed or on what, but [his/her] fall mat was beside [his/her] bed undisturbed. Neuro vitals taken, pain assessment, nursing head to toe, hoyered to bed, cleaned up, provider and family notified.Per review of Resident #2's care plan it states, 1/11/26 [Resident #2] was found on floor after attempting to self-transfer. No injury noted. 1/23/26 [Resident #2] was found on floor mat beside [his/her] bed.Per review of an incident note written on 2/3/26, it states, Resident was found sitting on [his/her] bottom on the fall mat stated that [s/he] was down on the loading dock of the amtrack trying to make it across before the train came when [his/her] legs buckled and [s/he] went down. Contacted [provider] orders for neuro [neurological] checks and reinforce fall protocol. Resident has no known injuries from this particular incident. [S/he] is resting in his room with call bell in reach.Per review of an incident note written on 2/1/26, it states, Resident attempted to self transfer out of bed to get remote when [s/he] lost control and almost fell head first when LNA darted in and scooped resident under arm to avoid hitting head. Two skin tears present which were cleansed with vashe, pat dry, and covered with tegaderm. Geri sleeves applied to bilateral arms. Family notified as well as MD. Neurovitals were within normal limits. Resting at present with call bell in reach.Per review of Resident #2's care plan there were no additional documented interventions in the resident's care plan for the falls that occurred on 1/11/26 on 1/23/26.An interview was conducted with the DON on 2/18/26 at 11:37 AM. The DON stated the resident's room was changed to be closer to the nurse's station. She stated the resident was being referred to rehabilitation and the resident was on frequent checks. She confirmed this information was not in the resident's care plan. An interview was conducted with the DON on 3/2/26 at 1:35 PM. The DON confirmed Resident #2's care plan did not have any interventions added after the falls on 1/11/26 and 1/23/26.

Based on interview and record review, the facility failed to ensure that staff have infection prevention and control training that covers facility policy and procedures for 10 of 10 sampled direct care staff. Findings include:Per review of employee education files, 5 of 5 licensed nursing staff and 5 of 5 LNAs did not have documentation to demonstrate that they received infection control training, including training on the facility infection prevention and control policy and procedures, other than hand hygiene.Per interview on 7/29/25 at 2:40 PM, Registered Nurse #1 explained that she is an agency nurse and the only training that the facility provided was training on the electronic medical record training and an onboarding packet.Per interview on 7/30/25 at 10:32 AM, the Director of Nursing, who is responsible for direct care staff training and competencies, described that infection control training should be done on hire and annually. She stated that there have been gaps in staff education and competency evaluation.Per interview on 7/30/25 at approximately 1:45 PM, the Administrator confirmed that there was no infection control education done during onboarding.Per interview on 7/30/25 at 3:01 PM the DON stated that they have no additional documentation of infection control education for the 10 staff sampled.

Based on interview and record review, the facility failed to have a system to ensure transfer notices and ombudsman notices were provided for 2 of 2 sampled residents transferred to the hospital. This has the potential to impact all residents. Findings include: 1.) Per record review, Resident #16 was admitted to the facility after a stay at the hospital for treatment of a stroke. A progress note dated 7/12/2025 reveals that Resident #16 was transferred to the hospital for evaluation of altered mental status. There is no evidence in the Resident's medical record that a bed hold, or transfer/discharge notice was provided to the Resident or their family member. Per a progress note dated 7/19/2025, Resident #16 was again transferred to the hospital for evaluation for altered mental status and aggressive behavior. The Registered Nurse who was transferring the Resident out documented Also, due to aggressive and combative behavior [her/his] bed would not be held and this was explained to the family. There is no documented evidence that a bed hold, or transfer notice was provided to the Resident. Per interview with the Administrator and DON on 7/29/2025 at 8:45 AM confirmed that the RN had told the family and the case manager at the receiving hospital that the Resident would not be able to return to the facility. Review of a letter dated 7/22/2025 that was sent to the Resident from the Administrator reads The administrative team at The Villa Rehab Center has met and has determined that at this time we will not be accepting you back at our facility. We are not able to meet your current needs due to recent behaviors including eloping and physical violence. As you know these behaviors have impacted our staff and other residents of this facility, as well as the care we are able to provide to you. The behaviors endangered the health and wellbeing if individuals in the facility. As of today, since this letter is serving as a discharge from our facility, we will no longer be able to monitor the care you are receiving at the hospital as you are no longer our patient. If you would like us to continue to monitor your care while you remain in the hospital to see if at some point you are again appropriate to return and would like to return, please let us know . Should you wish to appeal this decision, you will be required to remain in the hospital during that time due to the potential for endangerment to the staff and residents of this facility . Handwritten on the notice is Mailed to [the Resident] 7/22 and Mailed to state ombudsman 7/22/2025. Per interview on 7/30/2025 at approximately 3:30 PM, the owner was asked if the facility had notified the State Agency of the emergency discharge. She said she had not because it was not an emergency discharge. A copy of an email that was sent to the Ombudsman on 7/22/2025 that was provided by the Administrator states I am the Administrator of The Villa Rehab in St. Albans, [NAME]. I'm reaching out due to an emergency discharge we've had to initiate. Per record review, Resident # 4 was transferred to the emergency department (ED) on 1/1/25, 6/8/25, and 7/1/25. There is no evidence in Resident #4's medical record that a transfer notice was given to him/her for the above ED transfers. 2.) Review of facility policy titled Discharge and Transfer Communications, undated, reveals 4 sections, all referring to discharge (hospital, home, unauthorized, and death). There is no section referring to transfer. Under the section Discharge to hospital, the procedure includes giving a notice of bed hold but does not discuss a transfer notice or any of the required element of the notice. Per interview on 7/29/25 at 4:15 PM, the Social Services Director (SSD) described the notices given to a resident or their representative on transfer to the hospital. She stated that nursing gives the bed hold policy notice, and a transfer notice is not given to a resident unless they are admitted to the hospital. Per interview on 7/30/25 at approximately 12:50 PM, the Director of Nursing was asked if there was an additional policy regarding resident transfers and transfer communication and she stated she was only aware of the bed hold policy. Per interview on 7/30/25 at 12:50 PM, the Charge Nurse confirmed that nursing staff do not send a transfer notice when a resident is sent to the hospital. Per interview on 7/30/2025 at 1:26 PM, the SSD confirmed that there were no transfer notices for Resident #4 for the above ED visits. While reviewing the facility policy, she explained that she is not aware that the policy does not address transfer communication requirements. The SSD also stated that she does not send notification of transfers to the ombudsman as part of her process.

Based on observation, interview, and record review the facility failed to ensure that staff were competent in medication administration for 4 of 5 licensed nurses and failed to ensure that 10 of 10 direct care staff were competent in infection control measures. Findings include:Per review of the Facility Assessment, last reviewed 5/5/25, indicates that the facility offers medication management, and infection prevention and control as services and care offered to meet the residents' needs. The Facility Assessment reveals that the training program :included an orientation process and ongoing training for all new and existing staff . and is based on staff need and resident characteristics.1.) Medication administration errors were observed during survey. See F759 for more information.Per review of employee education files, 4 of 5 licensed nursing staff did not have documentation to demonstrate that they had the skill necessary to administer medication.2) Infection control deficiencies were identified with resident care during survey. See F880 for more information.Per review of employee education files, 5 of 5 licensed nursing staff and 5 of 5 LNAs did not have documentation to demonstrate that they were competent in infection control practices other than handwashing.Per interview on 7/29/25 at 2:40 PM, Registered Nurse #1 explained that she was an agency nurse and her competencies were not assessed before working. She stated that she received electronic medical record training and was handed a packet for onboarding.Per interview on 7/30/25 10:32 AM, the Director of Nursing (DON), who is responsible for direct care staff training and competencies, confirmed that infection control competencies include more than just hand washing. She explained that infection control competencies should also include standard precautions, how to handle fluids, personal protective equipment use, and medication handling. She stated that there have been gaps in staff education and competency evaluation.Per interview on 7/30/25 at 3:01 PM the DON stated that they have no additional documentation of competencies for the 10 staff sampled.

