Every finding on record at Center for Rehabilitation at Hampton Woods the

Based on observation, interview and review of facility policy, the facility failed to ensure proper storage of clean Hoyer lift pads (slings designed to cradle a person who is being transferred with a mechanical lift device). This had the potential to affect all residents in facility. The facility census was 21.Findings include:Observation of the dirty laundry room (the enclosed room where the soiled linen is stored, sorted, and washed) on 12/30/25 at 10:33 A.M. revealed clean Hoyer lift pads were stored on hook beside commercial washer on the dirty laundry side of the laundry room.Interview with Laundry Supervisor #135 on 12/30/25 at 10:33 A.M. confirmed the Hoyer pads hanging on the hook beside the commercial washing machines were clean. During the interview, Laundry Supervisor #135 stated that the proper storage site is in the clean laundry room (the adjacent room where clean laundry is brought to be dried, folded or hung to dry, then packed on linen carts to bring to the clean linen closets on the units) and that staff had been told several times that they were not to hang the clean Hoyer lift pads in the dirty laundry room.Interview with Housekeeper #33 on 12/30/25 at 3:10 P.M. revealed she put the Hoyer lift slings that were handing beside the commercial washer in the dirty linen room onto the clean linen closet. Review of the undated laundry policy, Procedure D, titled Drying of washed linens and personal revealed that clean items were to be taken to the dryer room (clean laundry area) and dried items were to be taken to the folding room.

Based on observation, interview, record review and review of facility policy, the facility failed to ensure the commercial dryer was free from excessive lint build-up. This had the potential to affect all residents in facility. The facility census was 21.Findings include:Observation and interview with Laundry Supervisor #135 on 12/30/25 at 10:35 A.M. confirmed lint compartment on commercial dryer had quite a bit of lint and that it appeared to not have been cleaned out prior to use on 12/30/25. Laundry Supervisor #135 indicated that the lint compartment was to be cleaned twice each shift with staff initialing the sign off log located beside commercial dryer once a shift.Review of dryer lint log on 12/30/25 at 10:35 A. M. revealed it contained laundry staff initials of Laundry Supervisor #135 on 12/29/25 as having completed the lint cleaning for 12/29/25; however, during the observation and interview on 12/30/25 at 10:35 A.M., Laundry Supervisor #135 confirmed that it had not been cleaned out properly prior to being used on 12/30/25.Review of the undated laundry policy, Procedure D, titled Drying of washed linens and personal revealed that laundry staff were to clean lint from the dryers each shift and that clean linen and supplies were to be delivered to linen supply closets daily.

Based on observation, record review, interviews and facility policy review, the facility failed to ensure food was safely stored and dated in both the kitchenette and the main facility kitchen. The facility also failed to maintain biannual cleaning of the hood system. This had the potential to affect all 21 residents residing in the facility. The facility identified all 21 residents as receiving food from the kitchen. Findings include:1. Observation of the kitchenette on 12/29/25 from 8:27 A.M. to 8:37 A.M. with Food Service Supervisor (FSS) #97 revealed sitting on a tray on top of the microwave was one 24-ounce container of Mrs. [NAME] Maple Syrup open to air due to the flip top part of the cap was missing. In the refrigerator, there was one five-pound container of cottage cheese half full with a best buy date of 12/18/25. At the time of observation FSS #97 confirmed the maple syrup was open to air, and the cottage cheese was outdated and should have been thrown away. Observation of the main kitchen on 12/29/25 from 8:39 A.M. to 9:07 A.M. with FSS #97 revealed in the dry storage area of the main kitchen was one bag (approximately 12 ounces) of miniature marshmallows open to air and not dated, one undated five-pound bag half full of elbow macaroni resealed, and one two and a half pound bag of opened Oreo cookie pieces resealed and undated. In the walk-in refrigerator located in the dry storage area was one half gallon container of lactose free milk with a best buy date of 12/27/25. FSS #97 confirmed areas of concern and stated all items should have been sealed and dated, and items should be used by the best buy date. Review of the undated facility policy titled Food Purchasing and Storage revealed all food items will be properly dated and labeled and placed in containers with lids or will be wrapped. This policy did not address outdated food items. 2. Observation of the main kitchen on 12/29/25 from 8:39 A.M. to 9:07 A.M. with FSS #97 revealed a sticker on the hood which indicated the hood system was last cleaned on April 2025 and was due to be cleaned on October 2025. FSS #97 confirmed that the hood was supposed to be cleaned in October 2025, but the vendor cancelled and cleaning had not been rescheduled. Review of the Kitchen Hood Fire Suppression System log for 2025 confirmed the professional hood cleaning company had completed the semiannual cleaning of the kitchen hood in April 2025 and there had been no other professional cleaning through 12/29/25. Interview on 12/29/2025 at 11:15 A.M. with Dietary Technician Registered (DTR) #140 confirmed the kitchen hood was last cleaned in April 2025 and should be cleaned every six months. DTR #140 stated there was no facility policy for hood cleaning.

