Based on interviews, observations, and policy review, the facility failed to ensure staff treated residents in a dignified manner during the dining experience. Specifically, for a resident who was dependent on staff for assistance with meals, staff were standing over the resident while providing assistance with feeding, on the first floor unit. Findings include: Review of the facility policy titled Residents' Rights Policy, dated 10/4/23, indicated Respect and dignity- The resident has right to be treated with respect and dignity. On 1/28/25 at 8:26 A.M., the surveyor observed a Certified Nurses Aide (CNA) feeding a resident in his/her room on the first floor. The CNA was observed to be standing over the resident who was in bed. On 1/29/25 from 8:12 A.M. to 8:14 A.M., the surveyor observed a CNA feeding the same resident in his/her room on the first floor. The CNA was observed to be standing over the resident who was in bed. During an interview on 1/30/25 at 8:19 A.M., Nurse #3 said staff should be seated while assisting a resident while eating for dignity. During an interview on 1/30/25 at 8:31 A.M., the Assistant Director of Nurses (ADON) said she expects staff to sit while feeding.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, observations and interviews, the facility failed to ensure resident centered care plans were developed and/or implemented for three Residents (#28, #96, and #92) out of a total sample of 26 residents. Specifically, 1. For Resident #28, the facility failed to implement bilateral lower extremity booties. 2. For Resident #96, the facility failed to implement a physician's order for a Do Not Resuscitate braclet. 3. For Resident #92, the facility failed implement the fall intervention for a low bed. Findings Include: Review of the facility policy titled Care Planning, dated [DATE], indicated The organization will develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that include measurable objectives and timeframes to meet resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. This will be developed within 7 days after the MDS and CAA completion. 1. Resident #28 was admitted to the facility in [DATE] with diagnoses including pressure ulcer of the sacral region, obesity, and osteomyelitis of vertebra, sacral and sacrococcygeal region. Review of Resident #28's most recent Minimum Data Set (MDS) assessment, dated [DATE], indicated Resident #28 had a Brief Interview for Mental Status (BIMS) exam score of 15 out of a possible 15, indicating intact cognition. The MDS further indicated Resident #28 requires dependent assistance with functional daily activities and is at risk for developing pressure ulcers/injuries. On [DATE] at 9:12 A.M., the surveyor observed Resident #28 laying in his/her bed. Resident #28 was not wearing his/her lower extremity booties, and the booties were not visible in his/her room. On [DATE] at 6:57 A.M., the surveyor observed Resident #28 laying in his/her bed. Resident #28 was not wearing his/her lower extremity booties, and the booties were not visible in his/her room. On [DATE] at 10:08 A.M., the surveyor observed Resident #28 laying in his/her bed. Resident #28 was not wearing his/her lower extremity booties, and the booties were not visible in his/her room. On [DATE] at 6:41 A.M., the surveyor observed Resident #28 laying in his/her bed. Resident #28 was not wearing his/her lower extremity booties, and the booties were not visible in his/her room. Review of Resident #28's physician order indicated the following order initiated on [DATE]: - Navy blue booties to bilateral feet as tolerated, every shift. Review of Resident #28's skin breakdown care plan interventions indicated the following: - Navy blue booties to bilateral feet as tolerated, effective date [DATE]. Review of Resident #28's medical record failed to indicate he/she refused to wear his/her bilateral lower extremity booties. During an interview on [DATE] at 1:51 P.M., Resident #28 said he/she was asked by staff today if he/she would wear booties if they ordered them for him/her. Resident #28 said he/she has not been wearing booties and doesn't understand why the facility wants him/her to wear them now. During an interview on [DATE] at 7:27 A.M., Unit Manager #2 said Resident #28 has orders for booties and wears them as tolerated. Unit Manager #2 said the Resident gets out of bed every day and wears his/her shoes and was not aware he/she had not been wearing his/her booties while in bed the past few days. Unit Manager #2 said she would expect the physician's order to followed and it to be documented accurately in the medical record. During an interview on [DATE] 7:41 A.M., The Director of Nursing said she would expect the physician's order to be acknowledged by nursing, accurately documented in the medical record, and indicated if the resident refuses. 3. Resident #92 was admitted to the facility in [DATE] with diagnoses that included aphasia following cerebral infarction, traumatic subarachnoid hemorrhage, hemiplegia and hemiparesis, epilepsy and traumatic brain injury. Review of Resident #92's Minimum Data Set (MDS) assessment, dated [DATE], indicated he/she was assessed by nursing staff to have severe cognitive impairments. On [DATE] at 8:05 A.M. and 2:40 P.M., the surveyor observed Resident #92 in bed, the height of the bed was observed to be about three feet high from the ground. On [DATE] at 8:13 A.M., 9:50 A.M., and 1:00 P.M., the surveyor observed Resident #92 in bed, the height of the bed was observed to be about three feet high from the ground. On [DATE] at 6:52 A.M., the surveyor observed Resident #92 in bed, the height of the bed was observed to be about three feet high from the ground and his/her door was closed. Review of Resident #92's fall care plan, dated [DATE], indicated Low bed when occupied. Review of Resident #92's most recent fall assessment, dated [DATE], indicated the resident had a fall in the past year. Review of Resident #92's active Certified Nurses Aide (CNA) [NAME] (from explaining to staff the needs of each resident), indicated Fall interventions: Low bed when occupied. During an interview and observation on [DATE] at 8:14 A.M., Nurse #2 said the Resident has a history of falling and his/her bed is not in a low position, the bed is in a high position. Nurse #2 said nursing staff are expected to follow each residents care plan. During an interview on [DATE] at 8:15 A.M., the MDS Nurse said the expectation is that nursing staff following the Resident's care plan. The MDS Nurse said if a resident has a plan of care of a low bed then the bed should be in the lowest locked position. During an interview on [DATE] at 8:31 A.M., the Assistant Director of Nurses (ADON) said the Resident has been a fall risk and staff are expected to follow the Resident's care plan. 2. Resident #96 was admitted to the facility in [DATE] and has active diagnoses which include chronic kidney disease and chronic obstructive pulmonary disease. Review of an untitled document, located in Resident #96's medical record and signed by the Resident, indicated the facility, effective [DATE]. adopted the use of the purple color coded Do Not Resuscitate (DNR) wristband alert for patients/residents. Review of Resident #96's plan of care dated [DATE], indicated a DNR code status and A purple DNR bracelet to left wrist, check placement every shift. Review of Resident #96's physician order dated [DATE], indicated DNR Bracelet every shift. Verify DNR Bracelet is in place on left wrist every shift. DNR Bracelet represents a time out, in the event of cardiac arrest. Do not initiate CPR (cardiopulmonary resuscitation) obtain patient MOLST (medical orders for life-sustaining treatment) and verify current DNR order. Review of Resident #96's physician orders dated [DATE], indicated Code Status: Do Not Resuscitate, Do Not Intubate, use noninvasive ventilation. Information only. Transfer to Hospital. Review of Resident #96's Minimum Data Set (MDS) assessment dated [DATE], indicated intact cognition and he/she did not refuse to accept care. Review of Resident #96's Medication Administration Record dated [DATE] and [DATE], indicated nursing staff documented the Resident wore a DNR bracelet every shift and every day, while in the facility. During an interview with Resident #96 on [DATE] at 12:29 P.M., he/she said his/her DNR bracelet had been missing for approximately six weeks. The Resident said he/she has repeatedly asked nurses and aides to provide a replacement bracelet since it went missing. The surveyor observed that the Resident was not wearing a DNR bracelet. Resident #96 said she had CPR performed on him/her once before at a hospital and did not want to have it ever again. During an interview with Unit Manager #3, she said she was unaware Resident #96 was not wearing a DNR bracelet, and that none of the staff reported this. Unit Manager #3 showed the surveyor a drawer at the nursing station, which held approximately a dozen purple DNR bracelets, and said staff know where to find these if a replacement was needed. During an interview with Resident #96's assigned nurse (Nurse #4), she said she was aware Resident #96 was not wearing a DNR bracelet, but did not know how long he/she had been without it.