Based on observation, interview, and record review the facility failed to ensure that food was prepared in a safe sanitary manner and environment. This has the potential to impact all residents in the facility. Findings include: Per record review of the facility's Food Safety Requirements policy [last revised 1/1/25] states, Food safety practices shall be followed throughout the facility's entire food handling process .Elements of the process include the following:.b. Storage of food in a manner that helps prevent deterioration or contamination of the food, including from growth of microorganisms.6. All equipment used in the handling of food shall be cleaned, sanitized, and handled in a manner to prevent contamination.Per observation of the kitchen on 7/28/25 at 8:45 AM, there was a pool of water on the floor in front of refrigerator. The kitchen staff member stated, The sink leaks. She stated the maintenance director would be in the next day to address the water on the floor.Per observation on 7/28/25 at 8:45 AM, there was food debris under serving table including pasta and breadcrumbs. There were dark stains on the floor directly under the serving table. There was food debris underneath the refrigerator. Per observation, the coffee maker had not been cleaned and had coffee stains and white smear stains on it. The shelves under the serving tray had white and brown stains on it. At approximately 8:50 AM the kitchen staff member confirmed the floor was dirty and had debris on it, stating, We sweep and mop before lunch and in the evening.Per observation of the kitchen on 7/29/25 at 9:30 AM, standing water was still present on the floor in front of the refrigerator. The kitchen staff member confirmed on 7/29/25 at 11:56 AM that the sink was still leaking water on the floor.Per observation of the freezer, a package of 8 hot dogs was found to have an expiration date of 8/27/24. A package of Hormel pepperoni was found to have expired on 5/22/24. On 7/29/25 at 11:59 AM the kitchen staff member confirmed these items were expired. Per observation of the kitchen on 7/30/25 at 9:44 PM, there was still standing water on the floor in front of the refrigerator. There is still debris and old food under the shelves that hold pots and pans and under the refrigerator. There was still dirt and debris under the refrigerator.

Based on interview and record review the facility failed to ensure that the facility assessment provided adequate information related to competencies and training and failed to address needed positions. Findings include: 1. Per review of the facility Infection Preventionist job description implemented on 5/1/2025 section 6. states The IP must be employed at least part-time and the amount of time should be determined by the facility assessment, to determine the resources it needs for its IPCP [Infection Prevention Control Program]. Designated IP hours per week may vary based on the facility and its resident population. Section 7. States The facility based on the facility assessment will determine if the individual functioning as the IP should be dedicated solely to the IPCP. The IP must have the time necessary to properly assess develop implement, monitor, and manage the IPCP for the facility, address training requirements, and participate in required committees such as QAA [Quality Assessment and Assurance]. 8. The IP will physically work on site in the facility. Per review of the Facility Assessment, last reviewed by the facility on 5/5/2025, revealed that it does not address the need for an IP. The facility did not identify the need for a part time Infection Preventionist. During an interview on 7/30/2025 at approximately 3:15 PM the Owner of the facility confirmed that there was not a designated part time IP employed by the facility. See F882 for more information. 2.) During survey, deficient practices were observed related to medication administration and infection control practices. See F 759 and F880 for more information. Investigation revealed that the facility failed to ensure that staff were competent in medication administration for 4 of 5 licensed nurses and failed to ensure that 10 of 10 direct care staff were competent in infection control measures. See F726 for more information. Per review of the Facility Assessment, last reviewed 5/5/25, indicates that the facility offers medication management, and infection prevention and control as services and care offered to meet the residents' needs. The Facility Assessment reveals that the training program: included an orientation process and ongoing training for all new and existing staff . and is based on staff need and resident characteristics. The section detailing competencies need to meet residents' needs refers to a worksheet titled Facility Education/Staff Competencies Necessary to Care for Resident Population and reads The worksheet identifies which staff are required certain competencies and skill sets, and the frequency of education. The Facility Assessment does not include this worksheet. During an interview on 7/30/25 at 10:32 AM with the Director of Nursing and the Administrator, it was confirmed that they do not have this attachment.

Based on observation, interview, and record review the facility failed to ensure that a risk assessment was completed to identify areas at risk for Legionella (a bacteria found in water that can cause a serious type of pneumonia, Legionnaires' disease) could grow and spread in the facility's water system, and failed to ensure proper infection control practices were followed. Findings include: 1. Per review of the facility's water management program, it did not contain a risk assessment to identify and prevent areas in the building where Legionella could grow and spread in the facility's water system. Per review of the facility policy with a reviewed/revised date of 3/2021 states, surveillance is one component of the facility's water management plans for reducing the risk of Legionella and other opportunistic pathogens in the facility's water systems and In the absence of Legionella infections for a period of at least one year, the facility shall implement primary prevention strategies. Per interview with the Infection Preventionist (IP), Administrator, and the Director of Nursing (DON) on 7/29/25 at approximately 3:30 PM, the facility had not completed a formal risk assessment, including identifying areas in the building where Legionella could grow or reside. The facility lacked a process to prevent the growth and transmission of communicable diseases and infections related to Legionella prevention. The Administrator deferred to the Director of Maintenance when asked regarding a Water Management plan. During an interview with the Director of Maintenance, the Administrator, and the facility Owner on 7/30/25 at approximately 9:00 AM, the Director of Maintenance confirmed that there is no written assessment of wastewater management. The Administrator stated there was a map of the facility's water system and would provide this information once it was located. The Administrator provided a flowgraph map of the water supply, but it fails to identify areas of potential contamination or risk. During an interview with the facility Owner on 7/30/25 at approximately 11:30 PM, she confirmed that the flowgraph was the only document for the wastewater assessment. The CDC's Developing a Water Management Program to Reduce Legionella Growth & Spread in Buildings: A PRACTICAL GUIDE TO IMPLEMENTING INDUSTRY STANDARDS example from page 11 labelled Identify Areas Where Legionella Could Grow & Spread - EXAMPLE: BUILDING A was shown to the Owner and asked if the facility had an assessment map showing the potential hazards. The Owner confirmed the facility doesn't have an assessment. https://www.cdc.gov/control-legionella/media/pdfs/toolkit.pdf/ 2. On 7/28/25 at 10:00 AM, the linen cart located on the second floor unit was observed to have the protective cover open and the linens uncovered, and at approximately 12:30 PM, a hospitality staff member was observed bringing a laundry basket of clothing to the second floor without a cover. Review of the Infection Prevention and Control Program policy [last revised 5/13/25] states, Clean linen shall be delivered to resident care units on covered linen carts with covers down, and the stored linen on care units will be covered. During an interview on 7/29/25 at 1:15 PM, the hospitality staff observed with the uncovered laundry basket on 7/28/25, confirmed that laundry baskets are transported uncovered when clean items are brought back to residents. They questioned whether baskets should be covered when transporting clean linens and clothing, as per the facility's policy. The hospitality staff also confirmed that linen carts on the units should be covered. 3.) Per observation on 7/29/25 at 8:34 AM, Registered Nurse #1 (RN #1) was observed preparing medications for Resident #7. When RN #1 took the pills out of the packaging, she put the pills in her ungloved hand before putting them in the medication cup. During the administration of the medications, RN#1 was observed handling the medications again with ungloved hands before they were administered to Resident #7. On 7/29/25 at10:01 AM RN #1 was observed preparing medications for another resident, again putting the medications directly into her ungloved hand. Per interview on 7/29 at 2:32 PM, the Charge Nurse confirmed that nursing staff should not touch medications with ungloved hands. 4.)Per interview with the Charge Nurse during observation of resident rooms on 7/29/25 at 12:35 PM, the Charge Nurse stated that oxygen tubing and humidifier bottle should dated when it is changed and should be done weekly. She confirmed that Resident #3 did not have dates on the tubing used on his/her wheelchair and concentrator and did not have a date on the humidifier bottle and should. She confirmed that the oxygen tubing on room [ROOM NUMBER] did not have a date on it and should. 5.) Per observation on 7/28/2025 at 9:47 AM, a Licenses Nursing Assistant came out of room [ROOM NUMBER] with dirty linens pressed on her chest wearing. This LNA was not wearing gloves.

Based on interviews and record review the facility failed to provide the required 12 hours of in-service training for 2 of 2 applicable licensed nursing assistants (LNAs). Findings include: Education records were reviewed for 5 LNA staff. 2 of the 5 LNAs have worked at the facility for over a year; LNA #4 was hired on 6/26/17 and LNA #5 was hired on 1/18/21.LNA # 4 did not have evidence of 12 hours of in-service training within the past year. LNA #5 had a checklist from a skills fair in their file. There was no other evidence that they received any additional in-service training within the past year.Per interview on 7/30/25 10:32 AM, the Director of Nursing (DON), who is responsible for direct care staff training and competencies, explained that the 12-hour in-service training is done at a skills fair. She revealed that the in-service is documented with the same checklist that is in LNA #5's file.On 7/30/25 at 12:43 PM, the Administrator explained that the in-service training only lasts 9 hours, being held from 7:00 AM until 4 PM and does not have any way to account for the other required hours.Per interview on 7/30/25 at 3:01 PM the DON stated that they have no additional documentation of in-service training for the 2 staff sampled.