Based on record review, interview, and review of the facility policies, the facility failed to develop and implement baseline care plans that include dates of completion/implementation, goals, instructions, and necessary interventions to be able to provide effective and person-centered care for Residents #17, #20, #31, #32, #33, #34, and #36. This affected seven residents (#17, #20, #31, #32, #33, #34, and #36) out of 15 residents whose care plans were reviewed. The facility census was 21.Findings include:1. Review of the medical record for Resident #20 revealed an admission date of 12/17/25 with diagnoses including periprosthetic fracture around the internal prosthetic left hip joint, generalized muscle weakness, difficulty in walking, gastroesophageal reflux disease (GERD) without esophagitis, neuromuscular dysfunction of the bladder, presence of unspecified artificial hip joint, anxiety disorder, essential (primary) hypertension, hypothyroidism, unspecified glaucoma, stage three chronic kidney disease, Parkinson's disease without dyskinesia, depression, vertigo of central origin, unspecified macular degeneration, pain, and falls. Review of the falls risk assessment completed on 12/18/25 revealed a score of 10 (10 or above represents a high risk for falls). Further review of the falls risk assessment revealed Resident #20 was intermittently confused, experienced one to three falls in the past three months, and required assistive devices. The admission Minimum Data Set (MDS) 3.0 assessment was in progress. Review of the physician's orders revealed Resident #20 had no orders related to fall precautions or non-pharmacological pain interventions. Further review of the medication orders revealed orders dated 12/24/25 for Resident #20 to receive the following medications: oxycodone hydrochloride (HCL) (an opioid pain reliever) 5 milligrams (mg) by mouth every six hours as needed for pain for seven days, Eliquis (an anticoagulant) 5 mg by mouth two times a day for atrial fibrillation, and Ativan (an antianxiety medication) 1 mg by mouth two times a day for anxiety. Review of the resident baseline care plan dated 12/18/25 to 12/29/25 revealed Resident #20 had a history of falls with a recent left hip open reduction and internal fixation (ORIF), a surgical procedure to fix severe bone fractures by realigning broken bone fragments and stabilizing them internally with hardware like plates, screws, rods, or pins, and included no interventions or safety precautions to prevent future falls. Review of the medication section of the baseline care plan listed that Resident #20 was on a prescribed pain regimen but did not indicate the prescribed regimen included an opioid and included no other pain related interventions. The medication section included no documentation that Resident #20 received a psychotropic medication or an anticoagulant and included no interventions for staff to assess for effectiveness or adverse effects. Review of the pain tool completed on 12/20/25 revealed Resident #20 had pain described as Hurts a Whole Lot on the faces pain scale, and that the pain was exacerbated by movement. Aside from prescribed opioid, the pain tool revealed that Resident #20 indicated pain relief measures included rest, ice, and repositioning (which was not included on the baseline or the comprehensive care plans). Interview on 12/30/25 at 5:04 P.M. with the Director of Nursing (DON) confirmed that the medication section of the baseline care plan dated 12/18/25 did not indicate Resident #20 received opioid medications, and that there were no interventions related to pain management, including non-pharmacological interventions and assessing for side effects of opioids. Further interview with the DON related to fall precautions revealed that it was the facility's stance that if a resident did not have a fall while in the facility, fall interventions would typically not be put into place, though the DON also confirmed that residents who came to the facility after a fall with injury would most likely be at high risk for falls. During the interview, the DON also confirmed that Resident #20's care plan made no indication that Resident #20 was taking an anticoagulant or a psychotropic medication and that perhaps they were ordered after the baseline care plan was first developed, and it was not updated. Review of the undated policy titled Psychotropic Medication Use revealed residents who received any type of psychotropic medication were required to have adequate monitoring for response to treatment and adverse side effects and should have appropriate behavioral and/or non-pharmacological interventions in place to aide in resident needs and permit the lowest possible dose to meet psychosocial needs Review of the policy titled Resident Care Plan, last revised May 2020, revealed the baseline care plan was to be used until the comprehensive care plan was developed (on or before day 21 of admission) to help each resident maintain their highest practical level of mental, physical, and psychosocial well-being. The baseline care plan was to include goals and interventions that addressed all the following, but not limited to, assistance needed for activities of daily living (ADL), problems related to diagnoses and physician orders, psychosocial well-being, safety concerns, preventative care, and problems related to physical, mental, or behavioral problems. According to the policy, the resident care card, which directed nursing interventions, only contained information related to ADL. 2. Review of the medical record for Resident #31 revealed an admission date of 12/24/25 with diagnoses including other fracture of upper and lower end of the right fibula, other injury of unspecified body region, type two diabetes mellitus with diabetic chronic kidney disease, atherosclerotic heart disease, bilateral primary open-angle glaucoma, heart failure, major depressive disorder, GERD, hypotension, unspecified fall, unspecified atrial fibrillation, hyperlipidemia, and hypertension. Review of the falls risk assessment completed on 12/24/25 revealed a score of 14 (a score above 10 indicates a high risk for falls). Further review of the falls risk assessment revealed Resident #31 was alert and oriented to person, place, and time, and sustained three or more falls in the past three months. The admission MDS 3.0 assessment was in progress. Review of Resident #31's resident care card dated 12/29/25 revealed the resident was alert and oriented times three (person, place, and time), Hoyer lift (a mechanical lift device) for transfers, and two person assist for bathing, personal hygiene, bathing, and toilet use. Review of the physician's orders dated 12/24/25 at 3:59 P.M. revealed Resident #31 was to receive oxycodone hydrochloride (HCL) oral tablet (an opioid analgesic) 5 mg by mouth every six hours as needed for pain for seven days, Eliquis oral tablet 5 mg by mouth two times a day for atrial fibrillation, escitalopram oxalate (an antidepressant) oral tablet 20 mg by mouth one time a day for depression. Further review of the medication orders revealed an order dated 12/26/25 at 9:00 A.M. for Resident #31 to start taking amoxicillin-potassium clavulanate oral tablet 875-125 mg (an antibiotic) one tablet by mouth two times a day for bronchitis for a total of 13 doses. Review of the undated resident baseline care plan revealed Resident #31 required total dependence for transfers, toileting, use of a Hoyer lift and standard wheelchair. Further review of the baseline care plan revealed a history of falls, and history of fall-related injury (right ankle fracture) with no interventions listed to prevent future falls. The baseline care plan also revealed no indication that Resident #31 was taking a psychotropic medication and there were no interventions related to opioid use, non-pharmacological pain interventions, or monitoring for adverse effects of psychotropic medication use. Interview on 12/30/25 at 5:04 P.M. with the DON confirmed that the medication section of the undated baseline care plan did not indicate interventions for Resident #31 related to the use of opioids or psychotropic medications. Further interview with the DON related to fall precautions revealed that it was the facility's stance that if a resident did not have a fall while in the facility, fall interventions would typically not be put into place, though the DON also confirmed that residents who came to the facility after a fall with injury would most likely be at high risk for falls. Review of the undated policy titled Psychotropic Medication Use revealed residents who received any type of psychotropic medication were required to have adequate monitoring for response to treatment and adverse side effects and should have appropriate behavioral and/or non-pharmacological interventions in place to aide in resident needs and permit the lowest possible dose to meet psychosocial needs