Blumenthal Health and Rehabilitation Center

Inspectors wroteBased on record review and resident, staff, and Nurse Practitioner interviews, the facility failed to ensure physician orders for daily weights were implemented as prescribed for 3 of 3 residents reviewed with orders for daily weights (Residents #9, #11, and #12).

Inspectors wroteBased on record review, and interviews with staff, Interim Director of Nursing, Former Director of Nursing, Assistant Director of Nursing, Medical Director, Nurse Practitioner, Regional Director of Clinical Services, Director of Pharmacy Operations, Pharmacist, and Infectious Disease Physician, the facility failed to provide services to ensure the acquiring, dispensing, and administration of a medication for 3 of 7 sampled residents whose medications were reviewed (Resident #3, Resident #13, Resident #24). The facility failed to ensure uninterrupted access to prescribed antiretroviral medication for Resident #24. The facility failed to have a medication used to treat diabetes available for administration to Resident #3. The facility failed to have a nasal spray available on the correct medication cart for Resident #13.

Inspectors wroteBased on record review, and interviews with staff, Nurse Practitioner, Medical Director, Pharmacist, Interim Director of Nursing, Assistant Director of Nursing, Pharmacy Operations manager and Infectious Disease Clinic Physician, the facility failed to prevent a significant medication error for 1 of 5 residents whose medications were reviewed (Resident #24). The facility failed to administer prescribed antiretroviral medication to Resident #24 when the initial supply was exhausted and for two subsequent scheduled administration times following delivery from the pharmacy.

Inspectors wroteBased on record review, and staff, Guardian, Nurse Practitioner, Infectious Disease Physician interviews, the facility failed to ensure Resident #24 attended a scheduled infectious disease clinic appointment as ordered, for 1 of 5 residents reviewed for professional standards of care (Resident #24).

Inspectors wroteBased on record review, observations, Resident interviews as well as staff and Nurse Practitioner interviews, the facility failed to provide pain management during a painful dressing change procedure. Resident #136 had a chronic unstageable pressure ulcer on his left heel requiring regular dressing changes. During an ordered dressing change, Resident #136 was observed to exhibit signs of pain which included facial grimacing, increased breathing rate, shifting of position and verbal expressions of the dressing change procedure being painful and was not provided pain management. The deficient practice occurred in 1 of 4 residents reviewed for pressure ulcers (Resident #136).

Inspectors wroteBased on observations and staff interviews, the facility failed to: prevent cross-contamination of dishware during the operation of the dishwashing machine; ensure dietary staff's personal belongings were not stored in the food preparation area; maintain food service equipment clean and free from debris; and store dishware clean and dry. These deficient practices had the potential to affect residents residing in the facility.1. During the initial tour of the kitchen on 9/8/25 at 11:20 a.m., Dietary Staff #1 was observed wearing plastic gloves as she scraped the excess food debris and placed the dirty dishware on a dish rack in preparation for cleaning in the dishwashing machine. The Dietary Staff #1 crossed to the opposite side of the machine and removed a rack of clean glassware without removing the soiled gloves and washing her hands. [...]

Inspectors wroteBased on observations, record review, and resident, family, ombudsman, and staff interviews, the facility failed to provide incontinence care (Resident #162), failed to assist with a meal (Resident #107and Resident #162), and failed to provide nail care and assistance with facial hair (Resident #85) to residents who were dependent on staff for assistance. This was for 3 of 13 residents reviewed for activities of daily living (ADL) (Residents #85, #107, #162). 1. a. Resident #162 was admitted to the facility on [DATE] and had cumulative diagnoses that included dementia, contracture of right and left hands, dysphagia, and aphasia. Resident #162's quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated she was non-verbal. [...]

Inspectors wroteBased on record reviews, observations and resident and staff resident interviews, the facility failed to provide supervision for a resident who was assessed as requiring both supervision and use of a smoking apron to promote safety while smoking. This deficient practice occurred for 1 of 16 residents reviewed for accidents (Resident #7)

Inspectors wroteBased on record review, observations, resident, staff and physician interviews, the facility failed to maintain accurate medical records for a peripherally inserted central catheter (PICC) line dressing change (Resident #112), intravenous antibiotic medication (Residents #101), and for assessing and documenting blood sugars and the administration of insulin (Resident #82). This was for 3 of 3 resident reviewed for resident records (Resident #112, #101, and #82).

