Every finding on record at Northampton Nursing and Rehabilitation Center

Based on record review, observation, staff interviews, a Hospice staff member interview, and a Medical Director interview, the facility failed to provide care in a safe manner to a resident who was immobile, severely cognitively impaired, was prescribed an antiplatelet medication (an antiplatelet prevents blood clots and increases the risk of bleeding), and had fragile skin that made her susceptible to injury with minimal force. On 7/29/2026 Resident #1 was transferred from a recliner to the bed with a two-person transfer instead of the care planned use of a mechanical lift. Following the transfer, Resident #1 was turned to her right side by Nurse Aide (NA) #3 during incontinent care, and her head hit an unpadded right-side rail. She sustained a laceration to her head described by Nurse #2 as gushing with blood. Resident #1 was transferred to the hospital where she was unresponsive upon arrival, had a 5 centimeter (cm) laceration to the right temporal area (the area on the side of the head behind the eyes and above the ears) with arterial bleeding (a severe, life threatening medical emergency where blood escapes a damaged artery) and diagnosed with a traumatic intracranial hemorrhage (bleeding inside the skull) with loss of consciousness, a traumatic acute on chronic subdural hematoma (blood collected between the brain's surface and its tough outer covering that happened over days to weeks prior with a new fresh bleed overlapping the old one) with a 1.1 cm midline shift (the accumulated blood was pushing the brain significantly to the left by about 1.1 cm, which indicated strong pressure inside the skull), and skin tears to the right hand. Resident #1's family declined surgical intervention and elected comfort care for the resident. Resident #1 expired on 8/7/2026. This occurred for 1 of 3 residents reviewed for accidents (Resident #1). Immediate Jeopardy began on 7/29/2026 when NA #3 turned Resident #1 onto her right- side during care and the resident hit her head on the right-side rail, resulting in head trauma. Immediate Jeopardy was removed on 8/10/2026 when the facility implemented a credible allegation of immediate jeopardy removal. The facility remains out of compliance at a lower scope and severity of a D, which is no actual harm with potential for more than minimal harm that is not immediate jeopardy, to ensure staff education and monitoring systems put into place are effective. Findings included: Resident #1 was admitted to the facility 3/3/2026 with diagnoses including diabetes mellitus, end-stage Alzheimer's disease, aphasia, and history of cerebral vascular accident. (Aphasia is a language disorder that affects your ability to speak and understand what others say.) Review of the resident care guide, used to inform nurse aides, initiated on 3/3/2026 documented that Resident #1 required use of a large sling for mechanical lift transfers, a recliner, an air mattress that was to remain in place and functioning properly, a turning/draw sheet for repositioning, and wedges for positioning. Physician's orders dated as initiated on 3/4/2026 indicated Resident #1 was prescribed 75 milligrams of Clopidogrel Bisulfate (Plavix) daily by mouth for the prevention of cerebrovascular accident. Plavix is an antiplatelet medication with a known increased risk of bleeding. Review of Resident #1's care plan initiated 3/11/2026 identified a focus area for the potential for skin integrity impairment related to impaired mobility. Interventions included padded side rails, wedges for positioning, assist with turning in bed, and protective arm sleeves as tolerated. A quarterly Minimum Data Set assessment dated [DATE] documented Resident #1 had severely impaired cognition, highly impaired hearing, and no speech. Resident #1 was dependent on staff for all activities of daily living tasks and mobility. Resident #1 was documented as having no wounds, pressure ulcers, or skin tears. Resident #1 received antiplatelet medication, hospice services, measured 5 feet tall and weighed 100 pounds. A Physical Device Use Evaluation dated 6/9/2026 completed by Nurse #3 documented Resident #1's use of left and right quarter rails due to unsafe movements in bed. Risks identified for device use were skin tears and bruises. Nurse #3 was interviewed on 8/11/2026, at 10:42 AM. She reported that Resident #1 utilized upper side rails for safety due to observed unsafe movements. Nurse #3 stated that the side rails also facilitated the provision of care, as Resident #1 would attempt to grab onto staff or objects and redirecting her to hold the rail allowed care to be completed safely. She further stated that padded side rails were always required because Resident #1 had fragile skin, and the padding was necessary to prevent skin injury. Nurse #3 indicated that ensuring padded side rails were in place was the responsibility of both licensed nursing staff and nurse aides. During the initial tour on 8/5/2026 at 9:04 AM, an observation was made of Resident #1's bed. The bed was positioned lengthwise against the wall, and a training/medical manikin was lying in it. Plastic half length bed rails were attached to both sides of the bed, spanning only the upper portion. An interview was conducted with Hospice Nurse #1 on 8/6/2026 at 10:38 AM. Hospice Nurse #1 stated Resident #1 had been receiving Hospice services for about a year, and she routinely visited her. Hospice Nurse #1 stated Resident #1 had severe or late-stage Alzheimer's, was very immobile, and had contractures of the right arm and leg. Hospice Nurse #1 stated Resident #1 had very fragile skin, but if care was performed properly, injury could be avoided. Hospice Nurse #1 stated Hospice nurse aides had provided care twice weekly since admission without injury. An interview was conducted with NA #1 on 8/5/2026 at 12:58 PM. NA #1 was assigned to provide care for Resident #1 during the 7:00 AM to 3:00 PM shift on 7/29/2026. NA #1 stated she was employed by an agency but had routinely worked at the facility caring for Resident #1. NA #1 reported that on the morning of 7/29/2026, the Director of Nursing (DON) notified her that Resident #1's air mattress needed to be changed due to continuous beeping. The DON instructed NA #1 to get Resident #1 out of the bed and to place her into a recliner. NA #1 stated that Resident #1 very rarely got out of bed and required a mechanical lift for transfers to the recliner. NA #1 reported she obtained assistance from NA #2 and used the mechanical lift to place Resident #1 in the recliner. NA #1 stated Resident #1 was not injured during the transfer, was positioned with pillows for comfort, and was transported to the activity/dining hall. NA #1 stated she removed everything from Resident #1's bed to include the linens, pillows, and cushions and then pushed the bed into the hallway. NA #1 stated she did not recall if she removed the padding on the side rails or lowered the side rails. NA #1 explained that she thought stripping the bed and putting the bed in the hallway would expedite the Maintenance Director changing the mattress. NA #2 was interviewed on 8/5/2026 at 1:46 PM. NA #2 stated she was agency staff and worked the 7:00 AM to 3:00 PM shift on 7/29/2026. NA #2 confirmed she assisted NA #1 with transferring Resident #1 to the recliner using the mechanical lift that morning. NA #2 reported she heard the DON instruct NA #1 to get Resident #1 out of bed, and NA #1 asked for help with the mechanical lift. NA #2 confirmed Resident #1 was not injured in the transfer. NA #2 recalled assisting Resident #1 with her lunch meal, reporting Resident #1 consumed 100 percent of her food and fluids. An interview was conducted with the Maintenance Director on 8/5/2026 at 1:57 PM. The Maintenance Director confirmed he changed the air mattress on Resident #1's bed on 7/29/2026 due to malfunction. The Maintenance Director recalled placing the new air mattress on the bed between 2:00 PM and 3:00 PM. The Maintenance Director confirmed the bed and mattress were out in the hallway, and he pushed the bed back into the room after changing the mattress. NA #1 was interviewed on 8/5/2026 at 12:58 PM. NA #1 reported that she made Resident #1's bed at the end of her shift on 7/29/2026. NA #1 stated she placed two fitted sheets over the right-side rail. NA #1 stated she put the sheets over on the right-side rail because Resident #1 tended to lean to the right side due to her contractures on the right side. NA #1 stated she was unsure whether padding was present on the left and right-side rails when she made the bed. NA #1 explained Resident #1 routinely had blue padding that was over the side rails as well as repositioning pillows to keep her in the middle of the bed. NA #1 reported Resident #1 remained in the recliner at the end of her shift. NA #4 was interviewed on 8/5/2026 at 4:30 PM. NA #4 reported she was working on the 3:00 PM to 11:00 PM shift on 7/29/2026 and assisted NA #3 performing a two-person lift to transfer Resident #1 from the recliner to the bed. NA #4 stated that there were no injuries, bruises, or skin tears sustained during the transfer. NA #4 acknowledged a mechanical lift should have been used because Resident #1 required total care, but the two-person lift was successful and quickly performed. NA #4 recalled the left-side rail on Resident #1's bed did not have padding, and the right-side rail had no padding and was covered only by a fitted sheet. NA #4 did not know why there was a fitted sheet over the right-side rail and did not know why the padding that was usually on the side rails was not there. Record review of a nurse's health status note dated 7/29/2026 at 4:30 PM written by Nurse #2 revealed Resident #1 was assessed with blood noted on the right forehead. Treatment was initiated, and a laceration measuring 4 cm by 2 cm was identified. Resident #1 was not observed to be in distress and had even unlabored respirations. While pressure was applied to the forehead, skin tears were observed on the right arm. The Medical Director was notified, and Resident #1 was transported to the emergency room. Review of a health status note dated 7/29/2026 at 4:52 PM written by Nurse #2 revealed a family member of Resident #1 was contacted and informed of the mishap of laceration to right lateral [toward the side] forehead. The family member was also notified that Resident #1 was being sent to the emergency room. Review of an incident note dated 7/29/2026 at 5:40 PM written by Nurse #2 revealed Nurse Aide (NA) #3 reported transferring Resident #1 from the recliner to the bed without using the mechanical lift. After NA #3 rolled Resident #1 during care, Resident #1's head contacted the right-side rail, leaving a blood spot on the rail and resulting in the forehead laceration and two skin tears on the right arm. NA #3 was interviewed on 8/5/2026 at 8:32 PM. NA #3 confirmed she was assigned to care for Resident #1 on 7/29/2026 for the 3:00 PM to 11:00 PM shift. NA #3 stated she was employed by an agency but was familiar with Resident #1's care needs because she had been assigned to care for her on many occasions. NA #3 described Resident #1 as a small lady with fragile skin who bruised and sustained skin tears easily and noted Resident #1 always leaned on the side rail when she was in bed. NA #3 thought the blue padding on the side rails was to protect Resident #1 from skin tears. NA #3 reported that on 7/29/2026, there was no lift pad underneath Resident #1 that would allow the mechanical lift to be used. NA #3 stated she and NA #4 performed a two-person lift, transferring Resident #1 from the recliner to the bed without using the mechanical lift, and stated Resident #1 was not injured during that transfer. NA #3 acknowledged Resident #1 was to be transferred with a mechanical lift, but she could not do so without a lift pad underneath her. NA #3 stated NA #4 left the room, and she then attempted to perform incontinent care. NA #3 reported placing a pillow on the left side rail and turning Resident #1 first to the left side and then to the right side. NA #3 did not recall whether padding was present on the right-side rail but recalled there was a sheet over it. NA #3 thought the sheet over the right-side rail would protect Resident #1 from skin tears. NA #3 stated she did not place a pillow on the right-side rail. NA #3 stated that while Resident #1 was on her right side, she noticed the pad underneath her was soiled and needed replacement. NA #3 reported she went across the room to retrieve a clean pad from the closet, and upon returning, she turned Resident #1 onto her back. NA #3 stated it was then that she noticed blood coming from Resident #1's head. NA #3 attempted to stop the bleeding with a washcloth and observed blood on the sheets and bedding. NA #3 activated the call light but felt that assistance would not arrive quickly enough, so she used her cell phone to call NA #4, receiving no response. NA #3 reported she positioned Resident #1 at a 90-degree angle in the bed, left the washcloth on her head, and went to the nurse's desk to obtain assistance. NA #3 stated nurses responded and assisted in stopping the bleeding. NA #3 stated she wished she had placed a pillow on the right-side rail before turning Resident #1. Nurse #2 was interviewed on 8/5/2026 at 4:04 PM. Nurse #2 confirmed she was the assigned nurse for Resident #1 on 7/29/2026 for the 3:00 PM to 7:00 PM shift. Nurse #2 reported that at approximately 4:30 PM, NA #3 approached the nurse's desk and stated Resident #1 was bleeding. Nurse #2 stated she grabbed the treatment cart and ran with Nurse #1 to Resident #1's room. Nurse #2 stated that blood was gushing from Resident #1's right temporal area and described blood as being everywhere. Nurse #2 stated her focus was on stopping the bleeding using supplies from the treatment cart. Nurse #2 reported immediately applying pressure to the laceration and wrapping Resident #1's head with a pressure dressing. Nurse #2 recalled the DON arriving to assist and addressing a skin tear on Resident #1's right hand. Nurse #2 stated that when emergency medical services arrived, Resident #1 was still alert but appeared confused. Nurse #2 reported hearing NA #3 and NA #4 state they had not used the mechanical lift during the transfer but had not dropped Resident #1. Nurse #2 stated she did not recall whether padding was present on the side rails because her focus was on Resident #1's bleeding. Nurse #2 stated she knew Resident #1 had fragile skin which was why she had an air mattress, padded side rails, and the mechanical lift needed to be used for transfers. Nurse #1 was interviewed on 8/5/2026 at 11:33 AM. Nurse #1 stated she was assigned to work 8:00 AM to 4:30 PM on 7/29/2026. Nurse #1 stated she overheard NA #3 report to Nurse #2 at the nurse's desk that Resident #1 was bleeding. Nurse #1 stated Nurse #2 grabbed the treatment cart, and they ran to Resident #1's room. Nurse #1 stated Resident #1 was bleeding from the right side of her head. Nurse #1 stated Nurse #2 applied pressure and gauze, but the bleeding would not stop, making it difficult to determine the size of the injury. Nurse #1 stated she called for additional nursing help and Nurse #3 arrived. Nurse #1 stated, while Nurse #3 assisted Nurse #2 with applying pressure dressings, she returned to the nurse's desk to notify the Medical Director, call emergency medical services, prepare paperwork, and contact the DON. Nurse #1 explained the DON had just left the facility. Nurse #1 confirmed that the Medical Director ordered transfer to the emergency room and 911 was called. Nurse #1 stated the DON returned to the facility and immediately went to Resident #1's room. Nurse #1 did not recall whether padding was present on the side rails but recalled there was a sheet on the right-side rail. Nurse #1 stated that Resident #1 had fragile skin and the side rail padding was usually on the rails to protect her from skin injury. Nurse #3 was interviewed on 8/5/2026 at 3:35 PM. Nurse #3 confirmed she was working the 3:00 PM to 11:00 PM shift on 7/29/2026. Nurse #3 stated Nurse #1 called her to assist Nurse #2 with Resident #1, who was bleeding. Nurse #3 reported she entered the room and saw blood running down Resident #1's face and into her ear. Nurse #2 was attempting to apply pressure with gauze, but when pressure was released, blood sprayed. Nurse #3 stated she handed fresh gauze packs to Nurse #2 from the treatment cart while efforts were made to stop the bleeding and assess the size of the wound. Nurse #3 stated Nurse #2 continued applying fresh gauze and ultimately wrapped Resident #1's head with a compression wrap. Nurse #3 reported the DON arrived and identified a bruise and a skin tear on Resident #1's right hand. Nurse #3 stated the DON removed Resident #1's right hand from underneath Resident #1's right side, repositioned the skin, cleaned the wound, and applied skin closure strips. Nurse #3 stated Resident #1 remained alert and was looking at the staff while emergency medical services arrived to transport her. Nurse #3 did not recall if padding was present on the side rails. The DON was interviewed on 8/5/2026 at 4:42 PM. The DON stated she returned to the facility after receiving a call from Nurse #1 on 7/29/2026 at approximately 4:30 PM. The DON stated the nursing staff was already applying pressure to Resident #1's head injury. Resident #1 was on her back, and a white sheet was draped over the right-side rail with a circular blood spot. The DON stated each time gauze was lifted from the laceration, blood squirted onto the floor and onto the DON. After bleeding was controlled, the DON stated she observed Resident #1's hand tucked underneath her body. Upon repositioning the hand, the DON observed two skin tears. The DON stated she cleaned the skin tears with normal saline, applied skin closure strips, and applied a dry dressing. The DON stated emergency medical services arrived and transported Resident #1 to the hospital. The DON stated she questioned NA #3 and NA #4 separately regarding the incident directly after Resident #1 was transported to the hospital. The DON stated she determined the laceration occurred due to improper turning and repositioning. The DON stated NA #3 turned Resident #1 to her right side when she went to obtain another incontinence pad. Resident #1 had her head up against the right-side rail, and her right hand was caught underneath her. The DON stated NA #3 did not pull Resident #1 to the left before rolling her to the right side, which would have prevented contact with the rail. The DON confirmed NA #3 and NA #4 performed a transfer without following the care guide instructions requiring a mechanical lift. The DON was interviewed again on 8/11/2026 at 1:50 PM. The DON stated that Resident #1 had padded side rails to help reduce the risk of skin injury due to fragile skin that bruised and teared easily due to her use of antiplatelet medication. The DON stated that the padded side rails were also used because Resident #1 leaned on the side rails. Review of the Emergency Medical Services (EMS) record dated 7/29/2026 revealed EMS staff arrived at the bed of Resident #1 at 5:07 PM. Initial vital signs obtained by EMS staff noted a low oxygen saturation level of 84% (normal range is 95% to 100%) but after a nasal cannula with oxygen was applied, her oxygen saturation level improved to 95%. The narrative portion of the report revealed Resident #1 was found by EMS staff lying on her left side with a bandage wrapped around her head with no bleeding noted. When the EMS staff inquired how the injury occurred, the facility staff stated that when Resident #1 was being provided with incontinent care, Resident #1 was rolled too far causing her head to hit the side rail of the bed. The EMS report also revealed Resident #1 had an irregular heart rate during the transport to the hospital. Documentation on a hospital record for Resident #1's 7/29/2026 admission revealed that in the emergency department she was unresponsive and had a 5-centimeter laceration on the right temporal scalp with arterial bleeding that was repaired. Resident #1's blood pressure initially was 112/60, then went to 89/44. (Her blood pressure dropped from a normal range to a low, unstable level.) A computed tomography scan of her head showed a large acute-on-chronic right hemispheric subdural hematoma with 1.1-centimeter leftward midline shift and concern for developing left-sided ventricular entrapment. (Ventricular entrapment means the left brain's fluid chambers are being pinched or blocked by pressure from the hematoma. This can trap fluids, increase pressure, and damage brain tissue.) Resident #1 was diagnosed with a traumatic subdural hematoma and a traumatic intracranial hemorrhage with loss of consciousness. Resident #1's family declined surgical intervention and elected comfort care in the hospital. An online obituary indicated Resident #1 expired on 8/7/2026. Resident #1's death certificate was requested but was not received. The Medical Director was interviewed on 8/6/2026 at 12:45 PM. The Medical Director stated he was notified that Resident #1 hit her head on the bedrail and sustained a laceration. The Medical Director stated Resident #1 had very fragile skin, making her susceptible to injury with minimal force. He stated the face was highly vascular (large number of blood vessels) and Resident #1's use of Plavix increased her susceptibility to bleeding. He stated Resident #1 may have had a pre-existing subdural hematoma of indeterminate duration that bled when her head contacted the side rail. The Administrator was notified of Immediate Jeopardy on 8/7/2026 at 12:29 PM.The facility provided the following credible allegation of immediate jeopardy removal plan dated as completed 8/10/2026.Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance:Resident #1 is an [AGE] year-old hospice resident with diagnoses including a history of transient ischemic attack (mini-stroke), aphasia, atherosclerotic heart disease, type 2 diabetes mellitus, and thrombocytopenia (low platelet count), and an antiplatelet. The resident is dependent on staff for activities of daily living and has very fragile skin. On 7/29/26, at approximately 4:30 pm, Nursing Assistant #3 received assistance from Nursing Assistant #4 to transfer the resident to bed. During the transfer, Nursing Assistant #3 and Nursing Assistant #4 transferred the resident using a two-person lift rather than the care-planned required mechanical lift. No injuries occurred during this transfer. Nursing Assistant #4 left the room following the transfer while Nursing Assistant #3 provided incontinent care to Resident #1.Nursing Assistant #3 utilized a turning pad to reposition the resident onto the right side. There was a white sheet covering the right bed rail instead of a bed rail padding. Nursing Assistant #3 did not use an appropriate technique to pull the resident toward her during the turning and positioning to ensure the resident was properly positioned in the center of the bed upon completion of the turn. Because the resident was experiencing loose stools, the nursing assistant left the resident on the side and briefly obtained additional incontinent care supplies from the resident's closet. While the resident remained positioned on the right side, the resident's head was noted to be leaning against the right-side rail. As the nursing assistant repositioned the resident back to the left side, a laceration to the resident's forehead was observed. Nursing staff were immediately notified and responded by assessing the resident. The laceration measured 4cm in length x 2 cm and was bleeding profusely. A pressure dressing was applied to the forehead laceration. During the assessment, nursing staff noticed the resident's right hand was tucked underneath the resident's body. After repositioning the resident's hand, two skin tears were identified on the top of the right hand. The skin tears were cleansed with normal saline and dry dressings were applied. The attending physician and resident representative were immediately notified. Due to the resident's injuries and antiplatelet therapy, the resident was transferred to the emergency department for evaluation and treatment. The resident remained alert with eyes open upon transfer and was nonverbal at baseline.Resident #1 was diagnosed at the hospital with a traumatic acute-on-chronic subdural hematoma with a 1.1 midline shift and laceration to the right forehead requiring sutures.On 7/30/26, the Administrator completed a root cause analysis for (1) Resident #1's injury during turning and repositioning (2) staff's decision not to follow the established care plan for transfers, and (3) reason for the appropriate protective padding not being on the bed rail. During the investigation, it was determined that Nursing Assistant #3 did not use an appropriate technique to pull the resident toward her during turning and repositioning to ensure the resident was properly positioned in the center of the bed upon completion of the turn. This caused the resident to be positioned out of the center of the bed and further towards the right side of the bed, causing the resident's head to hit the bedrail on the right side of the bed, resulting in a laceration and subdural hematoma. As a result, the facility identified the root cause of the incident to be ensuring the appropriate technique for turning and repositioning during care to prevent injury. Additionally, it was determined that Nursing Assistant #3 and Nursing Assistant #4 did not utilize the established care plan intervention for mechanical lift when transferring the resident due to not reading the resident's care guide prior to starting care. It was determined that a white sheet had been placed over the bed rail in lieu of protective padding because staff incorrectly believed that the sheet met the requirements for appropriate bed rail padding.On 7/30/26, the Assistant Director of Nursing initiated an audit of all residents' positioning in bed. This audit was to identify any resident who was not positioned in the center of the bed and away from the edge of the bed during and following care. No concerns were identified during the audit. Audit was completed by 7/31/26.On 7/30/26, the Director of Nursing completed 100% audit of all residents requiring padded bed rails to verify that protective padding designed for bed rails is in place, correctly applied, and in good condition. Additionally, each resident's care plan was reviewed to ensure the use of padded bed rails was accurately reflected. There were no other concerns identified.On 7/30/26, the Social Worker conducted interviews with all current alert and oriented residents with a Brief Interview for Mental Status score of 13-15 to identify any resident concerns related to turning and repositioning during care. There were no concerns voiced during the interviews. The interviews were completed by 7/31/26. On 7/30/26, the Director of Nursing initiated an audit of all incident reports for the past 30 days to (1) to identify any incidents related to not following the care guide in accordance with the established care plan for transfers and (2) to identify any incidents related to safe handling and/or turning and repositioning. There were no other concerns identified during the audit. The audit was completed by 7/30/26.On 8/3/26, the Social Worker initiated resident interviews with current alert and oriented residents with a Brief Interview Mental Status score 13-15, to identify any concerns related to transfers. There were no concerns voiced during the interviews. The interviews were completed by 8/3/26. On 8/5/26, the Resource Nurse completed 100% head-to-toe skin assessments of all residents including non interviewable residents, to identify any skin injuries related to turning and repositioning, transfer concerns, or bed equipment, including bed rails and bed rail padding. There were no other injuries identified. Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete:On 7/29/26, the Staff Development Coordinator, Assistant Director of Nursing, Director of Nursing, and Resource Nurse initiated an in-person in-service with all nurses, nursing assistants including agency and therapy staff regarding Turning and Positioning During Care with emphasis on (1) checking the care guide and providing care according to the care plan/care guide for safety (2) techniques for turning and positioning the resident when providing care to include pulling the resident toward the side nearest the staff prior to turning (3) positioning the resident back in the center of the bed following care after turning and positioning to prevent injury. A return demonstration was included during the in-service to validate staff knowledge and understanding of the education, including technique for turning and positioning during care to prevent injury. In-service with return demonstration was completed by 8/9/26 for all staff who worked. After 8/9/26, any nurse or nursing assistant, or therapy staff who has not completed the training with a return demonstration will complete it upon the start of the next scheduled shift. Any employee who does not successfully demonstrate competency during the return demonstration will receive immediate re-education by the validator following the observation. The employee will be required to repeat the return demonstration until competency is successfully demonstrated and validated. All newly hired nurses, nursing assistants, including agency and therapy will receive the education during orientation by the Staff Development Coordinator. The Staff Development Coordinator is responsible for monitoring completion of in-service and return demonstrations. On 8/5/26, the Director of Nursing completed a written education with the Staff Development Coordinator regarding this responsibility. On 8/5/26, the Regional [NAME] President completed a written education with the Administrator and Director of Nursing regarding the responsibility to provide oversight for the completion of in-services, questionnaires and return demonstrations to ensure facility ongoing compliance.On 7/30/26, the Assistant Director of Nursing initiated an audit of all care plans and care guides to ensure they accurately reflect (1) assistance/interventions required for bed mobility and (2) appropriate transfer status to include mechanical lift transfers for resident safety. There were no concerns identified during the audit. The audit was completed by 7/31/26.On 7/30/26, the Staff Development Coordinator initiated in-person staff questionnaires with all nurses, nursing assistants, and therapy staff related to turning and repositioning. The questions are to identify any concerns related to turning and positioning during care. The Director of Nursing and Assistant Director of Nursing will address any areas of concern identified during the audit, including therapy referrals when indicated and initiating interventions for resident safety. The questionnaires were completed by 8/9/26 for all staff who worked. After 8/9/26, any nurse, nursing assistant, or therapy staff who have not worked or completed the questionnaire will complete it upon the start of the next scheduled shift. The Staff Development Coordinator is responsible for monitoring completion of questionnaires. On 7/30/26, the Staff Development Coordinator initiated an in-person in-service with all nurses and nursing assistant to include agency regarding Safe Handling including (1) reading the electronic care guide on the tablet prior to transferring a resident for the correct transfer method (2) what to do if they do not feel the current transfer method is safe and (3) how to use the mechanical lift including sling selection. A return demonstration was included during the in-service to validate staff knowledge and understanding of (1) accessing the electronic resident care guide on the tablet for level of assistance and type of transfer required, and (2) demonstrating appropriate transfer techniques to include transfer utilizing mechanical lifts. In-service with return demonstration was completed by 8/9/26 for all staff who worked. After 8/9/26, any nurse or nursing assistant who has not completed the training with a return demonstration will complete it upon the start of the next scheduled