Review of the policy titled Resident Care Plan, last revised May 2020, revealed the baseline care plan was to be used until the comprehensive care plan was developed (on or before day 21 of admission) to help each resident maintain their highest practical level of mental, physical, and psychosocial well-being. The base line care plan was to include goals and interventions that addressed all the following, but not limited to, assistance needed for ADL, problems related to diagnoses and physician orders, psychosocial well-being, safety concerns, preventative care, and problems related to physical, mental, or behavioral problems. According to the policy, the resident care card only contained information related to ADL. 3. Review of the medical record for Resident #34 revealed an admission date of 12/21/25 with diagnoses including depression, heart failure, acute kidney failure, primary hypertension, type two diabetes mellitus, congestive heart failure, and repeated falls. Review of the Nursing Admission/readmission Assessment-2023 completed on 12/21/25 revealed Resident #34 was alert and oriented to person, place, time, and situation, and was verbally appropriate. The admission MDS 3.0 assessment was in progress. Review of the physician's orders dated 12/21/25 at 5:06 P.M. revealed Resident #34 was to receive Paroxetine (an antidepressant medication) 20 mg by mouth once daily for depression and bupropion hydrochloride (HCL) extended release (ER/XL) 24-hour tablet (an antidepressant medication) one 300 mg tablet by mouth daily for depression. An additional medication order, dated 12/21/25 at 5:06 P.M., included apixaban 5 mg oral tablet (an anticoagulant/blood thinner) give 5 mg by mouth two times a day for atrial fibrillation. Review of the baseline care plan revealed the care plan was undated (no date of completion or date the care plan was reviewed with Resident #34). Further review of the baseline care plan revealed Resident #34 had a history of falls with no safety goals or fall interventions indicated on the care plan. The baseline care plan indicated Resident #34 was on an anticoagulant and needed monitored for signs and symptoms of uncontrolled bleeding. The psychotropic medication area of the care plan was blank. Review of the non-pharmacological orders revealed an order dated 12/21/25 indicating that nursing interventions were to be completed per the POC/Resident Care Card. There were no orders for Resident #34 to be assessed for abnormal bleeding or side effects related to anticoagulant use or the use of psychotropic medications. Review of the Resident Care Card (RCC) last updated 12/24/25 revealed Resident #34 was alert and oriented to person, place, and time, was on a scheduled to be assisted with turning in bed, required two staff for assistance with bed mobility and transfers, and one staff for locomotion in the wheelchair. Further review of the RCC revealed there was no information related to the use of an anticoagulant or psychotropic medications and no interventions in place for monitoring Resident #34 for adverse effects. Interview on 12/30/25 at 3:36 P.M. with Certified Nurse Aide (CNA) #24 revealed the aides knew what interventions residents needed by looking at the RCC. During the interview, CNA #24 confirmed not knowing who needed to be monitored for side effects of blood thinners (anticoagulants) or psychotropic medications and that the care cards did not contain information related to monitoring or reporting resident behaviors or side effects of medications. Interview on 12/30/25 at 3:45 P.M. with CNA #26 revealed the aides were not informed of what residents were on high-risk medications or who needs monitored for certain adverse effects of the high-risk medications and further confirmed that there was no area on the RCC to indicate when a resident needed monitored for adverse medication effects. Interview on 12/30/25 at 5:04 P.M. with the DON confirmed that the medication section of the undated baseline care plan did not indicate Resident #34 received psychotropic medications and that there were no interventions related to psychotropic medications. During the interview, the DON also confirmed residents on anticoagulants should have an order for nurses to sign-off as documentation that the resident was being assessed every shift for abnormal bleeding, but there was no such order in Resident #34's medical record. Further interview with the DON related to fall precautions revealed that it was the facility's stance that if a resident did not have a fall while in the facility, fall interventions would typically not be put into place, though the DON also confirmed that residents who came to the facility after a fall with injury would most likely be at high risk for falls. Review of the undated policy titled Psychotropic Medication Use revealed residents who received any type of psychotropic medication were required to have adequate monitoring for response to treatment and adverse side effects and should have appropriate behavioral and/or non-pharmacological interventions in place to aide in resident needs and permit the lowest possible dose to meet psychosocial needs. Review of the policy titled Resident Care Plan, last revised May 2020, revealed the baseline care plan was to be used until the comprehensive care plan was developed (on or before day 21 of admission) to help each resident maintain their highest practical level of mental, physical, and psychosocial well-being. The base line care plan was to include goals and interventions that addressed all the following, but not limited to, assistance needed for ADL, problems related to diagnoses and physician orders, psychosocial well-being, safety concerns, preventative care, and problems related to physical, mental, or behavioral problems. According to the policy, the resident care card only contained information related to ADL. 4. Record review revealed Resident #17 was admitted on [DATE] with diagnoses of encounter for surgical aftercare following surgery on the circulatory system, heart failure, unspecified, unspecified asthma, uncomplicated, muscle weakness (generalized), difficulty in walking, benign prostatic hyperplasia without lower urinary tract symptoms, GERD without esophagitis, hyperlipidemia, atrial fibrillation, type II diabetes mellitus with other diabetic neurological complication, essential (primary) hypertension, malaise, polyneuropathy, unspecified, acute myocardial infarction, presence of aortocoronary bypass graft, ventricular tachycardia, respiratory failure, unspecified whether with hypoxia or hypercapnia, sleep apnea, acute diastolic (congestive) heart failure, and critical illness myopathy. Review of the admission MDS 3.0 assessment dated [DATE] revealed Resident #17 had no cognitive impairment. Review of functional abilities revealed Resident #17 required maximal assistance with toileting, dressing, showers, and moderate assistance with transfers. Review of the baseline care plan revealed Resident #17 had baseline care plan on 12/11/25. No evidence was found in the record to indicate a baseline care plan ensured to include any documentation of any interventions to ensure Resident #17 could meet goals to discharge to community, become independent in functional goals and ensure completion dates on the baseline care plan. Interview on 12/30/25 at 3:43 P.M. with the DON and Regional Quality Measures (RQM) Nurse #3 confirmed the missing intervention and completion date documentation on the baseline care plan for Resident #17. Review of the policy titled Resident Care Plan, last revised May 2020, revealed the baseline care plan was to be used until the comprehensive care plan was developed (on or before day 21 of admission) to help each resident maintain their highest practical level of mental, physical, and psychosocial well-being. The base line care plan was to include goals and interventions that addressed all the following, but not limited to, assistance needed for ADL, problems related to diagnoses and physician orders, psychosocial well-being, safety concerns, preventative care, and problems related to physical, mental, or behavioral problems. According to the policy, the resident care card only contained information related to ADL. 5. Record review revealed Resident #32 was admitted on [DATE] with diagnoses of pyothorax without fistula, acute respiratory failure with hypoxia, pneumonia, unspecified organism, osteoarthritis, unspecified site, difficulty in walking, essential (primary) hypertension, arthropathic psoriasis, and other acute postprocedural pain. Review of the admission MDS 3.0 assessment dated [DATE] revealed it was in progress status for Resident #32, and no information was available. Review of the baseline care plan revealed Resident #32 had baseline care plan on 12/23/25. No evidence was found in the record to indicate a baseline care plan ensured to include any documentation