Inspectors wroteBased on record review, resident, and staff interviews, the facility failed to document if the Covid-19 immunization was administered or if education was provided in the medical record regarding the benefits and potential side effects of the COVID-19 vaccines. This occurred for 3 of 5 residents reviewed for COVID-19 immunizations (Resident #15, Resident #53, and Resident #132). In addition, the facility was unable to provide evidence of Covid-19 immunization status or if education had been provided for 2 of 5 staff members (Staff #13 and Staff #14).

Inspectors wroteBased on observations, record reviews, and staff, resident, and Physician Assistant interviews, the facility failed to assess a resident for the ability to self-administer medications for 1 of 1 resident reviewed for self-administering medications (Resident #82).

Inspectors wroteBased on record review and staff interviews, the facility failed to provide a Centers for Medicare and Medicaid Services (CMS) Skilled Nursing Facility Advanced Beneficiary Notice (SNF-ABN) form 10555 prior to discharge from Medicare Part A skilled services for 2 of 3 residents reviewed for beneficiary protection notification review (Resident #28 and Resident #83).

Inspectors wroteBased on record review, and resident representative and staff interviews, the facility failed to maintain documentation of resolved grievances for 2 of 3 residents (Resident #121 and Resident #170) and evidence of the results of all grievances for 6 of 11 months reviewed (February 2025 to July 2025).

Inspectors wroteBased on record reviews, and interviews with staff, family, Nurse Practitioner, Medical Director, and responsible party (RP), the facility failed to protect the residents' right to be from resident- to- resident sexual abuse when a cognitively intact male resident (Resident #5) touched a female resident's (Resident #160's) breasts without her consent and made sexually explicit statements to her that included talking about the size of his penis. In addition, Resident #178 who was a moderately impaired male resident touched a female (Resident #163) between her legs near her vaginal area without her consent. This was for 2 of 4 residents reviewed for resident-to-resident abuse (Resident #160 and Resident #163).

Inspectors wroteBased on staff interviews and record reviews, the facility failed to complete annual Minimum Data Set (MDS) assessments within the required 14-day timeframe after the Assessment Reference Date (ARD, the last day of the assessment look-back period) for 2 of 54 residents whose MDS assessments were reviewed (Resident #107 and Resident #126).

Inspectors wroteBased on staff interviews and record reviews, the facility failed to complete significant change in status Minimum Data Set (MDS) assessments within the required 14-day timeframe after the Assessment Reference Date (ARD, the last day of the assessment look-back period) for 2 of 54 residents whose MDS assessments were reviewed (Resident #14 and Resident #158).

Inspectors wroteBased on staff interviews and record reviews, the facility failed to accurately code Minimum Data Set (MDS) assessments in the areas of: 1) Activities of Daily Living (Resident #107); 2) Use of an antibiotic medication (Resident #8), and 3) Brief Interview for Mental Status (BIMS) and Pain assessment interview (Resident #48). This occurred for 3 of 54 residents whose MDS assessments were reviewed.

Inspectors wroteBased on record review, observations, Resident Representative, and staff interviews, the facility failed to implement a fall mat for fall precautions for 1 of 4 residents reviewed for accidents (Resident #126).

Inspectors wroteBased on record review, resident representative, and staff interviews, the facility failed to revise a care plan for 2 of 54 residents reviewed for care plans (Resident #158 and #28).

Inspectors wroteBased on observation, record review, and resident and staff interviews, the facility failed to provide a record of an activity assessment and provide an ongoing resident centered activities program that included activities to meet the interests of a resident who did not participate in activities outside of his room for 1 of 1 resident reviewed for activities (Resident #3). Resident #3 was admitted to the facility on [DATE] with diagnoses which included hemiplegia and hemiparesis following cerebral infarction (stroke) affecting his right dominant side. The admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #3 was cognitively intact; and his activity preferences included books, music, animals, and being outside. [...]

Inspectors wroteBased on observations, resident and staff interviews, and record reviews, the facility failed to monitor a resident's vital signs and neurological status (referring to an evaluation of an individual's brain and nervous system functions) after sustaining an unwitnessed fall for 1 of 7 residents reviewed for the provision of care in accordance with professional standards (Resident #8).

Inspectors wroteBased on record review, observations, and resident, staff and physician interviews, the facility failed to change a dressing for a peripherally inserted central catheter (PICC- is a type of longer intravenous catheter that goes into a larger vein close to the heart) line as ordered by the provider. The deficient practice occurred for 1 of 1 resident reviewed for parenteral/IV fluids (Resident #112).

