Vibra Hospital of Northern California

“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 49418 Based on observation, interview, and record review, the facility failed to ensure that nursing staff implemented and maintained patient bathing schedules per facility policy for four of five sampled patients (Patients 1, 2, 3, and 4). This deficient practice had the potential to affect the comfort and dignity of all patients and increased the risk of infection and skin breakdown due to bacteria, perspiration, and skin oils, potentially resulting in adverse health outcomes. Findings: Review of facility policy and procedure (P&P) titled “Guidelines for Nursing and Respiratory Care,” dated 10/2025, indicated nursing staff were directed to “maintain quality care” by adhering to the established “minimum frequency” for performing essential nursing hygiene tasks as follows: A. Patient bathed, hair combed, shaved: Daily. B. If no contraindication (inadvisable as it could harm the patient), shower: Weekly and pro re nata (PRN - Latin for ‘as needed’). C. Hair shampooed: Weekly and PRN. D. Bed linens changed: Daily and PRN. E. Oral care: Every morning before breakfast, at bedtime, and PRN. F. Washcloth and mouthwash offered: After each meal and PRN. Review of an article titled “Assisting Patients with Personal Hygiene” on the National Institute of Health (NIH - primary agency of the United States government responsible for public health research) website, dated 9/26/22, indicated the provision of basic hygiene (oral care, bathing, elimination, shaving, and hair grooming) is essential for patient health. Staff should give bed baths to patients who need significant help with daily activities, and regular nail care helps prevent patients from scratching themselves and removes bacteria that can cause infection. Staff should continuously monitor patients’ hygiene needs, adjusting the frequency based on each patient’s medical condition, cultural practices, and personal preferences. During an interview with the Chief Executive Officer (CEO) on 7/2/26 at 8:55 am, CEO stated the facility had implemented a move away from paper documentation of patient baths and showers and began implementation of more streamlined documentation in the electronic health record (EHR) two weeks ago. CEO stated patient showers/baths were given twice a week and were staggered by patient group; for example, some patients were scheduled for bathing Monday and Thursday, some Wednesday and Saturday. CEO stated there should be a sign posted in each patient’s room indicating their scheduled days. 1. Review of document titled “History & Physical,” dated 5/7/26, indicated Patient 1 was admitted to the facility on 5/7/26 with a chief complaint of dependence on a ventilator (a machine that pumps oxygen into the lungs and removes carbon dioxide) and severe neurological deficits (an abnormal loss or impairment of nervous system function) following a stroke that caused left hemiplegia (complete or partial paralysis of the left side of the body). Review of “Long-Term Acute Care (LTAC) Daily: Acuity, Census, & Staffing,” dated 7/1/26 Day Shift, indicated Patient 1 was scheduled for showers on Wednesday and Saturday day shifts. During a concurrent observation and interview with Patient 1 in her room on 7/1/26 at 11:20 am, observed physical therapy staff at the bedside readying Patient 1 for transfer via wheelchair to the therapy room. Patient 1 exhibited a noticeable and pronounced “stale” odor. Her teeth appeared to contain food particles, and her hair was stringy with grease, containing multiple small and large, yellow-white flakes. Patient 1 was observed to have a tracheostomy (trach - a surgical procedure to create an airway by placing a tube through the neck/throat skin into the windpipe), which affected her ability to speak. Patient 1 shook her head and mouthed the word “no” when asked if she thought she was getting enough showers and felt clean. A sign indicating Patient 1’s shower schedule was not observed in the room. Review of Patient 1’s documents titled “Patient Rounding & ADLs” indicated the following: 6/20/26 (Saturday) at 7:12 am: Bathing Performed - “Maximum Assist,” Sponge Bath Performed - “Maximum Assist,” Shaving Performed - “Maximum Assist.” 6/24/26 (Wednesday) at 7:06 am: Bathing Performed - “Maximum Assist” Shaving Performed - “Maximum Assist.” 6/27/26 (Saturday) at 7:36 am: Perineal (peri - skin between the anus and vagina/penis) Care Performed - “Pericare, Incontinence (inability to control urine output) Care, Catheter (flexible tube inserted through the urinary opening into the bladder to continuously drain urine) Care” Bathing Performed - “Maximum Assist.” 7/1/26 (Wednesday), signed by Certified Nurse Assistant (CNA) C at 6:46 pm: Perineal Care Performed - “Pericare, Catheter Care,” Bathing Performed - “Moderate Assist, Hair Washed,” Linen - “Changed.” During concurrent observation and interview with Patient 1 in her room on 7/2/26 at 10:20 am, Patient 1’s hair appeared greasy with multiple small and large, yellow-white flakes visible in her hair and scattered on the mattress. Patient 1’s fingernails extended approximately one-quarter inch (1/4-inch - a unit of measure) past her fingertips; an unknown brownish-yellow substance was under each nail. Patient 1 was unable to open her left hand due to a stroke; on inspection, the left palm was scaly and dry with flaky skin. Patient 1’s right palm appeared pink, warm and dry, without scaling. During an interview with Licensed Nurse (LN) E on 7/2/26 at 11:46 am, LN E stated facility policy was “we can’t cut” patient’s nails, particularly if they are diabetic. LN E stated there were clippers, cuticle sticks, and files available, adding, “Nails need to be cut” because it “prevents infection” from dirt under the nails and “prevents wounds” from nails digging into palms, particularly when hands are contracted (shortened muscles, tendons, ligaments, or skin causing stiff joints, deformity). During an interview with Certified Nurse Assistant (CNA) D on 7/2/26 at 3:55 pm, CNA D stated, “Everyone has two days a week for shower or bath.” CNA D stated she was familiar with Patient 1, adding, “She wants to be repositioned and washed.” When asked how often they changed a patient’s bedding, CNA D stated “for sure” every shower day (twice weekly) unless they were soiled, “then I’ll do it more often.” For patients on an air mattress with no sheet, CNA D stated they would bleach wipe the bed every shower day, dry it off, then put a fresh pad down before the patient got back from their shower. During concurrent observation and interview with Patient 1, the DON, and the Clinical Supervisor of Nursing (CSN) in Patient 1’s room on 7/3/26 at 8:51 am, Patient 1 was propped up on pillows, a plate of scrambled eggs on the bedside table. Patient 1 picked up a bite of eggs with her bare right hand and ate it. Food particles were present on sheets and blankets covering the patient’s legs. Patient 1’s hair appeared greasy, with large and small, yellow-white flakes in her hair and on the bed. The right hand revealed an unknown yellow-brown substance and scrambled eggs beneath the nails. Inspection of the left hand indicated dry flaky skin of the palm and an unknown brown substance beneath the fingernails. Patient 1 nodded and mouthed the word “yes” when asked if she would like more showers. The DON and CSN informed Patient 1 that they would speak with staff and suggest an increase in bathing so she would be “comfortable and happy” with her care. During an interview with CEO, DON, and CSN on 7/3/26 at 9 am, CSN and DON acknowledged Patient 1 had “dirty hair and nails.” When asked if Patient 1’s hair appeared washed as documented on 7/1/26, CSN and DON stated “No.” During an interview with CNA C, DON, and CSN on 7/3/26 at 9:05 am, CNA C stated that if they documented “Bed Bath Performed,” that included a “head-to-toe cleaning,” including pericare, teeth brushed, and a hair wash. CNA C stated they remembered giving Patient 1 a bed bath on 7/1/26 and “scrubbed” her hair using a rinseless hair wash product (a disposable cap premoistened with a gentle waterless shampoo and conditioner). CNA C stated they “noticed her dandruff” but did not notice dry flaky skin in Patient 1’s left palm. CNA C stated they would only chart a comment in “Rounding Care” if hair care was refused. During an interview with CEO, DON, and CSN on 7/3/26 at 9:13 am, DON stated CNA C was a “great CNA” and believed CNA C performed Patient 1’s hair wash as they described and documented. CSN nodded her head in agreement. DON stated, “Perhaps it was the product.” When asked about Patient 1’s fingernails, CSN stated patients’ nails were generally cleaned, “but we don’t clip” (to prevent injury). DON stated Patient 1’s nails should be “cleaned and filed.” Regarding Patient 1’s left palm, DON stated staff could “wash better,” moisturize, and put a dry rolled-up washcloth in the palm to keep the fingernails from digging into the palm and creating the callus. DON stated, “She could use a good soak.” 2. Review of document titled “History & Physical,” dated 5/10/26, indicated Patient 2 was in their 60s, admitted to the facility on 5/10/26 for continued ventilator weaning and medical management. Patient 2 had a history of incomplete quadriplegia following a car accident, chronic severe wounds to the buttock area with osteomyelitis (infection and inflammation of the bone), diabetes, and chronic respiratory failure with ventilator dependence, a trach placed in 3/2026. Review of “Long-Term Acute Care (LTAC) Daily: Acuity, Census, & Staffing,” dated 7/1/26 Day Shift, indicated Patient 1 was scheduled for showers on Wednesday and Saturday night shifts. During concurrent observation and interview with Patient 2 in his room on 7/1/26 (Wednesday) at 12:05 pm, Patient 2 had a trach tube in place and was using a pencil-like stylus in his mouth to control a cell phone on a stand. Patient 2 acknowledged having no feeling below his mid chest. Observed Patient 2’s tube feed (liquid nutrients provided directly into a surgical opening in the stomach or small intestine) tubing to be leaking a tan liquid substance on the “chuck” (a disposable pad that collects body fluids) near the patient’s left hip. Patient 2’s right hand was contracted into a tight C shape, fingers bent inward with palm open. Observed dry scaling skin of hands and feet, white flakes on the mattress near the feet, and thick sharp fingernails extending approximately 1/4-inch past the fingertips. Observed a suction container on the wall with 200 milliliters (mL - a unit of measure equaling one-half of a pint) containing foamy brown-tan secretions. Review of document titled “[Patient 2] Shower Log through Length of Stay (LOS) Admit 5/10/26,” received from CSN on 7/3/26, indicated nursing staff performed consistent bathing as scheduled from 5/11/26 until 5/29/26. The document then indicated max assist bathing was performed: 5/29/26 (Friday) at 8:54 am, 6/8/26 (Monday) at 7:35 am, 6/13/26 (Saturday) at 7:16 am, 6/14/26 (Sunday) at 7:25 am, 6/21/26 (Sunday) at 7:34 am, 6/22/26 (Monday) at 7:18 am, 6/23/26 (Tuesday) at 7:01 am, 6/24/26 (Wednesday) at 7:47 am, 6/29/26 (Monday) at 8:47 am, 6/30/26 (Tuesday) at 7:33 am. The document indicated Patient 2 also received sponge baths on 6/8/26 at 7:30 pm and 6/30/26 at 8:45 pm. During concurrent interview with CEO, CSN, and DON and review of Patient 2’s medical record on 7/3/26 at 9:20 am, discussed the gaps in documented bathing, specifically 5/29/26 to 6/8/26 (10 days), 6/8/26 to 6/13/26 (five days), 6/14/26 to 6/21/26 (seven days), and 6/24/26 to 6/29/26 (five days). CSN stated the expectation was that nursing staff would document refused hygiene care. CSN stated she would expect nursing staff to ask to bathe the patient again the following shift, and if they again refused, “ask again each shift.” On EHR record review, CSN stated staff documented “refused bed bath” on 6/27/26 but acknowledged there was “no documentation of bath or refusal” each shift during the gaps noted above. 