of interventions to ensure Resident #32 could meet goals to discharge to community, become independent in functional goals and ensure completion dates on the baseline care plan. Interview on 12/30/25 at 3:43 P.M. with the DON and RQM Nurse #3 confirmed the missing interventions and completion date documentation on the baseline care plan for Resident # 32. Review of the policy titled Resident Care Plan, last revised May 2020, revealed the baseline care plan was to be used until the comprehensive care plan was developed (on or before day 21 of admission) to help each resident maintain their highest practical level of mental, physical, and psychosocial well-being. The base line care plan was to include goals and interventions that addressed all the following, but not limited to, assistance needed for ADL, problems related to diagnoses and physician orders, psychosocial well-being, safety concerns, preventative care, and problems related to physical, mental, or behavioral problems. According to the policy, the resident care card only contained information related to ADL. 6. Record review revealed Resident #33 was admitted [DATE] with diagnoses of wedge compression fracture of the fourth lumbar vertebra, subsequent encounter for fracture with routine healing, frequency of micturition, dorsalgia, paroxysmal atrial fibrillation, cardiomegaly, mixed hyperlipidemia, chronic atrophic gastritis without bleeding, chronic diastolic (congestive) heart failure, GERD without esophagitis, hypothyroidism, Vitamin D deficiency, essential (primary) hypertension, age-related osteoporosis without current pathological fracture, hyperuricemia without signs of inflammatory arthritis and tophaceous disease, prediabetes, bilateral primary osteoarthritis of knee, and other nonspecific abnormal finding of lung field. Review of the admission MDS 3.0 assessment dated [DATE] revealed Resident #33 had cognitive impairment. Review of functional abilities revealed Resident #33 required maximal assistance with toileting, dressing, showers, and moderate assistance with transfers. Review of the baseline care plan revealed Resident #33 had baseline care plan on 12/21/25. No evidence was found in the record to indicate a baseline care plan ensured to include documentation of any interventions to ensure Resident # 33 could meet goals to discharge to community and ensure completion dates on the baseline care plan. Interview on 12/30/25 at 3:43 P.M. with the DON and RQM Nurse #3 confirmed the missing interventions and completion date documentation on the baseline care plan for Resident # 33. Review of the policy titled Resident Care Plan, last revised May 2020, revealed the baseline care plan was to be used until the comprehensive care plan was developed (on or before day 21 of admission) to help each resident maintain their highest practical level of mental, physical, and psychosocial well-being. The base line care plan was to include goals and interventions that addressed all the following, but not limited to, assistance needed for ADL, problems related to diagnoses and physician orders, psychosocial well-being, safety concerns, preventative care, and problems related to physical, mental, or behavioral problems. According to the policy, the resident care card only contained information related to ADL. 7. Review of the medical record for Resident #36 revealed an admission date of 12/24/25 with diagnosis including non-infective gastroenteritis and colitis, acidosis, elevated white blood cell count, nausea with vomiting, diarrhea, and sepsis. Review of the Brief Interview for Mental Status (BIMS) evaluation dated 12/26/25 revealed Resident #36 had intact cognition. Review of Resident #36's care card dated 12/26/25 revealed the resident required assistance of one staff member for bed mobility, transfers, ambulating, dressing, toilet use, personal hygiene, and bathing. The resident was incontinent of bowel and bladder and required a pressure reduction mattress and wheelchair gel pad cushion. Review of Resident #36's undated baseline care plan revealed under that area of skin concerns revealed the only two interventions were to turn and reposition and cream buttock. Further review of the interventions under skin concerns revealed there was no specialty mattress or wheelchair cushion intervention listed. There was no documented evidence of when the baseline care plan was completed. Interview with RQM Nurse #3 on 12/30/25 at 5:00 P.M. confirmed there was no completion date for Resident #36's base line care plan and pressure reducing mattress and gel pad wheelchair cushion mattress interventions to help keep skin intact had not been listed on the baseline care plan for Resident #36. Review of the policy titled Resident Care Plan, last revised May 2020, revealed the baseline care plan was to be used until the comprehensive care plan was developed (on or before day 21 of admission) to help each resident maintain their highest practical level of mental, physical, and psychosocial well-being. The base line care plan was to include goals and interventions that addressed all the following, but not limited to, assistance needed for ADL, problems related to diagnoses and physician orders, psychosocial well-being, safety concerns, preventative care, and problems related to physical, mental, or behavioral problems. According to the policy, the resident care card only contained information related to ADL.

Based on record review, interview and facility policy review, the facility failed to develop a person-centered care plan for Resident #22. This affected one resident (#22) out of 15 residents reviewed for care plans. The facility census was 21.Findings include:Review of the medical record for Resident #22 revealed an admission date of 11/15/25 with diagnoses including abscess of the liver, cerebral infarction (stroke), atherosclerotic heart disease, cognitive communication deficit, neoplasm (tumor) of liver, non-ST elevation myocardial infarction (heart attack).Review of Resident #22's Fall Risk Assessments dated 11/15/25 revealed the resident was assessed to be a high fall risk.Review of Resident #22's care plan, initiated on 11/18/25, didn't address the resident was a high risk for falls. Review of facility document titled Investigation Report Record, dated 11/23/25, revealed while Resident #22 was sitting on the edge of the bed, the resident slid off the bed onto the floor with a new intervention to place bed in low position while the resident was in bed.Review of the discharge return anticipated Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #22 was independent for daily decision making and required partial/moderate assistance from staff for chair/bed to chair transfer, toilet transfer, sit to stand, and walking ten feet.Review of Resident #22's Fall Risk Assessments 12/15/25 revealed the resident was assessed to be a high fall risk.Review of the Investigation Report Record, dated 12/15/25, revealed on 12/15/25 Resident #22 reported to a certified nursing assistant (CNA) that she had fallen this A.M. since her legs were not working right. The resident was assessed to have no injuries; however, the physician ordered the resident to be sent to the emergency room for further evaluation.Review of the Investigation Report Record, dated 12/16/25, revealed an unidentified nurse was walking up hallway and noticed Resident #22 sitting on the floor in front of her wheelchair. The resident stated she slid out with a new intervention placing Dycem (a nonslip material) to the seat of the wheelchair.Review of Resident #22's Fall Risk Assessments 12/22/25 revealed the resident had was to be a high fall risk.Review of Resident #22's care plan, last revised on 12/30/25, didn't address the resident was a high risk for falls and/or that she had three falls since admission. Additionally, there were no interventions listed in the care plan to help prevent any future falls.Interview on 12/30/25 at 3:17 P.M. with the Director of Nursing (DON) confirmed the care plan for Resident #22 hadn't addressed the resident was at a high risk for falls and had falls since admission, and the fall prevention interventions of bed in low position while the resident was in bed or Dycem to the seat of the wheelchair hadn't been listed in the care plan and should have been.Review of the facility policy Resident Care Plans, revised May 2020, revealed the care plan serves to assist in assessing the resident and establishing a formal plan to reach or maintain the resident's highest practicable level of physical well-being. The resident care plan is the tool used to coordinate all care provided to the resident to be sure care is necessary, appropriate, and planned to meet the individual needs of the resident consistent with the physician's plan of care. The care plan must be reviewed and evaluated for effectiveness and revised (updated) as necessary, but at least every three months.