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview, and record review, the facility failed to ensure that respiratory care and services consistent with professional standards of practice, were provided for two Residents (#227 and #70), out of a total sample of 26 residents. Specifically, 1. For Resident #227, the facility failed to ensure a physicians order was in place for the use of a CPAP (continuous positive airway pressure) is a machine that uses mild air pressure to keep breathing airways open while you sleep. 2. For Resident #70, the facility failed to implement physician's orders for continuous oxygen at the correct flow rate. Findings include: 1. Review of the facility policy titled Non-Invasive Positive Pressure Ventilation, not dated, indicated Non-invasive positive pressure ventilation is the delivery of air pressure and/or mechanically assisted breaths without the application of an artificial airway. Procedure: 1. Verify physician's order. Resident #227 was admitted in January 2025 with diagnoses that included obstructive sleep apnea, acute respiratory failure, chronic obstructive pulmonary disease, hypoxemia, and influenza. Review of Resident #227's most recent Minimum Data Set (MDS) assessment, dated 1/22/25, indicated he/she scored a 13 out of a possible 15 on the Brief Interview for Mental Status (BIMS) indicating intact cognition. During an interview on 1/28/25 at 7:58 A.M., Resident #227 said he/she has used a CPAP for a long time and has been using it here while at the facility. Review of Resident #227's nursing progress note, dated 1/25/25, indicated patient did use his/her CPAP LAST NIGHT. Review of Resident #227's nursing progress note, dated 1/26/25, indicated compliant with the use of his/her CPAP. Review of Resident #227's nursing progress note, dated 1/27/25, indicated patient CPAP on. Review of Resident #227's nursing progress note, dated 1/28/25, indicated CPAP on during the night. Review of Resident #227's physician orders failed to indicate an order for the use of his/her CPAP. During an interview on 1/29/25 at 9:10 A.M., Nurse #1 said he has taken care of Resident #227 many times and said the Resident has been using their CPAP for at least a week here. Nurse #1 said there should be a doctors order in place for the Residents CPAP. During an interview on 1/29/25 at 9:55 A.M., the Respiratory Therapist said Resident #227 has been using his/her CPAP for a few days and said there should have been a doctors order in place for nursing to be aware of the use of the CPAP and the settings. 2. Review of the facility policy titled Oxygen Administration, revised and dated November 2016, indicated the following: - Oxygen therapy is administered as ordered by a physician. Oxygen is set up, delivered, and monitored by a licensed nurse or respiratory therapist. - Verify physician's order for oxygen administration or weaning. Resident #70 was admitted to the facility in December 2021 with diagnoses including chronic respiratory failure and congestive heart failure. Review of Resident #70's most recent Minimum Data Set Assessment (MDS) dated [DATE] indicated that the resident had a Brief Interview for Mental Status score of 15 out of 15 indicating intact cognition. Further review of section O of the MDS indicated that the Resident is currently on oxygen therapy. The surveyor made the following observations: - On 1/28/25 at 8:00 A.M., Resident #70 was laying in his/her bed receiving supplemental oxygen via nasal cannula. The oxygen machine was set to 1.5 liters. - On 1/28/25 at 12:17 P.M., Resident #70 was laying in his/her bed. The Resident was not wearing his/her nasal cannula to receive supplemental oxygen. The nasal cannula was on the floor. The oxygen machine was set to 1.5 liters. - On 1/29/25 at 12:12 P.M., Resident #70 was laying in his/her bed receiving supplemental oxygen via nasal cannula. The oxygen machine was set to 1.5 liters. Resident #70 asked the surveyor is air coming out of it (referring to the oxygen tubing), I can't even tell the difference. Review of Resident #70's physician's order dated 9/3/24 indicated the following: Continuous O2 (oxygen) administration every shift. Rate: 4L (liters) via NC (nasal cannula) to maintain O2 sat (saturation) greater than 92%. Review of Resident #70's alteration in respiratory function care plan dated 12/5/24 indicated the following intervention: - Administer oxygen as ordered by MD (medical doctor) if applicable. During an interview on 1/29/25 at 1:18 P.M., Unit Manager #3 said all physician's orders should be followed. The Unit Manager and surveyor reviewed Resident #70's physician's orders, and she said the Resident should be receiving oxygen at a flow rate of 4 liters and should be wearing the nasal cannula. Unit Manager #3 said if a staff member observed Resident #70 not wearing his/her nasal cannula they should encourage him/her to wear it. Unit Manager #3 and the surveyor observed the Resident's oxygen machine and she said it was set to 1.5 liters and not 4 liters. During an interview on 1/30/25 at 9:52 A.M., the Director of Nursing (DON) said she would expect Resident #70's physician's orders to be followed as written and the Resident should have been receiving oxygen at a flow rate of 4 liters. The DON also said staff should encourage the resident to wear his/her nasal cannula if the Resident is not.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to implement a physician's order to give phosphate binders (a medication to absorb phosphate from the food you eat) at the appropriate time for one Resident (#24) out of a total sample of 26 residents. Findings include: Review of the facility policy titled Dialysis Residents, Coordination of Care, dated and revised November 2018, indicated the following: - A comprehensive person-centered plan of care is developed and implemented based on comprehensive assessment in collaboration with the Dialysis Center, in accordance with professional standards of practice. The plan of care will be evaluated and revised as indicated based on resident's response to interventions. Care plan will include: Medication management before, during or after dialysis per physician's orders. Resident #24 was admitted to the facility in March 2020 with diagnoses including stage 4 chronic kidney disease, dependence on renal dialysis and type 2 diabetes. Review of Resident #24's most recent Minimum Data Set Assessment (MDS) dated [DATE] indicated that the Resident had a Brief Interview for Mental Status score of 13 out of 15, indicating intact cognition. Further review of the MDS indicated that the Resident receives hemodialysis treatment. Review of Resident #24's physician's order dated 2/19/22 indicated the following: - Renvela 800 MG (milligrams) (Sevelamer Carbonate) (a phosphate binder) 800MG Oral Three Times Daily for Dependence on renal dialysis - Give 800mg PO (by mouth) TID (three times daily) **MUST BE GIVEN W/ MEALS** for scheduled order times at 9:00 A.M., 1:00 P.M., 5:00 P.M. According to DaVita Kidney Care Professional Standards of Practice, phosphate binders help to pass excess