Life Care Center of Andover

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a safe environment free from accidents for Resident (R)1. On 03/28/26, Certified Nurse Aide (CNA) N and CNA M attempted to transfer R1 from his electric scooter to his bed using a full-body mechanical lift. R1's scooter became tangled with the lift, so CNA N turned her back to R1 to move the scooter. During this time, without the hands-on assistance of CNA N, CNA M moved the lift, and R1, who was approximately four feet in the air, began to sway. One of the sling loops came unhooked and R1 fell to the floor. As a result, R1 sustained head injuries, including a concussion (damage to the brain caused by violent jarring or shaking, such as a blow), a frontal skull fracture (a break in the bone forming the forehead), and subarachnoid hemorrhage (bleeding in the space just outside the brain). [...]

Inspectors wroteThe facility reported a census of 97 residents. The sample included eight residents who were reviewed for abuse. Based on observation, interview, and record review, the facility failed to ensure Resident (R)1 remained free from staff-to-resident abuse. On 09/17/25, R1, a severely cognitively impaired resident with a history of behaviors and traumatic brain injury (TBI-an injury to the brain caused by external forces), demonstrated escalating combative and aggressive behaviors. At approximately 08:30 PM, Licensed Nurse (LN) G intervened in R1's behavioral event, and as a result, R1 grabbed LN G's genitals and called LN G obscene names. LN G yelled at R1, grabbed his arm, and stated he would beat the resident up, then lock the resident in his room. LN G reported he employed a restraint technique that involved grabbing R1 around the neck to prevent further aggressive behaviors. [...]

Inspectors wroteThe facility reported a census of 97 residents. The sample included eight residents who were reviewed for abuse. Based on observation, interview, and record review, the facility failed to ensure Resident (R)1 remained free from staff-to-resident abuse. On 09/17/25, R1, a severely cognitively impaired resident with a history of behaviors and traumatic brain injury (TBI-an injury to the brain caused by external forces), demonstrated escalating combative and aggressive behaviors. At approximately 08:30 PM, Licensed Nurse (LN) G intervened in R1's behavioral event, and as a result, R1 grabbed LN G's genitals and called LN G obscene names. LN G yelled at R1, grabbed his arm, and stated he would beat the resident up, then lock the resident in his room. LN G reported he employed a restraint technique that involved grabbing R1 around the neck to prevent further aggressive behaviors. [...]

Inspectors wroteThe facility reported a census of 97 residents. The sample included eight residents who were reviewed for abuse. Based on observation, interview, and record review, the facility failed to ensure Resident (R)1 remained free from staff-to-resident abuse. On 09/17/25, R1, a severely cognitively impaired resident with a history of behaviors and traumatic brain injury (TBI-an injury to the brain caused by external forces), demonstrated escalating combative and aggressive behaviors. At approximately 08:30 PM, Licensed Nurse (LN) G intervened in R1's behavioral event, and as a result, R1 grabbed LN G's genitals and called LN G obscene names. LN G yelled at R1, grabbed his arm, and stated he would beat the resident up, then lock the resident in his room. LN G reported he employed a restraint technique that involved grabbing R1 around the neck to prevent further aggressive behaviors. [...]

Inspectors wroteThe facility reported a census of 93 residents. The sample included three residents. Based on interview and record review the facility failed to assess for pain and take action to manage severe pain for Resident (R)1. Additionally, the facility failed to communicate R1's pain between her nurses, doctors, and other healthcare providers. As a result of the deficient practice, R1 had severe pain with ineffective pain relief for six days. This deficient practice also placed R1 at risk for discomfort and further decline in her overall well-being.

Inspectors wroteThe facility identified a census of 96 residents. The sample included 20 residents and five Certified Nurse Aides (CNA) were reviewed for yearly performance evaluations and the associated in-service training. Based on record review and interview, the facility failed to ensure one of the five CNA staff reviewed had yearly performance evaluations completed. This placed the residents at risk for inadequate care.

Inspectors wroteThe facility identified a census of 96 residents with one kitchen and two dining rooms. Based on observation, record review, and interviews, the facility failed to follow sanitary dietary standards related to storage, preparation, and meal service. This deficient practice placed the residents at risk related to food-borne illnesses and food safety concerns. Findings Included: - On 03/24/25 at 07:10 AM, an inspection of the facility's kitchen was completed with the following concerns identified: An inspection of the dry food storage area revealed 4 large plastic bins of Fruits Loops, Raisin Bran, Frosted Flakes, and Frosted Mini Wheat. The bins lacked dates opened for the cereal. An inspection of the food serving area revealed a mobile counter for plate storage. The plates were stored upward with no barrier to prevent contamination of the eating surfaces. [...]