Based on record review, observation, interview and facility policy review, the facility failed to provide nutritional supplements as ordered by the physician to Resident #22. This affected one resident (#22) out of three residents reviewed for nutrition. The facility census was 21.Findings include:Review of the medical record for Resident #22 revealed an admission date of 11/15/25 with diagnoses including abscess of liver, type two diabetes mellitus with hyperglycemia (unusually high amount of glucose present in blood), cerebral infarction (stroke), atherosclerotic heart disease, cognitive communication deficit, neoplasm (tumor) of liver, and non-ST elevation myocardial infarction (heart attack).Review of 12/08/25 discharge return anticipated Minimum Data Set (MDS) 3.0 assessment revealed Resident #22 was independent for daily decision making, was independent for eating, and had a nonprescribed weight loss and was on a therapeutic diet.Review of Resident #22's 12/29/25 Minimum Data Set (MDS) Medicare five-day assessment and 12/18/25 MDS Medicare five day/End of PPS part A stay assessment revealed both assessments were still in progress.Review of meal intakes from 12/01/25 to 12/30/25 revealed Resident #22 consumed 26-75% of most meals.Further review of Resident #22's medical record revealed the resident had experienced a 24.6 pound (17.3%) weight loss from 11/30/25 when the resident weighed 141.6 pounds to 12/30/25 when the resident weighed 117.0 pounds.Continued review of Resident #22's medical record revealed a progress note dated 12/28/25 and authored by Dietitian #141 which confirmed the resident had a significant weight loss of 17.1% weight loss for one month with a recommendation to increase Glucerna (nutritional supplement) from two times a day to three times a day with meals. Another progress note dated 12/29/25 and authored by Dietitian #141 revealed the dietitian was recommending Magic Cups (nutritional supplement) with lunch and dinner.Review of physician orders for Resident #22 revealed an order dated 12/28/25 for Glucerna with all meals and an order dated 12/29/25 for Magic Cups two times a day.Observation on 12/30/25 at 8:29 A.M. revealed a container of Ensure Plus (nutritional supplement) sitting on the overbed table of Resident #22. At the time of observation, Certified Nursing Assistant (CNA) #145 revealed she had placed the supplement on the overbed table and confirmed the supplement was Ensure Plus.Observation on 12/30/25 at 8:50 A.M. revealed Resident #22 had drunk all her Ensure Plus supplement, which the resident confirmed at the time of the observation.Observation on 12/30/25 at 5:30 P.M. revealed the resident had been served a meal tray consisting of potato soup, crackers, applesauce, and a Glucerna supplement. There was no Magic Cup on the meal tray. Interview with CNA #145 confirmed there was no Magic Cup on the meal tray and stated the kitchen staff were responsible for adding the Magic Cup to the meal trays.Review of the meal ticket for Resident #22 with CNA #145 at the time of observation on 12/30/25 at 5:30 P.M. revealed the resident was to receive a Glucerna supplement with all meals but there was no indication on the meal ticket the resident was to receive Magic Cups at lunch and dinner, which CNA #145 confirmed at the time of the observation.Interview on 12/31/25 at 8:44 A.M. with Dietitian #141 confirmed Resident #22 had lost a significant amount of weight since admission. She stated since the resident was drinking her Glucerna well she had increased the supplement to all meals, and, since the resident and her family had indicated she had liked the special ice cream she had received in the past, she recommended to add Magic Cups to lunch and dinner. Dietitian #141 confirmed Resident #22 should have been receiving supplements as ordered.Review of undated facility policy titled Nutritional Supplements revealed residents are to receive supplements as ordered.

Based on record review, observation, interviews and facility policy review, the facility failed to ensure fall prevention interventions were in place for Resident #22, who was at high risk for falls and had a history of falls at the facility. This affected one resident (#22) out of two residents reviewed for accidents. The facility census was 21.Findings include:Review of the medical record for Resident #22 revealed an admission date of 11/15/25 with diagnoses including abscess of the liver, cerebral infarction (stroke), atherosclerotic heart disease, cognitive communication deficit, neoplasm (tumor) of liver, non-ST elevation myocardial infarction (heart attack).Review of Resident #22's Fall Risk Assessments dated 11/15/25 revealed the resident was assessed to be a high fall risk.Review of Resident #22's care plan, initiated on 11/18/25, didn't address the resident was a high risk for falls. Review of facility document titled Investigation Report Record, dated 11/23/25, revealed while Resident #22 was sitting on the edge of the bed, the resident slid off the bed onto the floor with a new intervention to place bed in low position while the resident was in bed.Review of the discharge return anticipated Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #22 was independent for daily decision making and required partial/moderate assistance from staff for chair/bed to chair transfer, toilet transfer, sit to stand, and walking ten feet.Review of Resident #22's Fall Risk Assessments 12/15/25 revealed the resident was assessed to be a high fall risk.Review of the Investigation Report Record, dated 12/15/25, revealed on 12/15/25 Resident #22 reported to a certified nursing assistant (CNA) that she had fallen this A.M. since her legs were not working right. The resident was assessed to have no injuries; however, the physician ordered the resident to be sent to the emergency room for further evaluation.Review of the Investigation Report Record, dated 12/16/25, revealed an unidentified nurse was walking up hallway and noticed Resident #22 sitting on the floor in front of her wheelchair. The resident stated she slid out with a new intervention placing Dycem (a nonslip material) to the seat of the wheelchair.Review of Resident #22's Fall Risk Assessments 12/22/25 revealed the resident had was to be a high fall risk.Review of Resident #22's care plan, last revised on 12/30/25, didn't address the resident was a high risk for falls and/or that she had three falls since admission. Additionally, there were no interventions listed in the care plan to help prevent any future falls.Interview on 12/30/25 at 7:31 A.M. with Resident #22 revealed she thought she had fallen twice since being a resident at the facility. She indicated for one of her falls she reached too far for something and fell out of her wheelchair. She stated sometimes the facility staff would place Dycem on the seat of her wheelchair to help prevent her from falling out of the wheelchair, but