Based on interview and record review the facility failed to ensure that a infection preventionist was employed at least part time. Findings include: During an interview with the Registered Nurse (RN) identified as the Infection IP and the Director of Nursing (DON) on 7/29/25 at approximately 3:30 PM, they confirmed that the RN was covering as the IP and is an employee of another facility that is owned by the same owner. The IP stated that they are at the facility on an as-needed basis, about one day a week. When asked to describe the facilities IP Program the IP stated that she works with the Pharmacist and reviews antibiotic usage and ensures that antibiotic time outs are implemented. When asked about the facilities infection surveillance logs, updates to policies and procedures, and water management (Legionella prevention) for the facility the IP deferred to the Administrator.The facility Infection Preventionist job description implemented on 5/1/2025 section 6. states The IP must be employed at least part-time and the amount of time should be determined by the facility assessment, to determine the resources it needs for its IPCP [Infection Prevention Control Program]. Designated IP hours per week may vary based on the facility and its resident population. Section 7. States The facility based on the facility assessment will determine if the individual functioning as the IP should be dedicated solely to the IPCP. The IP must have the time necessary to properly assess develop implement, monitor, and manage the IPCP for the facility, address training requirements, and participate in required committees such as QAA [Quality Assessment and Assurance]. 8. The IP will physically work on site in the facility.The facility policy titled Infection Prevention and Control Program last reviewed/revised on 5/13/2025 under Policy Explanation and Compliance Guidelines: The designated Infection Preventionist is responsible for oversight of the program and serves as a consultant to our staff on infectious diseases, resident room placement, implementing isolation precautions, staff and resident exposures, surveillance, and epidemiological investigations of exposures of infectious diseases Surveillance: a.b. The Infection Preventionist serves as the leader in surveillance activities, maintains documentation of incidents, findings, and any corrective actions made by the facility and reports surveillance findings to the facility's Quality Assessment and Assurance Commitee. Review of the Facility Assessment, last reviewed by the facility on 5/5/2025, revealed that it does not address the need for an IP. The facility did not identify the need for a part time Infection Preventionist.Per interview on 7/30/25 at 9:00 AM with the Administrator, DON, and Owner of the facility the IP is an employee at their other facility and is covering as IP. The Owner stated that the IP had no specific hours and the IP is used as needed. When told that the IP had reported that she was there one day a week the Owner stated that she was going to say something like that. When told of the regulatory requirement for a part-time IP, the Owner stated that a part-time IP was not needed for 20 residents. During an interview on 7/30/2025 at approximately 3:15 PM the Owner of the facility confirmed that there was not a designated part time IP employed by the facility.

Based on interview and record review the facility failed to ensure a medication error rate of less than %5. 2 of 26 medication administrations were observed to be in error making the error rate 7.7%. Findings include: 1.) Per record review, Resident has physician orders for 1 capsule metoprolol succinate 50 mg extended release oral capsule and 2 tablets PRN (as needed) docusate sodium 50 mg.Per observation of a medication administration for Resident #7 on 7/29/25 at 8:33 AM, Registered Nurse #1 (RN #1) administered one medication in the incorrect form and 1 medication in the incorrect dosage. RN #1 gave Resident #7 1 tablet metoprolol succinate 50 mg extended release oral tablet and 1 tablet docusate sodium. Per review of the Resident # 7's Medication Administration Record for that medication observation, RN #1 documented that Resident #7 received 1 tablet metoprolol succinate and 2 tablets of docusate sodium. RN #1 did not call a provider to notify them of the incorrect form of the metoprolol succinate or the change in dosage administered and there is no evidence in Resident #7's medical record that a provider was contacted of the change.Per review of the facility's Medication Administration policy [no revision date] states, Ensure that the six rights of medication administration are followed: a. Right resident b. Right drug c. Right dosage d. Right route e. Right time f. Right documentation.12. Compare medication source (bubble pack, vial, etc.) with MAR to verify resident name, medication name, form, dose, route, and time . 20. Sign MAR after administered.: Per interview on 7/30/25 at 12:50 PM, the Charge Nurse confirmed that the medication given did not match Resident #7's physician orders and the provider was not made aware that the medications administered were different than what was ordered.Per interview on 7/30/25 at approximately 1:45 PM, the Director of Nursing confirmed that the nurse was not following physician orders for both medications administered.

Based on interview and record review, the facility refused to allow a resident to return to the facility after being transferred to the hospital and inappropriately discharged the resident, for one of three residents in the applicable sample (Resident #16). Findings include:Per record review, Resident #16 was admitted to the facility after a stay at the hospital for treatment of a stroke. admission diagnoses include aphagia (a brain disorder that affects how you speak and understand language. It happens after damage to the language processing center of your brain), and cognitive communication deficit (difficulties in communication that arise from impairments in cognitive processes, such as attention, memory, and problem-solving). An admission Summary progress note dated 7/11/2025 reflects that Resident #16 was alert and oriented x 3 (person, place, and time), though has a history of forgetfulness in the evening, redirectable . Family reports sundowning [a state of confusion, agitation, and restlessness that some individuals with dementia or other cognitive impairments experience in the late afternoon and evening] in the evening since being in the hospital. Resident is impulsive and tends to want to get up on [her/his] own. Review of a MDS (Minimum Dats Set, a standardized, comprehensive assessment of an adult's functional, medical, psychological, and cognitive status) with an assessment reference date of 7/17/2025 reveals a Brief Interview for Mental Status (BIMS) score of 12 which suggests mild cognitive impairment. A progress note dated 7/12/2025 reveals that Resident #16 was walking/pacing around the room unassisted without walker. Resident had a frowned look on [her/his] face and began speaking in an agitated manner to this nurse . This resident began stating, 'I'm leaving. I passed all my tests, and I am going home.' This nurse explained to the resident that [s/he] is here to have therapy following [her/his] recent stroke. Resident became very irritated with this nurse and asked me to leave the room . At approximately [8:20 PM] resident came walking past the nurses station into the main lobby at a very fast pace with son following behind [her/him]. Again, without the use of [her/his] assistive device. This nurse immediately went to resident and attempted to offer the walker and assistance. Resident shoved this nurses arm and said, 'don't touch me' Resident became unsteady and began to go flaccid. Resident #16 was sent to the hospital for evaluation and returned with a diagnosis of dehydration and syncope (temporary loss of consciousness). There is no evidence in the Resident's medical record that a bed hold, or transfer/discharge notice was provided to the Resident or their family member. Per a progress note dated 7/19/2025, Resident #16 was exhibiting confusion regarding the wellbeing of their partner and their children and was attempting to leave the facility. Staff redirected the Resident several times and then s/he exited the facility through a door on Hall #3. A Licensed Nursing Assistant (LNA) saw her/him leaving and followed her/him out. While the LNA and a Registered Nurse (RN) were attempting to redirect her/him, the resident became aggressive, threatening, and combative. S/He was sent to the ED and was not allowed to return based on her/his condition at the time of transfer. The progress notes further state This nurse spoke with [Director of Nursing (DON)] about the events, and she requested that [the Resident] be transferred to the ED [emergency department] for Altered Mental Status and Aggressive Behavior. Also, due to aggressive and combative behavior [her/his] bed would not be held and this was explained to the family. There is no documented evidence that a bed hold, or transfer notice was provided to the Resident. Per interview with the Administrator and DON on 7/29/2025 at 8:45 AM confirmed that the RN had told the family and the case manager at the receiving hospital that the Resident would not be able to return to the facility. Review of the Facility Assessment that details the facility population and what resources are necessary to care for the residents competently during both day-to-day operations and emergencies states that the building is equipped with Entry/Exit Accessibility Equipment code alert wander system. A facility policy titled Elopements and Wandering Residents last reviewed on 5/1/2025 states, Policy: This facility ensures that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents, and receive care in accordance with their person-centered plan of care addressing unique factors contributing to wandering or elopement risk. Under section 6. Procedure Post Elopement part f, When repeated elopement attempts occur, after the facility has exhausted possible care approaches, the resident may be referred for alternate placement in an appropriate facility. There is no documented evidence that the facility attempted to refer Resident #16 to an appropriate facility. Although Resident #16 had been exhibiting behaviors throughout the morning there is no documented evidence that the Resident's physician was consulted with or notified regarding the above behaviors prior to transfer to the hospital. There is also no documented evidence that the Physician evaluated the Resident's status prior to the facility determining that the Resident's needs could not be met. Per interview on 7/30/2025 at 11:50 AM the RN who was on duty during the 7/19/2025 incident confirmed that the Resident's physician was not consulted with or notified of the Resident's behaviors and attempted elopements prior to being sent out to the hospital. Per interview with the hospital Case Manager on 7/30/2025 at 10:45 AM the RN on duty on 7/19/2025 had stated that the facility would not be taking the Resident back. Resident #16 has remained in the hospital waiting for an appropriate facility to accept her/him, since the transfer on 7/19/2025. Per interview with the facility Owner 7/30/2025 at approximately 3:15 PM she confirmed that the facility does admit residents who are at risk for wandering and elopement, but due to the Resident's violent behaviors, the facility could not care for her/him. Review of a letter dated 7/22/2025 that was sent to the Resident from the Administrator reads The administrative team at The Villa Rehab Center has met and has determined that at this time we will not be accepting you back at our facility. We are not able to meet your current needs due to recent behaviors including eloping and physical violence. As you know these behaviors have impacted our staff and other residents of this facility, as well as the care we are able to provide to you. The behaviors endangered the health and wellbeing if individuals in the facility. As of today, since this letter is serving as a discharge from our facility, we will no longer be able to monitor the care you are receiving at the hospital as you are no longer our patient. If you would like us to continue to monitor your care while you remain in the hospital to see if at some point you are again appropriate to return and would like to return, please let us know . Should you wish to appeal this decision, you will be required to remain in the hospital during that time due to the potential for endangerment to the staff and residents of this facility . Handwritten on the notice is Mailed to [the Resident] 7/22 and Mailed to state ombudsman 7/22/2025. Per interview on 7/30/2025 at approximately 3:30 PM, the owner was asked if the facility had notified the State Agency of the emergency discharge. She said she had not because it was not an emergency discharge. A copy of an email that was sent to the Ombudsman on 7/22/2025 that was provided by the Administrator states I am the Administrator of The Villa Rehab in St. Albans, [NAME]. I'm reaching out due to an emergency discharge we've had to initiate.