phosphorus out of the body in the stool, reducing the amount of phosphorus that gets into the blood. Usually, phosphate binders are taken within 5 to 10 minutes before or immediately after meals and snacks. Review of the facility's breakfast meal delivery schedule for the second-floor unit indicated that the unit receives three breakfast carts at 7:40 A.M., 7:50 A.M. and 8:10 A.M. The surveyor made the following observations: - On 1/29/25 at 8:20 A.M., Resident #24 was observed eating his/her breakfast in his/her room. - On 1/30/25 at 8:04 A.M., Resident #24 was observed eating his/her breakfast in his/her room. At 8:24 A.M., staff removed the Resident's breakfast tray. On 1/29/25 at 8:32 A.M., and 10:01 A.M., the surveyor observed Resident #24's electronic medication administration record (MAR) and the Resident was not documented as to receiving the Renvela medication. On 1/30/25 at 9:20 A.M., the surveyor observed Resident #24's electronic medication administration record (MAR) and the Resident was not documented as to receiving the Renvela medication. Review of Resident #24's Administration History for Renvela 800MG indicated the following: - Resident #24 was administered the medication at 10:50 A.M. on 1/29/25, 150 minutes after the Resident was observed eating his/her breakfast. - Resident #24 was administered the medication at 9:33 A.M. on 1/30/25, 89 minutes after the Resident was observed eating his/her breakfast. During an interview on 1/30/25 at 9:25 A.M., Nurse #4 said she has not passed medications to Resident #24 yet. Nurse #4 and the surveyor reviewed Resident #24's physician's orders for Renvela, Nurse #4 said the order should be changed for when breakfast arrives so the Resident can take the medication with food. Nurse #4 said 9:00 A.M. is too late for a scheduled time, it should be 7:30 A.M. She continued to say she was not aware the medication needed to be taken with meals because the order description does not match the order administration time. Nurse #4 said other dialysis residents on the unit with the same medication have an earlier administration time. During an interview on 1/30/25 at 9:36 A.M., Unit Manager #3 and the surveyor reviewed Resident #24's physician's orders, Unit Manager #3 said the Resident should be getting Renvela with meals and the administration time needs to be updated for when breakfast comes up at 8:00 A.M. During an interview on 1/30/25 at 9:54 A.M., the Director of Nursing (DON) said she would expect physician's orders to be followed as written. The DON continued to say for Resident #24, if his/her order for Renvela says to be taken with meals then the timing of his medication administration needs to be updated so he/she receives the medication with meals.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #96 was admitted to the facility in [DATE] and has active diagnoses which include chronic kidney disease and chronic obstructive pulmonary disease. Review of Resident #96's plan of care dated [DATE], indicated a DNR (do not resuscitate) code status and A purple DNR bracelet to left wrist, check placement every shift. Review of Resident #96's physician order dated [DATE], indicated DNR Bracelet every shift. Verify DNR Bracelet is in place on left wrist every shift. DNR Bracelet represents a time out, in the event of cardiac arrest. Do not initiate CPR (cardiopulmonary resuscitation) obtain patient MOLST (medical orders for life-sustaining treatment) and verify current DNR order. Review of Resident #96's Minimum Data Set (MDS) assessment dated [DATE], indicated intact cognition and he/she did not refuse to accept care. Review of Resident #96's Medication Administration Record (MAR) dated [DATE] and [DATE], indicated nursing staff documented the Resident wore a DNR bracelet every shift and every day while in the facility, including today ([DATE]). During an interview with Resident #96 on [DATE] at 12:29 P.M., he/she said his/her DNR bracelet had been missing for approximately six weeks. The Resident said he/she has repeatedly asked nurses and aides to provide a replacement bracelet since it went missing. The surveyor observed the Resident was not wearing a DNR bracelet. Resident #96 said she had CPR performed on him/her once before at a hospital and did not want to have it ever again. During an interview with Unit Manager #3, she said she was unaware Resident #96 was not wearing a DNR bracelet, and that none of the staff reported this. Unit Manager #3 showed the surveyor a drawer at the nursing station, which held approximately a dozen purple DNR bracelets, and said staff know where to find these if a replacement is needed. Unit Manager #3 said nursing staff should not have documented on the MAR that the Resident was wearing the bracelet when he/she was not, and that this error made the medical record inaccurate. During an interview with Resident #96's assigned nurse (Nurse #4), she said she was aware Resident #96 was not wearing a DNR bracelet, but did not know how long he/she had been without it. Nurse #4 said she did not know staff documented the Resident wore the DNR bracelet even though it was missing. Based on observation, record review, and interview, the facility failed to maintain an accurate medical record for two Residents (#28, and #96), out of a total sample of 25 residents. Specifically, 1. For Resident #28, the nurses documented in the Medication Administration Record (MAR) the Resident was wearing his/her bilateral lower extremity booties, when he/she was not. 2. For Resident #96, the nurses documented in the Medication Administration Record (MAR) the Resident was wearing his/her DNR bracelet, when he/she was not. Findings Include: Review of the facility policy titled Documentation-Clinical, dated [DATE], indicated the following: Policy: - Clinical documentation will be recorded according to Integritus Healthcare guidelines, as outlined below. The facility meets DPH (Department of Public Health) requirements for weekly summary of resident condition by ensuring documentation of medication and treatment administration every shift, interdisciplinary progress notes as needed, skin evaluations weekly, and Functional Performance point of care documentation every shift. Resident status, including change in condition, nursing or other services provided and resident response or progress will be documented as warranted. Purpose: - To ensure accuracy and completeness of clinical documentation. Guidelines: -Medication and Treatment: The licensed nurse notes the time and date of all medications and treatments administered on Medication Administration Record and/or treatment record. The nurse who administers the medication and/or treatment must document it on the resident's record. If a scheduled medication is withheld or not given as ordered, the nurse documents this and lists the reason for the resident receiving the medication and what was done to attempt to administer the medication. 1. Resident #28 was admitted to the facility in [DATE] with diagnoses including pressure ulcer of the sacral region, obesity, and osteomyelitis of vertebra, sacral and sacrococcygeal region. Review of Resident #28's most recent Minimum Data Set (MDS) assessment, dated [DATE], indicated Resident #28 had a Brief Interview for Mental Status (BIMS) exam score of 15 out of a possible 15, indicating intact cognition. The MDS further indicated Resident #28 requires dependent assistance with functional daily activities and is at risk for developing pressure ulcers/injuries. On [DATE] at 9:12 A.M., the surveyor observed Resident #28 laying in his/her bed. Resident #28 was not wearing his/her lower extremity booties, and the booties were not visible in his/her room. On [DATE] at 6:57 A.M., the surveyor observed Resident #28 laying in his/her bed. Resident #28 was not wearing his/her lower extremity booties, and the booties were not visible in his/her room. On [DATE] at 10:08 A.M., the surveyor observed Resident #28 laying in his/her bed. Resident #28 was not wearing his/her lower extremity booties, and the booties were not visible in his/her room. On [DATE] at 6:41 A.M., the surveyor observed Resident #28 laying in his/her