3. Review of document titled “History & Physical,” dated 4/9/26, indicated Patient 3 was in their 70s, admitted to the facility on 4/9/26 for ventilator weaning following hospitalization for septic shock (an emergent, life-threatening infection that triggers an extreme immune response) complicated by respiratory failure. A trach was placed 4/1/26, and she received tube feeding. Patient 3 also had Clostridium difficile colitis (C. diff - highly contagious bacterial illness that causes colitis - inflammation of the colon - and watery diarrhea), ulcers of the buttocks/coccyx (“butt bone”), and she required restraints and antipsychotic medication for agitation. Review of “Long-Term Acute Care (LTAC) Daily: Acuity, Census, & Staffing,” dated 7/1/26 Day Shift, indicated Patient 3 was scheduled for showers on Tuesday and Friday night shifts. During observation of Patient 3 in her room on 7/1/26 (Wednesday) at 11:52 am, observed Patient 3 lying on a sheetless mattress, a crumpled chuck under her buttocks, and a left wrist soft restraint attached to the bed. Drops of dried tan fluid stained the mattress and blankets covering her midsection. Hands and feet were dry and flaky. Observed her hair to be tangled, with white flakes on the mattress around shoulders and feet, smudged eyeglasses on the mattress underneath her right shoulder, and a strong “stale” odor emanating from Patient 3. Fingernails extended approximately 1/4- to 1/2-inch past the fingertips with a brownish substance beneath the nails. Observed a suction canister on the wall containing 500 mL of brown-red secretions. Review of document titled “Administration History,” received 7/2/26, indicated documented bathing of Patient 3 between 6/2/26 and 6/30/26. The document indicated bathing was “Not Complete” on 6/19/26 (Friday) at 5 pm with comment “per CNA.” Bathing was documented “Complete” on: 6/2/26 (Tuesday) at 4:20 pm, 6/9/26 (Tuesday) at 4:15 pm, 6/12/26 (Friday) at 5 pm, 6/16/26 (Tuesday) at 5:28 pm, 6/26/26 (Friday) at 6:40 pm, and 6/30/26 (Tuesday) at 5:49 pm. During concurrent interview with CEO, CSN, and DON and review of Patient 3’s medical record on 7/3/26 at 9:20 am, discussed missing documentation of bathing on 6/5 and 6/25/26. CEO, CSN, and DON acknowledged there was no documentation of a bed bath refused or made up between 6/5/26 and 6/9/26. Record review indicated a document titled “Rounding/ADLs” in the EHR dated 6/23/26 (Tuesday) at 5:23 pm of bed bath max assist, oral care, and pericare performed. CSN stated the expectation would be for staff to document an attempt to bathe or the patient’s refusal, and it was the primary nurse’s responsibility to coordinate with the CNA to get it done that shift. CSN stated the charge nurse was also “supposed to be rounding, asking about refusals.” During concurrent observation and interview with Patient 3, CSN, and CEO in Patient 3’s room on 7/3/26 (Friday) at 11:10 am, observed Patient 3 to have both wrists restrained, legs pulled in towards her abdomen, barefoot, with heels resting on a sheetless mattress. There were dry white flakes on the mattress and a large (approximately 1 foot by 1 foot) dry, white, circular stain on the mattress under her upper thighs. Hair was unkempt and tangled but appeared clean. CEO and CSN acknowledged nails were long and “the bed could have been cleaned.” CSN acknowledged observing stool on the mattress, went to the door, and requested staff assistance. The charge nurse returned with nursing staff holding bathing supplies, a folded gown, and folded sheets. 4. Review of document titled “History & Physical,” dated 3/4/26, indicated Patient 4 was in their 70s, admitted to the facility on 3/4/26 with a chief complaint of respiratory failure requiring ventilator management. Patient 4 “sustained severe multisystem trauma” with multiple fractures after a car-versus-pedestrian accident on 1/17/26 requiring surgery for spine stabilization. Patient 4 was paraplegic (unable to move his legs). Patient 4 suffered a heart attack on 2/5/26 that left him ventilator dependent, and he had a trach and feeding tube placed on 2/24/26. Patient 4 was transferred to the facility for ventilator weaning, “complex medical management,” and rehabilitation. Review of “Long-Term Acute Care (LTAC) Daily: Acuity, Census, & Staffing,” dated 7/1/26 Day Shift, indicated Patient 4 was scheduled for showers on Monday and Thursday night shifts. During observation of Patient 4 in his room on 7/1/26 (Wednesday) at 10:55 am, observed Patient 4 sleeping comfortably. Near Patient 4’s left hip, paper towels had been placed on the bed under a leaking feeding tube valve. There was a yellow stain at the neck of the gown. On gently pulling back the sheets and blankets, a pungent stale odor emanated from Patient 4. Thick fingernails were observed to be approximately 1/2-inch long, some extending past his fingertips and others curling over the tips. Observed a suction canister on the wall with 500 mL of foamy green secretions. Review of Patient 4’s documents titled “Rounding/ADLs,” received from CEO on 7/2/26, indicated the following: 6/21/26 (Sunday) at 5:15 pm: Oral Care Performed - “Oral Hygiene Kit.” Perineal Care Performed: “Pericare, Catheter Care.” Bathing Performed - “Maximum Assist.” 6/22/26 (Monday) at 5:17 am: Oral Care Performed - “Swab.” Perineal Care Performed: “Catheter Care.” Linen - “Changed.” Rounding Comments - “nurse performed bed bath at approximately 0100 (1 am).” 6/22/26 at 6:32 pm: Oral Care Performed - “Oral Hygiene Kit.” Perineal Care Performed: “Pericare, Catheter Care.” Bathing Performed - “Maximum Assist.” 6/29/26 (Monday) at 5:21 am: Perineal Care Performed: “Catheter Care.” Sponge Bath Performed - “Maximum Assist.” 6/29/26 at 5:48 pm: Oral Care Performed - “Oral Hygiene Kit.” Perineal Care Performed: “Incontinence Care, Catheter Care.” Bathing Performed - “Maximum Assist.” Linen - “Changed.” 6/30/26 at 6:25 pm: Oral Care Performed - “Oral Hygiene Kit.” Perineal Care Performed: “Pericare, Catheter Care.” Bathing Performed - “Maximum Assist.” During concurrent interview with CEO, CSN, and DON and review of Patient 4’s medical record on 7/3/26 at 9:20 am, discussed the gap between documented bathing between 6/22 (Monday) and 6/29/26 (Monday). CEO, CSN, and DON acknowledged there was no documentation of bathing or patient refusal between those dates; all acknowledged the expectation would be for documented make-up bath or refusal each shift during that time. During concurrent observation and interview with Patient 4, CSN, and CEO in Patient 4’s room on 7/3/26 (Friday) at 11 am, CEO and CSN acknowledged Patient 4’s nails were long enough to cause damage to the palms and “needed to be cleaned” underneath. CSN acknowledged “a definite smell” when the sheets were pulled back, stating she would recommend the CNA and RN coordinate a bed bath today. During an interview with CEO on 7/3/26 at 8:35 am, the CEO stated she and other staff noticed their overall “process was not clean” with bathing documentation spread across multiple areas of the EHR. The CEO stated she had interviewed three CNAs about their bathing procedures and charting. Discussed that there was a “Hair Washed” box for staff to check in the EHR documentation template. CEO stated CNAs informed her that “Bed Bath Max Assist” meant a full bed bath had been provided and “implied” hair was washed. At 8:45 am, CSN and DON joined the interview. When asked about hygiene “spot checks,” CSN and DON stated they relied on hygiene charting and did not observe patients directly. CSN stated administrators had discussed it and saw ways to improve the system.”

“INFECTION CONTROL PROGRAM CFR(s): 482.42(a)(1) The hospital infection prevention and control program, as documented in its policies and procedures, employs methods for preventing and controlling the transmission of infections within the hospital and between the hospital and other institutions and settings; This Standard is not met as evidenced by: 49418 Based on observation, interview, and record review, nursing staff failed to adhere to facility policies and recommended evidence-based practices for intravascular catheter (IV - thin flexible tube inserted into a vein to deliver fluids and medication) site care and dressing changes for three of five sampled patients (Patients 1, 2, and 5). This deficient practice increased the risk of skin and bloodstream infections, which could lead to poor health outcomes for all patients with IVs. Findings: Review of facility policy and procedure (P&P) titled “Guidelines for Nursing and Respiratory Care,” dated 10/2025, indicated staff were directed to “maintain quality care” by adhering to the established “minimum frequency” for performing essential nursing tasks as follows: (A) Change SPC location “when clinically indicated” based on site assessment and/or signs of complications. Label the dressing with date, time, and initials. (B) Change SPC dressings “every seven (7) days or when the dressing becomes damp, loose or visible soiled.” Label the dressing with date, time, and initials. (C) Change CVC dressings every seven (7) days with antimicrobial patch (biopatch - a small disc placed around the catheter insertion site that kills or stops growth of harmful microorganisms) and transparent semipermeable membrane dressing (TSM - clear sticky patch that allows skin visibility but protects the catheter insertion site from water, dirt, and germs). Review of document titled “SPC Dressing Change Competency (a tool used to establish a nurse’s competency with SPCs),” undated, directed staff to perform SPC site care and dressing changes “at established intervals” and “immediately” if the dressing integrity becomes compromised with moisture, drainage or blood or if signs of infection are present. The document indicated, “Routine site care and dressing changes are not performed on SPCs unless the dressing is soiled or no longer intact.” An observational tour of the facility on 7/1/26 from 10:55 am to 12:15 pm indicated the following: 1. At 11:20 am, observed Patient 1’s left arm SPC dressing to be undated and not initialed, with two of four dressing edges adhering to the patient’s skin. Physical therapy (PT) staff were present in the room to take Patient 1 to therapy. The Clinical Supervisor of Nursing (CSN) came in to observe the site and replaced the dressing, acknowledging it was “compromised.” 2. At 11:45 am, observed Patient 5 to be sleeping comfortably in bed while receiving dialysis (blood is pumped out of the body, filtered through an artificial kidney machine or dialyzer, and returned “clean”) through a tunneled CVC below his right clavicle (collarbone). A clear TSM dressing was present over the catheter insertion site. The TSM was initialed and dated 6/26/26 (six days old) without a time given. Under the TSM, a biopatch sat on top of the catheter insertion site rather than surrounding it. The TSM edges were loose, a small air pocket was observed beneath the TSM, and a brown-red substance had seeped from the insertion site to the dressing edges, staining it red-brown. A blue sticker at the bottom edge of the TSM indicated, “For Dialysis Only. Do Not Touch. Do Not Flush.” 3. At 12:09 pm, observed Patient 2 to have a right upper arm SPC with clear TSM dressing. The dressing indicated “extended, 6/9/26 (22 days old),” with a staff member’s initials. The time was not indicated. Two pieces of tape reinforced the extended catheter tubing and the TSM, and the tubing was unclamped. An observational tour of the facility on 7/2/26 from 9:45 am to 10:30 am indicated Patient 2’s SPC dressing dated 6/9/26 remained in place, the tubing was unclamped, and Patient 5’s tunneled dialysis catheter TSM dressing dated 6/26/26 also remained in place (seven days old). Review of “Order Listing Report for 5/10/26 to 7/1/26” indicated Patient 2 had an active order placed 5/17/26 at 8 am for “Line dressing and change every seven days. Request Type: Routine.” During an interview with Licensed Nurse (LN) B on 7/2/26 at 10:15 am, LN B stated Patient 5’s biopatch should be under the line, not on top, to protect the insertion site from infection; the TSM dressing was “poorly done;” and the blood under and on the TSM created a potential infection risk. LN B stated she had been trained that primary nurses were not to touch a dialysis catheter or dressing; only dialysis nurses were to change dialysis catheter dressings. LN B acknowledged surprise that the dialysis nurse had not changed the dressing at the time of dialysis on 7/1/26. During an interview with vascular access nurse LN A on 7/2/26 at 11:27 am: A. LN A stated Patient 2’s SPC dressing was “definitely outdated.” LN A acknowledged the extended tubing had not been clamped, which she stated was a risk for infection. LN A stated the primary nurse(s) should have replaced the dressing or called a vascular access nurse to do it. LN A stated an SPC could stay in place and be used “as long as it’s patent (unobstructed, open to flow) and doesn’t show sign of infection.” LN A acknowledged the time was not written on Patient 2’s SPC dressing per policy. B. LN A stated the TSM over Patient 5’s tunneled dialysis CVC “should have been changed yesterday” due to blood soilage under the dressing and the TSM “peeling up.” LN A acknowledged that the biopatch should be under the line, and the dressing did not indicate the time it was changed. LN A stated a dialysis nurse would typically be responsible to change a dialysis CVC dressing, and it was the expectation that the primary nurse would call an in-house dialysis nurse to change the dialysis CVC dressing if it was compromised. During an interview with the Chief Executive Officer (CEO), Director of Nursing (DON), Director of Quality & Risk Management (DQR), and CSN on 7/2/26 from 4:40 to 5:00 pm, the CEO stated that an SPC could remain in place if it stayed patent, the dressing was clean, and there were no signs of infection or infiltration. The CEO, DON, DQR, and CSN agreed that it was difficult to find a “good vein” for many of their patients due to their complicated medical issues, and an SPC dressing change could not always be accomplished without the catheter slipping out. The CSN confirmed nursing staff were trained to change the SPC site only if the site was infected and to change the dressing if it was compromised. During a concurrent review regarding the facility policy titled “Guidelines for Nursing and Respiratory Care” indicated SPC dressings should be changed every seven days or if damp, loose, or visibly soiled, whereas the SPC Dressing Change Competency directed nurses to change SPC dressings only if soiled or not intact. All acknowledged it was the expectation that nursing staff follow their training during SPC dressing change competency check. CEO and CSN acknowledged the “Lippincott Manual of Nursing Practice, 12th Edition” was also available at the nurses’ station as a resource for protocols and procedures of nursing care. Review of page 38 of the “Lippincott Manual of Nursing Practice, 12th Edition,” published 8/19/24, indicated nursing staff should choose vascular access devices based on patient needs and characteristics (like age and multiple coexisting diagnoses), IV therapy type, and duration of therapy. Nurses were directed to use SPCs for short-term therapy (less than four days), midline catheters for therapy lasting five to 30 days, and CVCs for long-term IV therapy lasting weeks, months, or years.”