Based on record review and staff interviews, the facility failed to document on the bed rail evaluation the alternatives that were attempted before the installation or use of the bed rail and failed to document how these alternatives did not meet the resident's assessed needs for 1 of 3 residents reviewed for bed rail use (Resident #1).Findings included:Resident #1 was admitted to the facility on [DATE] and discharged on 7/29/2026.Resident #1 had diagnoses of Alzheimer's disease, Type 2 diabetes mellitus, and a history of cerebral vascular accident.A quarterly Minimum Data Set assessment dated [DATE] indicated that Resident #1 had severely impaired cognition, highly impaired hearing, and no speech. Resident #1 was dependent on staff for all activities of daily living tasks and mobility.Review of the care plan dated as revised on 3/23/2026 documented a focus area identifying Resident #1's potential for skin integrity impairment related to impaired mobility. One of the listed interventions was the use of padded side rails on the bed.An additional care plan focus area revised on 3/11/2026 documented Resident #1 had impaired activity of daily living and personal care related to Alzheimer's disease and the history of cerebral vascular accident. One of the interventions identified Resident #1's dependence on staff for bed mobility. A Physical Device Use Evaluation (bed rail evaluation) dated 6/9/2026 signed by Nurse #3 documented Resident #1's use of left and right quarter rails due to unsafe movements in the bed. Risks that were identified for device use were skin tears and bruises. Under the section titled Alternatives to Device Usage, the only item listed was screening by [rehabilitation services]. The fields requiring documentation of how long the alternatives were attempted and the resident's response to the alternatives were completed as n/a (not applicable). During an interview conducted with Nurse #3 on 8/11/2026 at 10:42 AM, Nurse #3 stated that she did not recall specifically completing the Physical Device Use Evaluation for Resident #1 on 6/9/2026 because she completes many evaluations. Nurse #3 stated Resident #1 had side rails on her bed either for safety reasons or at the request of the family. Nurse #3 further stated that the side rails also facilitated the provision of care, because Resident #1 would attempt to grab onto staff or objects, and being redirecting to hold the rail allowed care to be provided safely. Nurse #3 reported she could not state specifically what alternatives were attempted for Resident #1, but explained that, according to facility policy, the rehabilitation staff was to assess the need for side rails upon admission and attempt alternatives such as positioning devices including pillows. Nurse #3 stated it was the combined responsibility of nursing and rehabilitation staff to determine if side rails on the bed were feasible and safe for the residents. Nurse #3 also stated that new admissions were expected to be trialed without side rails on the bed for one- or two-days using pillows or wedges, but she could not confirm if this was attempted for Resident #1. Nurse #3 stated she documented a rehabilitation screening under alternatives because this was usually done, and she documented n/a under how long alternatives were attempted and the resident's response to alternatives because she did not know when or if alternatives were used for Resident #1.During an interview with the Director of Nursing (DON) on 8/11/2026 at 1:50 PM, the DON stated Resident #1 had side rails in place to assist with bed mobility because the resident would hold the rail for balance when staff turned and repositioned her. The DON stated Resident #1 had padded side rails to reduce the risk of skin injury due to fragile skin that bruised and tore easily due to her use of antiplatelet medication. The DON stated that the padded side rails were also used because Resident #1 leaned on the side rails. The DON reported the alternatives attempted included wedges and pillows but stated that these were ineffective because they did not assist with bed mobility and balance. The DON stated it was her expectation that the Physical Device Use Evaluation be completed in its entirety, including documentation of what alternatives were attempted before applying the side rails and how those alternatives failed to meet the resident's assessed needs.

Based on record review and staff interviews, the facility failed to accurately code the Minimum Data Set (MDS) assessment in the areas of the use of supplemental oxygen and dialysis (Resident #39), the use of hypoglycemic medication (Resident #9), and hospice services (Resident #29). The deficient practice was for 3 of 26 residents whose MDS assessments were reviewed. The findings included: 1. Resident #39 was admitted to the facility on [DATE] with diagnoses which included end stage renal disease with dependence on dialysis and chronic obstructive pulmonary disease (COPD). Resident #39 had the following physician orders: 11/20/25 oxygen flow at 3 liters per minute (LPM) via nasal cannula (NC) to keep oxygen saturation greater than 90% every shift for hypoxia. 11/21/25 for dialysis on Monday, Wednesday, and Friday. The Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #39 had severe cognitive impairment and was not coded for the use of supplemental oxygen and dialysis while a resident at the facility. The MDS Nurse was interviewed on 4/22/26 at 9:36 am and revealed she completed the MDS assessments by reviewing physician orders, observations, and a review of nursing progress notes. The MDS Nurse stated she was aware of Resident #39's use of supplemental oxygen and dialysis but she just miscoded the assessment. During an interview with the Administrator on 4/22/26 at 2:51 pm she reported that the MDS Nurse was responsible for coding Resident #39's assessment correctly to be an accurate reflection of the care the resident received. 2. Resident #9 was admitted to the facility on [DATE] with diagnoses which included diabetes and long-term use of insulin. Resident #9 had a physician order dated 10/28/25 for insulin glargine (long-acting insulin) to inject 80 units subcutaneously (under the skin) at bedtime for diabetes. Review of the Medication Administration Record (MAR) for January 2026 revealed Resident #9 received the insulin glargine as ordered. The Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #9 was not coded for the use of a hypoglycemic medication which included insulin. An interview was conducted on 4/22/26 at 9:41 am with the MDS Nurse who revealed she would review physician orders and the MAR to complete the medication portion of the MDS assessment. The MDS Nurse stated she just miscoded Resident #9's quarterly assessment for insulin use. The Administrator was interviewed on 4/22/26 at 2:51 pm. The Administrator stated the MDS Nurse was responsible for coding Resident #9's assessment correctly to be an accurate reflection of the care the resident received. 3. Resident #29 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease, heart disease, and diabetes. A Physician's order dated 03/03/26 stated to continue hospice services in the long-term care facility. A hospice care plan was initiated on 03/03/26 and included the following interventions spiritual care consult, notify Physician of significant changes, and provide medication per Physician orders. An admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #29 was coded as not receiving hospice care while a Resident at the facility. An interview was completed on 04/22/26 at 12:34pm with the MDS Nurse. The MDS Nurse stated she mistakenly coded Resident #29 as not receiving hospice care while a resident on the 03/06/26 MDS assessment. The MDS Nurse verified Resident #29 should have been coded as receiving hospice care while a resident. An interview was completed on 04/22/26 at 3:03pm with the facility's Administrator. The Administrator stated the Resident's MDS should be an accurate reflection of the Resident when the assessment was completed.

Based on observation, record review, and staff interviews, the facility failed to implement their infection prevention program policies and procedures when Nurse Aide (NA) #3 failed to apply personal protective equipment (PPE) when activities of daily living (ADL) care was performed for a resident on Enhanced Barrier Precautions (EBP). This deficient practice was for 1 of 3 staff members observed for infection control practices (NA #3).The findings included:The facility's Infection Prevention and Control Program (IPCP) last revised April 2023 stated that the IPCP was designated to establish and maintain an effective program that provided a safe, sanitary, and comfortable environment and attempts to prevent the development and the transmission of diseases and infections. The facility's Enhanced Barrier Precautions (EBP) policy last revised 4/01/23 read in part that EBP was utilized in conjunction with standard precautions when performing high-contact resident care activities and included the use of both gowns and gloves. The policy noted in part that EBP applied to all residents with an indwelling medical device, such as an indwelling catheter. The policy further noted that resident care activities that were considered high-contact included dressing and transferring.An observation on 4/21/26 at 10:04 am revealed Resident #2 had signage posted at the entrance of the room that alerted staff that the resident was on enhanced barrier precautions. The signage noted that providers and staff must wear gloves and a gown for the following high-contact resident care activities which included dressing. A supply holder was observed hung on the door and was stocked with PPE, which included disposable gowns and disposable gloves.A continuous observation of resident care for Resident #2 was conducted on 4/21/26 at 10:05 am through 10:12 am with NA #3. NA #3 was observed to have gloves on and put Resident #2's shirt and pants on while the resident was on the bed. NA #3 then assisted Resident #2 to turn onto the left side and she pulled the shirt down to cover the resident's back and pulled the resident's pants up. The NA then assisted the resident to turn onto the right side and completed dressing Resident #2. NA #3 then had Resident #2 turn onto his back and then straightened the shirt and pants and moved the indwelling urinary catheter bag onto the bed in between the resident's legs without a disposable gown in place. NA #3 was then observed to remove the disposable gloves and perform hand hygiene with hand sanitizer. NA #3 failed to wear a gown during the resident care observation. An immediate interview was conducted with NA #3 on 4/21/26 at 10:12 am. NA #3 stated she was not aware she needed to wear a gown when she provided the care to Resident #2. NA #3 confirmed the signage and PPE supplies were present at the entrance of Resident #2's room but she stated she had not read the sign before she provided the care. The Infection Preventionist (IP) was interviewed on 4/22/26 at 1:29 pm. The IP stated that NA #3 was required to wear a gown and gloves when she provided care to Resident #2 related to the indwelling urinary catheter. The IP stated that all staff had received education regarding EBP and the use of PPE when providing specific care duties. The IP further stated that each resident who was on EBP had the signage and PPE supplies on the door that provided information about the requirement for gown and glove use when providing specific resident care. An interview was conducted on Director of Nursing (DON) on 4/22/26 at 2:43 pm. The DON stated that all staff had been educated regarding EBP and the use of PPE when resident care was provided. The DON stated NA #3 should have worn a gown when she provided care to Resident #2. During an interview with the Administrator on 4/22/26 at 2:52 pm she revealed EBP education was provided to all staff and the EBP signage was posted for Resident #2. The Administrator stated NA #3 should have worn the required PPE when she provided care to Resident #2.