bed. Resident #28 was not wearing his/her lower extremity booties, and the booties were not visible in his/her room. Review of Resident #28's physician order indicated the following order initiated on [DATE]: - Navy blue booties to bilateral feet as tolerated, every shift. Review of Resident #28's skin breakdown care plan interventions indicated the following: - Navy blue booties to bilateral feet as tolerated, effective date [DATE]. Review of the [DATE] MAR indicated that nursing documented on all shifts on [DATE]th, 29th and day shift on [DATE]th, that Resident #28 was wearing bilateral lower extremity booties, contrary to direct observation that he/she was not. Review of Resident #28's medical record failed to indicate he/she refused to wear his/her bilateral lower extremity booties. During an interview on [DATE] at 1:51 P.M., Resident #28 said he/she was asked by staff today if he/she would wear booties if they ordered them for him/her. Resident #28 said he/she has not been wearing booties and doesn't understand why the facility wants him/her to wear them now. During an interview on [DATE] at 7:27 A.M., Unit Manager #2 said Resident #28 has orders for booties and was not aware he/she had not been wearing his/her booties while in bed the past few days. Unit Manager #2 said she would expect it to be documented accurately in the medical record. During an interview on [DATE] at 7:41 A.M., The Director of Nursing said she would expect the physician's order to be acknowledged by nursing, accurately documented in the medical record, and indicated if the resident refuses.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to regularly inspect bed frames and mattress spacing to identify areas of potential entrapment. Specifically, the facility failed to regularly inspect and document findings regarding the seven zones of bed entrapment of Residents' beds for potential areas of entrapment as evidenced by a bed bolster (an object used to fill gaps between the mattress and headboard/footboard of a bed) that did not fit properly. Findings include: Review of the Food and Drug Administration (FDA) Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment, dated 3/10/2006, indicated: The term entrapment describes an event in which a resident is caught, trapped, or entangled in the space in or about the bed rail, mattress, or hospital bed frame. Resident entrapments may result in deaths and serious injuries. There are 7 zones of bed entrapment: Zone 1 (within the rail), Zone 2 (under the rail), Zone 3 (between rail and mattress), Zone 4 (Under the rail, at the ends of the rail), Zone 5 (between split bed rails), Zone 6 (between the end of the rail and the side edge of the head or foot board) and Zone 7 (Between the head or foot board and the mattress end). Review of guidance from the FDA titled Recommendations for Health Care Providers about Bed Rails, dated 07/09/2018, included: - Inspect and regularly check the mattress and bed rails to make sure they are still installed correctly and for areas of possible entrapment and falls. Regardless of mattress width, length, and/or depth, the bed frame, bed side rail, and mattress should leave no gap wide enough to entrap a patient's head or body. - Inspect, evaluate, maintain, and upgrade equipment (beds/mattresses/bed rails) to identify and remove potential fall and entrapment hazards. Review of the facility policy titled Bed Safety and Inspection, revised 10/19/17, indicated The facility will conduct regular inspection of all bed frames, mattresses, and bed rails, if any, as part of a regular maintenance program to identify area of possible entrapment. Nursing staff will observe the resident in the bed to look for potentially dangerous or uncomfortable situations that could be caused by the resident's weight, movement or bed position. Verify that no gap between the mattress, bed frame or side rail is wide enough to entrap a resident's head or body. -Maintenance staff will refer to the FDA guidelines for each of the seven zones. 1. Resident #117 was admitted to the facility in January 2025 with diagnoses that include acute on chronic diastolic heart failure, chronic kidney disease, and age-related nuclear cataract. At the time of the survey Resident #226 did not have a completed Minimum Data Set (MDS). Review of Resident #226's active Certified Nursing Assistant (CNA) [NAME] (a form explaining to staff each Residents level off assistance), indicated he/she is supervised or touching assistance for bed mobility, transfer, ambulation, and hygiene. The surveyor made the following observations on Resident #226's bed: - On 1/28/25 at 8:13 A.M., on the Rehab Unit, a resident was observed in bed. There was a bolster on the foot of the bed between the mattress and the footboard. The bolster was less than half the width of the mattress and the gap between the space above the bolster to the footboard was about six and a half inches. - On 1/29/25 at 8:12 A.M., on the Rehab Unit, a resident was observed in bed. There was a bolster on the foot of the bed between the mattress and the footboard. The bolster was less than half the width of the mattress and the gap between the space above the bolster to the footboard was about six and a half inches. Review of the Maintenance Directors entrapment spreadsheet for December 2024 indicated for this Resident's bed that only zones 1, 2 and 6 were checked. Zones 3, 4, 5 and 7 were left blank. Further review of the monthly spreadsheets indicated for November 2024 and December 2024 for first, second and third floors that only zones 1, 2 and 6 were checked. Zones 3, 4, 5 and 7 were left blank. During an interview and observation on 1/29/25 at 11:14 A.M., the Administrator and Maintenance Director observed Resident #226's bed. The Administrator and Maintenance Director said these gaps put the residents at risk for entrapment. The Maintenance Director said this bolster is not big enough for the gap at the end of this bed. 2. Resident #228 was admitted to the facility in January 2025 with diagnoses that included epilepsy, anemia, weakness, and low back pain. At the time of the survey Resident #228 did not have a completed Minimum Data Set (MDS). Review of Resident #228's active Certified Nursing Assistant (CNA) [NAME] (a form explaining to staff each Residents level off assistance), indicated he/she required substantial/maximal assistance for bed mobility and partial/moderate assistance for ambulation, toileting and dressing. The surveyor made the following observations on Resident #228's bed: - On 1/28/25 at 7:55 A.M., on the Rehab Unit, a resident was observed in bed. There was a bolster on the foot of the bed between the mattress and the footboard. The bolster was less than half the width of the mattress and the gap between the space above the bolster to the footboard was about six inches. - On 1/29/25 at 8:12 A.M., on the Rehab Unit, a resident was observed in bed. There was a bolster on the foot of the bed between the mattress and the footboard. The bolster was less than half the width of the mattress and the gap between the space above the bolster to the footboard was about six inches. Review of the Maintenance Directors entrapment spreadsheet for December 2024 indicated for this Resident's bed that only zones 1, 2 and 6 were checked. Zones 3, 4, 5 and 7 were left blank. Further review of the monthly spreadsheets indicated for November 2024 and December 2024 for first, second and third floors that only zones 1, 2 and 6 were checked. Zones 3, 4, 5 and 7 were left blank. During an interview and observation on 1/29/25 at 11:15 A.M., the Administrator and Maintenance Director observed Resident #228's bed. The Administrator and Maintenance Director said these gaps put the residents at risk for entrapment. The Maintenance Director said this bolster is not big enough for the gap at the end of this bed and said he does not have bigger bolsters in the facility. During an interview on 1/29/25 at 2:09 P.M., the Maintenance Director said he does a monthly inspection of every bed in the facility, the last completed inspection was done in December 2024 and prior to each admission that comes into the facility. The Maintenance Director said he does not measure the resident beds with extenders on them because they do not need to be measured and said he did not have to measure and assess zones 3, 4, and 5. The Maintenance Director said he uses a small ruler to do his bed measurement checks. During an interview on 1/29/25 at 2:20 P.M., the Administrator said she expects maintenance to do all the zones on each resident bed when he does the entrapment rounds.