Based on interview and record review the facility failed to provide adequate assessment and supervision for 1 of 3 residents in the sample (Resident #16), to prevent a resident who was exit seeking to exit the facility. This resulted in staff using physical restraint in attempt to return the Resident to the facility, causing the Resident to exhibit increased agitation, resistiveness, and combativeness toward staff. Findings include:Per record review, Resident #16 was admitted to the facility after a stay at the hospital for treatment of a stroke. admission diagnoses include aphagia (a brain disorder that affects how you speak and understand language. It happens after damage to the language processing center of your brain), and cognitive communication deficit (difficulties in communication that arise from impairments in cognitive processes, such as attention, memory, and problem-solving). A hospital Discharge summary dated [DATE], reveals that the Resident had been prescribed an antipsychotic medication for delirium and that s/he had remained hospitalized due to placement problems until the Villa had approved admission for 7/11/2025. An admission Summary progress note dated 7/11/2025 reflects that Resident #16 was alert and oriented x 3 (person, place, and time), though has a history of forgetfulness in the evening, redirectable . Family reports sundowning [a state of confusion, agitation, and restlessness that some individuals with dementia or other cognitive impairments experience in the late afternoon and evening] in the evening since being in the hospital. Resident is impulsive and tends to want to get up on [her/his] own. Review of the Resident's care plan reveals there is no mention of sundowning or interventions. A progress note dated 7/12/2025 states At [7:30 PM] this nurse was asked by [resident representative], to come into the resident's room. This nurse went in to find the resident walking/pacing around the room unassisted without walker. Resident had a frowned look on [her/his] face and began speaking in an agitated manner to this nurse. This nurse then attempted to reason with the resident and got [her/him] to allow me to obtain [her/his] vitals . This resident began stating, 'I'm leaving. I passed all my tests, and I am going home.' This nurse explained to the resident that [s/he] is here to have therapy following his recent stroke. Resident became very irritated with this nurse and asked me to leave the room. This nurse asked resident if [s/he] would allow this nurse to give [her/his] bedtime medications to [her/him]. [S/He] agreed. Resident had difficulty swallowing even with nectar thick liquids. Took four ties to administer [her/his] meds. This nurse explained to the [resident representative] that [s/he] needs time to calm down. [S/He] agreed . At approximately [8:20 PM] resident came walking past the nurses station into the main lobby at a very fast pace with [representative] following behind [her/him]. Again without the use of [her/his] assistive device. This nurse immediately went to resident and attempted to offer the walker and assistance. Resident shoved this nurses arm and said, 'Don't touch me' Resident became unsteady and began to go flaccid. This nurse held resident by the waistband to keep [her/him] from falling while [representative] ran to get wheelchair. Resident sat down and immediately became totally flaccid. Arms were dangling down alongside of wheelchair, head was hanging down and to the right, resident was severely drooling, pupils were sluggish and sightly dilated. This nurse immediately obtained a set of vitals . This nurse called 911 as the resident is a full code and sent to [emergency room] for eval and treat. [hospital] ER is discharging resident. Stated resident was dehydrated and will arrive back to facility shortly. A facility policy titled Elopements and Wandering Residents last reviewed on 5/1/2025 states, Policy: This facility ensures that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents, and receive care in accordance with their person-centered plan of care addressing unique factors contributing to wandering or elopement risk . Policy Explanation and Compliance Guidelines . 3. The facility shall establish and utilize a systemic approach to monitoring and managing residents at risk for elopement or unsafe wandering, including identification and assessment of risk, evaluation and analysis of hazards and risks, implementing interventions to reduce hazards and risks and monitoring for effectiveness and modifying interventions when necessary. 4. Monitoring and Managing Residents at [NAME] for Elopement or Unsafe Wandering a. Residents will be assessed for risk of elopement and unsafe wandering upon admission and throughout their stay by the interdisciplinary care plan team. Under section 6. Procedure Post Elopement part f, When repeated elopement attempts occur, after the facility has exhausted possible care approaches, the resident may be referred for alternate placement in an appropriate facility. There is no documented evidence that the facility attempted to refer Resident #16 to an appropriate facility. Although Resident #16 had been exhibiting behaviors throughout the morning there is no documented evidence that the Resident's physician was consulted with or notified regarding the above behaviors prior to transfer to the hospital. Review of the Residents record there is no evidence that the Resident was assessed for risks of elopement or re-evaluated by the interdisciplinary care plan team after s/he began exit seeking. A Skilled Evaluation dated 7/13/2025 stated under wandering chronic. Review of Resident #16's care plan reveals that the care plan was not updated on return and there were no interventions added related to the Resident's wandering, attempting to exit, or aggressive behaviors toward staff. An Alert Note dated 7/15/2025 at 12:15 AM reveals that on the 7:00 PM to 11:00 PM shift Resident #16 stated that s/he was so confused. S/He had been putting her/his robe on the wrong way then putting her/his shirt on over the robe, pacing all over the building saying that s/he was leaving. A wander Guard was placed for safety. A Behavior Note written on 7/15/2025 at 12:12 PM states Notified facility PA [physician assistant] that resident was wandering a lot in the evening and saying [s/he] is going to leave as [s/he] becomes more confused in the evening. Order to place wander guard for safety purposes at this time.Will continue to monitor behaviors and need for wander alarm. This morning resident had forgotten why s/he was here, reminded her/him s/he is getting therapy while here until strong enough to go home. Resident reoriented and in agreement. Review of Resident #16's care plan reveals a focus initiated on 7/16/2025 of A secure care wander guard was placed on [the Resident's] right ankle due to risk of elopement with interventions that include 1:1 visits as needed, Engage [resident] in facility activities as able, and Redirect/reorient [resident] as needed. There are no care plan interventions related to approaches in care related to the Resident's confusion or preventing/managing aggressive behaviors. A progress note dated 7/19/2025 reveals that between the hours 7:00 AM and 12:00 PM Resident #16 had been confused and had attempted to exit the facility several times throughout the morning, because s/he thought that her/his partner had been injured in a car accident and s/he needed to get to the hospital. The RN redirected the Resident to her/his room. The Wander Guard alarm went off and the Resident was attempting to elope at this time, following the night shift staff out the front door. The Resident was brought back inside and continued to want to get to the hospital and was redirected to her/his room. A short time later s/he was found in Hall 3 wandering in and out of rooms. The RN again redirected her/him to return to her/his room. The Resident went into the living room then was found wandering in the hall outside her/his room and going into other rooms. S/he was redirected to her/his room again where s/he fell asleep. The Resident woke up and came out wandering. The note states that the Resident appeared to be agitated and disorganized, carrying a shoe, and had 2 different shoes on, looking for their phone. The nurse returned to the nurse's station, and the Wander Guard alarm went off again as the Resident went out the back door. A Licensed Nursing Assistant (LNA) went after her/him. While outside, the Resident started heading to the end of the street to go through the bushes to head home. The LNA stayed with her/him for their safety; the Resident threatened to punch her if she did not remove her arm from behind her/his back. The RN went to assist the LNA in getting the Resident back into the building. But the Resident did not want to return to the building. The LNA and RN guided back toward the building as the Resident became combative and turned quickly pushing this nurse's arm away from her/him and drew her/his arm back to punch the RN. The LNA and RN continued to guide the Resident back toward the building. Resident #16 then stopped and let go of the two of them and laid down on the ground. Staff called over the walkie talkie and they were asked to call the Resident's youngest [child] and have [him/her] return to assist with the Resident. When her/his [representative] arrived, the LNA and the RN were able to get the Resident heading back to the building. The Resident started to struggle against them and told the RN to take her hand off her/him or s/he was going to punch her in the face. Once back in the building they brought her/him to her/his room. This nurse spoke with the [Director of Nursing] DON about the events, and she requested that [the Resident] be transferred to the ED for Altered Mental Status and Aggressive Behavior. Also, due to aggressive and combative behavior her/his bed would not be held and this was explained to the family. Per review of the facility's Internal investigation for incident on 7/19/2025, the facility was informed by the Case Manager at the hospital that the Resident had reported being pushed to the ground. Per an interview conducted by administration on 7/23/2025 with the LNA who was present during the incident on 7/19/2025, the LNA reflects that there is a path at the end of the cul-de-sac that the LNA physically blocked so the Resident would not go through. The RN joined her in attempting to get the Resident back into the building, and a CPI [Crisis Prevention Institute] maneuver was utilized per the RN's instructions. The LNA describes this as a hold with both the LNA and RN on one side of the Resident locking arms and walking with the Resident guiding where s/he would go. The LNA reports that there was a firm grip from the Resident at one point bending her hand backwards. The LNA reported that the RN's instruction was to lower the Resident to the ground. There is no documented evidence that staff attempted 1:1 visits or engaged the Resident in facility activities per Resident #16's care plan. Instead s/he was continuously redirected to her/his room and left unsupervised. Also, the Resident's care plan does not include the use of CPI maneuvers to manage elopement or aggressive behaviors. During an interview with the Director of Nursing (DON) and the Administrator on 7/29/2025 at 9:50 AM when discussing the facility internal investigation, the Administrator described the CPI maneuver as the RN and LNA locking arms and using their (the staff's) body weight to direct the Resident back to the facility. Resident #16 became aggressive and threatened them that he was going to hit them. During an interview on 7/29/2025 at 1:36 PM the RN who was on duty at the time of the incident confirmed the content of the progress note from 7/19/2025. She also stated that at one point the Resident began Resisting and pulling again so I asked [the LNA] if she knew CPI (Crisis Prevention Institute), she did not so I told her what to do. The RN stated that at that time the Resident laid down in the yard of the neighbor. When they tried to stand her/him up he stated If you don't take your hands off me I'm gonna punch you in the face. I told [the representative] let me the bad guy. [The Resident] settled down and we brought her/him in and s/he tried to go out again. The RN stated that she has a background in mental health nursing and received CPI training prior to working at this facility. When asked why staff hadn't increased supervision with the multiple attempts to leave the building or provide 1:1 throughout the morning, the RN stated that she was giving her/him space. When asked if she had reached out to the physician regarding the increased behaviors throughout the morning and she said no she hadn't. Further review of Resident #16's care plan reveals that no interventions related to aggressive behaviors, and the care plan does not include the use of CPI maneuvers to manage elopement or aggressive behaviors. Another care plan focus, states [Resident] receives an antipsychotic medication for symptoms of delirium following acute CVA with interventions initiated on 7/11/2025 of Monitor and notify MD of negative effects of medications- increase in agitation or anxiety, insomnia, parkinsonism, feelings of suicide, dizziness, hallucinations, mania, impaired concentration. There is no evidence that the physician was contacted at any point throughout the morning of 7/19/2025 when the Resident was showing signs of increased confusion, anxiety, and agitation. During an interview on 7/30/2025 at 11:50 AM with the RN who was on duty during the elopement on 7/19/2025, she confirmed that she had not received facility specific training regarding elopement prevention or what to do if a resident eloped, prior to the 7/19/2025 incident. Per interview with the Administrator and the DON on 7/30/2025 at approximately 12:30 PM the Administrator confirmed that the RN on duty during the elopement did use CPI Crisis Prevention Institute Nonviolent Crisis Intervention however, it is not a program approved for use by staff at this facility. The Administrator confirmed that CPI is not part of their protocol for use with residents in crisis.