Inspectors wrote- R55's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of spastic quadriplegic cerebral palsy (a progressive disorder of movement, muscle tone, or posture caused by injury or abnormal development in the immature brain, most often before birth), protein-calorie malnutrition (inadequate intake of protein and calories which may cause wasting of muscle and tissue), muscle spasms, muscle weakness, need for assistance with personal care, muscle weakness, and pneumonitis due to inhalation of food and vomit (an inflammation of the lungs). The Annual Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of zero which indicated severely impaired cognition. The MDS documented R55 had bilateral upper and lower limitation in range of motion (ROM - the full movement potential of a joint, usually its range of flexion and extension). [...]

Inspectors wroteThe facility identified a census of 96 residents. The sample included 20 residents, with four residents reviewed for tube feeding. Based on observation, record review, and interviews, the facility failed to ensure safe enteral nutritional feedings for Residents (R)71, R245, R9, and R55. This deficient practice placed the residents at risk for malnutrition and complications related to their enteral feedings (provision of nutrients through the gastrointestinal tract when the resident cannot ingest, chew, or swallow food). Findings Included: [...]

Inspectors wroteThe facility identified a census of 96 residents. The facility identified 32 residents on Enhanced Barrier Precautions (EBP - infection control interventions designed to reduce transmission of resistant organisms which employ targeted gown and glove use during high contact care) and three residents on contact precautions (safeguards designed to reduce the risk of transmission of microorganisms by direct or indirect contact). Based on record review, observations, and interviews, the facility failed to cover all linen, and store pillows in a sanitary manner. The facility further failed to ensure R69's urine bag was not dragging on the floor. The facility failed to ensure staff performed hand hygiene during wound dressing changes and urinary catheter (a tube inserted into the bladder to drain the urine into a collection bag) care. [...]

Inspectors wroteThe facility identified a census of 96 residents. The sample included 20 residents. Based on observation, record review and interviews, the facility failed to ensure adequate bariatric equipment was available to provide the necessary care and promote the resident's highest practicable level of function and quality of life for Resident (R) 43. The facility also failed to ensure R81 had foot pedals in use on the wheelchair and a call light available within reach. These deficient practices placed the residents at risk for impaired quality of life and health complications related to unmet needs. Findings Included: [...]

Inspectors wroteThe facility identified a census of 96 residents. The sample included 20 residents, with two residents reviewed for hospitalization. Based on observation, record review, and interview, the facility failed to ensure that written notification of transfer provided to Resident (R) 8 included the required information. The facility failed to ensure staff provided the written notification of transfer as soon as practicable to the resident's representative. This deficient practice placed R8 at risk for uninformed care choices.

Inspectors wroteThe facility identified a census of 96 residents. The sample included 20 residents. Based on observation, record review, and interviews, the facility failed to develop a comprehensive care plan for Resident (R) 24 which included individualized, person-centered interventions for her trauma-based care. The facility also failed to develop a comprehensive care plan for R9 which included individualized person-centered intervention for his activities. This deficient practice placed these residents at risk for impaired care due to uncommunicated care needs.

Inspectors wroteThe facility reported a census of 96 residents. The sample included 20. Based on observations, interviews, and record review, the facility failed to revise Residents (R)73s care plan to reflect her visitation requirements and R85's fall intervnetions. These deficient practices placed the residents at risk for impaired care due to uncommunicated care needs. Findings Included: - The Medical Diagnosis section within R73's Electronic Medical Records (EMR) included diagnoses of aphasia (difficulty speaking), hemiparesis/hemiplegia (weakness and paralysis on one side of the body), cerebral infarction (stroke - sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain), muscle weakness, and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). [...]

Inspectors wroteThe facility identified a census of 96 residents. The sample included 20 residents, with four residents reviewed for activities of daily living (ADLs). Based on observation, record review, and interviews, the facility failed to ensure Resident (R) 55 was provided a touch pad call light. This deficient practice placed R55 at risk of unmet care needs and inability to call for assistance if needed.