“NURSING CARE PLAN CFR(s): 482.23(b)(4) The hospital must ensure that the nursing staff develops, and keeps current, a nursing care plan for each patient that reflects the patient’s goals and the nursing care to be provided to meet the patient’s needs. The nursing care plan may be part of an interdisciplinary care plan. This Standard is not met as evidenced by: 49418 Based on observation, interview, and record review, the facility failed to ensure staff developed and updated individualized nursing care plans and patient goals for four of four sampled patients (Patients 1, 2, 3, and 4) as evidenced by: 1. Patient 1’s care plan was not updated to include increasingly erratic mood and behaviors when Patient 1 was found wandering the facility, becoming agitated and aggressive with staff, and “scaring family members in three different rooms.” 2. Patient 2’s care plan was not updated to include impaired urinary elimination with care of his Foley catheter (flexible sterile tube inserted through the urethra into the bladder to continuously drain urine). During his hospitalization, Patient 2 required transfer to an emergency room (ER) when his Foley catheter became clogged with blood. 3. Patient 3’s care plan did not include constipation, which worsened during his stay, requiring transfer to another facility for imaging and surgery consultation for potential bowel obstruction. 4. Patient 4’s care plan was not updated to include a new skin rash to the right upper extremity (RUE - right arm) that developed during his stay. These deficient practices caused real and potential negative clinical outcomes affecting the health and safety of patients, visitors, and staff and a breakdown in communication between members of the Interdisciplinary Care Team (IDT - a team with members from different disciplines who work together to set goals and make patient care decisions). Findings: Review of facility policy and procedure (P&P) titled “Plan for Provision of Care,” dated 1/2026, indicated nursing process activities were as follows: A. Assessment: RNs were directed to fully assess each patient upon admission and every shift thereafter, re-evaluating as conditions change. B. Planning: RNs were directed to create individualized care plans in conjunction with the patient and Interdisciplinary Care Team (IDT) within 24 hours of admission. The care plan and interventions were to be updated as patient needs changed. C. Interventions: Nursing staff were to provide major interventions including but not limited to personal care, medications and intravenous (IV - into a vein) therapy, wound care, bowel/bladder management, pain management, and education. D. Evaluation: Treatment responses were to be reviewed and care plans adjusted accordingly. 1. Review of Patient 1’s “Face Sheet” (a document showing the patient’s essential personal, financial, and clinical data), dated 5/20/26, indicated Patient 1 was admitted to the hospital on 2/3/26 and discharged on 3/28/26. Review of “History and Physical,” dated 2/3/26, indicated Patient 1 was transferred from another facility for long-term IV antibiotics and “complex medical management.” Diagnoses included osteomyelitis (serious, painful infection of bone tissue, usually caused by bacteria or fungi) and abscess of the thoracic (mid back) spine, Methicillin-resistant Staphylococcus aureus (MRSA - a staphylococcus bacterial infection resistant to antibiotics) blood infection, diabetes, chronic pain with opioid dependence, tobacco use disorder, schizoaffective disorder - bipolar type (mood fluctuations cycling between mania and depression with delusions or hallucinations), and deconditioning. Review of “Licensed Practical Nurse (LPN) Notes” indicated: -2/22/26 at 7 am: At 4:15 pm, Licensed Nurse (LN) D notified the physician after Patient 1 stated he had increased depression and “I can’t be at the hospital any longer.” At 6:30 pm, LN D documented, “Care plans reviewed.” -2/25/26 at 7:15 am: At 4:30 pm during rush-hour traffic, Patient 1 “left the hospital walking North up [street name],” a busy thoroughfare that connects to a major interstate highway. The note indicated the Charge Nurse (LN B) “retrieved” Patient 1, returned him to the lobby, and the physician was notified. At 6 pm, LN B documented, “Plan of care ongoing.” During an interview with Chief Executive Officer (CEO) and Director of Quality & Risk Management (DQR) on 5/20/26 at 4:20 pm, CEO stated Patient 1 reported to staff that he had been “in a fit of rage” and “just had to leave for a minute” on 2/25/26. Review of “LPN Notes” indicated: -2/28/26 at 7:30 pm: Heard [Patient 1] roaming the hall singing to himself “bitch, bitch, bitch.” He became “agitated and distressed” when staff asked his pain level, then began pacing, was tearful, and asked staff why they were being disrespectful. Patient later returned to bed. LN F documented, “Care plans reviewed.” -3/14/26 at 7:53 pm: Patient 1 exhibited “paranoia and anxiety,” was “too afraid to go into his room alone,” checking the bathroom “several times” because he “believes someone is in there.” At 11 pm, Patient 1 was “walking up and down the halls having flight of ideas, difficulty focusing on topic.” LN H documented, “Plan of care reviewed and carried out.” Review of “Medical Doctor (MD) Physician Progress Note,” dated 3/15/26, indicated Patient 1 “continues to be significantly out of control” with ongoing agitation, paranoia, hallucinations, pressured thoughts, and “behavioral dysregulation (unable to manage/control) similar to the day prior.” Patient 1 was assessed by MD A as having acute agitation with methamphetamine use and exacerbation of psychosis with “high risk for impulsive behavior and treatment nonadherence.” The plan was to “continue close behavioral monitoring” and “monitor mental status and safety closely.” Review of “LPN Notes” indicated: -3/15/26 at 7 pm: Patient 1 was “hiding in the corner” stating he heard “staff screaming and being shot at.” Patient acknowledged the sounds were not real. LN J documented she spent time orienting and listening to Patient 1 until he stated he was okay with her leaving “for a short while” to check on other patients. Charge nurse and MD were notified. LN J documented, “Please review flow sheets, assessments, and care plans reviewed and implemented for further details (sic).” -3/20/26 at 7 pm: At 2 am on 3/21/26, Patient 1 began pacing hallways and following staff and patients around. LN A informed Patient 1 this was “not appropriate.” Patient 1 became “easily agitated and walked away while talking to objects and walls in hallways.” Patient 1 was asked to return to his room as he was “disturbing patients and staff.” At 6:30 am, LN A documented, “Care plans reviewed.” Review of “Incident Report” by LN A, dated 3/21/26 at 2 am, indicated Patient 1 wandered the second-floor halls, entered the nurses’ station “grabbing” supplies, then went to the cafeteria (downstairs) and “stacked the tables and chairs.” Staff downstairs called LN A when Patient 1 tried to enter their patient care unit. Back upstairs, Patient 1 entered patient rooms claiming he was “following a man.” When redirected by staff, he “pulled away and pushed arm (sic).” LN A described Patient 1 as “Zombish (sic),” aggravated, and talking about racism. Patient 1 then entered the physical therapy kitchen and obtained a “steak knife.” Patient 1 was redirected to his room where staff found and discarded “butter knives and scissors.” Review of “MD Physician Progress Note,” dated 3/21/26, indicated nursing staff reported a “significant behavioral change” overnight with Patient 1 walking in the hallway holding a plastic knife, frightening other patients, and reportedly talking to hallucinations. The plan was to change Patient 1’s medications, avoiding lorazepam (Ativan - anti-anxiety medication) for agitation “unless absolutely necessary,” directing staff to continue close mental status and behavioral monitoring, safety precautions, and “reassess need for further medication adjustment.” Review of Patient 1’s “Plan of Care,” dated 5/20/26, indicated a nursing diagnosis of “Alteration in Coping, Mood, or Behavior” related to cognitive deficit/decline (impaired mental processes) was documented on 2/3/26 (date of admission). The goal was for patient/caregiver to “acknowledge and begin to accept change in body image” with a target date of 5/3/26. Nursing interventions included encouraging Patient 1 to verbalize fears, feelings, and concerns, and staff were to provide individual/group therapy sessions and encourage involvement in support groups and peers. Despite ineffective interventions as evidenced by escalating behaviors, nursing staff did not update the care plan for Alteration in Coping, Mood and Behavior after 2/3/26. During an interview with CEO and DQR on 5/21/26 at 10:05 am, CEO and DQR acknowledged that Patient 1’s care plan interventions had not been revised to reflect his escalating behaviors. The CEO stated it would be reasonable to expect nursing staff to update a patient’s care plan, especially for this long-term patient. DQR agreed that the care plan should have been adjusted after admission when the initial interventions were ineffective. DQR added that they planned to address care plan updates in the future during staff education. 