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to follow the physical therapist's recommendation for a referral to a functional maintenance program (FMP) for one Resident (#42) out of a total sample of 26 residents. Findings include: Resident #42 was admitted to the facility in August 2023 with diagnoses including chronic respiratory failure with hypoxia and congestive heart failure. Review of Resident #42's most recent Minimum Data Set Assessment (MDS) dated [DATE] indicated that the Resident had a Brief Interview for Mental Status score of 15 out of a possible 15 indicating that he/she is cognitively intact. Further review of the MDS indicated that Resident #42 required partial/moderate assistance with sitting to lying, lying to sitting on the side of bed, chair/bed to chair transfer and toilet transfer as well as substantial/maximum assistance when going from sitting to standing. Review of the facility policy titled Activities of Daily Living, dated 11/14/16, indicated the following: *The care and services for activities of daily living will be based on resident's ability as identified in MDS assessment, Rehab evaluation, nursing assessment and person-centered care plan. During an interview on 2/27/24 at 11:50 A.M., Resident #42 said he/she has not seen physical therapy for a long time and he/she has had a hard time getting in and out of bed. Review of Resident #42's Physical Therapy Discharge summary dated [DATE] through 10/10/23 indicated the following: *Patient Progress: Educated LNAs (Licensed Nursing Assistants) with FMP (functional maintenance program) for transfers and gait and LNAs demonstrating good comprehension of tx (treatment) program. Will D/C (discontinue) PT (physical therapy) at this time. *D/C Recommendations: 24 hour care, [NAME] with basket/bag, Reacher, low bed, grab bars, home exercise program and Functional Maintenance Program. *Prognosis to maintain CLOF (current level of function): Good with consistent staff follow-through. Review of Resident #42's physician's orders, [NAME] (a form listing the level of care a resident needs) and care plans failed to indicate that the Resident required an FMP to maintain his/her current level of function. Review of Resident #42's room change history indicated that he/she was transferred from the short-term rehab floor to the long-term care floor on 10/23/23; 13 days after being discharged from physical therapy services. Review of the functional maintenance program binders titled Nursing Carry Overs on the first floor, second floor (where Resident #42's currently resides) and in the therapy department failed to indicate Resident #42 has been on a FMP since being discharged from therapy services on 10/10/23. During an interview on 2/28/24 at 12:31 P.M., Resident #42 said he/she thinks his/her ability to walk has decreased because he/she has not seen therapy in a long time. During an interview on 2/28/24 at 1:21 P.M., Unit Manager (UM) #2 said residents are screened by therapy periodically. When they are put on an FMP the staff on the resident's unit get in-serviced and the FMP gets documented in the resident's [NAME] and care plans. UM #2 continued to say when therapy is following a resident they will get discussed in weekly quality of life rounds. When asked if any residents on the unit were on an FMP, UM #2 said only one resident was and it was not Resident #42. During an interview on 2/28/24 at 2:05 P.M., the Director of Rehab (DOR) said the entire rehab team is new to the building as of six months ago. She said when a resident is screened by therapy and an FMP is recommended, the staff on the unit will be educated and the FMP will be put in the resident's plan of care and it will be implemented. She continued to say that the Rehab department and each resident unit in the building has a binder listing each resident on an FMP which explains what the FMP is and which staff members have been educated. The DOR said if therapy has not screened a resident in a long time then rehab will check in with the resident. The surveyor and DOR reviewed Resident #42's Physical Therapy Discharge Summary from 10/10/23 and the DOR said Resident #42 was recommended to be on an FMP and he/she should have been on one. The surveyor and DOR reviewed Resident #42's medical record and FMP book in the therapy department and failed to identify any documentation that Resident #42 is on or has been on an FMP. During an interview on 2/28/24 at 2:24 P.M., UM #2 said she had no knowledge of Resident #42 being referred for an FMP. The surveyor and UM #2 reviewed Resident #42's medical record and the FMP book on the unit and failed to identify any documentation that Resident #42 is on or has been on an FMP. UM #2 continued to say if a Resident is supposed to be on an FMP and is not they are risk of having a decline in movement. During an interview on 2/29/24 at 8:30 A.M., UM #2 said Resident #42 transferred to his/her current unit on 10/23/23, 13 days after being discharged from PT. UM #2 said she thinks the FMP recommendation might have gotten forgotten with Resident #42's room change. During an interview on 2/29/24 at 8:37 A.M., CNA #2 said Resident #42 is dependent with care, walking and transfers. CNA #2 continued to say she does not recall being educated by therapy for an FMP.

Based on observation, record review and interviews, the facility failed to provide a dignified dining experience in the second floor dining room for one Resident (#65) out of a total 25 sampled Residents. Findings include: Resident #65 was admitted in July 2022 with diagnosis including dementia, glaucoma and cataracts. Review of Resident #65's Quarterly Minimum Data Set assessment, dated 10/6/22, indicated he/she was cognitively impaired and he/she could make him/herself understood and he/she can understand others. Review of Resident #65's plan of care related to nutrition, dated as initiated 7/12/22, indicated for staff to encourage social dining. During an observation of the second floor dining room on 1/4/23: -At 12:05 P.M., Resident #65 was set up his/her lunch meal by CNA #2. The surveyor observed 7 other Residents in the dining room who had not been served their meals. -At 12:08 P.M., CNA #2 picked up Resident #65's lunch meal that he/she was eating and brought Resident #65 back to his/her room. The surveyor heard Resident #65 ask CNA #2 where am I going?. -At 12:10 P.M., CNA #2 brought Resident #65 into his/her room and set's up his/her meal. During an interview on 1/4/23 at 12:12 P.M., CNA #2 said that Unit Manager #3 told her to bring Resident #65 back to his/her room with his/her lunch. CNA #2 said that Unit Manager #3 told her that she should not have provided Resident #65 with his/her meal when the other Residents in the dining room had not received their meals. -At 12:14 P.M., Resident #65 was in his/her bed laying down. Resident #65 said I haven't eaten yet, why am I here. The surveyor observed Resident #65 lunch tray on the bedside table. -At 12:37 P.M., the 7 Residents in the second floor dining begun to receive their lunch meals, 32 minutes after Resident #65 was set-up for his/her meal in front of those 7 Residents. During an interview on 1/4/23 at 12:43 P.M., with the Dietician and the Food Service Director (FSD) the surveyor reviewed the dining observations. The Dietician and the FSD said Residents should be given meals at the same time. During an interview on 1/4/23 at 4:20 P.M., Unit Manager #3 said Residents should be served at the same time. Unit Manager #3 said she was not aware that Resident #65 had started to eat his/her lunch meal. Unit Manager #3 said CNA #2 should have allowed him/her to finish his/her meal and not brought Resident #65 into his/her room.