Inspectors wroteThe facility identified a census of 96 residents. The sample included 20 residents, with four reviewed for pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, because of pressure, or pressure in combination with shear and/or friction). Based on interviews, observations, and record reviews, the facility failed to ensure staff set the appropriate weight for Resident (R) 245's low air-loss mattresses (specialized air mattress used to reduce pressure on the body) and failed to ensure R55's low air-loss mattress was plugged in and functioning. This deficient practice placed both residents at risk for complications related to skin breakdown and pressure ulcers. Findings Included: [...]

Inspectors wroteThe facility identified a census of 96 residents. The sample included 20 residents with four residents reviewed for positioning and mobility. Based on observation, record review, and interviews, the facility failed to ensure Resident (R)55 was provided services and treatment to prevent worsening of contractures (abnormal permanent fixation of a joint or muscle) in his left hand. This deficient practice placed R55 at risk for discomfort and decreased range of motion (ROM - the full movement potential of a joint, usually its range of flexion and extension).

Inspectors wroteThe facility reported a census of 96 residents with 20 residents sampled. Based on observation, interview, and record review the facility failed to provide timely incontinenct care to Resident (R) 81, to prevent an incontinence episode during the lunchtime meal in the dining room, which left a puddle of urine on the floor by the resident. This failure placed the resident at risk for potetial negative psychosocial well-being, due to embarassment and frustration. The facility staff also failed to ensure they educated R10 regarding keeping the urinary catheter bag below the level fo the bladder, in order to prevent the potential infection control issue, which could lead to urinary tract infections.

Inspectors wroteThe facility identified a census of 96 residents. The sample included 20 residents, with three sample residents reviewed for respiratory care. Based on observation, record review, and interview, the facility failed to ensure Resident (R) 4 had her physician-ordered supplemental oxygen on as ordered. The facility failed to ensure R4's nasal cannula (NC - a thin hollow tube that assists in providing supplemental oxygen) was appropriately stored when not used. The facility failed to ensure R43's continuous positive airway pressure (CPAP- ventilation device that blows a gentle stream of air into the nose to keep the airway open during sleep) mask was stored appropirately when not in use. This deficient practice placed R4 and R43 at risk of respiratory complications and possible infection.

Inspectors wroteThe facility identified a census of 96 residents. The sample included 20 residents, with one resident reviewed for trauma informed care (treatment or care directed to prevent re-experiencing or reducing the effects of traumatic events). Based on observation, record review, and interviews, the facility failed to identify trauma-based triggers related to Resident (R) 24's post-traumatic stress disorder (PTSD- mental disorder characterized by an acute emotional response to a traumatic event or situation involving severe environmental stress) and failed to implement individualized interventions to prevent re-traumatization. These deficient practices placed R24 at risk for decreased psychosocial well-being and ineffective treatment.

Inspectors wroteThe facility identified a census of 96 residents. The sample included 20 residents with two reviewed for bed rails. Based on observation, record review, and interviews, the facility failed to ensure that Residents (R) 15 and R55 had a safety assessment for the use of side rails that acknowledged the risks of their low air-loss mattress. This deficient practice placed both residents at risk for uninformed decisions and impaired safety related to the risks associated with the use of side rails. Findings Included: [...]

Inspectors wroteThe facility identified a census of 95 residents. The sample included 20 residents, with one resident reviewed for trauma informed care (treatment or care directed to prevent re-experiencing or reducing the effects of traumatic events). Based on observation, record review, and interviews, the facility failed to identify and provide medically related social services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for Resident (R) 24, who has a history of posttraumatic stress disorder (PTSD- mental disorder characterized by an acute emotional response to a traumatic event or situation involving severe environmental stress). This deficient practice placed R24 at risk for further decline of her emotional and mental wellbeing.

Inspectors wroteThe facility identified a census of 96 residents. Based on record review and interviews, the facility failed to maintain the posted daily nurse staffing data for the required 18 months.

Inspectors wroteThe facility identified a census of 90 residents. The sample included three residents reviewed for falls. Based on observation, record review, and interviews, the facility failed to ensure an environment free from preventable accidents for Resident (R) 1. On 04/30/24, Certified Nurse Aide (CNA) M was providing incontinence (lack of voluntary control over urination or defecation) care for R1 when she noticed R1 was close to the edge of the bed. She moved her hand to wipe R1's buttocks and R1 rolled off the bed onto the floor. R1 was sent to the Emergency Department (ED) for evaluation and treatment where he received 13 staples for a laceration to his scalp because of the fall. The deficient practice also placed the resident at risk for increased pain and a further decline in mobility.