Based on observations, record reviews, and staff interviews, the facility failed to post an updated daily nurse staffing sheet for residents and visitors for 1 of 4 days during the survey period (4/19/26).The findings included:On 4/19/26 (Sunday), during the initial tour of the facility at 9:40 AM the daily nurse staffing sheet posted near the facility entrance was dated 4/16/26 (Thursday). The daily nurse staffing sheet was not updated to reflect the current date, census, and staffing information.During an interview on 4/19/26 at 10:15 AM, Nurse #1 stated the Scheduler prepared the daily nurse staffing sheets and placed them in a binder on Fridays at the nurses' station for nurses to update and post on the weekends. Nurse #1 indicated she worked on 4/18/26 (Saturday) and the day of the interview (4/19/26) and had not noticed the daily nurse staffing sheet posted near the facility entrance had not been updated since 4/16/26.During an interview with the Scheduler on 4/19/26 at 2:01 PM, the Scheduler confirmed she completed and posted the daily nurse staffing sheets. The Scheduler explained she had last worked on Thursday (4/16/26) and had given the completed daily nurse staffing sheets for 4/17/26, 4/18/26, and 4/19/26 to the Assistant Director of Nursing before leaving work. The Scheduler further stated the facility nurses usually ensured the daily nurse staffing sheet was current and updated to reflect the actual staff working in the facility.During an interview with the Assistant Director of Nursing (ADON) on 4/19/26 at 2:33 PM. The ADON stated the Scheduler had given her the daily nurse staffing sheets for 4/17/26, 4/18/26, and 4/19/26 on 4/16/26. The ADON stated that she placed the daily nursing staffing sheets in the green staffing binder that was kept at the nurse's station. The ADON stated the nurses usually ensured the daily nurse staffing was current and updated. She did not know what happened to the documents that she had placed in the binder.During an interview with the Director of Nursing (DON) on 4/19/26 at 11:24 AM, the DON stated facility charge nurse was responsible for ensuring that the daily nurse staffing sheets were posted. The DON verified that Nurse #1 was the charge nurse that weekend and would have been responsible for updating and posting the staffing sheets. During an interview on 4/19/25 at 3:37 PM, the Administrator stated that it was the Scheduler's responsibility to complete the daily nurse staffing sheet Monday through Friday. The Administrator stated nurses were responsible for posting the daily nurse staffing sheets on weekends. The Administrator stated the charge nurse should have updated the daily nurse staffing sheet to reflect the current date, current census and staffing information and posted the document so it clearly visible to residents and visitors.

Based on observations and staff interviews, the facility failed to date opened leftover food items in 2 kitchen refrigerators (the walk-in refrigerator and the free-standing refrigerator), failed to remove an expired food item stored for use from the dry goods storage room, and failed to remove a plastic measuring cup from the sugar storage bin located near the tray line. The plastic measuring cup was resting in the sugar which has the potential for cross-contamination. These practices had the potential to affect food served to residents. The findings included: During the initial observation of the kitchen on [DATE] at 9:36 am with the Dietary Manager the following was observed: a. The walk-in refrigerator, located near the dry goods storage room, was observed to have the following: 1 open plastic bag of shredded lettuce without a date. b. The free-standing refrigerator, located near the tray line, was observed to have an open, large box of grated parmesan cheese without a date. c. The dry goods storage room, located in the kitchen near the walk-in refrigerator, was observed to have one box of hard taco shells with an expiration date of [DATE]. d. A plastic measuring cup was observed inside the large sugar storage bin resting in the sugar. The Dietary Manager confirmed all findings and removed identified items from the refrigerators, dry goods storage room, and the sugar storage bin. During an interview on [DATE] at 1:53 pm with the Dietary Manager she revealed all items placed in the refrigerator were to be dated when opened. The Dietary Manager stated the measuring cup was to be washed after being used and was not to be left inside the bin. She stated she must have missed the hard taco shells when she checked the dry goods storage room for expired items. The Dietary Manager stated she was responsible for ensuring food items were stored properly in the kitchen. An interview was conducted with the Administrator on [DATE] at 5:35 pm who revealed the Dietary Manager was responsible for ensuring food items were dated, labeled, and stored properly in the kitchen.

Based on record review, staff interviews, and Responsible Party (RP) interview, the facility failed to hold a care plan meeting and invite the resident and the RP to participate in the care planning process for 1 of 3 residents reviewed for care planning (Resident #76). The findings included: Resident #76 was admitted to the facility on [DATE]. Review of the Care Plan General Note dated 8/22/24 by the Social Worker revealed Resident #76 had a care plan meeting held with the Responsible Party (RP) via telephone. Review of Resident #76's electronic medical record revealed no documentation that a care plan meeting was held or that Resident #76 or the RP was invited to participate in a care plan meeting after the 8/22/24 meeting. Review of the Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #76 had moderate cognitive impairment. A telephone interview was conducted with Resident #76's RP on 1/21/25 at 3:02 pm who revealed he had not been invited to participate in a care plan meeting or notified that a meeting was held for Resident #76. An interview was conducted on 1/23/25 at 2:04 pm with the Social Worker who reported the MDS Nurse provided her with a list of the residents that were due for a care plan meeting, and she was responsible for scheduling and inviting the resident and RP to the meetings. The Social Worker stated Resident #76 was not listed on the care plan meeting list provided by the MDS Nurse for November 2024, so Resident #76's care plan meeting was not scheduled. During an interview on 1/23/25 at 3:06 pm the MDS Nurse reported she provided the Social Worker with a list of residents that required a care plan meeting every month along with a date range that the meetings should be scheduled. The MDS nurse confirmed Resident #76 was on the list provided to the Social Worker for November 2024 to have a care plan meeting scheduled. The MDS Nurse stated the Social Worker was responsible for the coordination of the care plan meeting. A follow-up interview was conducted with the Social Worker on 1/24/25 at 8:02 am who revealed she reviewed the November 2024 list provided by the MDS Nurse and she did see that Resident #76 was listed and should have been scheduled for a care plan meeting. The Social Worker stated she just missed Resident #76's name on the list and no care plan meeting was held. An interview was held on 1/24/25 at 5:39 pm with the Administrator who revealed the Social Worker was responsible for scheduling Resident #76's care plan meeting.

Based on observations, record review, and resident and staff interviews, the facility failed to revise the care plan in the area of indwelling urinary catheter (Resident #36) and use of side rails (Resident #67) for 2 of 3 residents reviewed for care plan revision. The findings included: 1. Resident #36 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #36 has severe cognitive impairment and was always incontinent of bladder. Review of Resident #36's care plan last reviewed 11/26/24 revealed no care plan for use of an indwelling urinary catheter. Resident #36 had a physician order dated 1/11/25 to place an indwelling urinary catheter until further notice for decreased urine output. The nursing progress note dated 1/11/25 at 2:35 pm by the Nurse Supervisor revealed Resident #36 had an indwelling urinary catheter placed and the resident tolerated the procedure. An observation was conducted on 1/21/25 at 10:37 am of Resident #36 who was observed to have an indwelling urinary catheter in place. A telephone interview was conducted on 1/24/25 at 11:16 am with the Nurse Supervisor who revealed she obtained a physician order to place Resident #36's indwelling urinary catheter but she did not start a care plan because she believed the Resource Nurse would make sure a care plan was put in place. An interview was conducted on 1/24/25 at 1:49 pm with the Resource Nurse who revealed Resident #36 should have had a care plan started and the care guide should have been updated for the use of an indwelling urinary catheter when it was placed. She stated that either the Nurse Supervisor or the MDS Nurse should have revised Resident #36's care plan to reflect the use of the indwelling urinary catheter. The Resource Nurse stated resident orders would have been reviewed during the next clinical meeting and if no care plan was noted the MDS Nurse would start the care plan based on the orders. The Resource Nurse stated she was not responsible to ensure Resident #36 had a care plan in place for the indwelling urinary catheter. During an interview on 1/24/27 at 2:47 pm with the MDS Nurse she revealed the nurse that obtained the order and placed the indwelling catheter should have revised Resident #36's care plan. The MDS Nurse stated she would assist nursing with care plans when asked but she did not recall discussing Resident #36's new indwelling urinary catheter during the clinical meetings. An interview was conducted with the Director of Nursing (DON) on 1/24/25 at 3:08 pm who revealed the Nurse Supervisor who placed Resident #36's indwelling urinary catheter was responsible for revising the care plan. The DON stated all new resident orders were reviewed in the clinical meetings. She stated she recalled seeing the new order and discussing in the clinical meeting and she thought the MDS Nurse revised the care plan but must have been sidetracked. An interview was conducted with the Administrator on 1/24/25 at 5:41 pm. The Administrator stated that the missing care plan should have been identified during the clinical meeting. 2. Resident #67 was admitted to the facility on [DATE]. Review of the physical device use evaluation dated 11/15/24 revealed Resident #67 was assessed for the use of 1/4 assist side rails for mobility. The side rails were noted as used daily for enhanced independence. The Minimum Data Set (MDS) admission assessment dated [DATE] revealed Resident #67 had moderate cognitive impairment and required assistance by staff for turning, repositioning, and transfers. Review of Resident #67's care plan last reviewed 11/27/24 revealed no care plan was in place for use of side rails for mobility. An observation and interview were conducted with Resident #67 on 1/21/25 at 10:49 am who revealed he had the side rails on his bed since he was admitted to the facility, and he stated he just received a new bed the other day that did not have side rails and he had the nurse put the side rails on the new bed. An interview was conducted with the Resource Nurse on 1/24/25 at 1:54 pm who revealed a care plan was required for a resident that used side rails for mobility. She stated Resident #67 would have been reviewed in the clinical meeting upon admission and the MDS Nurse would have put in a care plan. The Resource Nurse stated she was not responsible for the care plan, and she was unable to state why a care plan was not in place for Resident #67's side rails. An interview was conducted on 1/24/25 at 2:49 pm with the MDS Nurse who reported the nursing staff were responsible to revise Resident #67's care plan for side rails when they were placed on his bed. She stated she would assist with care plans when asked but she would not know about Resident #67's use of side rails if she was not told by nursing. During an interview on 1/24/25 at 3:14 pm the Director of Nursing (DON) stated Resident #67's use of side rails for mobility should have been added to his care plan. She stated Resident #67 had side rails since admission. The DON stated a care plan should have been in place for Resident #67's use of side rails, but she stated it must have been missed during the clinical meeting. An interview was conducted with the Administrator on 1/24/25 at 5:41 pm. The Administrator stated that the missing care plan should have been identified during the clinical meeting.