Inspectors wroteBased on observations, record reviews, and staff and family interviews, the facility: failed to obtain an order for oxygen administration (Resident #121 and Resident #131), failed to administer supplemental oxygen at the prescribed rate (Resident #13) and failed to post cautionary signage for oxygen in use (Resident #13). These practices affected 3 of 3 residents reviewed for respiratory services (Residents #121, #131 and #13).

Inspectors wroteBased on record review, and resident, and staff interviews, the facility failed to provide sufficient nursing staff to provide activity of daily living (ADL) assistance to residents who required extensive to total care with toilet hygiene and eating (Resident #162). This affected 1 of 13 sampled residents. 1. a. Resident #162 was admitted to the facility on [DATE] and had cumulative diagnoses that included dementia, contracture of right and left hands, dysphagia, and aphasia. Resident #162's quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated she was barely/rarely understood and her cognitive skills were severely impaired. Resident #162 had functional limitation in range of motion to one side of her upper extremity and to both sides of lower extremities. She was dependent on staff for all ADLs and was always incontinent with bowel and bladder. [...]

Inspectors wroteBased on record review, observations and staff interviews, the facility failed to: discard expired medications on 1 of 3 medication carts observed (Medication Cart #1) and 1 of 2 Medication Rooms (Medication room [ROOM NUMBER]); Failed to remove loose and unsecured pills of various shapes, sizes and colors on 2 of 3 medication carts (Medication Cart #1 and Medication Cart #4); and failed to store medication in accordance with the manufacturer's storage instructions on 1 of 3 medication carts (Medication Cart #1).

Inspectors wroteBased on observation, record review, and staff interviews, the facility failed to implement their infection control policy when they failed to dispose of a soiled brief left on a resident's nightstand after performing incontinence care for 1 of 18 residents reviewed for activities of daily living (Resident #84). The facility also failed to implement their infection control policy regarding handwashing while providing ostomy care for 1 of 2 residents reviewed for ostomies (Resident #9). In addition, the facility failed to implement their infection control policy regarding handwashing and enhanced barrier precautions while providing wound care for 1 of 4 residents reviewed for pressure ulcers (Resident #9). This deficient practice occurred for 2 of 15 staff members observed for infection control practices (Nurse #9 and Nurse Aide #11).

Inspectors wroteBased on record reviews and staff interviews, the facility failed to include documentation in the medical record of education regarding the benefits and potential side effects of the Influenza and pneumococcal vaccines and failed to include documentation in the medical record for the acceptance or declination of the vaccinations for 3 of 5 residents reviewed for influenza and pneumonia vaccines (Resident #13, Resident #53, and Resident #132).

Inspectors wroteBased on staff interviews, the facility failed to employ a full-time, qualified social worker. This had the potential to affect all residents. The facility census was 130 at the time of the survey.

Inspectors wroteBased on record review and staff interviews, the facility failed to notify the Resident Representative in writing of the reason for the unplanned transfer/discharge to the hospital and failed to provide the bed hold policy to the Resident Representative for 3 of 4 residents reviewed for hospitalizations (Resident #13, #97, and #2). Resident #13 was admitted to the facility 6/20/25. The admission Minimum Data Set assessment dated [DATE] documented Resident #13 was severely cognitively impaired. Resident #13 was discharged to the hospital 8/20/25 for a change in condition and readmitted to the facility 8/31/25. Review of the medical record revealed no documentation indicating a bed hold policy had been provided to Resident #13 or her Representative. Review of the medical record for Resident #13 revealed documentation for a notice of transfer form that had not been completed. [...]

Inspectors wroteBased on staff interviews and record reviews, the facility failed to complete quarterly Minimum Data Set (MDS) assessments within the required 14-day timeframe after the Assessment Reference Date (ARD, the last day of the assessment look-back period) for 8 of 54 residents whose MDS assessments were reviewed (Residents #31, #10, #92, #7, #109, #78, #52 and #85). 8. Resident #85 was admitted to the facility 9/8/23. Review of the medical record on 9/10/25 revealed the quarterly MDS assessment had an Assessment Reference Date (ARD) of 6/26/25. The assessment was signed as completed by the facility's Registered Nurse MDS coordinator on 8/15/25. An interview was conducted on 9/10/25 at 3:23 PM with the MDS Coordinator, who was later joined by MDS Nurse #2. [...]