Inspectors wroteThe facility reported a census of 94 residents, with three residents sampled for accidents with a mechanical lift. Based on observation, interview, and record review, the facility failed to ensure Resident (R)1 remained free from accident hazards on 02/20/24 when Certified Nurse Aide (CNA) E used a mechanical lift by himself, while transferring R1. As a result, R1 fell from the full body mechanical lift and fractured her pelvis. This failure placed R1 in immediate jeopardy and placed 30 residents, who required a full body mechanical lift for transfers, at risk for injury. Findings Included: [...]

Inspectors wroteThe facility reported a census of 93 residents. The sample of 22 residents included 10 residents sampled for personal hygiene related to grooming, bathing, nail care, and shaving. Based on observation, interview, and record review the facility failed to ensure necessary services to maintain good personal hygiene for the nine of the 10 sampled residents, including Resident (R)45, R73, R 25, R 59, R 64, R 4, R 8, R 19, and R 22.

Inspectors wroteThe facility reported a census of 93 residents. Based on interview and record review, the facility failed to ensure sufficient qualified nursing staff available at all times to provide nursing and related services to meet the residents' needs safely and in a manner that promotes each resident's rights, physical, mental and psychosocial well-being.

Inspectors wroteThe facility reported a census of 93 residents. Based on observation, interview and record review, the facility failed to have Registered Nurse (RN) coverage for at least eight continuous hours on 07/22/23, 07/23/23, 08/05/23, 08/06/23, 08/19/23, 08/23/23, 09/12/23, 09/24/23, 09/30/23, 10/08/23, 10/14/23 and 10/15/23, as required. The facility may permit the DON to serve as a charge nurse only when the facility had an average daily occupancy of 60 or fewer residents. This placed the residents in the facility at risk for unsupervised nursing care and services.

Inspectors wroteThe facility reported a census of 93 residents. Based on interview and record review, the facility failed to complete an annual performance review at least once every 12 months for two of the five Certified Nurse Aides (CNA) reviewed, CNA P and CNA Q, to ensure adequate appropriate cares and services provided to the residents of the facility.

Inspectors wroteThe facility reported a census of 93 residents. Based on observation, interview, and record review the facility failed to prepare, store, and serve food under sanitary conditions, to the residents of the facility. Findings Included: - On 10/16/23 at 02:42 PM, the following concerns were identified during the initial tour of the kitchen with Dietary Staff BB: 1. Five cup cake pans, with 24 cup capacity, sat stacked together ready for use. The pans inside held a brown substance in contact in the edges which would contact the food when used. 2. The refrigerator contained an open to air sliced turkey package which lacked a date to indicate when it was opened. 3. The refrigerator contained an open to air package of sliced ham in the unsealed package. On 10/16/23 at 02:52 PM, Dietary Staff BB confirmed the above findings. [...]

Inspectors wroteThe facility reported a census of 93 residents. Based on observation, interview and record review, the facility failed to maintain a quality assurance committee that developed and implemented appropriate plans of action to correct identified infractions of resident rights, nursing services, food and nutritional services, pharmacy services, comprehensive resident centered care plans, infection control, physical environment, and quality of life and quality of care concerns for all residents.

Inspectors wroteThe facility reported a census of 93 residents. Based on observation, interview, and record review, the facility failed to maintain an effective infection control program with the failure of staff to perform proper transportation of soiled linen and hand hygiene when appropriate and failure of the staff to clean resident transfer equipment between resident use. This deficient practice has the potential to negatively affect every resident in the facility.

Inspectors wroteThe facility reported a census of 39 residents. Based on observation and interview, the facility failed to provide a safe, functional, and sanitary environment in the kitchen.

Inspectors wroteThe facility reported a census of 93 residents. Based on observation, interview, and record review, the facility failed to ensure all residents were free from accident hazards regarding several residents not having access to their call lights while in their beds.

Inspectors wroteThe facility reported a census of 93 residents. Based on observation, interview, and record review, the facility failed to maintain a clean, comfortable and homelike environment, regarding concerns in the clean utility closet on one of four resident halls.