Based on interview and record review the facility failed to ensure that one of three residents (Resident #16) was free from physical restraints. During staff use of physical restraint Resident #16 became more agitated, aggressive, and resistive to redirection causing combative behavior, and threatening to hurt staff. As a result of the aggressive behaviors the facility refused to allow the Resident to return to the facility causing an extended stay in the hospital. Findings include:Per record review of progress notes between the hours of 7:00 AM and 12:00 PM Resident #16 made several attempts to exit the building throughout the morning. A progress note dated 7/19/2025 reveals that the Wander Guard alarm went off as Resident #16 went out the back door. A Licensed Nursing Assistant (LNA) went after her/him. While outside the Resident started heading to the end of the street to go through the bushes to head home. The LNA stayed with her/him for their safety. At this time, the Resident threatened to punch her if she did not remove her arm from behind her/his back. This nurse went to assist the LNA in getting the Resident back into the building. The note states [Resident #16] was not having any part of this. The LNA and RN (Registered Nurse) were able to guide the Resident back toward the building as the Resident turned quickly pushing the nurse's arm away from her/him and then drew her/his arm back to punch the RN. The Resident was guided again back toward the building. The LNA and RN were able to get the Resident heading back to the building but [the Resident] started to struggle and told the RN to take their hand off her/him or s/he was going to punch the RN in the face. Once the Resident was back in the facility the RN called the DON and was instructed to send the Resident to the emergency room for evaluation of altered mental status. The RN documents in the progress note that she informed the family that the facility would not be holding the Resident's bed. Per review of a First Report of Injury form completed on 7/20/2025 by the RN the description of the event was Resident eloped, refusing to return. Assisted resident back to facility due to unstable gait and altered balance. Resident was physically combative and verbally abusive. Resident jerked away from hold and my knee twisted. Resident became physically combative pulling and pushing myself and [LNA]. Per review of the facility's Internal investigation for incident on 7/19/2025, the facility was informed by the Case Manager at the hospital that the Resident had reported being pushed to the ground. Per an interview conducted by administration on 7/23/2025 with the LNA who was present during the incident on 7/19/2025, the LNA reflects that there is a path at the end of the cul-de-sac that the LNA physically blocked so the Resident would not go through. The RN joined her in attempting to get the Resident back into the building, and a CPI [Crisis Prevention Institute] maneuver was utilized per the RN's instructions. The LNA describes this as a hold with both the LNA and RN on one side of the Resident locking arms and walking with the Resident guiding where s/he would go. The LNA reports that there was a firm grip from the Resident at one point bending her hand backwards. The LNA reported that the RN's instruction was to lower the Resident to the ground. Per review of Resident #16's Physicians orders there was no order for the use of the CPI maneuver. During an interview with the Director of Nursing (DON) and the Administrator on 7/29/2025 at 9:50AM when discussing the facility internal investigation, the Administrator described the CPI maneuver as the RN and LNA locking arms and using their (the staff's) body weight to direct the Resident back to the facility. Resident #16 became aggressive and threatened that he was going to hit them. Review of Resident #16's care plan reveals a focus initiated on 7/16/2025 of A secure care wander guard was placed on [the Resident's] right ankle due to risk of elopement with interventions that include 1:1 visits as needed, Engage [resident] in facility activities as able, and Redirect/reorient [resident] as needed. There is no documented evidence that staff attempted 1:1 visits or engaged the Resident in facility activities on the morning of 7/19/2025. The care plan does not include the use of CPI maneuvers to manage elopement or aggressive behaviors for Resident #16. Another care plan focus states [Resident} receives an antipsychotic medication for symptoms of delirium following acute CVA with intervention initiated on 7/11/2025 of Monitor and notify MD of negative effects of medications- increase in agitation or anxiety, insomnia, parkinsonism, feelings of suicide, dizziness, hallucinations, mania, impaired concentration, tachycardia, orthostatic hypotension, syncope, constipation. There is no evidence that the physician was made aware of the Residents increase confusion, anxiety, and agitation. During an interview on 7/29/2025 at 1:36 PM with the RN who was on duty at the time of the incident, she explained that when she arrived on duty the morning of 7/19/2025, Resident #16 wanted to leave because her/his partner had been in a bad accident. The RN stated that at this time she was able to redirect the Resident. When the night shift staff were leaving, Resident #16 tried to go out with them and the wander guard alarm went off. The night shift brought her/him back. S/He was a little upset about having to return but ate breakfast and took her/his medication. The RN reported that the Resident was anxious and irritable but not combative, kind of obstinate. A short time later the wander guard went off again and she found her/him in the cul-de-sac with an LNA. The LNA and RN steered her/him around to try to get her/him back. The Resident said take your hands off me or I'm going to punch you. Resisting and pulling again the RN asked the LNA if she knew CPI, she did not so the RN told the LNA what to do. The RN stated that at that time the Resident laid down in the yard of the neighbor and was no longer combative. When they tried to stand the Resident up s/he stated, If you don't take your hands off me I'm gonna punch you in the face. The son had arrived and was upset with the Resident for saying that, so the RN told the son Let me be the bad guy. The Resident settled down and we brought her/him in, and s/he tried to go out again. The RN stated that she has a background in mental health nursing. When asked if CPI was a technique that was approved by the facility, she said that she had received the training prior to working at this facility. When asked why staff hadn't increased supervision or provided 1:1 throughout the morning the RN stated that she was giving her/him space. The RN also was asked if she had reached out to the physician regarding the increased behaviors throughout the morning and she said no she hadn't. Per interview with the Administrator and the DON on 7/30/2025 at approximately 12:30 PM the Administrator confirmed that the RN on duty during the elopement did use CPI Crisis Prevention Institute Nonviolent Crisis Intervention however, it is not a program approved for use by staff at this facility. The Administrator confirmed that CPI is not part of their protocol for use with residents in crisis.