there were other times when the Dycem was not placed on the seat of her wheelchair. She was unaware of any other interventions which had been put into place to help prevent any future falls. Observation at the time of the interview revealed Resident #22 was in bed, and the bed was not in the lowest position and the blue Dycem was lying on the armrest of a chair in the resident's room. Resident #22's wheelchair was in the bathroom, and there was no Dycem on the seat of the wheelchair.Observation on 12/30/25 at 11:29 A.M. revealed Resident #22 was sitting in a wheelchair. There was no Dycem on the wheelchair, and the Dycem remained on the armrest of a chair in the resident's room.Interview on 12/30/25 at 12:30 P.M. with CNA #145 revealed if a resident had fall interventions, they would be listed on a sheet of paper in a blue folder at the nurse's station or on the resident's care card located in the care card binder in the wall cabinet located at the nurse's station. CNA #145 confirmed the only two places she would look for fall interventions would be the blue folder or the resident's care card. CNA #145 indicated Resident #22 had no fall interventions and confirmed Resident #22's bed was at normal height when she was in bed, and there was no Dycem on her wheelchair. Observation of the blue folder and the care card binder at the time of the interview with CNA #145 revealed there were no interventions documented in the folder for Resident #22, and there were no fall interventions listed on the 12/23/25 care card for Resident #22, which was confirmed by CNA #145 at the time of observation.Interview on 12/30/25 at 1:31 P.M. with Licensed Practical Nurse (LPN) #41 revealed she would go into a resident's chart to look for any orders for fall interventions to determine if a resident needed any fall interventions. She indicated Resident #22 was a stroke victim and she believed she would have fall interventions in place, but she would need to look at the chart to determine what fall interventions had been put into place for Resident #22.An additional interview on 12/30/25 at 2:58 P.M. with LPN #41 revealed she had just got done looking through Resident #22's chart and the only fall intervention which she saw had been put into place for Resident #22 was Dycem to the wheelchair.Interview on 12/30/25 at 3:17 P.M. with the Director of Nursing (DON) revealed she would initially fill out an intervention sheet when new fall interventions had been initiated for a resident and would place the sheet in the blue folder at the nurse's station until the resident's care card could be updated. She indicated staff were to look at both the blue folder and the resident's care card for fall interventions for residents. The DON confirmed currently there was no intervention paper for Resident #22 in the blue folder, and Resident #22's care card dated 12/23/25 did not indicate the resident's bed should be in low position while in bed and Dycem should be placed on the seat of the resident's wheelchair. She also confirmed Resident #22's bed should have been in low position while the resident was in bed and Dycem should have been applied to the seat of the resident's wheelchair.Review of the facility policy titled Falls, revised June 2025, revealed the supervisor will evaluate the interventions that should be in place to prevent any further occurrence. The interdisciplinary team will review all falls for appropriate intervention/implementation to prevent further events and/or injuries.

Based on record review, interview, and facility policy review the facility failed to notify Resident #12's physician that he had an active infection and was currently being isolated before sending him to an appointment at the physician's office. This affected one resident (#12) of three residents reviewed for infection control. The facility census was 23. Findings include: Review of the medical record for Resident #12 revealed an admitted [DATE]. Diagnoses included congestive heart failure, type two diabetes mellitus, and diarrhea unspecified. Review of the hospital information sent to the facility on admission, printed on 03/19/24 revealed Resident #12 had a positive stool for clostridioides difficile (c-diff) on 03/14/24. Resident #12 was started on oral vancomycin 250 milligrams (mg) (antibiotic) four times daily on 03/19/24. Review of the physician's order dated 03/20/24 and discontinued on 04/02/24 revealed Resident #12 was to remain in contact isolation for c-diff. Review of the physician's order dated 03/20/24 and ended on 04/02/24 revealed an order to administer vancomycin 250 mg by mouth to Resident #12 four times a day for c-diff. Review of the care plan for Resident #12 dated 03/20/24 revealed he had an infection. Interventions included to administer medications as ordered and to provide perineal care after each incontinent episode. Review of the transfer for Resident #12 dated 03/21/24 revealed he was leaving for an appointment at a physician's office. No diagnoses were listed on the form, just emergency contact information. At the bottom of the form where the physician writes a response, the physician left a note questioning the facility for sending a patient to his office with an active c-diff diagnosis. The form was signed by the physician. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #12 had intact cognition. Resident #12 required some help of another person for self-care and was independent for ambulation with or without a device. Resident #12 was occasionally incontinent of urine and bowel. He had also received an antibiotic in the past seven days. Interview on 04/12/24 at 10:00 A.M. with the Director of Nursing (DON) confirmed Resident #12 was admitted to the facility late on 03/19/24. He had been diagnosed with c-diff in the hospital and began vancomycin treatment on 03/17/24. The DON confirmed Resident #12 was in contact isolation from the time of admission until the order was discontinued on 04/02/24. She reported Resident #12 did go to an outside physician's appointment on 03/21/24 but at the time Resident #12 was not having any loose stools and had no fever. She confirmed the facility sent Resident #12 but did not notify the physician of the diagnosis or his current condition prior to sending him to the appointment. Review of the undated facility policy titled isolation of a resident with infectious disease revealed residents are transported as follows, appropriate barriers such as masks and impervious dressing are used to prevent transmission of organisms when isolated residents leave their rooms, the facility is to notify personnel in the area to which the resident is to be taken if precautions are to be used, and if the transport vehicle is contaminated with infectious material, do not remove the vehicle from the room until disinfected by environmental services. This deficiency represents non-compliance investigated under Complaint Number OH00152318.