Inspectors wroteThe facility census totaled 93 residents on four halls with a commons area where residents gather for meals and activities and with a medication cart and a nurse treatment cart for each hallway. Based on observation, interview, and record review, the facility failed to provide a safe environment for 21 residents by the failure to ensure a medication cart used by the facility remained locked when not in direct line of vision of the nurse and medication aide passing medications from their carts.

Inspectors wroteThe facility reported a census of 93 residents with 22 residents sampled, including two residents reviewed for dignity. Based on observation, interview, and record review, the facility failed to show respect and dignity to one Resident (R)4, by failing to ensure the resident had appropriate clothing to wear, rather than hospital-type gowns.

Inspectors wroteThe facility had a census of 93 residents. The sample included 22 residents with four reviewed for hospitalization. Based on observation, interview, and record review, the facility failed to provide a bed hold notice to two residents, Resident (R)25 and R46, or their representative when the residents were sent and admitted to the hospital. This deficient practice placed R25 and R46 at risk to not be allowed to return to their former rooms at the facility.

Inspectors wrote- R33's physician orders dated [DATE] revealed the following diagnoses: dementia (progressive mental disorder characterized by failing memory, confusion), heart failure (heart muscle doesn't pump blood as well as it should), and anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear). The Significant Change in Status Minimum Data Set (MDS) dated [DATE], revealed the resident had severe cognitive impairment with memory problems and severely impaired decision-making ability. The resident had shortness of air with all activity and required the use of oxygen (O2). The resident had a terminal diagnosis and received hospice services. The Quarterly MDS dated [DATE], revealed no significant changes in cognition. The resident received hospice services and use of O2. [...]

Inspectors wrote- Review of Resident (R) 25's Physician's Orders, dated 10/04/23 documentation included diagnoses of morbid obesity (severely overweight), type two diabetes mellitus (DM-when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), protein calorie malnutrition, heart failure, chronic kidney disease (CKD), coronary artery disease (CAD- abnormal condition that may affect the flow of oxygen to the heart), abnormalities of gait and mobility, chronic ulceration (wound) of the left foot, needed assistance for personal care, dependence on wheelchair, and with left and right buttock wounds. The admission Minimum Data Set, (MDS) dated [DATE], documented the resident's Brief Interview for Mental Status, (BIMS) score of 15, indicating cognitively intact. She did not exhibit behaviors nor reject care. [...]

Inspectors wroteThe facility reported a census of 93 residents with 22 residents sampled, including one resident reviewed for activities. Based on observation, interview and record review, the facility failed to provide an ongoing program of appropriate activities for one Resident (R)4.

Inspectors wroteThe facility reported a census of 93 residents with 22 residents selected for review, which included four residents reviewed for pressure ulcers. Based on observation, record review, and interview, the facility failed to reposition one Resident (R67), with a high risk for development of pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction) over two hours and 15 minutes. In addition, the facility failed to implement interventions to prevent further development of pressure areas for R85.

Inspectors wroteThe facility reported a census of 93 residents with 22 residents sampled, including one resident reviewed for restorative services. Based on observation, interview, and record review, the facility failed to provide restorative services for Resident (R)22, to maintain or prevent decline in range of motion (ROM) ability.

Inspectors wroteThe facility reported a census of 93 residents with 22 residents included in the sample, that included one resident reviewed for respiratory services. Based on observation, interview, and record review the facility failed to ensure one Resident (R) 33's oxygen (O2) tubing dated to ensure safe oxygen treatment and failed to document in the clinical records, when the resident required use of the O2, identified by staff that the resident required the O2 continuously.

Inspectors wroteThe facility reported a census of 93 residents with 22 residents sampled, that included five residents reviewed for unnecessary medications. Based on observation, interview, and record review, the facility failed to ensure the consultant pharmacist identified and reported the lack of an appropriate/ timely Abnormal Involuntary Movement Scale ([AIMS] a clinical outcome measure used to assess abnormal movements in people with tardive dyskinesia [abnormal condition characterized by involuntary repetitive movements of the muscles of the face, limbs, and trunk]) for Resident (R)55, who received an antipsychotic (class of medication used to treat psychosis) medication.

Inspectors wroteThe facility reported a census of 93 residents with 22 residents sampled. Based on observation, interview, and record review, the facility failed to complete an Abnormal Involuntary Movement Scale (AIMS) assessment for one Resident (R)55, who takes an antipsychotic (medication which treats psychosis) medication.