Based on interview and record review the facility failed to ensure that an allegation of staff to resident abuse was reported to the licensing agency for one of three residents in the applicable sample (Resident #16). Findings include:Per review of a facility Internal Investigation for an incident on 7/19/2025, Resident #16 was transferred to the hospital due to increased behaviors on 7/19/2025. The hospital case manager alerted the facility Director of Nursing (DON) that while at the hospital, Resident #16 had made an allegation that staff had pushed her/him to the ground by a staff member prior to being transferred to the hospital. The internal investigation did not include evidence that the allegation had been reported to the State Licensing Agency. Per interview on 7/29/2025 at 8:45 AM with the Administrator and DON the Case Manager from the hospital had sent an email to the DON stating that she had made a report to Adult Protective Services regarding an allegation from Resident #16 that she/he had been pushed. The Administrator and DON confirmed that they had done an internal investigation of the incident, but they did not file a report with the licensing agency.

Based on observation, interview, and record review, the facility failed to ensure that resident environments were free of accident hazards related to safe handwashing water temperatures. Findings include: During unit observations on 7/29/2024 at 2:45 PM, the hot water was assessed from a faucet in an unlocked, common area bathroom, accessible to all residents. The water was too hot to hold a hand under comfortably, so a thermometer was used to take the temperature of the water. The highest reading was 124.1 degrees Fahrenheit (F). The sample was then expanded to include other common areas sinks and resident rooms. The left hallway sink read 121.8 degrees F, a right hallway sink read 121.7 degrees F, a second common area bathroom read 121.1 degrees F. The Resident in room [ROOM NUMBER] is independent with care and uses the bathroom for toileting and bathing. The water temperature in their bathroom sink read 123.4 degrees F. The above temperatures were confirmed by the facility Dietary Manager who was accompanying the surveyors at the time. Per interview with the facility Administrator (LNHA) on 7/29/24 at 3:45 PM there have been no issues with water temperatures throughout the facility. The LNHA was able to produce a water temperature monitoring log that that s/he maintains. There were no documented water temperatures above 119 degrees F. At 3:49 PM the water temperatures were rechecked by the surveyor and the LNHA using the thermometer that they use to monitor the water temperatures for the logs. The water temperature from the Hall 1 bathroom sink read 121.2 degrees F. Room number #7 read 123 degrees F, and the Hall 2 bathroom read 121.8. The LNHA confirmed all of the above water temperatures.

Based on interview and record review, the facility failed to address in their facility assessment what the staff competencies that are necessary to provide the level and types of care needed for the resident population identified in the assessment. This deficient practice has the potential to affect all 20 residents residing in the facility. Findings include: Per review of the 2024 Facility Assessment does not indicate what specific competencies are necessary to provide care to the Residents who reside in the facility. The facility assessment also fails to indicate which competencies will be evaluated. Per interview on 7/31/24 at 2:37 PM with the Licensed Nursing Home Administrator (LNHA) the licensed staff are evaluated for competency during orientation and annually. Additional training is provided to staff when a skill is needed that is not something that they routinely care for. The LNHA confirmed that the facility assessment does not identify the specific training or competencies to be evaluated that are needed to provide care to the residents.

Based on observation, interview, and record review, the facility failed to ensure that food was stored in accordance with professional standards for food safety. The facility failed to document the temperatures of 1 of 3 freezers and the temperatures of 2 of 3 refrigerators, served food items to residents outside of the facility's standard for food temperatures, and failed to discard expired food items. Findings include: A Meat Freezer log was provided to surveyors. Per the facility's Equipment Temperature Log the accepted freezer temperature is -10 [degrees Fahrenheit] to 0 [degrees Fahrenheit]. In addition to one abnormal temperature of -12 [degrees Fahrenheit] recorded there was no month documented for the Meat Freezer log. An interview was conducted with the Dietary and Housekeeping Manager on [DATE] at 1:35 PM. The Dietary and Housekeeping Manager confirmed on [DATE] that there was no documentation identifying the month where temperature of -12 [degrees Fahrenheit] was recorded. The Dietary and Housekeeping Manager confirmed s/he did not know the month of the Meat Freezer log provided. Per the facility's Equipment Temperature Log the facility's accepted refrigerator temperatures are 33 [degrees Fahrenheit] to 41 [degrees Fahrenheit]. Per record review of the milk refrigerator for [DATE] revealed ten temperatures for the refrigerator that were below accepted limits. The milk refrigerator had abnormally high temperatures on [DATE] and [DATE] with no intervention documented. In addition to the milk refrigerator, the facility also utilizes what is labeled a Milk Cooler. Per record review of the Milk Cooler temperatures for [DATE], there were seventeen Milk Cooler temperatures that were abnormally low with no intervention corrective action documented on the Equipment Temperature Log. On [DATE] at 1:35 PM the Dietary and Housekeeping Manager confirmed that the temperatures of the milk refrigerator and milk cooler temperatures were out of the facility's accepted range for the internal temperature of the refrigerator. 2.) Per the facility's Temperature Log and Checklist, Ground entrees are to be 170 [degrees Fahrenheit]. Entrees, Meats, Starch, Soup, Vegetables should be at 160 [degrees Fahrenheit]. Per record review from [DATE] to [DATE] there were thirteen abnormally low temperatures for ground entrees. From [DATE] to [DATE] there were twelve entrees, and three vegetable temperatures documented that were below the accepted temperature. 3.) On [DATE] a facility assessment of the kitchen was conducted. Per observation, one of two freezers in the basement had thirty Magic Cup ice cream cups that were expired on [DATE]. On [DATE] at 1:35 PM the Dietary and Housekeeping Manager confirmed the box of 30 Magic Cup ice cream cups that expired on [DATE] should have been discarded but were not.

