Brookside Rehab & Nursing Center

reviewed, and revised by a team of health professionals.

review or revise the comprehensive care plan for one of 14 residents, Residents in the survey sample,

comprehensive care plan to address behaviors of play with and ingesting fecal material. R2 was admitted to the facility with diagnosis that included but was not limited to bipolar disorder (1) and dementia (2). On the most recent comprehensive MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 09/13/2025, R2 scored 0 (zero) out of 15 on the BIMS (brief interview for mental status), indicating R2 was severely impaired of cognition for making daily decisions.

The Psychiatric Note for R2 dated 09/27/2025 documented in part, Relevant Interval History (Symptoms) Staff reported observing concerning behavior where the patient had a bowel movement and was subsequently playing with and eating her own feces, though the timing of when this behavior started is uncertain.

The patient does not exhibit any anxiety, depression, delusional thoughts, or hallucinations at this time .Review of R2's comprehensive care plan dated 11/12/2024 failed to evidence documentation to address behaviors of play with and ingesting fecal material. On 10/20/2025 at approximately 3:50 p.m. an interview was conducted with CNA (certified nursing assistant) #1 regarding R2. CNA #1 stated she worked on the North Wing and was usually assigned and provided care to R2.

When asked if she recalled an incident of R2 ingesting feces CNA #1 stated yes.

She further stated that R2 frequently puts her hands in her pants and removes feces and having it on her hands and lips. CNA #1 also stated that even after being toileted R2 would engage in the behavior of removing fecal material with her hands.

When asked if she was aware of a plan to prevent R2 from removing and ingesting feces she stated no. On 10/20/2025 at approximately 4:00 p.m. an interview was conducted with CNA (certified nursing assistant) #2 regarding R2. CNA #2 stated she worked on the North Wing and was usually assigned and provided care to R2.

When asked if she recalled an incident of R2 ingesting feces CNA #2 stated yes.

She further stated that R2 frequently puts her hands in her pants and removes feces and ingests it . CNA #2 also stated that even after being toileted R2 would engage in the behavior of removing fecal material with her hands.

When asked if she was aware of a plan to prevent R2 from removing and ingesting feces she stated that when she sees R2 reaching into her pant CNA #2 stated she intervenes and either redirects R2 or takes her to the bathroom.

When asked if she was aware of a plan to prevent R2 from removing and ingesting feces she stated no. On 10/21/2025 at approximately 12:39 p.m. an interview was conducted with LPN (licensed practical nurse) #1 regarding R2 playing with and ingesting feces. LPN #1 stated she worked on the North Wing and was aware of two incidences of R2 playing with her feces with her hands and one of the incidences LPN #1 witnessed.

After reviewing R2's comprehensive care plan dated 11/12/2024 LPN #1 stated that the care plan failed to document or address R2's behavior involving feces.

When asked to describe the purpose of a resident's care plan she stated the purpose of the care plan is for all disciplines to have a picture of the resident. On 10/21/2025 at approximately 3:05 p.m. ASM (administrative staff member) #1, administrator, ASM #2, director of nursing, ASM #3, regional director of clinical operations and ASM #4 risk nurse, were made aware of the above findings.

No further information was provided prior to exit.

Reference:(1) A brain disorder that causes unusual shifts in mood, energy, activity levels, and the ability to carry out day-to-day tasks.

This information was obtained from the website: https://www.nimh.nih.gov/health/topics/bipolar-disorder/index.shtml. (2) A loss of brain function that occurs with certain diseases. It affects memory, thinking, language, judgment, and behavior.

This information was obtained from the website: https://medlineplus.gov/ency/article/000739.htm.

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Brookside Rehab & Nursing Center 614 Hastings Lane Warrenton, VA 20186

also stated that if the physician or nurse practitioner orders an X-ray it is scheduled and obtain as

fracture.

When asked what a nurse should do if a phone call has not been received from the X-ray

X-ray company for the results.

After reviewing the nurse's notes and X-ray report for R8 LPN #1 stated that the nurse should have called the X-ray company for the result. LPN #1 agreed that there was a delay in treatment for R8. On 10/21/2025 at approximately 1:25 p.m. an interview was conducted with RN (registered nurse) #5.

When asked if she recalled receiving a telephone call from (Name of X-ray Company) on 11/19/2024 with the results of R8's X-ray RN #5 stated she did not recall receiving a call.

After reviewing the nurse's notes and X-ray report for R8 RN #5 stated that the X-ray company should have been called for the result and it was a delay in treatment. On 10/21/2025 at approximately 3:05 p.m. ASM (administrative staff member) #1, administrator, ASM #2, director of nursing, ASM #3, regional director of clinical operations and ASM #4 risk nurse, were made aware of the above findings. No further information was provided prior to exit.

References:(1) A loss of brain function that occurs with certain diseases. It affects memory, thinking, language, judgment, and behavior.

This information was obtained from the website: https://medlineplus.gov/ency/article/000739.htm. (2) A type of broken hip.

The hip is made up of two bones: the femur (thigh bone) and the pelvis (socket).

This information was obtained from the website: https://ota.org/for-patients/find-info-body-part/3720#/+/0?score/desc/

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Brookside Rehab & Nursing Center 614 Hastings Lane Warrenton, VA 20186

notified. A review of R1's clinical record revealed a nurse's note dated 2/26/25 that documented,

notified, arrived to unit and prescribed ativan (anti-anxiety medication) 0.5 mg (milligrams) PO (by

safety.

Further review of R6's clinical record revealed a nurse's note dated 3/20/25 that documented, This nurse was informed by a staff member that the resident had hit another resident (R14) on her back when she had told her to get out of her room .This nurse did not witness the incident.

This nurse approached resident (R6) and redirected her back into her room.

Resident (R6) has no recollection of what had happened.

Skin assessment completed and no injuries at this time .UM (Unit Manager), DON, NP, RP and the Administrator all informed on all parties involved.

Police notified.

Labs were drawn for residents [sic] agitation and aggressive behavior.

Will continue to monitor. A review of R14's clinical record revealed a nurse's note dated 3/20/25 that documented, (R14) was noted to be in an altercation with another resident .dayshift nurse caring for resident noted to have informed RP of incident and per Dayshift nurse assigned to resident no new injuries at this time.

On 10/20/25 at 3:58 p.m., an interview was conducted with CNA (Certified Nursing Assistant) #1. CNA #1 stated it's hard to monitor every resident going into every resident's room. CNA #1 stated when there is less staff, each CNA has a bigger assignment and has less time to supervise residents because the CNAs are providing care in resident rooms and can't be in the dining room or halls to supervise residents going in and out of other resident rooms.

On 10/21/25 at 12:26 p.m., an interview was conducted with LPN (Licensed Practical Nurse) #1. LPN #1 stated R6 wandered into other resident rooms multiple times a week and could be combative. LPN #1 stated if the unit census was full (60 residents), staff wasn't always able to keep R6 out of other resident rooms.

On 10/21/25 at 1:12 p.m., an interview was conducted with LPN #2. LPN #2 stated R6 was always protective of her space, even if it wasn't her space. LPN #2 stated R6 was always easily agitated and very confrontational. LPN #2 stated residents wander on the North Unit and staff are not always able to keep their eyes on the residents all the time. LPN #2 stated it was important to provide adequate supervision for R6 and to keep all residents safe.

On 10/21/25 at 3:11 p.m., ASM (Administrative Staff Member) #1, (the Administrator) and ASM #2 (the Director of Nursing) were made aware of the above concerns.

No further information was presented prior to exit.

495267 10/21/2025

Brookside Rehab & Nursing Center 614 Hastings Lane Warrenton, VA 20186