Based on record review and interviews, for one of 25 sampled Residents (Resident #56), the facility failed to ensure nursing staff notified his/her provider of a medication error, when Unit Manager #3 documented she notified his/her provider but Unit Manager #3 did not. Findings include: Resident #56 was admitted to the facility in July 2021 with diagnoses including dementia. Review of Resident #56's Quarterly Minimum Data Set assessment, dated 12/8/22, indicated he/she usually could make self understood and that he/she usually understands others. Review of the Medication Variance Report, dated 1/4/23, indicated that on 1/4/23 at 4:40 P.M., the Nurse Practitioner was notified of a medication error. The report indicated: -On 12/12/22 an order for sodium chloride was written to be discontinued. The Nurse who noted the order did not discontinue the medication (Resident #56 continued to receive the medication). On 1/2/23 the sodium level (was elevated). During an interview on 1/4/23 at 4:12 P.M., Unit Manager #3 said staff should have discontinued the sodium tablets. Unit Manager #3 said she was going to write up a medication error and she would call the Nurse Practitioner to see about discontinuing Resident #56's sodium chloride tablets. During an interview on 1/5/23 at 10:05 A.M., the Nurse Practitioner said he did not speak to anyone at the facility about the medication error. The NP said this was the first time it was brought to his attention. The NP said he did not have any messages from facility staff. During a follow up interview on 1/5/23 at 10:12 A.M., Unit Manager #3 said she left a message for the NP and said she did not speak to him. Unit Manager #3 said she reviewed the order from 12/12/22 and discontinued the sodium tablets based on the order written 24 days prior. During an interview on 1/5/23 at 10:39 A.M. the Director of Nursing said that is acceptable to leave a message for the NP and furthermore said it was acceptable for Unit Manager #3 to discontinue the sodium chloride tablets based on the physician's order from 12/12/22.

Based on record review and interview, the facility failed to ensure that it's staff accurately coded Minimum Data Set (MDS) assessments for one Resident (#10) out of a total sample of 25. Specifically, the facility failed to ensure its staff accurately coded Resident #10's fall with major injury. Findings include: Resident #10 was admitted to the facility in April 2021 with diagnoses including dementia and osteoporosis. Review of Resident #10's significant change in status Minimum Data Set assessment, dated 2/22/22, indicated he/she had not experienced any falls including no falls with major injury. Review of Resident #10's nursing note, dated 2/16/22, indicated he/she had a fall and was transferred to the hospital for an evaluation. Review of Resident #10's hospital after visit summary, dated 2/16/22, indicated he/she had a facial fractures and a closed head injury. Review of Resident #10's nursing note, dated 2/16/22, indicated he/she returned from the hospital with fractures of the right sinus and right orbital area. During an interview on 1/4/23 at 4:00 P.M., the Director of Nursing said that Resident #10's MDS was not coded correctly.

Based on record review and interview, the facility failed ensure that one Resident (#56) of 25 sampled Residents, received treatment and care in accordance with professional standards of practice. Specifically, when nursing did not implement a physician's order dated 12/12/22 until 1/4/22 which indicated for nursing to discontinue sodium chloride tablets, Resident #56 continued to receive the sodium chloride tablets for approximately 24 days after the order should have been discontinued and his/her sodium level was not within normal range and was high. Finding include: Review of the facility policy, physician's orders, accepting, transcribing and implementing, dated as revised 1/11/16, indicated nursing will ensure orders will be recorded and implemented. The policy indicated that monthly physician's orders will be reviewed at the end of the month including the current physician's order sheets in the clinical record. Resident #56 was admitted to the facility in July 2021 with diagnoses including dementia. Review of Resident #56's Quarterly Minimum Data Set assessment, dated 12/8/22, indicated he/she usually could make self understood and that he/she usually understands others. Review of the Nurse Practitioner note, dated 11/9/22, indicated Resident #56 was found to have a sodium level of 131 (136-145 is normal range). The note indicated he/she was hyponatremic (low sodium level) and he/she would receive sodium chloride tablets. Review of Resident #56 physician's order dated 11/9/22, indicated sodium chloride tablets, administer 1 gram by mouth twice a day. Review of the Dietician's note, dated 12/8/22 indicated on 11/21/22 Resident #56's sodium level was 138. The note indicated the dietician left a note for the Nurse Practitioner to review labs. Review of Resident #56's physician's order, dated 12/12/22, indicated to discontinue sodium chloride tablets. Review of the Medication Administration Record, dated 12/12/22-1/4/22, indicated nursing continued to administer Resident #56 the sodium chloride tablets. 24 days after the physician's order to discontinue to sodium chloride tablets. Review of Resident #56's lab report, dated 1/2/23, indicated a sodium level of 148 (136-145) High . During an interview on 1/4/23 at 4:12 P.M., the surveyor and Unit Manager #3 reviewed the physician's order from 12/12/22 and reviewed the active physicians order for the sodium chloride tablets. The surveyor reviewed the high sodium level from 1/2/23. The Unit Manager said staff should have discontinued the sodium tablets. During an interview on 1/5/23 at 10:05 A.M., the Nurse Practitioner said that nursing should have discontinued the sodium chloride tablets back on 12/12/22. The NP said Resident #56's sodium level is elevated which was not good and because nursing did not discontinue the sodium chloride tablets that could have been the reason.