Based on staff interviews and record review the facility failed to provide adequate supervision or assistance devices to prevent accidents (falls) that resulted in a fractured rib, for one applicable resident, (Resident #20). The findings include the following: Per review of the medical record, Resident #20 has [DIAGNOSES REDACTED]. An incident report dated 09/12/19 at 06:57 AM, identifies that the resident fell from his/her bed while an LNA (Licensed Nursing Assisstant) was providing care independently to the resident. Per review of Resident #20's Minimum Data Set Assessment (MDS), a Federal/State mandated assessment completed on 06/18/19, identifies the resident requires total dependence with one staff member for personal hygiene, bathing/dressing and two staff members for transfer utilizing a mechanical lift. The resident is unable to ambulate and does not require bed rails. Resident #20's person centered care plan, confirms the staff assistance required to provide activities of daily living (ADL). Per review of the incident report dated 09/12/19 at 06:57 AM, Resident #20 was receiving personal ADL care by the LN[NAME] At the time of the incident the resident was on the bed, facing away from the LNA, who had turned around to rinse out the washcloth in the wash basin. The resident rolled off the bed and onto the floor. The LNA notified the nurse immediately who was in an adjacent room. Per interview with the LNA on 11/19/19 at approximately 3 PM and 09/12/19 at approximately 1 PM, confirmation was made that s/he was getting Resident #20 ready for breakfast, providing personal care and preparing to dress the resident for the day. The LNA turned the resident to his/her left side facing a tall dresser in the direction of the doorway. The LNA had washed the resident's back and bottom, s/he turned to rinse the washcloth (wash basin was on an over the bed table behind the LNA), when she heard a thud. The LNA identified that the resident was lying on the floor, landed on his/her right side with her upper body facing under his/her bed. The LNA confirms by demonstration, that the fall was some 25-30 inches from the height of the bed to the floor. S/he also confirms that while s/he was providing care s/he was aware that the resident was not positioned in the center of the bed, s/he was lying on the edge of the left side of the mattress. There were no pull/draw sheet or incontinent pads under the resident, therefore, s/he felt s/he was unable to position the resident properly, nor did she ask for assistance. The LNA confirmed s/he did not actually witness the fall, just the resident lying on the floor. The resident was not moved at this time and the LNA left the room to notify the Licensed Practical Nurse (LPN), who was in an adjacent room, of the incident. The LNA cannot recall if s/he turned the resident onto his/her back before the LPN assessed Resident #20. Per interview with the LPN on 11/19/19 at 10:45 AM, the LNA had alerted him/her to the incident. S/he was in the adjacent room and immediately responded to the LNA's request. The LPN confirmed the resident was lying on the floor, on his/her right side beside the bed. S/he evaluated the resident by obtaining vital signs, began neurological checks and documented the incident. On mechanical lift transfer back to bed, the resident was found with a bruise to the right patella (knee cap), light blue in color, measuring, 5 cm. x 7 cm. (centimeters). Both the LNA and the LPN confirm that the resident did not complain of pain, for s/he was unable to express him/herself verbally. Per facility policy, Post Fall Assessment effective 3/2019: 1). First person with the resident witnessed or unwitnessed, will stay with the resident and call for assistance. Per interview the LNA, confirmation was made that s/he left the resident unattended to alert the nurse of the fall. 2). Avoid moving the resident until his/her status is fully evaluated to prevent further injury if an injury has occurred as a result of the fall. Per interview with the LNA confirmation was made that s/he left the resident unattended to alert the nurse of the fall. Interviews with both the LPN and the LNA confirmed that the resident was transferred back to bed, via mechanical lift before the Registered Nurse conducted an assessment. 5). The nurse will evaluate resident for injury and need for first aid. Complete vital signs, full body check for bruising, abrasion, skin tears, changes in range of motion and sign of pain immediately as appropriate. The RN, DNS confirmed that s/he was aware of the incident, had been informed of the information gathered by the LPN, but did not conduct a full assessment of the resident prior to transfer. Per review of the progress notes dated 09/12/19 at 7:42 AM, identifies the physician and the Director of Nurses (DNS) were notified of the incident. Incident report dated 09/12/19 identifies that the resident was not examined by the physician, nor was the resident transferred to the hospital. Per interview with the DNS on 11/20/19 at approximately 7:45 AM, confirms that the s/he conducted a 24 hour follow up related to the fall. S/he also confirms that the care plan was updated at that time identifying new initiatives such as proper positioning of residents in bed, placement of wash basin and necessary supplies when providing bed side care, all to avoid future occurrences. Education was provided by the DNS with the LNA who was involved in the incident. The Policy titled Fall Management was reviewed with both the LPN and the LNA during the interviews. The LPN was knowledgeable about the policy, but the LNA stated (I think I have seen that when I first started). A chest x-ray was ordered on [DATE] to rule out pneumonia. Findings showed [MEDICAL CONDITION] congestion, with no significant change from prior chest x-ray on 08/20/19. It is unclear if the ribs were fully visualized in the first x-ray. Per request of Resident #20's family, a second portable x-ray of the chest and bilateral ribs was obtained on 09/20/19. The results identified a fractured lateral right 10th rib with moderate cardiomegaly (an enlarged heart).

Based on record review and staff interview, the facility failed meet professional standards of quality regarding nursing assessment by a registered nurse at the time of a fall and before transfer for 1 applicable resident, (Resident #20). The findings include the following: Per review of the medical record, Resident #20 has [DIAGNOSES REDACTED]. An incident report dated 09/12/19 at 06:57 AM, identifies that the resident fell from his/her bed while an LNA (Licensed Nursing Assisstant) was providing care independently to the resident. The facility failed to ensure an assessment of the resident was performed by a qualified professional at the time of the fall and prior to mechanically lifting the resident off the floor, for a resident who is unable to communicate injury or pain verbally. Per review of Resident #20's Minimum Data Set Assessment (MDS), a Federal/State mandated assessment completed on 06/18/19, identifies the resident requires total dependence with one staff member for personal hygiene, bathing/dressing and two staff members for transfer utilizing a mechanical lift. The resident is unable to ambulate and does not require bed rails. Resident #20's person centered care plan, confirms the staff assistance required to provide activities of daily living (ADL). Per review of the incident report dated 09/12/19 at 06:57 AM, Resident #20 was receiving personal ADL care by the LN[NAME] At the time of the incident the resident was on the bed, facing away from the LNA, who had turned around to rinse out the washcloth in the wash basin. The resident rolled off the bed and onto the floor. Per interview with the LNA on 11/19/19 at approximately 3 PM and 09/12/19 at approximately 1 PM, the LNA identified that the resident was lying on the floor, landed on his/her right side with her upper body facing under his/her bed. The LNA confirms by demonstration, that the fall was some 25-30 inches from the height of the bed to the floor. The resident was not moved at this time and the LNA left the room to notify the Licensed Practical Nurse (LPN), who was in an adjacent room, of the incident. The LNA cannot recall if s/he turned the resident onto his/her back before the LPN came in to the room of Resident #20. Per interview with the LPN on 11/19/19 at 10:45 AM, the LNA had alerted him/her to the incident. S/he was in the adjacent room and immediately responded to the LNA's request. The LPN confirmed the resident was lying on the floor, on his/her right side beside the bed. S/he evaluated the resident by obtaining vital signs, began neurological checks and documented the incident. On mechanical lift transfer back to bed, the resident was found with a bruise to the right patella (knee cap), light blue in color, measuring, 5 cm. x 7 cm. (centimeters). Both the LNA and the LPN confirm that the resident did not complain of pain, for s/he was unable to express him/herself verbally. Per facility policy, Post Fall Assessment effective 3/2019: 1). First person with the resident witnessed or unwitnessed, will stay with the resident and call for assistance. Per interview the LNA, confirmation was made that s/he left the resident unattended to alert the nurse of the fall. 2). Avoid moving the resident until his/her status is fully evaluated to prevent further injury if an injury has occurred as a result of the fall. Per interview with the LNA confirmation was made that s/he left the resident unattended to alert the nurse of the fall. Interviews with both the LPN and the LNA confirmed that the resident was transferred back to bed, via mechanical lift before the Registered Nurse conducted an assessment. 5). The nurse will evaluate resident for injury and need for first aid. Complete vital signs, full body check for bruising, abrasion, skin tears, changes in range of motion and sign of pain immediately as appropriate. The RN, DNS confirmed that s/he was aware of the incident, had been informed of the information gathered by the LPN, but did not conduct a full assessment of the resident prior to transfer. Per review of the progress notes dated 09/12/19 at 7:42 AM, identifies the physician and the Director of Nurses (DNS) were notified of the incident. Incident report dated 09/12/19 identifies that the resident was not examined by the physician, nor was the resident transferred to the hospital. A chest x-ray was ordered on [DATE] to rule out pneumonia. Findings showed [MEDICAL CONDITION] congestion, with no significant change from prior chest x-ray on 08/20/19. It is unclear if the ribs were fully visualized in the first x-ray. Per request of Resident #20's family, a second portable x-ray of the chest and bilateral ribs was obtained on 09/20/19. The results identified a fractured lateral right 10th rib with moderate cardiomegaly (an enlarged heart). In the State Board of Nursing Scope of Practice & Decision Tree for RN, APRN, and LPN the following is stated: LPN role in assessment, planning, and implementation of a strategy of care: -LPNs may not independently assess the health status of an individual or group and may not independently develop or modify the plan of care. LPNs may contribute to the assessment and nursing care planning processes; however, patient assessment and care plan development or revision remain the responsibility of the RN/APRN/licensed physician/licensed dentist. -LPNs may not modify a patient care protocol. If the situation and/or data collected by the LPN are not clearly consistent with a protocol, the LPN must consult with the supervising professional or authorized provider before taking action or making a recommendation to a patient. *Reference: Based on Standards of Professional Nursing Practice, Lippincott Manual of Nursing Practice 19th edition, Wolters Kluwer Health/Lippincott[NAME], Page #17, Standards of Practice was deviated with the failure of a RN assessment at the time of a fall and prior to transfer. (see F689)