Inspectors wroteThe facility reported a census of 93 residents. Based on observation, interview, and record review, the facility failed to ensure the use of recipes reviewed by the facility's dietitian or other clinically qualified nutrition professional for nutritional adequacy, also failure to prepare adequate nutritional food in accordance with the menus/follow recipes for the residents of the facility.

Inspectors wroteThe facility reported a census of 93 residents. Based on interview and record review, the facility failed to ensure two Residents (R)89 and R 11 acknowledged receipt of the 2022-2023 vaccination information, related to influenzas or pneumococcal (vaccines designed to prevent pneumonia or influenza) vaccination. In addition, the facility failed to ensure R11 acknowledged receipt related to COVID-19 vaccination information to make informed declination decisions as required.

Inspectors wroteThe facility reported a census of 88 residents, with three residents sampled for accidents. Based on observations, record review, and interview, the facility failed to follow Resident (R) 1's care planned, which required total dependence of two staff for toilet use. R1 slid out of his bed when Certified Nurse Aide (CNA) M failed to follow the resident's care plan and have an additional staff member present to assist with toileting. The resident slid out of his bed during cares and sustained a fracture to his right knee.

Inspectors wroteThe facility reported a census of 75 residents with 20 residents sampled, including 11 residents reviewed for Activities of Daily Living (ADL). Based on interview, record review, and observation the facility failed to provide appropriate bathing opportunities to 10 of the 11 residents including; Residents (R)35, R 177, R 9, R 44, R 62, R 57, R 128, R 16, R 30, and R43 to ensure personal hygiene needs are met.

Inspectors wroteThe facility reported a census of 75 residents. The 20 residents selected for review included five residents reviewed for quality of care including three residents for non-pressure wounds and one with alignment positioning. Based on observation, interview and record review, the facility failed to provide non-pressure wound care to two residents (R)30 and R57 and failed to provide assessment and timely treatment for non-pressure skin wounds for R177. Furthermore, the facility failed to provide alignment positioning for the one resident R25, who sat in the wheelchair with feet handing behind the foot pedals and above the floor without any support.

Inspectors wroteThe facility reported a census of 75 residents with 20 residents sampled, including two residents sampled for dignity. Based on interview, record review, and observation, the facility failed to ensure Resident (R)25 was treated with respect and dignity, when sitting in the commons area with drool down the front of his face and clothing and staff failure to stop and clean him off.

Inspectors wroteThe facility reported a census of 75 residents with 20 selected for review. Based on observation, interview and record review, the facility failed to review and revise one sampled resident's (R) 30's care plan for interventions for pressure relieving devices for a preventative boot which the resident often refused and staff failed to identify the failure and implement an effective interventnion for the resident's diabetic heel ulcer.

Inspectors wroteThe facility reported a census of 75 residents with 20 residents sampled, including three residents sampled for activities. Based on observation, record review, and interview, the facility failed to provide an ongoing program of individualized activities for one of the three residents, Resident (R)25.

Inspectors wroteThe facility reported a census of 75 residents with 20 selected for review which included one resident reviewed for restorative services. Based on observation, interview and record review, the facility failed to provide restorative services to ensure one resident (R)34 received restorative services to her bilateral foot (drop- extended) contractures with proper wheelchair positioning devices and bed device to enhance anatomical joint alignment as much as possible to prevent further decline.

Inspectors wroteThe facility reported a census of 75 residents with 20 residents sampled, including two residents reviewed for accidents. Based on observation, interview and record review, the facility failed to ensure staff safe transports for one of the two, dependent Resident (R)17 while in her wheelchair to prevent accidents.

Inspectors wroteThe facility reported a census of 75 residents with 20 selected for review, which included three residents reviewed for urinary catheters. Based on observation, interview and record review, the facility failed to provide proper catheter care and services for the three sampled residents (R)30, R43 and R35 to prevent pulling trauma and infection.

Inspectors wroteThe facility reported a census of 75 residents 20 selected for review, which included five residents reviewed for unnecessary medications. Based on observation, interview and record review, the facility failed to ensure the consistent administration for one of the five residents, Resident (R) 30 antibiotic therapy following lack of intravenous site, which created a significant medication error for this resident with pneumonia.