Based on observation, record review and interview, the facility failed to ensure staff assisted one Resident (#10) out of 25 total sampled Residents with follow up dental arrangements. Findings include: Resident #10 was admitted to the facility in April 2021 with diagnoses including dementia, osteoporosis and maxillary fracture. Review of Resident #10's quarterly Minimum Data Set assessment, dated 11/10/22, indicated he/she could usually make self understood and he/she usually understands others. The MDS indicated that he/she did not have dentures. Review of Resident #10's Nursing note, dated 4/26/21, indicated he/she was admitted with dentures. Review of Resident #10's Social Service note, dated 10/19/22, indicated he/she would see the dentist on 10/20/22. Review of Resident #10's consulting Dental note, dated 10/20/22, indicated he/she required a fabrication of a full upper and full lower dentures. During an observation on 1/3/23 at 10:40 A.M. Resident #10 was in his/her room. Resident #10 was edentulous (no teeth) and there was a denture adhesive on his/her bedside table. During an interview on 1/4/23 at 4:18 P.M., Unit Manager #3 said that she was not aware that Resident #10 required a follow up for the fabrication of dentures until Resident #10's activated Health Care Agent brought it to her attention around 12/25/22. Unit Manager #3 said she was not sure where the facility was in the process for replacing his/her dentures. During an interview on 1/4/23 at 4:27 P.M., The Assistant Director of Nursing (ADON) said that the Unit Managers are responsible for the oversite of consulting dental services. The ADON said she was not sure where Resident #10's dental replacement was but would follow up with Health Drive. During an interview on 1/5/23 at 9:24 A.M. Resident #10's activated Health Care Agent said she was not sure why she had not heard anything back about Resident #10's denture replacement. During an interview on 1/5/23 at 11:56 A.M., Nurse #4 said she was aware the Resident #10 needed his/her dentures replaced but she was not sure where the facility was in the process. During a follow up interview on 1/5/23 at 12:30 P.M., Unit Manager #3 said the facility just received the consent for dentures from the consulting dental provider. Unit Manager #3 said that she obtained verbal consent from Resident #10's activated Health Care Agent and was able to fax the consent to the consulting dental provider. Unit Manager #3 said that the facility should have obtained a consent back in October 2022 when the recommendation was made.

Based on record review and interview, the facility failed to maintain an accurate medical record related to medication administration for 1 Resident (#26) out of a total sample of 25 residents. Findings include: Review of the facility policy titled, Physicians Orders, Accepting, Transcribing and Implementing, dated as revised 1/11/16, indicated for licensed nurses to verify each order for completeness, clarity, and appropriateness. Resident #26 was admitted in 11/2022 with diagnoses including type 2 diabetes, hypertension, and a G tube feeding (gastrointestinal tube feeding; a tube that provides all nutrition). Review of the Medication Administration Record for December 2022 and January 2023 indicated that Resident #26 had received Hydroxyzine HCl (a medication used for itching), 25 milligrams, orally, twice daily. During an interview on 1/5/23 at 8:55 A.M., Nurse #2 said that Resident #26 takes all of his/her medications through the G-tube. Nurse #2 said that she administered Resident #26 Hydroxizine HCl this morning via the G-tube. Nurse #2 said the physician's order should not say administer orally but should say via the G-tube. During an interview on 1/5/23 at 9:00 A.M., Unit Manager #1 said that all of Resident #26's medications should be given through the G-tube. Unit Manager #1 said the physician's order should say to administer Resident #26's Hydroxyzine HCl via G-tube.

Based on observation, interview and policy review, the facility failed to ensure staff practiced appropriate hand hygiene and wore appropriate personal protective equipment (PPE) on 2 of 3 Resident units. Findings include: Review of the facility policy titled Donning and Doffing-COVID pandemic revised 3/9/22 indicated the following: *It is the policy of this facility to put on (donning) and to remove (doffing) personal protective in the correct sequence in accordance with the best approach to infection prevention and control. Proper procedure for donning (putting on) PPE. *Before entering a resident room, refer to signage outside the resident room door to indicate what level of PPE is required. *Before entering an isolation room, obtain new NIOSH-approved N95 respirator and ensure it is on. *Face shield is required when going into isolation rooms, follow the sign at the door. *Collect the correct PPE indicated. *Perform hand hygiene by using alcohol-based hand rub, soap and water for 20 seconds. *Don isolation gown and secure all fasteners. *Apply gloves, covering the cuffs of the gown Proper sequence for doffing(removing) PPE. *Remove gloves taking care not to contaminate hands. *The gown is removed next, removing the gown away from body in a manner to prevent contamination. *Place gown in proper receptacle, if reusable gown is used, once removed, place in soiled laundry container identified for reusable gowns. *Perform hand hygiene when exiting the room with alcohol-based hand rub. 1.) On 1/4/23 at 8:28 A.M., the surveyor observed Nurse #1 in the room of a COVID-19 positive Resident wearing an N95 masks, gown and gloves. Nurse #1 was not wearing eye protection. Nurse #1 exited the room at 8:31 A.M. During an interview with Nurse #1 on 1/4/23 at 8:37 A.M. she said she was not wearing eye protection because the Resident was asleep and not coughing. During an interview with the Infection Preventionist on 1/5/23 at 12:17 P.M. she said that Nurse #1 should have been wearing eye protection while in the room of a COVID-19 positive resident. 2.) On 1/3/23 at 8:30 A.M., CNA #5 was observed going into a room with COVID-19 positive Resident to drop off his/her breakfast tray. CNA #5 did not perform hand hygiene prior to room entry and did not don a gown. After CNA #5 dropped off the tray, she left the room and went across the hallway to retrieve personal protective equipment. Without performing hand hygiene CNA #5 pulled open a drawer and removed a gown and a face shield. CNA #5 then donned the gown but did not tie the back of her gown, donned gloves, went back into the Resident's room and then put on a face shield. CNA #5 then waited for another CNA to help boost the Resident. After boosting the Resident, CNA#5 exited the room then removed all of the PPE. CNA #5 did not perform any hand hygiene then opened the drawer to the PPE cart across the hall and pulled out and donned a new N95 mask. During an interview with CNA #5 on 1/3/23 at 8:39 A.M., CNA #5 said she should have worn a gown and tied it prior to entering Resident #27's room, performed hand hygiene prior to room entry and before wearing gloves. CNA #5 also said she should have performed hand hygiene after doffing all her PPE and before putting on a new N95 mask. During an interview with the Unit Manager (UM) #5 on 1/3/23 at 8:55 A.M., she said staff should wear PPE appropriately prior to room entry, perform hand hygiene prior to wearing gloves and after removing gloves. She said that staff should also perform hand hygiene prior to donning new PPE. During an interview with the infection prevention nurse on 1/4/23 at 12:40 P.M., she said staff are supposed to wear PPE appropriately, perform hand hygiene prior to and after the removal of gloves.