Based on observation, record review, and staff interviews, the facility failed to obtain physician orders for the management of an indwelling urinary catheter for 1 of 3 residents reviewed for urinary catheter (Resident #36). The findings included: Resident #36 was admitted to the facility on [DATE] with diagnoses which included stroke. The Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #36 had severe cognitive impairment and was coded as always incontinent of bladder. Resident #36 had a physician order dated 1/11/25 to place an indwelling urinary catheter until further notice for decreased output. Review of Resident #36's electronic medical record revealed no physician orders regarding what size of catheter, how many cubic centimeters (cc) of fluid to anchor the catheter, the time frame to change the indwelling urinary catheter, and time frame to change the indwelling catheter bag. The nursing progress note dated 1/11/25 at 2:35 pm by the Nurse Supervisor revealed Resident #36 had an 18 french (size of the catheter) 5 cubic centimeters (amount of fluid placed in the bulb to anchor the catheter) indwelling urinary catheter placed and tolerated the procedure well. A physician order dated 1/12/25 to monitor and record indwelling urinary catheter output every shift. An observation was conducted on 1/21/25 at 10:37 am revealed Resident #36 had an indwelling urinary catheter in place. A telephone interview was conducted on 1/24/25 at 11:16 am with the Nurse Supervisor who revealed she obtained a physician order for the indwelling urinary catheter for Resident #36, and she entered the order she received. She stated she did not enter any other orders for the management of Resident #36's indwelling urinary catheter, because she believed the Resource Nurse would enter any other orders that were needed. An interview on 1/24/25 at 1:49 pm with the Resource Nurse revealed when a resident had an indwelling urinary catheter physician orders were required for the catheter to be in place, the size of the catheter, how often to change the indwelling catheter and the catheter bag, and monitoring urine output. The Resource Nurse stated the Nurse Supervisor was responsible for entering all standing orders that were associated with the indwelling urinary catheter management. An interview was conducted with the Director of Nursing (DON) on 1/24/25 at 3:08 pm who revealed the nurse who obtained the physician order and placed the indwelling urinary catheter for Resident #36 was responsible for implementing all the standing orders that were required for the catheter. The DON stated Resident #36 should have had orders for the size of the catheter, changing the catheter, and how often to change the catheter bag. The DON stated she was not aware Resident #36 was missing physician orders for the management of the catheter, but she must have missed it when the orders were reviewed. The Administrator was interviewed on 1/24/25 at 5:42 pm who revealed the nurse who obtained the order was responsible for entering associated orders for Resident #36's indwelling urinary catheter.

Based on a review of the facility arbitration agreement and staff interviews, the facility failed to provide an arbitration agreement that explicitly granted the resident or their representative the right to rescind the agreement within 30 days of signing it. The deficient practice was for 3 of 3 residents reviewed for arbitration (Resident #63, Resident #76, and Resident #33). The findings included: A review of the facility's arbitration agreement titled, Arbitration Agreement, dated 7/15/24 was conducted. The Arbitration Agreement read in part that the agreement may be rescinded by written notice to the facility from the Resident within thirty (30) days of signature. The arbitration agreement did not include the statement that the resident or his or her representative has the right to rescind the agreement within 30 days of signing it. a. Resident #63 was admitted to the facility on [DATE]. Resident 63's arbitration agreement revealed the resident representative signed the agreement on 10/29/24. b. Resident #76 was admitted to the facility on [DATE]. Resident #76's arbitration agreement revealed Resident #76 signed the agreement on 7/30/24. c. Resident #33 was admitted to the facility on [DATE]. Resident #33's arbitration agreement was signed by the resident representative on 9/18/24. An interview was conducted on 1/24/25 at 8:35 am with the Admission Director who revealed she was responsible for reviewing the arbitration agreement with the Resident or the Representative at the time of admission. The Admission Director stated she was provided with the document by the facility and had no knowledge of what was required to be included. During an interview on 1/24/25 at 5:33 pm with the Administrator she revealed she was new to the facility and was not familiar with the facility's arbitration agreement.

Based on observation, record review, and staff interviews, the facility failed to implement its infection prevention and control program when 1 of 1 facility staff (Nurse Aide #1) failed to perform hand hygiene before donning and after removing gloves for 4 of 4 resident rooms (room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER]). The facility also failed to implement its Personal Protective Equipment (PPE) policy when 2 of 2 staff (Wound Treatment Nurse, Nurse Aide #2) failed to wear isolation gowns while in a resident's room on Enhanced Barrier Precautions (EBP). The findings included: The facility's Infection Prevention and Control Program policy last updated 4/2023 read in part: The infection Prevent and Control Program of this facility of designated to establish and maintain an effective program that provides a safe, sanitary, and comfortable environment and attempts to prevent the development and transmission of disease. The Objective was to ensure proper utilization of standard precautions and or when needed, transmission-based precautions which should be the least restrictive for a resident under the given circumstances. Review of the facility's hand hygiene policy last updated 4/2023 indicated personnel are to wash their hands after each direct or indirect resident contact to include between resident contacts. 1. A continuous observation was conducted on 1/21/25 at 12:02 PM. Nurse Aide (NA) #1 was observed to leave out of room [ROOM NUMBER] and walk down the hall to the clean linen cart where she retrieved a clothing protector. NA #1 returned to the room and placed a clothing protector on the resident. NA #1 was observed to leave the room without performing hand hygiene. NA #1 entered resident room [ROOM NUMBER] without performing hand hygiene. NA #1 donned gloves and assisted to slide resident in A bed up in the bed. NA #1 removed gloves and was observed to exit the room and retrieve meal tray for resident in the B bed from the meal cart without performing hand hygiene. NA #1 set the meal tray up for the resident and exited the room without performing hand hygiene. NA #1 walked to the meal cart and retrieved the meal tray for resident in room [ROOM NUMBER]. NA #1 placed the meal tray on the bedside table and exited the room. An interview was conducted with NA #1 on 1/21/25 at 12:16 PM. NA #1 stated she was supposed to perform hand hygiene when exiting each resident's room and between residents. NA #1 stated she was trying to get the trays out and didn't realize she had not performed hand hygiene. An interview was conducted with the Director of Nursing on 1/21/25 at 12: 22 PM. The DON stated she expected staff to perform hand hygiene and wear PPE as indicated. An interview was conducted with the Administrator on 1/24/25 at 5:49 PM. The Administrator stated hand hygiene was to be performed as warranted and staff were to perform hand hygiene techniques to prevent the spread of infection. 2. Review of the EBP policy dated 4/1/24 stated EBP used in conjunction with Standard Precautions to reduce the risk of MDRO transmission during high-contact resident care. EBP included the use of gown and gloves. EBP was meant to be in place for the duration of the resident's stay or until resolution of the wound. Resident care activities that are considered high contact include but are not limited to dressing, bathing/showering, changing linens, wound care. During an observation of wound care on 1/24/25 at 9:32 AM, the Wound Treatment Nurse and Nurse Aide #2 completed wound care for Resident #17. Resident #17's room door had Enhanced Barrier Precautions signage that instructed staff to utilize Personal Protective Equipment when performing specific care which included wound care. The signage indicated everyone had to clean their hands before entering and after leaving the room. The signage further indicated that all healthcare personnel must wear gowns and gloves for all the following high-contact resident care activities to include wound care. A bin was observed hanging on the back of the door with PPE supplies readily available. The Wound Treatment Nurse and NA #2 were observed to perform hand hygiene and don gloves, no gown was used by either staff member. Resident #17 was positioned on her left side and the old dressing was removed by Wound Treatment Nurse. The Wound Treatment Nurse removed her gloves and hand hygiene was completed with hand sanitizer. Clean gloves were donned by the Wound Treatment Nurse and the wound bed was washed with soap and water. Gloves were removed and hand hygiene was completed using hand sanitizer. Clean gloves were donned, and calcium alginate (used to promote the formation of new granulation tissue) was applied to the wound bed and foam border dressing was applied over the calcium alginate. Resident #17's brief was applied and resident repositioned. Hand hygiene was completed prior to leaving Resident #17's room by the Wound Treatment Nurse and NA #2. An interview was conducted on 1/24/25 at 9:55 AM with the Wound Treatment Nurse who reported she was nervous during the wound care observation and realized she did not wear the PPE gown when providing wound care. The Wound Treatment Nurse stated she was nervous and just forgot to put the gown on. An interview was conducted on 1/24/25 at 10:25 AM with NA #2 who reported she was aware she did not wear the gown. NA #2 stated she told the Wound Treatment Nurse after they left the room, they had forgotten to wear their gowns. During an interview with the Infection Preventionist on 1/24/25 at 10:30 AM, she revealed when a resident is on EBP the staff were required to wear gowns when wound care was performed. The Infection Preventionist stated PPE was available in all residents that were on EBP. The Infection Preventionist reported both the Wound Treatment Nurse and NA#2 had been educated in the past regarding EBP on 12/23/24 -1/6/25. During an interview with the Director of Nursing on 1/24/25 at 3:24 PM, she stated staff were to wear proper PPE when providing wound care. During an interview with the Administrator on 1/24/25 at 5:38 PM, she stated the Infection Preventionist was responsible for ensuring all staff were educated.

Based on observation and staff interviews, the facility failed to maintain the area surrounding the dumpster free of debris for 2 of 2 dumpsters observed. The findings included: During an observation of the dumpster area with the dietary manager (DM) and dietary consultant on 9/27/22 at 10:12 AM, approximately 400 square feet of debris was behind and to the right of dumpster #1 and dumpster #2. Debris items included: Styrofoam containers, plastic lids, plastic cups, straws, napkins, rubber gloves, a cookie wrapper, a paper straw box, aluminum cans, etc. The DM stated a lot of racoons and cats occupy this area. The dietary consultant stated the dumpster area should be a lot cleaner than observed, and the dumpsters were shared by all departments. An observation of the dumpster area conducted with the dietary consultant on 9/29/22 at 8:25 AM revealed the dumpster area to be in the same condition. The dietary consultant indicated that he spoke to the department heads about the excess debris yesterday afternoon, and they warned him of snakes in the area. He stated he thought the area would be picked up by now, but it looked the same. During a follow-up interview with the dietary consultant on 9/29/22 at 11:34 AM, he stated he had cleaned up the area around the dumpsters himself, and he was not sure who would be the point person to manage the area in the future. The Administrator was interviewed on 9/29/22 at 2:53 PM. She revealed that her expectation was to keep the dumpster area clean, and it was the housekeeping and dietary departments' responsibility to clean up after themselves. The Administrator stated she planned to assign an administrative staff member to oversee the cleanliness of the dumpster area going forward.

Based on record reviews, staff interviews, Physician interview, and Pharmacy Consultant interview, the facility failed to ensure Physician's orders for PRN (as needed) psychotropic medications were time limited in duration for 1 of 5 Residents (Resident #16) reviewed for unnecessary medications. The findings included: Resident #16 was admitted to the facility on [DATE] with diagnoses that included Parkinson's disease and Lewy Body dementia. The admission Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was moderately cognitively impaired. He was not coded as having any behaviors during the assessment period. A care plan was last revised on 8/29/22 for use of psychotropic medication use. Interventions included administer medications as ordered by the Physician and monitor and notify Physician of any side effects related to the medication. A Physician order dated 6/8/22 indicated Lorazepam 0.5 milligrams (mg) 1 tab by mouth every 4 hours as needed (PRN) for anxiety was ordered without a stop date. A Physician order dated 8/27/22 indicated Haldol 0.5 mg 1 tab every 6 hours PRN for hallucinations was ordered without a stop date. A telephone interview was completed on 9/29/22 at 1:06 pm with the Pharmacy Consultant. She indicated PRN psychotropic medications required an initial 14 day stop date. The Pharmacy Consultant continued to state the Physician then reevaluated the Resident for continued use of the medication and documented the rationale for extending the medication. An interview was conducted on 9/29/22 at 3:25 pm with the Director of Nursing (DON). She indicated she was aware all PRN psychotropic medications required an initial 14 day stop date, and the Physician then reevaluated the resident at the end of the medication regimen for continued use. An interview was completed on 9/29/22 at 4:43 pm with the Administrator. She stated it was her expectation all PRN psychotropic medications have a stop date included in the order. A telephone interview was completed on 9/30/22 at 8:20 am with the Physician. He revealed all PRN psychotropic medications were ordered for 14 days. The Physician stated he then revaluated the resident and extended the medication for a time frame he felt appropriate. The Physician indicated he did not recall being notified Resident #16's medications did not include stop date and planned to reevaluate the Resident during his next visit for continued use.