Based on record review, staff interview, and facility policy review the facility failed to provide residents and/or resident representatives of bed hold notice and/or bed hold policy upon discharge to the hospital. This affected four residents (#3, #11, #14, and #26) of four residents reviewed for hospitalization s. The facility census was 17. Findings include: 1. Review of the medical record for Resident #3 revealed admitted [DATE] and a discharge date of [DATE] with diagnoses including pleural effusion (accumulation of excess fluid around the lungs), cystitis (inflammation of the urinary bladder), cerebral infarction (stroke), hemiplegia (paralysis) affecting left nondominant side and right dominant side, dysphagia (difficulty swallowing), diabetes mellitus, chronic kidney disease stage three, and systolic congestive heart failure, and depressive disorder. Review of the progress notes for Resident #3 revealed on 04/08/23 Resident #3 had increased edema to thighs and abdomen, and family had expressed concerns regarding the increase edema. The nurse practitioner was notified and gave an order to send Resident #3 to the emergency department. On 04/09/23, Resident #3 was admitted to the hospital with a diagnosis of pleural effusion. On 04/14/23, Resident #3 was readmitted to the facility from the hospital. A progress note dated 04/19/23 revealed Resident #3 felt an increase in shortness of breath and wanted to be sent to the emergency department. On 04/20/23, Resident #3 was admitted to the hospital with pleural effusion. Further review of the medical record for Resident #3 revealed no documented evidence of a bed hold notification and/or bed hold policy was provided to Resident #3 and/or Resident #3's representative when the resident was sent to the hospital on 04/08/23 and 04/19/23. 2. Review of the medical record for Resident #11 revealed an admitted [DATE] and a discharge date of [DATE] with diagnoses including gross hematuria (blood in urine), long term use of anticoagulants (blood thinners), permanent atrial fibrillation (abnormal heart rhythm), and cirrhosis (impaired function caused by formation of scar tissue) of liver. Review of the progress notes for Resident #11 revealed on 04/11/23 Resident #11 was complaining of abdominal pain, the Foley catheter (a flexible tube that passes through the urethra and into the bladder to drain urine) was noted to have blood-tinged urine in the bag, the Foley catheter was unable to be flushed, and the Foley catheter was removed. The doctor was notified and ordered Resident #11 sent to the emergency room . On 04/12/23, Resident #11 was admitted to the hospital for acute hematuria. Further review of the medical record for Resident #11 revealed no documented evidence of a bed hold notification and/or bed hold policy was provided to Resident #11 and/or Resident #11's representative when the resident was sent to the hospital on 04/11/23. 3. Review of the medical record for Resident #14 revealed admitted [DATE] and a discharge date of [DATE] with diagnoses including anxiety, atrial fibrillation (abnormal heart rhythm), congestive heart disease (heart failure), hypertension (high blood pressure), hyperlipidemia (high levels of lipids in the blood), and hyponatremia (low sodium levels in the blood). Review of the progress notes for Resident #14 revealed on 05/10/23 according to the lab report, Resident #14 had a low sodium level, and the nurse practitioner ordered Resident #14 be sent out to the emergency room for evaluation and treatment. Resident #14 was admitted to the hospital on 05/10/23 with a diagnosis of hyponatremia. Further review of the medical record for Resident #14 revealed no documented evidence a bed hold notification and/or bed hold policy was provided to Resident #14 and/or Resident #14's representative when the resident was sent to the hospital on 05/10/23. 4. Review of the medical record for Resident #26 revealed an initial admitted [DATE] and a discharge date of [DATE] with diagnoses including urinary tract infection, cognitive communication deficit, type two diabetes mellitus with hyperglycemia (high blood sugars) , hypertension, hyperlipidemia, chronic kidney disease stage three, and multiple fractures of pelvis. Review of the progress notes for Resident #26 revealed on 02/25/23 Resident #26 was observed in bed with a large coffee ground emesis and had a temperature of 104.3 degrees Fahrenheit. The doctor was notified and ordered Resident #26 sent to the emergency room for evaluation. On 02/26/23, Resident #26 was admitted to the hospital with a diagnosis of sepsis. Further review of the medical record for Resident #26 revealed no documented evidence of a bed hold notification and/or bed hold policy was provided to Resident #26 and/or Resident #26's representative when the resident was sent to the hospital on 02/25/23. Interview on 05/22/23 at 4:31 P.M. with the Administrator confirmed the facility did not send bed hold notification and/or bed hold policy upon transfer to the hospital since most residents would not be able to pay the bed hold cost, and the facility would normally hold the bed for them without charging them. Interview on 05/24/23 at 8:20 A.M. with the Administrator and Director of Nursing confirmed bed hold notices had not been sent as required when Residents #3, #11, #14, and #26 were sent to the hospital. Review of the undated facility policy titled Woodlands Bed Holds & Leave of Absence revealed the facility charged on a per day basis for each day the resident resided in the facility. If a resident were to leave the facility on an overnight basis, which included hospital stays, it would be considered a voluntary discharge, unless the resident elected to have the facility hold the bed so the resident may return to it. The routine per day basic rate would be charged for every day the resident was absent from the facility and if bed hold payments were not made, then a bed would not be held.

Based on record review, interview, and facility policy review the facility failed to ensure Resident #7's discharge assessment was submitted within 14 days after completion. This affected one resident (#7) of one resident reviewed for assessments. The facility census was 17. Findings include: Review of the medical record for Resident #7 revealed an admitted [DATE] and a discharge date of [DATE]. Medical diagnoses included diverticulitis (the inflammation or infection of small pouches) of large intestine, influenza, osteoarthritis of the right knee, moderate protein-calorie malnutrition, obsessive compulsive disorder, anxiety, gastro-esophageal reflux disease (stomach acid repeatedly flows back up into the esophagus), and hypercholesterolemia (high cholesterol levels in the blood). The Discharge Return Not Anticipated Minimum Data Set (MDS) assessment was completed with an assessment reference date of 12/27/22. Review of the facility batch status report dated 05/23/23 revealed Resident #7's Discharge Return Not Anticipated MDS assessment dated [DATE] was submitted and accepted on 05/23/23. Interview on 05/23/23 at 9:02 A.M. with Registered Nurse #504 verified Resident #7's Discharge Return Not Anticipated MDS assessment dated [DATE] was not submitted until 05/23/23, which was not within the required timeframe. Review of the facility policy titled Minimum Data Set , dated May 2015, revealed the MDS coordinator would transmit all completed assessments to the appropriate state agency in a timely manner in compliance with federal regulations.

Based on record review, interview, and facility policy review the facility failed to administer all doses of an antibiotic to treat a urinary tract infection for Resident #81. This affected one resident (#81) of three residents who were all receiving antibiotics for a urinary tract infection. Findings include: Review of the medical record for Resident #81 revealed an admitted [DATE]. Diagnoses included acute cystitis with hematuria, acute kidney failure, urinary tract infection (UTI), and cerebral infarction. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #81 had mild cognitive impairment. Resident #81 required limited one-person assistance for bed mobility, transfers, dressing, toilet use, and personal hygiene; and supervision with set up help only for eating. Resident #81 was always continent of urine and bowel. Review of the admission physician's order dated 05/12/23 revealed an order to administer Keflex (antibiotic) 250 milligrams every eight hours for infection for 20 administrations. Review of the initial care plan for Resident #81 dated 05/12/23 revealed she had a urinary tract infection and to administer her antibiotic as ordered. Review of nursing note dated 05/21/22 at 9:14 A.M. revealed Resident #81 was experiencing increased weakness and requiring more assistance with transfers and urinary frequency. Resident #81's antibiotics were discontinued on 05/19/23 for a urinary tract infection. Resident #81's physician was notified and a new order for stat lab work and urinalysis with culture and sensitivity. The nurse collected the urine sample via straight catheterization. Review of physician's order dated 05/21/23 for Resident #81 revealed an order for stat complete blood count and complete metabolic panel (lab work) and a urinalysis with culture and sensitivity. Review of the Medication Administration Record (MAR) for Resident #81 from 05/12/23 to 05/22/23 revealed Resident #81 received the Keflex three times a day from 05/13/23 to 05/18/23 and only one morning dose on 05/19/23. The total number of doses received was equal to 19. Interview on 05/21/23 at 10:04 A.M. with Resident #81 revealed she was admitted with a urinary tract infection and today she is feeling very weak. She reported she had finished her antibiotics, but she feels the infection was not completely treated. Interview on 05/22/23 at 10:00 A.M. with the Director of Nursing (DON) confirmed the Keflex for Resident #81 was only administered 19 times not the 20 doses that were ordered. She also confirmed Resident #81 became symptomatic again on 05/21/23. Review of the facility policy titled Medication Administration, effective May 2015, revealed the purpose is to ensure that all medications are administered safely and appropriately to aid residents to overcome illness, relieve pain, and prevent symptoms and help in diagnosis. A physician's order that indicates dosage, route, frequency, duration, and other required considerations are required for administration of medications.