2. Review of Patient 2’s “Face Sheet,” dated 5/20/26, indicated Patient 2 was admitted to the hospital on 3/4/26 and was still a patient in the facility on 5/20/26. Review of “History and Physical,” dated 3/4/26, indicated Patient 2 was transferred from another facility for respiratory failure requiring ventilator (vent - medical device that pumps oxygen into the airway and removes carbon dioxide) management. Patient 2 was involved in an auto versus pedestrian accident on 1/17/26 and sustained “severe multisystem trauma” to the brain, spine (resulting in loss of function below the waist), and ankle, followed by a heart attack on 2/5/26. Patient 2 developed vent-associated pneumonia and pleural effusions (PEs - abnormal buildup of fluid between lungs and chest wall) requiring surgery to remove the fluid. Patient 2 was transferred to the facility for “ventilator weaning, complex medical management, and rehabilitation.” Review of Patient 2’s “Order Listing Report for 3/4/26 to 5/20/26” indicated MD orders: -Start date 3/5/26, Foley catheter for neurogenic bladder (nerve damage causing loss of urinary control), gravity to drainage (sic), every shift. -Start date 3/5/26, Foley catheter care every shift. -Start date 4/9/26, Continuous bladder irrigation, End date 4/14/26. -Start date 4/14/26, Transfer to [Hospital B] ER for gross hematuria (blood in the urine) and clogged three-way Foley catheter. Review of online Centers for Disease Control’s (CDC) National Healthcare Safety Network article titled “Urinary Tract Infection (Catheter-Associated Urinary Tract Infection [CAUTI] and Non-Catheter-Associated Urinary Tract Infection [UTI]) Events,” dated 1/2026, indicated the significant risk and preventable harm associated with indwelling urinary catheters. The document provided clear guidelines for identifying, reporting, and analyzing CAUTIs. To prevent CAUTIs, healthcare staff were directed to limit the use and duration of indwelling urinary catheters to what is medically necessary, use aseptic (“germ-free”) insertion and maintenance techniques, regularly assess catheter necessity, and promptly remove catheters when no longer needed. Staff were also directed to monitor catheter use daily, educate themselves on infection prevention, and follow evidence-based protocols for catheter care. The article indicated these steps reduced CAUTIs, minimized patient complications, and improved safety in healthcare facilities. Review of Patient 2’s “Plan of Care,” dated 5/20/26, indicated Patient 2 received a nursing diagnosis of “Infection or Risk for Infection related to invasive lines and tubing” on 3/5/26. Goals included Patient 2 would remain free of signs/symptoms of infection with risk factor reduction for infection, target date 7/4/26. Interventions included assessing skin around tubes for wounds or signs of infection around the site, monitoring heart rate and blood pressure for signs of sepsis (a life-threatening complication of infection, potentially leading to organ malfunction, shock, and death), and monitoring lab tests. Patient 2’s “Plan of Care” did not include a diagnosis of Impaired Urinary Elimination to address elimination issues, Foley catheter care, goals, or interventions. 3. Review of Patient 3’s “Face Sheet,” dated 5/20/26, indicated Patient 3 was admitted to the hospital on 5/5/26 and transferred to another facility on 5/16/26. Review of “History and Physical,” dated 5/5/26, indicated Patient 3 was transferred from another facility for management of sepsis due to right below-knee amputation (BKA) stump infection. Patient 3 had a history of end-stage kidney disease on dialysis (life-sustaining treatment that filters the kidneys), poorly controlled diabetes, heart failure, stroke, and recent (4/2026) bleeding of the upper gastrointestinal (GI) tract (stomach and colon). Review of Patient 3’s “Order Listing Report for 5/5/26 to 5/20/26” indicated MD orders: A. Start date 5/5/26, End date 5/16/26: -Bisacodyl suppository (stimulant laxative) 10 milligrams (mg - a unit of measure) inserted rectally daily for constipation, -Sennosides (stimulant laxative) 8.6 mg tablet to promote elimination, -Docusate sodium (stool softener) 100 mg capsule for constipation, -Check bowel care protocol daily at 10 pm for constipation. B. Start date 5/14/26, End date 5/16/26: -Soap suds enema daily at 3 pm for “severe constipation.” Review of “MD Physician Progress Note,” dated 5/16/26, indicated Patient 3 “continues to report no bowel movement, now approximately 6-7 days without stool,” with persistent abdominal pain. MD B documented they had repeatedly offered Patient 3 transfer to an ER for imaging and surgical evaluation for possible fecal impaction, though he declined in the past. After further discussion, Patient 3 agreed to an ER transfer for further evaluation. Review of Patient 3’s “Order Listing Report for 5/5/26 to 5/20/26” indicated: Start date 5/16/26, End date 5/16/26: Transfer to Acute (Hospital C) ER stat (immediately) for imaging of the abdomen due to no bowel movement for seven days despite medications and enemas, with hypoactive (less than normal) bowel sounds and abdominal pain. Review of Patient 3’s “Plan of Care,” dated 5/20/26, did not include a nursing diagnosis of Constipation to address elimination issues on admission, goals of care, or interventions to prevent bowel obstruction. 4. Review of Patient 4’s “Face Sheet,” dated 5/20/26, indicated Patient 4 was admitted to the hospital on 4/11/26 and was still a patient in the facility on 5/20/26. Review of “History and Physical,” dated 4/11/26, indicated Patient 4 was transferred from another facility for continued IV antibiotics and wound care of multiple toe amputations related to chronic left foot osteomyelitis (bone infection) with gangrene. Patient 4 had a history of heart failure, heart attack, high blood pressure affecting the arteries in the lungs and right side of the heart, and a history of methamphetamine use. The plan of care included left foot “wound care per protocol.” Review of Patient 4’s “Plan of Care,” dated 5/20/26, indicated Patient 4 received a nursing diagnosis on 4/13/26 of “Alteration in Skin Integrity” related to identified injuries: right heel deep tissue injury (DTI - pressure sore deep in the muscle near the bone), left heel DTI, left great toe DTI, surgical wound to left second, third, fourth, and fifth toes, and a right dorsal foot sinus tract wound (STN). Review of Patient 4’s “Order Listing Report for 4/11/26 to 5/20/26” indicated Start date 5/2/26, End date 5/7/26: Hydrocortisone 1 percent (unit of measure) ointment, apply topically three times daily to right upper extremity (RUE) for “skin rash.” During an interview with Patient 4 in his room on 5/19/26 at 4 pm, observed Patient 4 to have an approximately 3-inch wide by 4-inch tall, swollen, reddened area over the right biceps muscle between the shoulder and elbow. Patient 4 stated his right arm IV (thin tube placed in a vein for fluid and medication delivery) had been itchy, so nursing staff removed it and placed a new IV in the left arm. Patient 4’s Plan of Care for “Alteration in Skin Integrity,” dated 5/20/26, was not updated to include the RUE skin rash, goals for healing, and interventions. During an interview with CEO, DQR, Clinical Supervisor (CS) of Nursing, and Director of Nursing (DON) on 5/22/26 at 1:30 pm, DON stated nursing staff should be referencing each individual patient’s care plan “daily,” and care plans should have been updated for Patients 1, 2, 3, and 4 as patient problems and care needs changed throughout their hospitalization. CEO, DQR, CS, and DON acknowledged care plans that were not updated were a patient safety issue and would be addressed with staff.”

“SUPERVISION OF CONTRACT STAFF CFR(s): 482.23(b)(6) All licensed nurses who provide services in the hospital must adhere to the policies and procedures of the hospital. The director of nursing service must provide for the adequate supervision and evaluation of all nursing personnel which occur within the responsibility of the nursing service, regardless of the mechanism through which those personnel are providing services (that is, hospital employee, contract, lease, other agreement, or volunteer). This Standard is not met as evidenced by: 49418 Based on observation, interview, and record review, nursing staff failed to follow facility policies and procedures (P&Ps) when: A. Staff did not regularly update Patient 1’s Plan of Care to address his increasingly erratic moods and behaviors as evidenced by staff documenting, “We struggled to control the situation” when Patient 1 wandered the facility, became agitated and aggressive with staff, and was “scaring family members in three different rooms.” B. Staff did not call for assistance from the security guard on the premises, the administrator on call (AOC), or the 911 emergency line. These deficient practices caused a breakdown in communication between the patient and members of the Interdisciplinary Care Team (IDT - a team with members from different disciplines who work together to set goals and make patient care decisions) and created real and potential negative clinical outcomes affecting the health and safety of patients, visitors, and staff (Refer to A-0396). Findings: Review of P&P titled “Plan for Provision of Care,” dated 1/2026, indicated registered nurses (RNs) were required to fully assess each patient upon admission and every shift thereafter, re-evaluating as conditions change. Individualized care plans were to be developed by nursing staff in collaboration with the patient and the Interdisciplinary Care Team (IDT - a team with members from different disciplines who work together to set goals and make care decisions) within 24 hours of admission. Staff were directed to review treatment responses and update the plans and interventions as patient needs evolved. Review of P&P titled “Administrative On Call Procedures,” dated 1/2026, indicated a senior administrator was to be available “24 hours each day.” The Administrator On Call (AOC) carried a facility-issued phone and was to be consulted regarding “all serious incidents” and critical administrative issues or decisions such as the need to call police and safety/care issues. Nursing supervisors and security were directed to “immediately” call the AOC for “all incidents involving harm or potential harm to patients, staff/physicians, visitors, physical plant or hospital operations.” Review of “Face Sheet,” dated 5/20/26, indicated Patient 1 was admitted to the hospital on 2/3/26 and discharged on 3/28/26. Review of “History and Physical,” dated 2/3/26, indicated Patient 1 was transferred from another facility for long-term IV antibiotics and “complex medical management.” Diagnoses included bone infection and abscess of the thoracic (mid back) spine, blood infection, chronic pain with opioid dependence, and schizoaffective disorder - bipolar type (mood fluctuations cycling between mania and depression with delusions or hallucinations). Review of Patient 1’s “Plan of Care,” dated 5/20/26, indicated a nursing diagnosis of “Alteration in Coping, Mood, or Behavior” related to cognitive deficit/decline (impaired mental processes) was documented on 2/3/26 (date of admission). The goal was for patient/caregiver to “acknowledge and begin to accept change in body image” with a target date of 5/3/26. Nursing interventions included encouraging Patient 1 to verbalize fears, feelings, and concerns, and staff were to provide individual/group therapy sessions and encourage involvement in support groups and peers. Review of “Licensed Practical Nurse (LPN) Note,” dated 2/25/26 at 7:15 am, indicated Patient 1 “left the hospital walking North up [street name],” a busy thoroughfare that connects to a major interstate highway, at 4:30 pm during rush-hour traffic. The note indicated the Charge Nurse (LN B) left the facility and “retrieved” Patient 1, returned him to the lobby, and the physician was notified. At 6 pm, LN B documented, “Plan of care ongoing.” During an interview with Chief Executive Officer (CEO) and Director of Quality & Risk Management (DQR) on 5/20/26 at 4:20 pm, CEO stated, upon return to the facility on 2/25/26, Patient 1 reported he had been “in a fit of rage” and “just had to leave for a minute.” Review of “LPN Notes” indicated: -2/28/26 at 7:30 pm: Heard [Patient 1] roaming the hall singing to himself “bitch, bitch, bitch.” He became “agitated and distressed” when staff asked his pain level, then began pacing, became tearful, and asked staff why they were being disrespectful. LN F documented, “Care plans reviewed.” -3/14/26 at 7:53 pm: Patient 1 exhibiting “paranoia and anxiety,” “too afraid to go into his room alone,” checking the bathroom “several times” because he believes someone is in there.” At 11 pm, Patient 1 was “walking up and down the halls having flight of ideas, difficulty focusing on topic.” LN H documented, “Plan of care reviewed and carried out.” -3/15/26 at 7 pm: Patient 1 was “hiding in the corner” stating he heard “staff screaming and being shot at.” Patient 1 acknowledged the sounds were not real. LN J documented she spent time with Patient 1 until he stated he would be okay if she left “for a short while” to check on other patients. Charge nurse and MD were notified. LN J documented, “Please review flow sheets, assessments, and care plans reviewed and implemented for further details (sic).” Review of “Medical Doctor (MD) Physician Progress Note,” dated 3/15/26, indicated Patient 1 “continues to be significantly out of control” with severe agitation, paranoia, hallucinations, pressured thoughts, and “behavioral dysregulation (unable to manage/control) similar to the day prior.” MD A assessed Patient 1 as having acute agitation with methamphetamine use and exacerbation of psychosis with “high risk for impulsive behavior and treatment non-adherence.” The plan was to “continue close behavioral monitoring” and “monitor mental status and safety closely.” Review of “Licensed Practical Nurse (LPN) Note,” dated 3/20/26 at 7 pm, indicated Patient 1 began pacing hallways and following staff and patients around at 2 am. LN A informed Patient 1 this was “not appropriate.” Patient 1 became “easily agitated” and walked away, “talking to objects and walls in hallways.” Patient 1 was asked to return to his room as he was “disturbing patients and staff.” At 6:30 am, LN A documented, “Care plans reviewed.” Review of “Incident Report” by LN A, dated 3/21/26 at 2 am, indicated Patient 1 wandered the second-floor hallways (near his room), entered the nurses’ station, and was “grabbing” supplies. Patient 1 then went to the cafeteria (first floor) where he “stacked the tables and chairs.” Staff in the patient care unit downstairs called to inform LN A that Patient 1 was attempting to enter their unit. Upon Patient 1 returning to the second floor, he went into three other patient rooms and stated he was following a man and wanted to speak with him. On staff attempt to redirect Patient 1, he “pulled away and pushed arm (sic).” Patient 1 appeared “Zombish (sic),” spoke about racism, and was “aggravated.” Patient 1 then went into the physical therapy kitchen and obtained a “steak knife.” Patient 1 remained aggravated and was redirected to his room where “butter knives and scissors” were found by staff, taken, and discarded. Review of email sent 3/21/26 at 2:52 am from LN C (charge nurse) to CEO, DQR, DON and other staff indicated Patient 1 was “acting up big time again.” Patient 1 was reportedly “roaming the entire building,” “walking in all patient rooms” upstairs, was racist towards staff, and “aggressive.” LN C reported staff were “unable to direct and or aide (sic) in any of the medications he has,” adding that he was “scaring family members in three different rooms” and “we struggled to control the situation.” Review of “MD Physician Progress Note,” dated 3/21/26, indicated nursing staff reported a “significant behavioral change” overnight with patient walking in hallway holding a plastic knife, frightening other patients, and reportedly talking to hallucinations. The plan was to change his medications, “avoid lorazepam (Ativan - anti-anxiety medication) for agitation unless absolutely necessary,” continue close behavioral monitoring and safety precautions, and “monitor mental status closely; reassess need for further medication adjustment.” During an interview with CEO on 5/19/26 at 12:50 pm, CEO stated she was the administrator on call on 3/21/26 (Saturday) when Patient 1’s behaviors escalated, but she did not receive a phone call, only the email at 2:52 am. CEO stated they tell staff in instances like Patient 1’s escalating behaviors to “call 911 and/or the admin on call” and “put security outside the room” if need be. CEO acknowledged nursing staff did not follow policy when they did not call the AOC, law enforcement, or the 911 emergency line. Despite ineffective interventions as evidenced by “significant behavioral changes” throughout his hospitalization, nursing staff did not update Patient 1’s Plan of Care for Alteration in Coping, Mood and Behavior after 2/3/26 to include multiple medication changes and new MD directives to provide safety precautions and closely monitor Patient 1’s mental status and behaviors. During an interview with CEO and DQR on 5/21/26 at 10:05 am, CEO and DQR acknowledged that Patient 1’s care plan should have been revised to document his escalating behaviors and to evolve the nursing interventions when the initial interventions proved ineffective.”

“PATIENT RIGHTS:PARTICIPATION IN CARE PLANNING CFR(s): 482.13(b)(1) The patient has the right to participate in the development and implementation of his or her plan of care. This Standard is not met as evidenced by: 47884 Based on observation, interview and record review, the facility failed to protect one of 10 patient’s right (Patient 1) to refuse care when Occupational Therapist (OT) prevented Patient 1 from returning to bed after verbalizing he was tired. This failure violated Patient 1’s right to refuse care and caused him to experience grief and fear. Findings: Review of facility policy titled, “Patient Rights and Responsibilities,” dated 1/1/25, indicated that all hospital personnel would demonstrate high professional standards, be familiar with and honor all patient rights, and provide safe, considerate, respectful and dignified care. The policy indicated patients had the right to have all treatments planned and timed appropriately around clinical activities to promote optimal patient comfort, compliance, and well-being. The policy indicated a patient has the right to accept or refuse medical treatment or procedures offered by the hospital. Review of an undated document titled, “Patient Rights and Responsibilities,” provided to all patients in the facility upon admission, indicated that every patient had the right to receive considerate and respectful care that honored personal choice. The document emphasized that every patient had the right to be comfortable and participate in the development and implementation of their care plan. Review of record titled, “History and Physical,” completed by Doctor of Osteopathy (DO - a licensed physician) on 11/28/25, indicated Patient 1 was admitted to the facility on 11/28/25 following a stroke (bleeding in the brain) and kidney injury with new orders for hemodialysis (HD - an invasive procedure to filter toxins from the blood when the kidneys are not functioning). Known side effects of HD are blood pressure fluctuations, fatigue, and physical exhaustion. Patient 1’s medical history included heart attack, high blood pressure, previous stroke, and brain aneurysm (a weak blood vessel inside the brain). Patient 1 was dependent on facility staff for care. Review of record titled, “Plan of Care,” dated 11/28/25, indicated Patient 1 had altered coping and that caregivers should demonstrate appropriate adaptive strategies to assist Patient 1. Additionally, Patient 1 had a risk for falls from deconditioning (loss of strength and endurance). Review of record titled, “OT Note,” dated 12/1/25 at 3:23 pm, indicated that Patient 1 expressed tiredness from dialysis but agreed to attempt therapy. Patient 1 then requested to stop therapy and attempted to lay back down. Review of record titled, “Investigation Summary Report,” dated 12/8/25, indicated Patient 1 reported OT was “pushy and aggressive” in encouraging participation in therapy on 12/1/25 “despite his repeated refusals.” The report indicated Occupational Therapy Aide (OTA) reported witnessing a “forceful, hands-on redirection in contradiction to [Patient 1’s] verbal refusals” to continue therapy. The report concluded OT’s behavior constituted failure to respect Patient 1’s refusal of care. During an interview with Patient 1 on 1/7/26 at 2:17 pm, Patient 1 stated that he was in the facility recovering from a stroke and had been “slapped” by OT and did not want OT in his room again. Patient 1 stated, “I just had a stroke. Why is she hitting me?” Patient 1 stated that he did not feel safe in the facility after the incident with OT. During an interview with the Chief Nursing Officer (CNO) and Director of Quality and Risk Management (DQR) on 1/8/26 at 1:37 pm, CNO and DQR acknowledged OT violated Patient 1’s right to refuse care.”

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 47884 Based on observation, interview and record review, the facility failed to provide a safe clean environment when chipped surfaces were observed in Room 288 and the adjoining bathroom that was in use by Patients 1 and 11 and chipped surfaces with exposed particle board were observed in the hall immediately outside the room near the safety handrail. This deficient practice created a risk for infection and was not safe for all patients, staff, and visitors. Findings: During a facility tour on 1/7/26 at 2:17 pm, lifting, peeling paint and chipped surfaces with brown discoloration were observed in a bathroom shared by Patients 1 and 11 behind the toilet, on the walls, around the shower, and at the edge of the handwashing sink. During a tour and concurrent interview on 1/7/26 at 2:30 pm, the Chief Nursing Officer (CNO) and the Director of Facilities (DOF) confirmed that there was peeling paint and chipped surfaces in Room 288, and chipped surfaces with exposed particle board were observed in the hall immediately outside the room near the safety handrail. Review of a facility policy titled, “Cleaning and Disinfecting,” dated 11/1/24, indicated that evidenced-based cleaning methods were to be used to clean patient areas to prevent the spread of infections. The policy did not describe any evidence-based methods to safely and effectively disinfect a chipped or porous surface. During an interview on 1/7/26 at 4:30 pm, the Director of Quality and Risk management (DQR) stated the chipped surfaces and peeling paint were not safe, could not be adequately cleaned, and risked patient safety. During an interview on 1/7/26 at 4:40 pm, the Infection Control Nurse (ICN) stated that chipped surfaces, exposed porous surfaces, and peeling paint were not safe for patients and could cause a hospital-acquired infection (HAI). The ICN stated the facility standard was to provide safe patient care by preventing HAIs.”

“PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT CFR(s): 482.13(c)(3) The patient has the right to be free from all forms of abuse or harassment. This Standard is not met as evidenced by: 47884 Based on observation, interview and record review, the facility failed to protect one of 10 patients’ (Patient 1) right to be free from abuse when Occupational Therapist (OT) attempted to physically prevent Patient 1 from returning to bed after he communicated feeling unsafe and too tired to safely participate in therapy. This failure had the potential to cause physical injury to Patient 1 and caused Patient 1 to experience grief and fear. Findings: Review of a facility policy titled, “Patient Rights and Responsibilities,” dated 1/1/25, indicated that every patient had the right to be free from abuse. Review of a facility policy titled, “Abuse and Neglect,” dated 1/1/25, indicated that all patients had the right to be free from abuse or mistreatment of any kind and the right to safe care that would protect emotional health. The policy defined patient abuse as any incident of mistreatment or neglect reported by the patient or witnessed by an employee. The policy defined neglect as any failure to provide prescribed care to maintain physical and mental health needs. Review of record titled, “History and Physical,” completed by Doctor of Osteopathy (DO - a licensed physician) on 11/28/25, indicated Patient 1 was admitted to the facility on 11/28/25 following a stroke (bleeding in the brain) and kidney injury with new orders for hemodialysis (HD - an invasive procedure to filter toxins from the blood when the kidneys are not functioning). Known side effects of HD are blood pressure fluctuations, fatigue, and physical exhaustion. Patient 1’s medical history included heart attack, high blood pressure, previous stroke, and brain aneurysm (a weak blood vessel inside the brain). Patient 1 was dependent on facility staff for care. Review of record titled, “Plan of Care,” dated 11/28/25, indicated Patient 1 had altered coping and that caregivers should demonstrate appropriate adaptive strategies to assist Patient 1. Additionally, Patient 1 had a risk for falls from deconditioning (loss of strength and endurance). Review of record titled, “OT Note,” dated 12/1/25 at 3:23 pm, indicated that Patient 1 expressed tiredness from dialysis but agreed to attempt therapy. Patient 1 then requested to stop therapy and attempted to lay back down. Review of “Social Services Note,” dated 12/2/25 at 4:35 pm by Case Manager (CM), indicated Patient 1 was sad, had expressed feelings of grief and frustration, and was tearful. Review of “Nursing Note,” dated 12/2/25 at 7:06 pm by Licensed Nurse (LN) C, indicated Patient 1 was upset and made an accusation of being slapped by staff. Review of “Social Services Note,” dated 12/9/25 at 4:59 pm by Licensed Clinical Social Worker (LCSW), indicated Patient 1 did not feel safe. Review of record titled, “Investigation Summary Report,” dated 12/8/25, indicated an allegation that OT “slapped a patient” during a therapy session on 12/1/25. The report contained a witness statement from Occupational Therapy Aide (OTA) which indicated Patient 1 had communicated feeling weak to OT after completing HD. Additionally, the report indicated Patient 1 reported OT was “pushy and aggressive” in encouraging participation in therapy on 12/1/25 “despite his repeated refusals.” The report indicated Occupational Therapy Aide (OTA) reported witnessing a “forceful, hands-on redirection in contradiction to [Patient 1’s] verbal refusals” to continue therapy. OTA’s statement indicated OT was “very rushful and inconsiderate” of Patient 1’s status, “forcing” him up to sit on the side of the bed. OTA’s statement indicated Patient 1 grabbed OT’s hand and pushed it away, saying, “Don’t you touch me again please.” The report concluded OT’s behavior constituted failure to respect Patient 1’s refusal of care. Review of OT’s employee file indicated that a license from the Board of Occupational Therapy was issued in 2008, and OT worked in the facility from 9/17 to 12/19/25. A document titled, “Elder and Dependent Adult Abuse Training Exam,” dated 9/29/25, indicated OT received training and passed the exam. Review of a letter on OTs employee file from the facility, titled “Re: Employment Status,” dated 12/19/25, indicated that OT had been terminated. The letter indicated an allegation of “inappropriate and forceful physical contact had been substantiated” after investigation of OTs interaction with Patient 1. Additionally, the letter indicated that OT failed to respect Patient 1’s “explicit verbal refusal” to participate and OT failed to provide safe, patient-centered care. Furthermore, the facility indicated that OT had failed to act professionally when providing care to Patient 1. During an interview with facility Director of Quality and Risk Management (DQR) on 1/7/25, at 10:15 am, the DQR confirmed that OT was terminated and confirmed OTs actions did not follow facility expectations. DQR confirmed that Patient 1 had expressed feeling afraid following allegations of mistreatment. And DQR indicated the facility expectation is all patients have the right to refuse treatment and the right to be free from mistreatment (abuse) in the facility. During an interview on 1/7/26, at 10:28 am, the facility Chief Nursing officer (CNO) indicated that the facility expectation was for patients to have freedom to refuse and indicated that P1 had a right to refuse therapy. The CNO confirmed that P1 had expressed feeling mistreated and that P1 had indicated OT1 slapped him. The CNO confirmed that the facility considered slapping or mistreating patients abuse. During an interview with Patient 1 on 1/7/26 at 2:17 pm, Patient 1 stated that he was in the facility recovering from a stroke and had been “slapped” by OT and did not want OT in his room again. Patient 1 stated, “I just had a stroke. Why is she hitting me?” Patient 1 stated that he did not feel safe in the facility after the incident with OT. During an interview on 1/8/26, at 1:37 pm, the CNO and DQR confirmed that Patient 1 had reported forceful, aggressive behavior, and had expressed he felt mistreated by OT. CNO indicated that Patient 1 had perceived assistive touch as a slap from OT.”

“SUPERVISION OF CONTRACT STAFF CFR(s): 482.23(b)(6) All licensed nurses who provide services in the hospital must adhere to the policies and procedures of the hospital. The director of nursing service must provide for the adequate supervision and evaluation of all nursing personnel which occur within the responsibility of the nursing service, regardless of the mechanism through which those personnel are providing services (that is, hospital employee, contract, lease, other agreement, or volunteer). This Standard is not met as evidenced by: 49418 Based on observation, interview and record review, nursing staff failed to implement facility policies and procedures (P&Ps) when: 1. An accusation of potential patient abuse by Occupational Therapist (OT) was not reported in accordance with facility P&P for one of 10 sampled patients (Patient 1). This deficient practice prevented physician assessment for a potential unrecognized injury to Patient 1 and prevented law enforcement from ensuring patient safety and investigating alleged abuse of a patient by a healthcare worker. 2. Pain scores were not reassessed and documented per policy within one hour of pain medication administration for four of 10 sampled patients (Patients 7, 8, 9, and 10). This deficient practice created the potential for unacknowledged pain and suffering for four of 10 patients. 3. Interpreters’ names/identification numbers and content of communication were not documented per policy for one of 10 sampled patients (Patient 10). This deficient practice prevented confirmation as to the accuracy of communication provided to Patient 10, which compromised the continuity of care, informed decision-making, and patient safety. Findings: Review of facility P&P titled, “Patient Rights and Responsibilities,” dated 1/2025, indicated all hospital personnel and medical staff were to be knowledgeable of patients’ rights and abide by them, including but not limited to: A. Respect and Dignity: The patient has the right to considerate, respectful care “at all times and under all circumstances,” with recognition of the patient’s personal dignity. B. Personal Safety: The patient has a right to expect a safe environment as it relates to the physical plant, medical care, and medication management. C. Information: The patient has the right to have “complete and current information” about their care communicated in terms the patient can reasonably be expected to understand. D. Communication: When the patient does not speak or understand the predominant language of the community, access to an interpreter will be provided at no cost to the patient. E. Consent: The patient has the right to “informed participation” when making their healthcare decisions. F. Refusal of Treatment: The patient has the right to accept or refuse medical treatment or procedures offered by the facility. 1. Review of facility P&P titled, “Abuse and Neglect,” dated 1/2025, indicated the facility supported the patient’s right to receive care in a safe setting and maintained a strict policy to prevent or respond to alleged abuse, neglect, or mistreatment, including “prompt reporting” of alleged abuse to hospital leaders and state agencies. The P&P indicated the employee who first became aware of alleged abuse/neglect must protect the patient from the accused and notify the Unit Supervisor and/or Administrator on Call (AOC), Director of Quality and Risk Management (DQR), and Adult Protective Services (APS) immediately or as soon as practicably possible. The P&P indicated Chief Executive Officer (CEO) or AOC would contact local police to report alleged abuse, and the patient’s attending physician would be notified. Review of facility document titled, “Investigation Summary Report,” dated 12/8/25, indicated Patient 1 alleged OT “slapped him across the face and acted aggressively” during an occupational therapy evaluation on the afternoon of 12/1/25. The report indicated a nurse informed the Director of Rehabilitation (DOR) 12/1/25 at 2:20 pm of the incident, and DOR “immediately” notified administration. The report did not indicate staff contacted law enforcement, APS, or Patient 1’s physician. An internal investigation was held, and the report’s “Conclusion” indicated: A. Confirmation that physical contact to Patient 1’s face/neck did occur and that Patient 1 perceived the contact as a slap. B. An eyewitness reported “forceful, hands-on redirection” despite Patient 1’s verbal refusals of care. C. Although evidence did not support an intentional “slap,” the behavior constituted “inappropriate physical contact,” failure to respect patient refusal of care, poor judgment and “unsafe handling,” and deviation from patient-centered care expectations. D. The allegation was “substantiated in regard to inappropriate and forceful physical handling.” During concurrent observation and interview with Patient 1 in his room at the facility on 1/7/26 at 2:17 pm, Patient 1 stated he was admitted for rehabilitation following a stroke in 11/2025. When asked to recall the alleged abuse incident involving Patient 1 and OT, Patient 1 stated, “You mean when [OT] smacked me?” Patient 1 stated the incident occurred when OT requested Patient 1 stand up and participate in therapy; Patient 1 stated he informed OT he was tired and wanted to stay in bed. Patient 1 stated as he attempted to lie down in bed, OT “hit me” with their right hand to his left cheek/neck. Patient 1 stated he grabbed her arm, pushed it away, and asked, “Why are you hitting me?” Patient 1 stated OT “wasn’t supporting me. I know the difference between a hit and support.” When asked if Patient 1 felt safe in the facility, Patient 1 stated he was “still not feeling safe because what if somebody else does it again?” During an interview with CNO and DQR on 1/8/26 at 1:37 pm, CNO and DQR acknowledged Patient 1’s physician, law enforcement, and APS were not notified in accordance with the facility’s abuse P&P. On 1/8/26, CNO sent this surveyor text messages to the California Department of Public Health-issued iPhone indicating the facility made a police report “just now” (2:47 pm) regarding the alleged abuse of 12/1/25 and that APS had also been called (3:02 pm). 