Based on observation, record review and staff interview, the facility failed to implement its personal protective equipment policy when 1 of 1 staff (Nursing Assistant #1) failed to remove an isolation gown before exiting a resident's room on isolation precautions. The findings included: Review of the Infection Control Policy last updated 5/22 read in part personal protective equipment (PPE) was to be worn when performing tasks for residents on isolation precautions. The policy further stated that PPE should be removed and discarded in an appropriate container prior to exiting room. An observation was conducted of the 100 Hall on 9/29/22 at 8:30 AM. The room door had a sign that read to use eye wear, mask, gown, and gloves to protect residents on room restrictions. An observation was conducted of Nursing Assistant (NA) #1 on 9/29/22 at 8:35 AM. The room door had caution signage that indicated the resident was on isolation precautions and staff were required to use eyewear, mask, gown, and gloves when entering residents' room. NA #1 exited a resident's room that was on isolation precautions without removing her gown and gloves. NA #1 walked over to the meal cart and placed a tray on the cart. NA #1 then returned to the same resident's room and removed her gown and gloves. An interview was conducted with NA #1 on 9/29/22 at 8:48 AM. NA #1 stated that she was not aware that she could not wear her gown in the hallway. NA #1 stated that she had been educated on donning and doffing personal protective equipment. NA #1 stated that she had read the sign. An interview was conducted with the Director of Nursing (DON) on 9/29/22 at 9:10 AM. The DON stated that NA #1 should have discarded her gown and gloves in the waste receptable inside the room before exiting the resident's room.

Based on observation, staff interview, dietary consultant interview, and record review the facility failed to dispose of a food product stored past the use by date in the side-by-side freezer, failed to label and date food items in the walk-in refrigerator and freezer, failed to close food items that had been opened in the walk-in freezer, failed to store foods off the floor in the dry storage area, and refrigerate a perishable cheese item found in dry storage for 4 of 5 observed kitchen areas were food was stored. Findings included: The following observations and interviews were made in the facility kitchen on [DATE] beginning at 9:57 AM. a.The side-by-side freezer had a food product labeled chicken rice with the date [DATE]. An interview was conducted with the dietary manager at the time of the observation. The dietary manager stated the chicken rice should have been thrown away after 7 days in the freezer. b. Observations of the walk-in refrigerator revealed two trays with small dishes of mixed fruit. The two trays did not have a label or date of preparation. An interview was conducted with the kitchen manager at the time of the observation. The kitchen manager confirmed the trays of mixed fruit did not have a label or date of preparation. c. Observations of the walk-in freezer revealed an unsealed opened bag of what appeared to be waffle fries and an unsealed open bag of what appeared to be potato wedges. Both the waffle fries and the potato wedges were unlabeled or dated. The walk-in freezer also contained an opened package of Polska Kielbasa sausage with no date. An open unsealed bag of frosty looking crab cakes was observed in the walk-in freezer with a date of [DATE]. An interview was conducted at the time of the observation with the dietary manager. The dietary manager stated with no labels or dates the food had to be thrown out although she thought the sausages were on the menu last week. The dietary manager stated the crab cakes needed to be in a sealed container in the freezer for storage. The dietary manager was observed to throw away the waffle fries, potato wedges, sausage, and the crab cakes in the garbage. d. Observations were made in the dry storage revealed several cases of food were on the floor in dry storage. The cases of canned food on the floor contained fruit cocktail, diced peaches, green beans, and mixed vegetable. One #10 can of green beans was on the floor underneath a storage shelf. A cardboard box with potatoes on top and sweet potatoes inside was on the floor. On a shelf in dry storage a container of grated parmesan cheese opened and dated [DATE] was stored unrefrigerated. Observation of the label on the grated parmesan revealed the product had to be refrigerated after opening. An interview was conducted with the kitchen manager at the time of the observation of the dry storage area. The kitchen manager revealed the facility received an order of new stock yesterday and the staff were doing the best they could to get the stock stored on the shelves where it belonged. e. A box of potatoes dated [DATE] was observed on the floor directly outside the door of the dry storage in the corner next to the ice machine. Observation of the potatoes revealed they were starting to sprout with long pale shoots. Sprouts are a sign of imminent spoilage in potatoes. An interview was conducted with the kitchen manager at the time of the observation who acknowledged the potatoes should not have been on the floor and needed to be disposed of. An interview was conducted with the facility dietary consultant on [DATE] at 10:53 AM. The dietary consultant confirmed opened food items needed to be labeled and dated. The dietary consultant stated it was an incorrect time frame to throw away opened food items in the freezer after 7 days but confirmed the chicken rice dated [DATE] was past the date of use. The dietary consultant stated food items in the freezer should be sealed and not left open to prevent freezer burn. The dietary consultant confirmed food items should not be stored on the floor and the worst place to store potatoes was in the warm moist environment next to the ice machine. The dietary consultant provided invoices revealing potatoes and sweet potatoes were received on [DATE] and an eighty-count box of potatoes was received on [DATE]. The dietary consultant stated she visited the facility frequently but could not be at the facility daily. The dietary consultant indicated the dietary manager and kitchen manager needed to monitor the food storage areas for proper storage and expired food.

Based on record review and staff interviews, the facility failed to document weekly skin assessments on vascular wounds that included staging, measurements, drainage, pain, and assessment of the wound bed and surrounding tissue for 1 of 1 resident reviewed for wound care. (Resident #1) Finding included: Resident #1 was admitted to the facility on [DATE]. His diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The care plan dated 9/22/2021 indicated Resident #1 had actual venous stasis ulcerations to both lower legs, and interventions included documenting weekly evaluations and assessments of the ulcerations. The admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #1 was moderately cognitively impaired, required extensive assistance of one person with his activities of daily living except for eating and personal hygiene and the presence of vascular ulcerations. Resident #1's wound assessment dated [DATE] identified three vascular wounds on the right lower extremity and two vascular wounds on the left lower extremity. The wound assessment recorded measurements for each vascular wound and documented a red wound bed with an odorless heavy serosanguinous drainage. There were no further wound assessments documented in Resident #1's electronic medical record from 12/8/221 to 1/14/2022. On 12/19/2021, nursing documentation revealed both legs of Resident #1 were red, swollen and drainage that was foul smelling. The physician was called, and Resident#1 was started on antibiotics and was scheduled for the wound care clinic on 12/21/2021. On 1/14/2022 at 12:38 p.m. in an interview with Nurse #1, she stated she had served as the wound nurse for the facility until 1/12/2022. She stated wound assessments were scheduled weekly on Wednesdays and stated she had not been able to assess the wounds for the last four weeks because she was assigned to a medication cart. She stated she did not know who was performing the assessments. On 1/14/22 at 4:19 p.m. in an interview with the former Director of Nursing, she stated the wound assessments were conducted on Tuesday or Wednesday weekly by the wound nurse, and the wound nurse was available to complete the wound assessments. She stated if the wound nurse was not available, another nurse would had been delegated to conduct the weekly wound assessments. On 1/14/2022 at 4:50 p.m. in an interview with the Director of Nursing, she stated the wound nurse was to evaluate the wounds weekly and documented the wound assessment in the electric medical record

Based on record review, resident interview and staff interview, the facility failed to accurately document the application of [CONDITION(S)] sleeves as physician ordered when the [CONDITION(S)] sleeves were not available in the facility for 1 of 1 resident. (Resident #1) Findings included: Resident #1 was admitted to the facility on [DATE]. His diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The care plan dated 9/22/2021 indicated Resident #1 had actual venous stasis ulcerations to both lower legs, and interventions included treatments as ordered by the physician. The admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #1 was moderately cognitively impaired and the presence of vascular ulcerations. Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] #1 to both legs twice a day for one hour to decrease [CONDITION(S)]. There was no order to hold [CONDITION(S)] sleeves for Resident #1. Nursing documentation indicated the [CONDITION(S)] sleeves were not available in the facility in November 2021 and December 2021. Nursing documentation revealed on 12/21/2021, the physician held application for [CONDITION(S)] sleeves for Resident #1 until [CONDITION(S)] sleeves were available. The December 2021 Treatment Administration Record (TAR) indicated [CONDITION(S)] sleeves were applied as ordered twice a day for thirteen days out of the first twenty days of December and once a day on four days of the first twenty days in December. On December 21, 2021, the MAR indicated the order for [CONDITION(S)] sleeves was held for seven days. Nursing documentation for January 2022 indicated [CONDITION(S)] sleeves were unavailable at the facility and until 1/11/2022 at 6:00 p.m. when nursing documentation revealed [CONDITION(S)] sleeves were applied to Resident #1's legs. The January 2022 TAR for Resident #1 recorded [CONDITION(S)] sleeves were applied six days of the first eleven days in January 2022 when the [CONDITION(S)] sleeves were not available. On 1/14/2022 at 2:08 p.m. in an interview with Nurse #1, she stated Resident #1's [CONDITION(S)] sleeves were not available at the facility in December 2021 and arrived at the facility last week. She stated she documented on the December 2021 TAR [CONDITION(S)] sleeves were applied as ordered when the [CONDITION(S)] sleeves were not available to apply to Resident #1. She stated she documented the [CONDITION(S)] sleeves were applied because other nurses had documented [CONDITION(S)] sleeves were applied. She stated the Director of Nursing informed the nursing staff application of [CONDITION(S)] sleeves could not be documented, and an order was received to hold the application of the [CONDITION(S)] sleeves. On 1/14/2022 at 2:35 p.m. in an interview with Resident #1, he stated the [CONDITION(S)] sleeves arrived at the facility on Monday 1/10/2022, and he had been wearing the [CONDITION(S)] sleeves every day since Tuesday 1/11/2022. On 1/14/2022 at 3:40 p.m. in an interview with the central supply manager, she stated the facility was not able to locate a supplier with [CONDITION(S)] sleeves for Resident #1. She stated the [CONDITION(S)] sleeves arrived at the facility during the first part of January 2022. She was not able to provide an exact date on the arrival of the [CONDITION(S)] sleeves. On 1/14/2022 at 4:19 p.m. in an interview with the former Director of Nursing (DON), she stated she was not aware the facility was not able to receive [CONDITION(S)] sleeves for Resident #1. Upon learning Resident #1 did not have [CONDITION(S)] sleeves available at the facility and the TAR indicated nursing documentation of application of [CONDITION(S)] sleeves, she conducted in-services on documentation of care with the nursing staff. She stated nursing staff cannot document resident care as given when it was not provided. On 1/14/2022 at 4:50 p.m. in an interview with the DON, she stated resident care was documented on the Medication Administration Record (MAR) and Treatment Administration Record (TAR). She stated codes were available to document on the MAR and TAR why resident care was not given as ordered and nurses could document reasons in the nurse notes also. She stated nursing staff should not document resident care as given on the MAR or TAR that was not provided.

Based on record review, observations and staff interviews, the facility failed to update the care plans for 2 of 4 residents reviewed for care plans. (Resident #1, #2) Findings included: 1. Resident #1 was admitted to the facility on [DATE], and diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The care plan dated 9/22/2021 indicated Resident #1 had actual venous stasis ulcerations to both lower legs. Interventions included to evaluate and assess ulcer weekly and document results, observe for signs and symptoms of pain and infection and notify the physician and to provide treatment as ordered by physician. A goal for venous ulcerations to show positive signs of healing was dated initiated on 12/23/21 and was revised on 1/2/2022. There were no new interventions listed for the care plan for venous stasis ulcerations. The admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #1 was moderately cognitively impaired and the presence of vascular ulcerations. Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #1's wound care clinic notes recommendations included the use of [CONDITION(S)] sleeves to reduce [CONDITION(S)] in his lower legs. Nursing documentation in November 2021 and December 2021 revealed [CONDITION(S)] sleeves were not available. Nursing documentation revealed [CONDITION(S)] sleeves were applied to Resident #1 lower legs on 1/11/2022. On 1/14/2022 at 2:35 p.m., Resident #1 was observed lying in bed with [CONDITION(S)] sleeves applied to both lower extremities. On 1/14/2022 at 5:29 p.m. in an interview with the MDS Nurse, she stated she updated care plans with quarterly and annual assessments. She stated the nursing staff updated care plans between the quarterly and annual assessments based on new orders, and the [CONDITION(S)] sleeves arrived at the facility for Resident #1 this week. On 1/14/2022 at 5:30 p.m. in an interview with Nurse #2, she stated the use of the [CONDITION(S)] sleeves were not listed on Resident #1's care plan as an intervention for venous ulcers. She stated Resident #1's care plan should have been updated when the order was written for the [CONDITION(S)] sleeves. She stated she activated the order for the [CONDITION(S)] sleeves and missed updating Resident #1's care plan. On 1/14/2022 at 5:32 p.m. in an interview with the Director of Nursing, she stated all nurses had access to update the care plans and Resident #1's care plan should had been updated when the [CONDITION(S)] sleeves were ordered. 2. Resident #2 was admitted [DATE] to the facility. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 12/14/2021, [MEDICATION(S)] Solution one gram intravenously every twenty-four hours for seven days was ordered for Resident #2 for a urinary tract infection. The December 2021 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Nursing documentation dated 12/14/2021 revealed vascular services started an intravenous catheter in Resident #2's right arm. On 12/22/2021 nursing documentation revealed the intravenous catheter was intact and the completion of intravenous antibiotics. The annual Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #2 received intravenous medications. The care plan dated 1/12/2022 revealed Resident #2 was at risk for recurrent urinary tract infections and interventions included to administer medication as ordered by the physician. There was no plan of care for intravenous therapy on the care plan dated 1/12/2022 or the previous care plan dated 10/4/2021. On 1/14/2022 at 4:43 p.m. in an interview with Nurse #1, she stated she removed the IV catheter on 12/27/2021 and did not document the removal of the IV catheter in Resident #2's electronic medical record. On 1/14/2022 at 5:40 p.m. in an interview with the MDS nurse, she stated she updated care plans with the scheduled quarterly and annual MDS assessments, and nurses updated the care plans based on orders between the scheduled MDS assessments. She stated intravenous (IV) therapy was not included on the care plan after 12/23/2021 because Resident #2 had completed her IV therapy prior to 12/23/2021 MDS assessment On 1/14/2022 at 5:43 p.m. in an interview with Nurse #2, she stated IV therapy was not included on Resident #2's care plan. She stated she activated the order for the IV therapy on 12/13/2021 and should have updated the care plan. On 1/14/2022 at 5:45pm in an interview with the Director of Nursing, she stated care plans were updated quarterly, annually and when treatment plans or resident's condition changed. She stated resident's care plans should be updated when there was a new order for IV therapy.