Based on record review and staff interview, the facility failed to notify the physician of consistent refusals of daily weights for Resident #25 and weight changes per physician's orders [REDACTED]. This affected two of 12 residents reviewed for notification. Findings include: 1. Review of the medical record revealed Resident #25 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The physician's orders [REDACTED]. Review of the weight record in the medical record revealed the resident had weights obtained on 07/06/17, 07/10/17, 07/17/17, 07/21/17, 07/24/17 and 07/31/17. Review of the medication administration records (MARs) for July and August 2017 revealed the resident refused the daily weights as ordered for the remainder of the days in July and August 2017. There was no evidence in the medical record the physician was notified Resident #25 refused the daily weights. The lack of physician notification was verified with Registered Nurse #10 on 08/09/17 at 12:35 P.M. 2. Review of Resident #54's medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED].#54's physician orders [REDACTED]. Review of Resident #54's weight record revealed on 08/03/17 at 5:23 A.M. Resident #54 weighed 288.9 pounds. Review of Resident #54's weight record dated 08/04/17 at 5:03 A.M. revealed Resident #54 weighed 292.8 pounds. There was no evidence of physician notification of this 3.9 pound weight gain. Review of Resident #54's weight record revealed on 08/05/17 at 5:09 A.M. Resident #54's weighed 290 pounds. Review of the weight record revealed on 08/06/17 at 5:23 A.M. Resident #54's weighed 295 pounds. There was no evidence of physician notification of this five pound weight gain. Interview on 08/08/17 at 11:48 A.M. with Licensed Practical Nurses (LPN) #12 revealed Resident #54 was to be weighed daily and changes in weight of two pounds in a day or three to five pounds in a week were to be told to the physician. LPN #12 confirmed there was no evidence of physician notifications of weight gains from 08/01/17 through 08/08/17.

Based on record review, interview, observation, and policy review, the facility failed to ensure Resident #54's medical record was accurate related to physician notes, notification of physician, and skin assessments. The facility failed to ensure Resident #91's medical record accurately reflected Resident #91's bruising on the back of the right knee. This affected two of three residents reviewed for skin conditions. Findings include: 1. Review of Resident #54's medical record revealed an admission date of [DATE], with [DIAGNOSES REDACTED].#54's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident was cognitively intact. A. Review of Resident #54's SBAR communication form, skilled nursing notes, and nursing progress notes dated 07/31/17 following the fall that occurred at 9:00 P.M. that day revealed no evidence of any acquired skin conditions or abrasion on the right knee. Review of the incident report for the fall that occurred on 07/31/17 at 9:00 P.M. revealed Resident #54 had an abrasion on his right knee following the fall. There was no further evidence in the skilled notes, skin assessments, or progress notes from 07/31/17 through 08/08/17 related to a scabbed area or an abrasion on Resident #54's right knee. Observation on 08/08/17 at 9:52 A.M. revealed Resident #54 in his chair with a scabbed area on the right knee. The resident was interviewed at this time and indicated he was told that he had this abrasion from a fall but he may have gotten it from the wheelchair. Observation of the resident and interview on 08/09/17 at 8:08 A.M. with Licensed Practical Nurse (LPN) #11 confirmed Resident #54 had a scabbed area on his right knee. Interview on 08/09/2017 at 8:52 A.M. with LPN #11 revealed the incident report for the fall that occurred on 07/31/17 at 9:00 P.M. revealed Resident #54 had an abrasion on his right knee. LPN #11 confirmed the incident report was not part of the resident's medical record and there was no evidence of this abrasion in the medical record. B. Review of Resident #54's physician orders [REDACTED]. There was no evidence of physician orders [REDACTED]. Interview on 08/08/17 at 12:37 P.M. with Nurse Practitioner #13 confirmed the nursing staff should notify her or one of the physicians that were associated with the practice where she was employed, when there was a weight change per the order and the resident's nephrologist should be notified. Interview on 08/08/17 at 4:52 P.M. with the Director of Nursing and Registered Nurse (RN) #10 revealed they were unaware of any orders or direction to notify Resident #54's nephrologist of changes in weight. C. Review of the physician orders [REDACTED].#54 had physician orders [REDACTED]. Review of the Medication Administration Record [REDACTED]. Review of Resident #54's physician follow-up note dated 08/02/17 revealed Resident #54 was to continue on [MEDICATION NAME]-[MEDICATION NAME], and continue on [MEDICATION NAME]. Review of Resident #54's physician follow-up note dated 08/04/17 revealed Resident #54 was to continue on [MEDICATION NAME]-[MEDICATION NAME], and continue on [MEDICATION NAME]. Interview on 08/08/17 at 12:37 P.M. with Nurse Practitioner #13 confirmed she inaccurately documented Resident #54 was receiving [MEDICATION NAME] and [MEDICATION NAME] on 08/02/17 and 08/04/17 in her physician follow up note. Nurse Practitioner #13 revealed she copied and pasted her note from previous notes when the resident was on [MEDICATION NAME] and [MEDICATION NAME]-[MEDICATION NAME] and did not catch the mistake. 2. Review of Resident #91's medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the admission skin assessment date 07/28/17 revealed Resident #91 had a two centimeter by two centimeter bruised area on the front of her right knee. Review of Resident #91's MDS 3.0 assessment dated [DATE] revealed she was cognitively intact. There was no documented evidence in Resident #91's medical record from 07/28/17 through 08/08/17 of a bruise on the back of the right leg behind the knee. Observation on 08/07/17 at 11:30 A.M. revealed Resident #91 walked in the dining area with a walker. The resident had a large purple bruised area on the back of her right leg behind the knee and above her white knee high anti-embolic stockings. Interview on 08/09/17 at 1:54 P.M. with Resident #91 revealed she had significant bruising behind her right knee prior to entering the facility. Observation and interview on 08/09/17 at 2:05 P.M. with Nurse Practitioner #13 confirmed Resident #91 had bruising on the back of her right knee. Nurse Practitioner #13 indicated the resident had areas of bruising since admission and the bruise was in a state of healing. Nurse Practitioner #13 confirmed there was green, yellow and purple areas suggesting that the bruise was healing. Interview on 08/09/17 at 2:30 P.M. with RN #10 confirmed there was no documentation of the bruise on the back of the right knee. RN #10 revealed the area was present on admission and indicated the area may have been documented as the right knee bruise on the front of the knee instead of the back.