2. Review of facility P&P titled, “Medical Record Documentation - Nursing,” dated 3/2025, indicated facility documentation requirements followed standards of The Joint Commission (an independent, nonprofit organization that sets standards for quality and patient safety for healthcare facilities) and federal/state regulations. The P&P directed nursing staff to document daily patient assessments and to continually reassess patients, documenting reassessment findings with any change in condition or diagnosis and/or patient’s response to care and/or treatment, including response to pain medication. Review of facility documents titled, “Core Competency/Demonstration,” dated 5/2025, indicated licensed nurses were required to comply with organizational/facility P&Ps and reassess pain intensity within one hour after giving medications. Review of undated facility document given to patients on admission titled “Patient Rights and Responsibilities” indicated patients had the right to “appropriate assessment and management” of pain. During concurrent interview and medical record review with LN B, CNO, and DQR on 1/8/26 at 11:40 am, LN B stated he was educated to “reassess [patient’s pain level] in an hour” after administration of pain medication. Review of the electronic medication administration record (eMAR) indicated Patient 10 received morphine sulfate (an opioid pain reliever) on 1/8/26 at 6:03 am from LN G for a pain score of 9 out of 10 (0 = no pain, 10 = worst pain). CNO and DQR acknowledged pain reassessment was not documented within one hour of administration of pain medication per policy. Review of Patient 7’s eMAR records indicated the following: A. Dilaudid (an opioid pain reliever) was given 5/8/25 at 5:16 pm for pain of 8, 5/14/25 at 11:03 am for pain of 7, 5/14/25 at 6:13 pm for pain of 8, 5/18/25 at 9:58 pm for pain of 8, 5/19/25 at 1:50 am and 4 am for pain of 8, and 5/21/25 at 8:12 am for pain of 8. “Effectiveness” post-administration pain scores were not documented on any of those dates. B. Morphine was given 5/8/25 at 9:42 pm for pain of 9 and 5/9/25 at 1:09 am for pain of 8. Pain reassessment was not documented within one hour. C. Oxycodone was given 5/9/25 at 2:38 pm and 11:46 pm for pain of 8 and 9, respectively, and 5/10/25 at 10:27 pm for pain of 8. Pain reassessment was not documented within one hour. D. Morphine was given 5/11/25 at 12:19 am for pain of 6. Pain reassessment was not documented within one hour. E. Percocet (combination of oxycodone and Tylenol) was given 5/13/25 at 5:51 pm for pain of 9 and 5/15/25 at 5:58 pm for pain of 8. Pain reassessment was not documented within one hour. Review of Patient 8’s eMAR records indicated Norco (combination of opioid hydrocodone and Tylenol) was given on 10/14/25 at 1:52 am for pain of 8. Pain reassessment was not documented within one hour. Review of Patient 9’s eMAR records indicated oxycodone was given 11/4/25 at 1:46 pm for pain of 8. Pain reassessment was not documented within one hour. During an interview with CNO on 1/8/26 at 11:15 am, CNO acknowledged Patient 9’s pain was not reassessed and documented within one hour per policy. 3. Review of facility P&P titled, “Language and Communication Assistance Services,” dated 3/2023, indicated interpretation services were offered to patients to provide “meaningful access” to the patient’s healthcare decisions, benefits, healthcare programs, and/or healthcare activities. The P&P directed staff and physicians who use interpretation services to document in the patient’s medical record the patient’s preferred language, the name and identification number of the interpreter assisting with translation, and the substance of the communication. Review of documents titled, “Nursing Shift Assessment” (NSA) for Patient 10 indicated assessments dated 1/6/26, signed by Licensed Nurse (LN) D and LN E, and dated 1/7/26, signed by LN F and LN G. The NSAs indicated a “certified interpreter” was used during Patient 10’s assessments on both days and that Patient 10’s preferred language was Spanish. The documents directed staff to “list name or interpreter identification (ID) number in comments;” however, “Comment” boxes provided were left blank and did not indicate interpreter name, ID number, or the substance of communications. During an interview with LN B on 1/7/26 at 11:40 am, LN B stated he had been the nurse caring for Patient 10 until their discharge today at 11 am. LN B stated he spoke “fluent Spanish” and did not require the use of translation services to communicate with Patient 10. LN G stated if he ever needed to use translation services, he was trained to document the interpreter’s name or ID number into the patient’s medical record. During concurrent interview with CNO and DQR and review of Patient 10’s medical record on 1/8/26 at 4:05 pm, CNO and DQR acknowledged staff did not follow documentation requirements as outlined in the facility’s Language and Communication Assistance Services policy.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(4)(i) The use of restraint or seclusion must be-- (i) in accordance with a written modification to the patient’s plan of care. This Standard is not met as evidenced by: 47884 Based on observation, interview and record review, the facility failed to ensure licensed staff, Registered Nurses and Licensed Vocational Nurses (RNs and LVNs) updated the physical restraint care plans for one patient (Patient 2) to reflect current orders and restraint use. This failure had to potential for negative outcomes like deteriorating health and increased complications and reduced quality of care. Findings: Review of a facility provided nursing policy titled: “Restraint Use”, last reviewed 10/2025 and in effect, indicated restraint use was to keep patients safe, clinical indicators (behaviors) would be documented, and the least restrictive restraint would be used. The policy outlined that a Licensed Independent Practitioner (LIP)’s order was required to initiate, change, continue, or discontinue a restraint, and each order would include the restraint type, instructions and duration of use. And the policy indicated that documentation of alternative treatment, patient behaviors and patient response was required at least every two hours. Additionally, the policy indicated if a restraint was discontinued documentation would indicate when and why it was discontinued; and the care plan would be updated to reflect the current restraint ordered and used. Review of a facility provided nursing policy titled: “Care Planning”, last reviewed 10/2025 and in effect, indicated that care, treatment and services would be planned for each patient’s individual care needs and goals. And the care plan would be updated regularly based on assessment findings. Review of a facility job description titled Registered Nurse (RN), last revised 2/1/2017, indicated that the RN would follow all hospital policies, ensure physicians orders were followed. Additionally, the RN duties included assessment and implementation of individualized care plans to meet the needs of each patient. Review of a document titled; core competencies RN, last reviewed 5/1/25, indicated all RNs in the facility would demonstrate competency to obtain orders for restraints, and discontinue restraints when less restrictive measures are sufficient, monitor if the restraint is clinically indicated, and document all findings and actions into the medical record. Review of a facility job description titled Licensed Practical/LVN, last revised 2/1/2017, indicated that the LVN comply with hospital policies. Review of a document titled; core competencies LPN/LVN, last reviewed 5/1/25, indicated all LPN/LVNs would demonstrate competency of the facility restraint policy and obtain LIP orders appropriately, monitor the need for continuation of the restraint and document all restraint assessments and actions into the medical record. During a facility tour on, 11/24/25, at 11:00 AM a patient Patient 2 was observed cooperating with Physical Therapy (PT) transferring to a wheelchair. There was no restraint observed. Review of Patient 2’s medical record indicated Patient 2 was admitted to the facility on 10/14/25 with a history of severe weakness, contractures, acute renal failure (sudden loss of kidney function), and mechanical ventilation (a machine that helps with breathing). Review of facility provided documents titled: “LTAC Restraint Physician Order”, dated 11/21/25, at 8:30 AM, indicated Patient 2 had an order for bed rails x4 and wrist restraints to right and left wrist. On 11/21/25, from 7:00 AM to 5:00 PM, RN 4 documented bed rails x4 and bilateral wrist restraints. RN 4 continued the care plan. On 11/21/25, from 7:00 PM, to 11/22/25, at 4:40 AM, RN 5 documented restraint checks, but did not indicate the type of restraint used. RN 5 continued the restraint care without indicating the type of restraint therapy provided to Patient 2. Review of facility provided documents titled: “LTAC Restraint Physician Order”, dated 11/22/25, at 8:00 AM, Patient 2 had an order for bed rails x4 and wrist restraints to right and left wrist. On 11/22/25, from 7:15 AM to 5:15 PM, RN 6 documented bed rails x4 only. RN 6 did not update the care plan to reflect only bed rails. And RN 6 continued the restraint care plan indicating bed rails x4 and bilateral wrist restraints were in use. On 11/22/25, from 7:17 PM, to 11/23/25, at 6:36 AM, RN 7 documented bed rails x4 and wrist restraint to left arm. RN 7 continued the care plan. Review of facility provided documents titled: “LTAC Restraint Physician Order”, dated 11/23/25, at 8:00, Patient 2 had an order for bed rails x4 and wrist restraints to left wrist only. On 11/23/25, from 7:00 AM to 5:00 PM, RN 6 documented bed rails x4 and bilateral wrist restraints were used in the care plan. And documented bed rails x4 was the only restraint used under restraint checks. RN 6 continued the care plan without updating to reflect the current treatment provided to Patient 2. During an interview with concurrent medical record review on 11/24/25, at 11:10 AM, the Director of Nursing (DON) indicated that Patient 2’s care plan should have been updated to reflect the current treatment plan that was in use. DON confirmed it had not been updated.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(4)(ii) [The use of restraint or seclusion must be--] (ii) implemented in accordance with safe and appropriate restraint and seclusion techniques as determined by hospital policy in accordance with State law. This Standard is not met as evidenced by: 47884 Based on observation, interview and record review, the facility failed to implement restraint policies that were intended to promote dignity and keep patients safe when restraints were removed and re-applied without a physician order, and when clinical assessment of patient behaviors that would identify appropriate use of restraints was not consistently documented for two patients (Patient 1 and Patient 2). This failed practice had the potential to cause negative outcomes including physical and psychological harm to Patients 1 and 2 and to other patients with physical restraints. Findings: Review of a facility provided nursing policy titled: “Restraint Use”, last reviewed 10/1/2025 and in effect, indicated the use of restraint was or patient safety. And indicated clinical indicators (behaviors) would be documented to indicate why the restraint was needed, and the least restrictive restraint would be used. The policy outlined that a Licensed Independent Practitioner (LIP) order that included the restraint type, instructions for use, and duration of use was required to initiate, change, continue, or discontinue a restraint. The policy indicated that documentation of alternative treatment, patient behaviors and patient response was required at least every two hours, and if a restraint was discontinued documentation would indicate when and why it was discontinued; and the care plan would be updated to reflect the order and current treatment. Additionally, the policy indicated when a restraint was discontinued a new order would be obtained if a restraint was needed again. And that a restraint should never be ordered or used “as needed” (PRN). Review of a facility provided nursing policy titled: “Care Planning”, last reviewed 10/1/2025 and in effect, indicated that care, treatment and services would be planned for each patient’s individual care needs and goals. And the care plan would reflect current orders and be updated regularly based on assessment findings. Review of a facility job description titled, “Registered Nurse (RN),” last revised 2/1/2017, indicated that the RN would follow all hospital policies, ensure physicians orders were followed. Additionally, the RN duties included assessment and implementation of individualized care plans to meet the needs of each patient. Review of a document titled; “Core Competencies RN,” last reviewed 5/1/25, indicated all RNs in the facility would demonstrate competency to obtain orders for restraints, and discontinue restraints when less restrictive measures are sufficient, monitor if the restraint is clinically indicated, and document all findings and actions into the medical record. Review of a facility job description titled Licensed Practical/Vocational Nurse (LVN), last revised 2/1/2017, indicated that the LVN comply with hospital policies. Review of a document titled; “Core Competencies LPN/LVN, last reviewed 5/1/25, indicated all LPN/LVNs would demonstrate competency of the facility restraint policy and obtain LIP orders appropriately, monitor the need for continuation of the restraint and document all restraint assessments and actions into the medical record. During an interview on 11/24/25, at 10:30 AM, the Director of Quality and Risk Management (DQRM) indicated that a LIP would assess the patient face to face to order or renew a restraint, and indicated the LIP was available in the facility until 7:00 PM or later, and with Tele Health (a computer screen with assistance from a bedside nurse) after hours. And DQRM indicated that the LIP signed the order after completing the face-to-face assessment of the patient. 