Based record review and staff interviews, the facility failed to remove a peripheral intravenous catheter after intravenous therapy was completed for 1 of 2 residents reviewed for intravenous (IV) therapy. (Resident #2) Findings included: The facility's Removal of a Peripheral Intravenous Catheter dated 1/2008 stated a catheter should be removed when therapy was completed, during routine site rotation and when contamination or complications was suspected. Resident #2 was admitted [DATE] to the facility. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 12/14/2021, [MEDICATION(S)] Solution one gram intravenously every twenty four hours for seven days was ordered for Resident #2 for a urinary tract infection. The December 2021 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Nursing documentation dated 12/22/2021 revealed the intravenous catheter was intact and intravenous antibiotics was completed. There were no nursing documentation indicating when the intravenous catheter was removed. The annual Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #2 received antibiotics for four days and intravenous therapy. The care plan dated 1/12/2022 revealed Resident #2 was at risk for recurrent urinary tract infections and interventions included to administer medication as ordered by the physician. There was no plan of care for intravenous therapy on the care plan dated 1/12/2022 or the previous care plan dated 10/4/2021. On 1/14/2022 at 4:43 p.m. in an interview with Nurse #1, she stated she was not the assigned nurse when Resident #2 completed her intravenous antibiotics. She stated intravenous catheters were discontinued at the end of therapy and did not know why the IV catheter had not been removed. Nurse #1 stated she removed the IV catheter on 12/27/2021 and did not document the removal of the IV catheter in Resident #2's electronic medical record. She stated the site of the IV catheter was not red or swollen when the IV catheter was removed. On 1/14/2021 at 4:50 p.m. in an interview with the Director of Nursing, she stated IV catheters should to be removed at the end of IV therapy.

Based on family and staff interviews and record review, the facility imposed a restricted visitation schedule which limited resident visitations for 2 of 2 residents reviewed for visitation. (Resident #25 and Resident #5). This practice had the potential to affect all residents. The findings included: 1. Resident #25 was admitted to the facility on [DATE]. The quarterly Minimum Data Set revealed Resident #25 was cognitively impaired. On 10/27/21 at 2:30 PM an interview was conducted with Resident #25's family member. She stated she could visit her mother from 1:00 PM to 5:00 PM daily. She stated she has not been made aware if visiting hours were different. She stated she has asked to visit after 5:00 PM and the facility said no. On 10/28/21 at 3:22 PM an interview was conducted with the Administrator. She stated visiting hours, both indoor and outdoor, were from 1:00 PM to 5:00 PM. She stated she thought if the facility was in a high positivity area, visiting hours could be limited. 2. Resident #5 was admitted to the facility on [DATE]. The admission Minimum Data Set revealed Resident #5 was cognitively impaired. On 10/26/21 at 3:22 PM an interview was conducted with Residents #5's family member. She stated she could visit her Aunt from 1:00 PM to 5:00 PM daily. She stated it would be more convenient if some of the time, she could visit in the morning. On 10/28/21 at 3:22 PM an interview was conducted with the Administrator. She stated visiting hours, both indoor and outdoor, were from 1:00 PM to 5:00 PM. She stated she thought if the facility was in a high positivity area, visiting hours could be limited.

Based on observations, resident interview, staff interviews and record review, the facility violated 1 of 1 resident's (Resident #10) rights, who required a motorized wheelchair for independent mobility, by not allowing the resident to bring and utilize his motorized wheelchair to the facility, which resulted in a loss of his independent mobility both inside and outside of the facility. The findings include: Resident #10 was originally admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of a Home visit/agreement note, written by the facility Social Worker, dated 7/27/16 at 11:30 AM, was signed by Resident #10. The home visit/agreement note which was witnessed by the facility Social Worker prior to Resident #10's admission to the facility, read in part, Resident informed writer that he had a motorized wheelchair and wanted to know if he could bring the wheelchair to the facility. Writer informed Resident that the facility administrator said corporate was not allowing new admits to bring their motorized wheelchairs into the facility due to accidents and liability. Resident stated when he went for rehabilitation a couple of years ago in another facility he was unable to have his chair. Resident asked if the facility would provide him with a regular wheelchair, writer answered yes. Resident asked if staff would take him outside to smoke. Writer answered yes. Resident stated, well I am ready to come to the nursing home. I plan on staying long term. According to the most recent Admission Minimum Data Set ((MDS) dated [DATE], Resident #10's cognition was intact. He required extensive assistance in the areas of bed mobility, toileting and personal hygiene. He was totally dependent in transfers, dressing, bathing and locomotion on and off the unit. Review of Resident #10's Care Area Assessment Summary (CAA) dated 8/9/16, revealed the resident was at risk for complications of immobility, such as contractures and depression. The CAA noted, Resident with Diagnosis: [REDACTED]. A review of Resident #10's Care plan dated 8/9/16, revealed problem areas that read in part, Feelings of sadness, emptiness, anxiety, uneasiness and depression characterized by ineffective coping. The other problem areas included low self-esteem, tearfulness, motor agitation and withdrawal from care/activities related to: Admission to facility and relocation. The goal was to have improved mood state, happier, calmer appearance, no signs/symptoms of depression and no anxiety or sadness through the next review. The interventions included to discuss feelings about placement with resident, document mood state, sadness, anxiety and signs/symptoms of depression and encourage resident to take an active social role within facility. During an interview on 09/19/2016 at 2:24 PM Resident #10 wanted to know if there was a reason why he could not bring his motorized wheelchair to the facility. He revealed he had a motorized wheelchair at home that he had been using for twenty years or more and he was told by the Social Worker that the head person (Administrator) said he could not bring his motorized wheelchair to the facility because he might run into someone or the motorized wheelchair might make too much noise. He revealed staff let him use a manual wheelchair which he could not push independently. Resident #10 stated staff had to push him in the manual wheelchair wherever he wanted to go and he had used the manual wheelchair since he was admitted to the facility. During an interview on 09/19/2016 at 2:29 PM the Occupational Therapist stated she did not see any reason why Resident #10 could not use a motorized wheelchair. She revealed he was cognitively intact and they could not find any adaptations for the manual wheelchair that would provide him independence. During an observation on 09/20/2016 at 8:38 AM, the Occupational Therapist was pushing Resident #10 in his manual wheelchair to the therapy room. During an interview on 09/20/2016 at 3:41 PM, the facility Social Worker (SW) revealed she conducted a home visit with Resident #10 prior to his admission to the facility. The Social Worker stated during the home visit Resident #10 asked if he could bring his motorized wheelchair to the facility if he decided to come. The SW stated she made him aware that the Administrator was not accepting any new admissions bringing motorized wheelchairs into the facility. The Social Worker stated Resident #10 asked why motorized wheelchairs were no longer allowed in the facility and she told him it was because of incidents in the facility involving residents with motorized wheelchairs and liability. The Social Worker said Resident #10 explained he could drive his motorized wheelchair and he would not hit anyone. The Social Worker stated she asked Resident #10 if he still wanted to come to the facility even though he could not bring his motorized wheelchair and the resident said yes. She stated she explained to him one more time to make sure he understood that the facility was not allowing any more motorized wheelchairs in the facility. The Social Worker recalled Resident #10 said he understood, but he hoped it would change eventually so that he could bring his motorized wheelchair to the facility. The Social Worker emphasized she did another home visit with Resident #10 to have him sign paperwork, to make sure he had someone to clean his apartment as well as to make sure he had transportation to pick him up, since he decided he wanted to come to facility. She revealed she typed up everything about what they discussed and they initialed and signed the agreement. During an interview on 09/20/2016 at 3:18 PM, the Administrator explained, before Resident #10 was admitted to the facility, the facility's Social Worker conducted a home visit and Resident #10 was informed that the facility had a new policy of not taking on anymore residents with motorized wheelchairs. The Administrator revealed during the home visit, Resident #10 signed information the Social Worker reviewed with him regarding the facility was not admitting any more residents in motorized wheelchairs, and he agreed not to bring his motorized wheelchair to the facility. The Administrator revealed there had been some safety issues with residents in motorized wheelchairs running into staff and other residents. She said they grandfathered two residents with motorized wheelchairs already in the facility and one of the residents was in the hospital. The Administrator stressed it was a burden to residents when a motorized wheelchair broke down and the resident did not have the money to fix it. The Administrator was asked for a copy of the facility policy not allowing anymore residents with motorized wheelchairs to be admitted to the facility. During another interview on 09/20/2016 at 4:05 PM Resident #10 stated the Social Worker told him he could not bring his motorized wheelchair with him to the facility and she would have to talk to her boss about it. Resident #10 said when he was told he could not bring his wheelchair to the facility he felt that they took his legs away from him and he was not used to people pushing him in a wheelchair. Resident #10 stated he knew how to put the motorized wheelchair on low speed and drive in the middle of the hallway not close to resident's rooms to prevent from scaring them if they came out of their rooms. Resident #10 added that if he had his motorized wheelchair in the facility he could independently go whenever he got ready to go. Resident #10 stressed if he had known there was never a possibility of bringing his motorized wheelchair to the facility he would have not given up his home. During another interview on 09/21/2016 at 10:00 AM, the Occupational Therapist (OT) revealed Resident #10 was progressing slowly. She stated Resident #10 would not be able to use a manual wheelchair and he would benefit from using a motorized wheelchair. The Occupational Therapist revealed she was not informed about incidents when residents in motorized wheelchairs were running into staff and residents. She stated if she had known, she would have done an evaluation and instructed residents on the proper use of the motorized wheelchairs and would have made sure that the residents could function in the motorized wheelchairs safely. During an interview on 09/21/2016 at 2:03 PM, the facility Physical Therapist/Rehabilitation Director revealed the facility had a policy of trying to the limit use of motorized wheelchairs. He said he learned about the policy three weeks ago when he asked Resident #10 if he could bring his motorized wheelchair to the facility. The Rehabilitation Director stated he inquired about it and was told by the Administrator that they were trying to get rid of motorized wheelchairs for safety concerns. He stated no one reported any motorized wheelchair incidents to him. The Rehabilitation Director revealed he had not assessed Resident #10 in a motorized wheelchair because Resident #10 did not have his motorized wheelchair to practice. He revealed Resident #10 used his motorized wheelchair when he was at home and he would benefit from using a motorized wheelchair in the facility. During an interview on 09/21/2016 at 3:35 PM the Administrator revealed she didn't have a definite number of accidents caused by residents in motorized wheelchairs hitting staff and residents. She said she did not have any dates nor did she present any documentation of when the incidents occurred. She stated the last two incidents one of the two residents with motorized wheelchairs ran into a staff member. She stated there were no injuries caused by the accidents. The Administrator said both of the residents in motorized wheelchairs almost ran over resident's feet and bumped into them. The Administrator said on 6/1/16 the facility decided to implement the policy not to admit any more residents with motorized wheelchairs in the facility. She stated they felt residents in motorized wheelchairs had the potential to become a hazard. When asked again about the facility's written policy, the Administrator revealed the facility did not have a written policy which specified they did not allow residents in motorized wheelchairs from being admitted to the facility. During another interview on 09/22/2016 at 10:50 AM, the Administrator explained her concern was that the facility had two residents capable of using motorized wheelchairs and if they kept admitting residents with motorized wheelchairs it had the potential to become a hazardous situation. She revealed she was looking at the bigger picture because the facility had narrow halls and if there were so many residents in the facility with motorized wheelchairs it would become a hazard. The Administrator stated this was something they would revisit. During an observation on 09/22/2016 at 11:30 AM, Resident #10 was being pushed in his manual wheelchair from therapy to his room. During another interview on 09/22/2016 at 2:51 PM, Resident #10 revealed he's had a doctor's order for his motorized wheel chair for years. Resident #10 stated this facility was the only one that asked him to leave his wheelchair at home. He revealed his motorized wheelchair was the only way he could get around independently and it was a substitute for him walking. He said it was easy for staff to say not to bring his motorized wheelchair to the facility, but if they put themselves in his situation they would feel the same way. Resident #10 revealed he was able to live an independent life with his motorized wheelchair and without his motorized wheelchair someone had to get everything for him. Resident #10 said no one in the facility had seen him in his motorized wheelchair. He revealed if he had his motorized wheelchair he would drive his motorized wheelchair with care. During an interview on 9/22/2016 at 3:38 PM, the Medical Director revealed he felt motorized wheelchairs were dangerous and the facility had a policy not to accept any more residents in motorized wheelchairs. He emphasized he did not feel the facility was violating Resident #10's rights by not allowing him to bring his motorized wheelchair from home to the facility.