Based on record review, observation, and staff interviews the facility failed to assure that one resident (Resident #16) in a Stage 2 sample of 13 received the necessary treatment and services to prevent the development and worsening of a Pressure Ulcer. Findings include: Per staff interview on 10/13/14 Resident #16 has a Stage 3 Pressure Ulcer. Per observation at 2:10 PM on 10/13/14 Resident#16 has a Stage 3 Pressure Ulcer with undermining. Undermining is the destruction of tissue or ulceration extending under the skin edges (margins) so that the pressure ulcer is larger at its base than at the skin surface. In a review of the Minimum Data Set (MDS) assessments, the resident was admitted with no pressure ulcers. In an MDS assessment dated [DATE] is the first noted Stage 2 Pressure Ulcer. Additional MDS assessments dated 8/4, 8/14/ and 8/17/2014 all note a Stage 2 Pressure Ulcer. In a review of assessments, the resident was admitted on [DATE] with no pressure ulcers. On 5/7/14 the Comprehensive Nursing Assessment reveals a Stage 1 Pressure Ulcer of the Sacrum. In a paper Pressure Ulcer Record dated 7/17/14, a Stage 2 Pressure Ulcer measuring 4x4 centimeters (cm.) was noted. On 8/1/14 the Pressure Ulcer Record notes a Stage 3 Pressure Ulcer is present and on other skin assessments dated 8/6/14 through 9/18/14 the Pressure Ulcer is recorded as a Stage 3 Pressure Ulcer varying in size from 4x4 cm. to 2.5 cm x 1.5 cm. In a review of the record, the initial comprehensive plan of care did not contain any preventative measures specific to pressure ulcer prevention. On 4/15/14 a reddened area is noted on the care plan and a [MEDICATION NAME] dressing placed over the coccyx to be changed every 72 hours. No other interventions specific to pressure ulcer prevention were initiated in the plan of care until the Stage 2 ulcer is noted on 7/17/14 when wound care and an air mattress were initiated. On the Risk factors in the pressure ulcer record initiated 7/17/14 [MEDICAL CONDITION], Immobility, Poor PO (oral) intake of food and fluids, Resistive to care, Refusal to stay in side lying position are all listed as risk factors. After the Pressure Ulcer was determined to be a Stage 3 the interventions of repositioning every hour and use of a wedge for pressure relief were added. In an interview on 10/15/14 at 2:45 PM the Director of Nursing Service (DNS) confirmed that new interventions were added to the care plan in response to an increase in the stage and size of the pressure ulcer rather than as an initial preventative care plan. In staff interviews on 10/13/14 at 2:10 PM the Charge Nurse stated that the resident had not seen a wound nurse, but that s/he had spoken with a representative of 3M (a wound care supply company) who is a wound specialist. She confirmed that the wound specialist had never seen Resident #16's pressure ulcer. In an interview on the afternoon of 10/13/14 the DNS stated that the resident had been seen by the Therapist who is a Certified Wound Specialist and that the Therapist would be in the facility the following day. In an interview on 10/14/14 at 12:45 PM the Occupational Therapist stated that s/he had been trained in [MEDICAL CONDITION] care which included wounds. S/he stated that this led to her/his interest in wounds. S/he has worked with several wound nurses and taken some training but is not a Certified Wound Specialist and has not done training specific to pressure ulcers. S/he further stated that s/he has not seen or treated Resident #16's Pressure Ulcer or consulted with nursing staff about the ulcer. In record review on 10/15/14, the Licensed Nurse Aide (LNA) Electronic Activities of Daily Living (ADL) record, evidences 31 instances where the turn and reposition care area for each shift was not initialed as being done. In an interview on 10/15/14 at 12:30 PM, the DNS stated that the Electronic flowsheet reflects the standard turning every 2 hours and that there are no special flowsheets for residents who are turned more frequently.

Based on observation, medical record review and staff interview, the facility failed to develop, review and revise the comprehensive care plan for 2 of 13 residents (Resident #16 and Resident #41) in the applicable sample. The findings include the following: 1. Per staff interview on 10/13/14, Resident #16 has a Stage 3 Pressure Ulcer. Per observation at 2:10 PM on 10/13/14, Resident #16 has a Stage 3 Pressure Ulcer with undermining. Undermining is the destruction of tissue or ulceration extending under the skin edges (margins) so that the pressure ulcer is larger at its base than at the skin surface. In a review of the Minimum Data Set (MDS) assessments, the resident was admitted with no pressure ulcers. In an MDS assessment dated [DATE] is the first noted Stage 2 Pressure Ulcer. Additional MDS assessments dated 8/4, 8/14/ and 8/17/2014 all note a Stage 2 Pressure Ulcer. In a review of assessments, the resident was admitted on [DATE] with no pressure ulcers. On 5/7/14 the Comprehensive Nursing Assessment reveals a Stage 1 Pressure Ulcer of the Sacrum. In a paper Pressure Ulcer Record dated 7/17/14, a Stage 2 Pressure Ulcer measuring 4x4 centimeter (cm.) was noted. On 8/1/14 the Pressure Ulcer Record notes a Stage 3 Pressure Ulcer is present and on other skin assessments dated 8/6/14 through 9/18/14 the Pressure Ulcer is recorded as a Stage 3 Pressure Ulcer varying in size from 4x4 cm. to 2.5 x 1.5 cm. In a review of the record the initial comprehensive plan of care did not contain any preventative measures specific to pressure ulcer prevention. On 4/15/14 a reddened area is noted on the care plan and a [MEDICATION NAME] dressing placed over the coccyx to be changed every 72 hours. No other interventions specific to pressure ulcer prevention were initiated in the plan of care until the Stage 2 ulcer is noted on 7/17/14 when wound care and an air mattress were initiated. On the Risk factors in the pressure ulcer record initiated 7/17/14 [MEDICAL CONDITION], Immobility, Poor PO (oral) intake of food and fluids, Resistive to care, Refusal to stay in side lying position are all listed as risk factors. After the Pressure Ulcer was determined to be a Stage 3, the intervention of repositioning every hour and use of a wedge for pressure relief were added as interventions. In an interview on 10/15/14 at 2:45 PM the Director of Nursing Services (DNS) confirmed that new interventions were added to the care plan in response to an increase in the Stage and Size of the pressure ulcer rather than as an initial preventative care plan. 2. Per medical record review on 10/14/14 at approximately 3:30 PM, Resident #41 was admitted on [DATE] with [DIAGNOSES REDACTED]. Per Physician orders [REDACTED]. Per interview with the Regional Director of Quality Improvement at approximately 3:30 PM on 10/14/2014 confirmation is made that there is no evidence that the Interdisciplinary Care Plan includes a written plan of care for comfort as prescribed by the physician.