3.) For Resident #56 the facility failed to ensure that a). he/she had padding to his/her wheel chair and b). that he/she received a two person assist for care. Resident #56 was admitted to the facility in July 2021 with diagnosis including dementia with behavioral disturbances. Review of Resident #56's Quarterly Minimum Data Set assessment, dated 12/8/22, indicated he/she usually could make self understood and that he/she usually understands others. The MDS indicated he/she was totally dependent and required two staff members for bed mobility, transfers, toilet use, personal hygiene and bathing. a). Review of Resident #56's plan of care related to skin care, dated as initiated 11/1/22, indicated pad arms of chair that he/she sits in. During an observation on 1/3/23 at 10:56 A.M., Resident #56 was in his/her wheel chair and the arms of the wheel chair were not padded. During an observation on 1/4/23 at 8:49 A.M., Resident #56 was in his/her wheel chair and the arms of the wheel chair were not padded. During and interview on 1/4/23 at 4:33 P.M., the Assistant Director of Nursing said that Resident #56 required his/her wheel chair arms to be padded. On 1/4/23 at 4:43 P.M., the Surveyor observed Unit Manager #4 walking down the hall with a wheel chair bolster in her hand. Unit Manager #4 was observed going into Resident #56's room. Unit Manager #4 was observed trying to apply the bolster to Resident #65's wheel chair. Unit Manager #4 said she was told to apply padding to Resident #56's wheel chair. During an interview on 1/5/23 at 10:25 A.M., Unit Manger #3 said Resident #56 only had one padded side rail right now. Unit Manager #3 said they are waiting on another padded side rail to be delivered from the sister facility. b). Review of Resident #56's plan of care related to behaviors, dated as revised 11/17/22, indicated that he/she requires two person assistance with activities of daily living because he/she becomes combative during care. -On 1/4/23 at 9:47 A.M., Certified Nurse Aide (CNA) #1 was observed standing outside of of Resident 56's room. The surveyor observed a basin of water at the beside table. CNA #1 said she was providing care to Resident #1 alone and Resident #65 became combative and was yelling at her. CNA #1 said she left the room and went to find another staff member who told her that the Resident required a two person assist. CNA #1 said she did not get report about Resident #56, she said she did not know what Resident #56's care needs were. CNA #1 said she should have received report about Resident #56's care needs but she did not. During an interview on 1/5/23 at 10:27 A.M., CNA#4 said that Resident #56 is a two person assist for care. During an interview on 1/5/23 at 10:23 A.M., Unit Manger #3 said that CNA #1 told her that she was providing care to Resident #56 alone. Unit Manager #3 said that Resident #2 is a two person assist. 4.) For Resident #66 the facility failed to ensure nursing implemented a physician's order for compression (TED) stockings. Resident #66 was admitted to the facility in June 2021 with diagnoses including atrial fibrillation and peripheral vascular disease. Review of Resident #66's Minimum Data Set assessment, dated 12/17/22, indicated he/she was cognitively impaired and he/she was totally dependent on two staff members for dressing which includes application of TED stockings. Review of Resident #66's physician's order, dated 6/20/21, indicated for nursing to apply TED stockings daily on the day shift (7:00 A.M.- 3:00 P.M.). Review of Resident #66's Treatment Administration Record, dated 1/1/23 to 1/31/23, indicated that nursing applied his/her TED stockings on 1/3/23 and 1/4/24. During an observation on 1/3/23 at 10:44 A.M., Resident #66 was in activity room and his/her legs were visible. His/her legs were swollen and he/she was not wearing TED stockings. During an observation 1/4/23 at 12:21 P.M., Resident #66 was in bed and did not have TEDs on. During an observation 1/4/23 at 12:47 P.M., CNA #2 said Resident #66 did not have any TEDS on. CNA #2 said she was not aware that Resident #66 wore TEDs. During an observation on 1/4/23 at 4:22 P.M., Unit Manager #3 and the surveyor observed Resident #66 in bed. He/she did not have TEDs on. Unit Manager #3 was unable to find any TEDs in his/her room. During an interview on 1/5/23 at 10:18 A.M., CNA #3 said that Resident #66 wears TEDs. She said that she will apply the TEDs in the morning if she has TEDs. During an interview on 1/5/23 at 10:21 A.M., Unit Manger #3 said that if nursing documented the TEDs were applied they should have been on Resident #66. During an interview on 1/5/23 at 10:32 A.M., the Assistant Director of Nursing said that nursing should have applied Resident #66's TEDs. Based on record review, interview and observation, the facility failed to implement the plan of care for 4 Residents ( #65, #89, #56 and #66) out of a sample of 25 Residents. Findings include: 1. For Resident #65, the facility failed to ensure it implemented the plan of care for skin breakdown. Resident #65 was admitted to the facility in July 2012, with diagnoses including dementia. Review of Resident #65's Minimum Data Set (MDS) assessment, dated 10/6/22, indicated he/she required extensive staff assistance for bed mobility and transfers, was at risk for skin breakdown, and had severely impaired cognitive skills for daily decision making. Resident #65 plan of care for skin breakdown, related to unsteady gait, incontinence, and limited mobility, dated 7/21/22, indicated: - weekly skin checks - report pink, red or open areas to nurse Resident #65's physician's orders, dated 12/30/22, indicated: - Air mattress every shift, air mattress to be set at 2-3. Check every shift. During observations of Resident #65's air mattress and air pump setting on 1/3/22 at 9:45 A.M., the pressure was set to 5. Resident #65 was lying in bed, resting. During observations of Resident #65's air mattress and air pump setting on 1/4/22 at 10:09 A.M. and at 1:36 P.M., the pressure was set to 5. Resident #65 was lying in bed and resting at these times. During an observation of Resident #65's air mattress and air pump setting on 1/5/22 at 7:20 A.M., the pressure was set to 5. Resident #65 was dressed and sitting in a bedside chair, awake. On 1/5/23 at 7:25 A.M., the surveyor and Unit Manager #3 observed Resident #65's air mattress and pump setting and that it was set for 5. Unit Manager #3 said she believed the pressure was supposed to be set to either 2 or 3, but would confirm the order. Unit Manager #3 said Resident #65 recently recovered from a pressure injury to the coccyx and was still at risk for skin breakdown. 2. For Resident #89, the facility failed to ensure it implemented the plan of care for fall risk. Resident #89 was admitted to the facility in March 2022, and had diagnosis which included dementia. Review of Resident #89's Minimum Data Set assessment, dated 11/24/22, indicated he/she had severely impaired cognition for daily decision making, required extensive staff assistance for bed mobility and transfers, used a walker, and had a recent history of falls. Review of Resident #89's care plan for fall risk, revised December 2022, indicated he/she was at risk due to severe cognitive deficits, dementia, poor safety awareness, a recent history of falling and medication that affect gait and balance. Interventions included: Non-skid strips on floor next to bed. Review of Resident #89's Falls Incident Report, dated 12/6/22, indicated he/she fell in the bedroom and sustained a bruise to the head and pain to the right side of the body. The Report indicated an immediate new intervention was to apply non-skid strips to the floor at bedside. Review of Resident #89's Fall Risk Assessment, dated 12/31/22, indicated he/she fell in the bedroom on this date, with no injuries. During an observation on 1/3/23 at 10:50 A.M., non-skid strips were not applied to the floor. Resident #89 was lying in bed. During an observation on 1/4/23 at 10:49 A.M., non-skid strips were not applied to the floor. Resident #89 was not present in the bedroom. During an observation on 1/5/22 at 7:34 A.M., there were no non-skid strips applied to the floor. Resident #89 was lying in bed. On 1/5/22 at 7:40 A.M., the surveyor and Unit Manager #3 entered Resident #89's bedroom and observed that there were no non-skid strips applied to the floor. Unit Manager #3 said Resident #89 was at risk for falls, and that maintenance staff needed to install these as soon as possible.