Based on observations, resident interview, staff interviews and record review, the facility failed to accommodate 1 of 1 resident (Resident #10), who required a motorized wheelchair for independent mobility, by not allowing the resident to bring and utilize his motorized wheelchair in the facility, which resulted in a loss of his independent mobility both inside and outside of the facility. The findings include: Resident #10 was originally admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of a Home visit/agreement note, written by the facility Social Worker, dated 7/27/16 at 11:30 AM, was signed by Resident #10. The home visit/agreement note which was witnessed by the facility Social Worker prior to Resident #10's admission to the facility, read in part, Resident informed writer that he had a motorized wheelchair and wanted to know if he could bring the wheelchair to the facility. Writer informed Resident that the facility administrator said corporate was not allowing new admits to bring their motorized wheelchairs into the facility due to accidents and liability. Resident stated when he went for rehabilitation a couple of years ago in another facility he was unable to have his chair. Resident asked if the facility would provide him with a regular wheelchair, writer answered yes. Resident asked if staff would take him outside to smoke. Writer answered yes. Resident stated, well I am ready to come to the nursing home. I plan on staying long term. According to the most recent Admission Minimum Data Set ((MDS) dated [DATE], Resident #10's cognition was intact. He required extensive assistance in the areas of bed mobility, toileting and personal hygiene. He was totally dependent in transfers, dressing, bathing and locomotion on and off the unit. Review of Resident #10's Care Area Assessment Summary (CAA) dated 8/9/16, revealed, the resident was at risk for complications of immobility, such as contractures and depression. The CAA noted, Resident with Diagnosis: [REDACTED]. A review of Resident #10 ' s Care plan dated 8/9/16, revealed problem areas that read in part, Feelings of sadness, emptiness, anxiety, uneasiness and depression characterized by ineffective coping. The other problem areas included low self-esteem, tearfulness, motor agitation and withdrawal from care/activities related to: Admission to facility and relocation. The goal was to have improved mood state, happier, calmer appearance, no signs/symptoms of depression and no anxiety or sadness through the next review. The interventions included to discuss feelings about placement with resident, document mood state, sadness, anxiety and signs/symptoms of depression and encourage resident to take an active social role within facility. During an interview on 09/19/2016 at 2:24 PM Resident #10 wanted to know if there was a reason why he could not bring his motorized wheelchair to the facility. He revealed he had a motorized wheelchair at home that he had been using for twenty years or more and he was told by the Social Worker that the head person, (Administrator) said he could not bring his motorized wheelchair to the facility because he might run into someone or the motorized wheelchair might make too much noise. He revealed staff let him use a manual wheelchair which he could not push independently. Resident #10 stated staff had to push him in the manual wheelchair wherever he wanted to go and he had used the manual wheelchair since he was admitted to the facility. During an interview on 09/19/2016 at 2:29 PM, the Occupational Therapist stated she did not see any reason why Resident #10 could not use a motorized wheelchair. She revealed he was cognitively intact and they could not find any adaptations for the manual wheelchair that would provide him independence. During an observation on 09/20/2016 at 8:38 AM, the Occupational Therapist was pushing Resident #10 in his manual wheelchair to the therapy room. During an interview on 09/20/2016 at 3:41 PM, the facility Social Worker (SW) revealed she conducted a home visit with Resident #10 prior to his admission to the facility. The Social Worker stated during the home visit Resident #10 asked if he could bring his motorized wheelchair to facility if he decided to come. The SW stated she made him aware that the Administrator was not accepting any new admissions bringing motorized wheelchairs into the facility. The Social Worker stated Resident #10 asked why motorized wheelchairs were no longer allowed in the facility and she told him it was because of incidents in the facility involving residents with motorized wheelchairs and liability. The Social Worker said Resident #10 explained he could drive his motorized wheelchair and he would not hit anyone. The Social Worker stated she asked Resident #10 if he still wanted to come to the facility even though he could not bring his motorized wheelchair and the resident said yes. She stated she explained to him one more time to make sure he understood that the facility was not allowing any more motorized wheelchairs in the facility. The Social Worker reported Resident #10 said he understood, but he hoped it would change eventually so that he could bring his motorized wheelchair to the facility. The Social Worker emphasized she did another home visit with Resident #10 to have him sign paperwork, to make sure he had someone to clean his apartment as well as to make sure he had transportation to pick him up, since he decided he wanted to come to facility. She revealed she typed up everything about what they discussed and they initialed and signed the agreement. During an interview on 09/20/2016 at 3:18 PM, the Administrator explained, before Resident #10 was admitted to the facility, the facility's Social Worker conducted a home visit and Resident #10 was informed the facility had a new policy of not taking on anymore residents with motorized wheelchairs. The Administrator revealed during the home visit Resident #10 signed information the Social Worker reviewed with him regarding the facility was not admitting any more residents in motorized wheelchairs. She stated Resident #10 agreed not to bring his motorized wheelchair to the facility. The Administrator revealed there had been some safety issues with residents in motorized wheelchairs running into staff and other residents. She said they grandfathered two residents with motorized wheelchairs already in the facility and one of the residents was in the hospital. The Administrator stressed it was a burden to residents when a motorized wheelchair broke down and the resident did not have the money to fix it. The Administrator was asked for a copy of the facility policy not allowing anymore residents with motorized wheelchairs to be admitted to the facility. During another interview on 09/20/2016 at 4:05 PM Resident #10 stated the Social Worker told him he could not bring his motorized wheelchair with him to the facility and she would have to talk to her boss about it. Resident #10 said when he was told he could not bring his wheelchair to the facility he felt that they took his legs away from him and he was not used to people pushing him in a wheelchair. Resident #10 stated he knew how to put the motorized wheelchair on low speed and drive in the middle of the hallway not close to resident's rooms to prevent from scaring them if they came out of their rooms. Resident #10 added that if he had his motorized wheelchair in the facility he could independently go whenever he got ready to go. Resident #10 stressed if he had known there was never a possibility of bringing his motorized wheelchair to the facility he would have not given up his home. During an interview on 09/20/2016 at 6:14 PM, Resident #10's family member revealed the motorized wheelchair was Resident #10's car. She stated he was able to go where ever he wanted to go wearing his vest and flag on his motorized wheelchair. Resident #10's family member said he was able to travel all downtown in his hometown. During an interview on 09/20/2016 at 6:24 PM, a Home Health Care Aide who cared for Resident #10 in his home revealed he handled his motorized wheelchair very well. She added that Resident #10 did not run into anyone in his motorized wheelchair and he maneuvered his motorized wheelchair very well in his home. During another interview on 09/21/2016 at 10:00 AM, the Occupational Therapist (OT) revealed Resident #10 was progressing slowly. She stated Resident #10 would not be able to independently use a manual wheelchair and he would benefit from using a motorized wheelchair. The Occupational Therapist revealed she was not informed about incidents when residents in motorized wheelchairs were running into staff and residents. She stated if she had known, she would have done an evaluation and instructed residents on the proper use of the motorized wheelchairs and would have made sure that the residents could function in the motorized wheelchairs safely. During an interview on 09/21/2016 at 2:03 PM, the facility Physical Therapist/Rehabilitation Director revealed the facility had a policy of trying to the limit use of motorized wheelchairs. He said he learned about the policy three weeks ago when he asked Resident #10 if he could bring his motorized wheelchair to the facility. The Rehabilitation Director stated he inquired about it and was told by the Administrator that they were trying to get rid of motorized wheelchairs for safety concerns. The Rehabilitation Director stated no one reported any motorized wheelchair incidents to him. The Rehabilitation Director revealed he had not assessed Resident #10 in a motorized wheelchair because Resident #10 did not have his motorized wheelchair to practice. He revealed Resident #10 used his motorized wheelchair when he was at home and he would benefit from using a motorized wheelchair in the facility. During an interview on 09/21/2016 at 3:35 PM the Administrator revealed she didn't have a definite number of accidents caused by residents in motorized wheelchairs hitting staff and residents. She said she did not have any dates nor did she present any documentation of when the incidents occurred. She stated the last two incidents one of the two residents with motorized wheelchairs ran into a staff member. She stated there were no injuries caused by the accidents. The Administrator said both of the residents in motorized wheelchairs almost ran over resident's feet and bumped into them. The Administrator said on 6/1/16 the facility decided to implement the policy not to admit any more residents with motorized wheelchairs in the facility. She stated they felt residents in motorized wheelchairs had the potential to become a hazard. When asked again about the facility's written policy, the Administrator revealed the facility did not have a written policy which specified they did not allow residents in motorized wheelchairs from being admitted to the facility. During another interview on 09/22/2016 at 10:50 AM, the Administrator explained her concern was that the facility had two residents capable of using motorized wheelchairs and if they kept admitting residents with motorized wheelchairs it had the potential to become a hazardous situation. She revealed she was looking at the bigger picture because the facility had narrow halls and if there were so many residents in the facility with motorized wheelchairs it would become a hazard. The Administrator stated this was something they would revisit. During an observation on 09/22/2016 at 11:30 AM, Resident #10 was being pushed by a staff member in his manual wheelchair from therapy to his room. During another interview on 09/22/2016 at 2:51 PM, Resident #10 revealed he had a doctor ' s order for his motorized wheel chair for years. Resident #10 stated this facility was the only one that asked him to leave his motorized wheelchair at home. He revealed his motorized wheelchair was the only way he could get around independently. Resident #10 revealed he was able to live an independent life with his motorized wheelchair and without his motorized wheelchair someone had to get everything for him. Resident #10 said no one in the facility had seen or assessed his ability to drive his motorized wheelchair. He stated he would drive his motorized wheelchair with care. During an interview on 9/22/2016 at 3:38 PM, the Medical Director revealed he felt motorized wheelchairs were dangerous and the facility had a policy not to accept any more residents in motorized wheelchairs. He emphasized he did not feel the facility was violating Resident #10's rights by not allowing him to bring his motorized wheelchair from home to the facility.