1. During a facility tour on, 11/24/25, at 10:40 AM a Patient 1 was observed in bed with side rails up x4. And there was a soft wrist restraint attached to Patient 1’s left bed rail but not attached to Patient 1’s wrist. DQRM confirmed this finding. Review of Patient 1’s record indicated Patient 1 was admitted to the facility on 9/13/25 with a history of cancer and recent stroke. Review of facility provided orders sets titled: “LTAC Restraint Physician Order”, dated between 11/20 and 11/25/25, indicated that: On 11/20/25, at 8:00 AM, Patient 1 had an order for a left wrist restraint, and side rails x4. The order had been renewed from the previous day. On 11/21/25, at 8:00 AM, Patient 1 had an order for a left wrist restraint, and side rails x4. The order had been renewed from the previous day. On 11/22/25, at 8:00 AM, Patient 1 had an order for a left wrist restraint, and side rails x4. The order had been renewed from the previous day. On 11/23/25, at 8:00 AM, Ptient 1 had an order for a left wrist restraint, and side rails x4. The order had been renewed from the previous day. On 11/24/25, at 8:00 AM, Patient 1 had an order for a left wrist restraint, and side rails x4. The order had been renewed from the previous day. On 11/25/25, at 8:00 AM, it indicated that Patient 1 had an order for a left wrist restraint, and side rails x4. The order had been renewed from the previous day. A review of the orders sets were preprinted on paper with check boxes to fill in. And included a box to check if the order was a new order, or a renewal of the previous order. Five of five restraint orders reviewed in Patient 1’s record indicated the order was a renewal of orders (continuation of the last order). Review of restraint care plan documentation in Patient 1’s record from 11/20/25 to 11/25/25 indicated Patient 1 had restraints documented: On 11/20/25, from 7:00 AM to 7:00 PM, LVN 1 documented left wrist restraint. The restraint care plan was continued. The restraint care plan was continued. On 11/20/25, from 7:00 PM to 11/21/25, 5:00 AM, RN 1 documented left wrist restraint and bed rails x4. The restraint care plan was continued. On 11/21/25, from 7:30 AM to 10:30 AM, LVN 2 documented left wrist restraint and bed rails x4. The restraint care plan was continued. On 11/21/25, from 12:30 PM to 11/22/25, 5:00 AM, LVN 3 documented left wrist restraint and bed rails x4. The restraint care plan was continued. On 11/22/25, unsigned documentation indicated that the care plan was continued with left wrist restraint, and bed rails x4. No restraint checks had been documented for Patient 1 between 5:01 AM to 7:00 PM. The restraint care plan was continued. On 11/22/25, from 7:00 PM to 11/23/25, 5:00 AM, LVN 3 documented left wrist restraint and bed rails x4. The restraint care plan was continued. On 11/23/25, from 7:30 AM to 11:15 PM, LVN 4 documented left wrist restraint and bed rails x4. The restraint care plan was continued. On 11/24/25, at 1:10 AM, LVN 5 documented assumed care of Patient 1. There was no restraint checks documented from 1 AM to 6:59 AM. There was no documentation to indicate the restraints had been discontinued, and the restraint care plan was continued with left wrist restraint and bed rails x4. On 11/24/25, from 1:00 AM to 5:00 AM LVN 5 documented side rails x4 and soft wrist restraint to left wrist. The care plan was continued. On 11/24/25, from 7:00 AM to 5:00 PM, LVN 6 documented bed rails x4. And at 5:30 PM LVN 6 documented that the left wrist restraint had been removed with Patient 1 was tolerating safely with no attempts to remove oxygen. The restraint care plan was continued. On 11/24/25, at 6:44 PM, LVN 7 documented a left wrist restraint was applied to Patient 1. And documented an hour later Patient 1 had removed the restraint. LVN 7 indicated a deal was made with Patient 1 to keep the restraint off. On 11/25/25, at 6:05 AM, LVN 7 documented that Patient 1 remained safe without a restraint to the left wrist through the shift, and the restraint was still off with no safety issues. An order to renew a restraint to Patient 1s left wrist was signed on 11/24/25 at 8:00 AM despite the documented change in Patient 1’s condition and documentation that indicated removal of Patient 1’s wrist restraint the shift prior had been tolerated safely. 2. During a facility tour on, 11/24/25, at 11:00 AM Patient 2 was observed cooperating with PT transferring to a wheelchair. There was no restraint observed. Review of Patient 2’s record indicated Patient 2 was admitted to the facility on 10/14/25 with a history of severe weakness, contractures, acute renal failure (sudden loss of kidney function), and mechanical ventilation (a machine that helps with breathing). Review of facility provided documents titled: “LTAC Restraint Physician Order”, dated between 11/20/25 and 11/25/25, indicated that: On 11/20/25, at 9:00 AM, Patient 2 had an order for bed rails x4. The order had been renewed from the previous day. On 11/21/25, at 8:30 AM, Patient 2 had an order for bed rails x4 and wrist restraints to right and left wrist. The order had been renewed from the previous day. On 11/22/25, at 8:00 AM, Patient 2 had an order for bed rails x4 and wrist restraints to right and left wrist (bilateral). The order had been renewed from the previous day. On 11/23/25, at 8:00 AM, Patient 2 had an order for bed rails x4 and wrist restraints to left wrist only. The order had been renewed from the previous day. On 11/24/25, at 8:00 AM, Patient 2 had an order for bed rails x4 only. The order had been renewed from the previous day. A revew of the orders sets were preprinted on paper with check boxes to indicate if the order was a new order, or a renewal of the previous order. Five of five restraint orders reviewed in Patient 2’s record were renewal orders (continuation of the last order), five of five restraint orders included side rails x4, two of five orders included bilateral wrist restraint that had not been ordered previously to be renewed, and one of five orders included a left wrist only. Review of restraint care plan documentation in Patient 2’s record from 11/20/25 to 11/25/25 indicated Patient 2 had restraints documented: On 11/20/25, from 7:00 AM to 5:00 PM, RN 2 documented bed rails x4, and bilateral wrist restraints. The restraint care plan was continued by RN 2 with the addition of bilateral wrist restraints. On 11/20/25, at 4:40 PM RN 2 documented, “soft wrist restraints placed on BIL (bilateral) wrist”. The facility was unable to provide an order signed by any LIP for bilateral wrist restraints on 11/20/25. On 11/20/25, from 7:05 PM to 11/21/25, at 5:06 AM, RN 3 documented bed rails x4 and bilateral wrist restraints. RN 3 continued the care plan. On 11/21/25, from 7:00 AM to 5:00 PM, RN 4 documented bed rails x4 and bilateral wrist restraints. RN 4 continued the care plan. On 11/21/25, from 7:00 PM, to 11/22/25, at 4:40 AM, RN 5 documented restraint checks, but did not indicate the type of restraint used. RN 5 continued the restraint care plan. On 11/22/25, from 7:15 AM to 5:15 PM, RN 6 documented bed rails x4 only. RN 6 did not update the care plan to reflect only bed rails. And RN 6 continued the restraint care plan. The facility could not provide an order to discontinue bilateral wrist restraints. On 11/22/25, from 7:17 PM, to 11/23/25, at 6:36 AM, RN 7 documented bed rails x4 and wrist restraint to left arm. RN 7 continued the care plan. The facility could not provide an order to discontinue the right wrist restraint. On 11/23/25, at 9:30 AM, RN 6 documented bed rails x4 and indicated Patient 2 was unable to follow commands. On 11/23/25, from 7:00 AM to 5:00 PM, RN 6 documented bed rails x4 and bilateral wrist restraints were used in the care plan. And documented bed rails x4 was the only restraint used under restraint checks. RN 6 continued the care plan without updating to reflect the current treatment provided to Patient 2. The documentation was inconsistent, and the facility could not provide an order to discontinue either the right or left wrist restraint. On 11/23/25, from 7:00 PM, to 11/24, at 5:00 AM, RN 5 documented bed rails x4 and continued the care plan. The facility was unable to provide an order to remove the left wrist restraint that was ordered. On 11/24/25, at 10:32 AM, RN 8 indicated restraints with an “x”. RN 8 did not document in the restraint flow sheet or the restraint care plan. The facility was unable to provide documentation to clearly indicate if Patient 2 had restraints in use from 7AM to 7PM on 11/25/25. On 11/24/25, at 7:00 PM, to 11/25, at 5:00 AM, RN5 documented bed rails x4 were used. RN5 continued the care plan. The facility could not provide an order to discontinue restraints for Patient 2. During an interview and concurrent record review on 11/24/25, at 11:10 AM, the Director of Nursing (DON) and DQRM confirmed that restraint documentation observed in Patient 1’s record did not reflect the current restraint orders. The DON agreed that the documentation did not always clearly indicate if Patient 1 and Patient 2 had restraints on or off. The DON indicated that restraint documentation was expected to be completed each shift, at a minimum of every two hours, and documentation should include the type of restraint on the patient, the patient behaviors, the patient response to the restraint and ongoing assessments of the need for the restraint. Additionally, the DON indicated that if the restraint was removed there should be a note that described the patient’s status change, and the care plan should have been updated to reflect the current treatment plan that was in use. The DON and DQRM indicated they were unsure if an order was needed to discontinue restraints. And the DON indicated that when an order included two different restraint types (bed rails x4 and wrist restraints) the nurse had discretion to use the least restrictive option or both at any time until the order was discontinued. DQRM and DON indicated the restraint order was good for 24 hours and provided the nurses with removal criteria and indicated the nurse did not need to notify the doctor if the restraint was discontinued because it was included in the order.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(5) §§482.13(e)(5) - The use of restraint or seclusion must be in accordance with the order of a physician or other licensed practitioner who is responsible for the care of the patient and authorized to order restraint or seclusion by hospital policy in accordance with State law. This Standard is not met as evidenced by: 47884 Based on observation, interview and record review, the facility did not ensure that nursing staff obtained an order for wrist restraints for one patient (Patient 2), when Registered Nurse (RN) 2 applied bilateral wrist restraints to Patient 2. This failed practice had the potential the potential to lead to serious consequences such physical and psychological harm. Findings: Review of a facility provided nursing policy titled: “Restraint Use”, last reviewed 10/2025 and in effect, indicated the use of restraint was for patient safety. And indicated clinical indicators (behaviors) would be documented to indicate why the restraint was needed, and the least restrictive restraint would be used. The policy outlined that a Licensed Independent Practitioner (LIP) order was required to initiate, change, continue, or discontinue a restraint, and each order would include the restraint type, instructions and duration of use. And the policy indicated that if a restraint was ordered emergently a signed order would be obtained within a few minutes of restraint application. Additionally, the policy indicated when a restraint was discontinued (not used) a new order would be obtained by the LIP if the restraint was needed again. Review of a facility job description titled, Registered Nurse, last revised 2/1/2017, indicated that the RN would follow all hospital policies, ensure physicians orders were followed. Review of Patient 2’s record indicated Patient 2 was admitted to the facility on 10/14/25 with a history of severe weakness, contractures, acute renal failure (sudden loss of kidney function), and mechanical ventilation (a machine that helps with breathing). Review of facility provided documents titled: “LTAC Restraint Physician Order”, dated between 11/20/25 and 11/21/25, indicated that: On 11/20/25, at 9:00 AM, Patient2 had an order for bed rails x4. The order had been renewed from the previous day. On 11/21/25, at 8:30, Patient 2 had an order for bed rails x4 and wrist restraints to right and left wrist. The order had been renewed from the previous day. On 11/20/25, from 7:00 AM to 5:00 PM, RN 2 documented bed rails x4, and bilateral wrist restraints. The restraint care plan was continued by RN 2 with the addition of bilateral wrist restraints. On 11/20/25, at 4:40 PM RN 2 documented, “soft wrist restraints placed on BIL (bilateral) wrist”. The facility was unable to provide an order signed by any LIP for bilateral wrist restraints on 11/20/25. During an interview on11/24/25, at 10:30 AM, the Director of Quality and Risk Management (DQRM) indicated that a LIP order was needed to use a restraint on patients, and the LIP must assess the patient face to face to order or renew a restraint. DQRM indicated the LIP was available in the facility until 7:00 PM or later, and with Tele Health (a computer screen with assistance from a bedside nurse) after hours. Additionally, the DQRM indicated that the LIP would sign the order after completing the face-to-face assessment of the patient. DQRM confirmed there was not an order for bilateral wrist restraints on 11/20/25.”