Inspectors wroteBased on staff interviews and record review, the facility failed to submit a discharge Minimum Data Set (MDS) assessment within the required timeframe for 2 of 54 residents whose MDS assessments were reviewed (Resident #32 and Resident #13). 1 2. Resident #13 was admitted to the facility 6/20/25 and transferred to the hospital on 8/20/25. The discharge Minimum Data Set assessment dated [DATE] was marked as completed on 9/10/25. An interview was conducted on 9/10/25 at 3:23 PM with the MDS Coordinator, who was later joined by MDS Nurse #2. During the interview, the nurses reported they were two months behind on completing MDS assessments when they started their positions at the facility and were still working towards catching up on the assessments. [...]

Inspectors wroteBased on record review and staff interviews, the facility failed to accurately report staffing for 5 of 5 daily posted sheets reviewed (5/1/25, 6/14/25, 7/4/25, 8/10/25, and 9/1/25).

Inspectors wroteBased on observation, record review, and staff and Wound Nurse Practitioner (NP) interviews, the facility failed to obtain a treatment order for a suspected deep tissue injury when it was first observed which resulted in a delay in the initiation of treatment for 1 of 3 residents reviewed for pressure ulcers (Resident #5).

Inspectors wroteBased on staff interviews and record review, the facility failed to: 1) Obtain a provider's order prior to requesting radiology testing (x-ray) be completed for a resident; and 2) Notify the Nurse Practitioner (NP) when the results of the x-ray revealing 4 rib fractures became available. This occurred for 1 of 3 residents (Resident #2) reviewed for accidents.

Inspectors wroteBased on record review and interviews with the resident's Responsible Party (RP), Medical Director and staff, the facility failed to notify the physician at the onset of pain and when the x-ray could not be completed stat (immediately) after Resident #1 had an unwitnessed fall on 11/17/24 (Sunday). The x-ray was not performed until 11/18/24 and the results indicated an acute nondisplaced (the bone does not break completely and there will be a crack on the bone) transverse (horizontal and perpendicular to the bone) left femur (thigh bone) fracture. The physician was not made aware of the fracture until 11/22/24 and was not notified the orthopedic consult ordered on 11/19/24 was scheduled for 11/26/24. The facility also failed to notify the physician when the resident's pain was not manageable on night shift (11/20/24 and 11/21/24). [...]

Inspectors wroteBased on record review, and facility staff, Nurse Practitioner (NP), Medical Director, and Responsible Party (RP), and Orthopedic Surgeon interviews, the facility failed to protect a resident's right to be free of neglect as evidenced by the following: they failed to notify the physician at the onset of pain and when an x-ray could not be completed STAT (immediately) after Resident #1 had an unwitnessed fall on 11/17/24 and reported pain in her left hip. The x-ray was completed on 11/18/24 and revealed an acute nondisplaced (the bone does not break completely and there will be a crack on the bone) transverse (horizontal and perpendicular to the bone) left femur (thigh bone) fracture. [...]

Inspectors wroteBased on record review and interviews with the Medical Director, the Nurse Practitioner (NP), Orthopedic Surgeon, Responsible Party (RP) and staff, the facility failed to recognize the seriousness of the injury Resident #1 sustained from a fall and identify the need for urgent orthopedic evaluation. Resident #1 reported pain in her left hip on 11/17/24 following a fall. A STAT (immediately) x-ray was ordered on Sunday 11/17/24, was not completed until 11/18/24, and revealed a nondisplaced (the bone does not break completely and there will be a crack on the bone) transverse (horizontal and perpendicular to the bone) left femur (thigh bone) fracture. On 11/19/24 the NP ordered scheduled opioid medication for increased pain and ordered an orthopedic consultation at the request of Resident #1's RP. [...]

Inspectors wroteBased on record review, and staff, Medical Director and Nurse Practitioner (NP) interviews, the NP failed to communicate and collaborate with the Medical Director when Resident #1 was diagnosed on [DATE] with an acute nondisplaced (the bone does not break completely and there will be a crack on the bone) transverse (horizontal and perpendicular to the bone) left femur (leg) fracture following an unwitnessed fall on 11/17/24. The NP did not consult with the Medical Director before making the decision the resident was probably not a surgical candidate and attempting to treat the resident in-house. Due to the lack of communication and coordination the Medical Director was not aware of the fracture until he saw Resident #1 on 11/22/24 at which time he ordered the resident to be sent to the emergency department if she could not be seen by the orthopedist that day. [...]

Inspectors wroteBased on record review, and Medical Director, Nurse Practitioner, Responsible Party and staff interviews, the facility failed to effectively intervene for complaints of pain, failed to provide thorough and ongoing pain assessments, and failed to effectively manage a resident's pain. This was for 1 of 1 resident reviewed for pain (Resident #1).

Inspectors wroteBased on record review and Administrator interview, the facility failed to report an allegation of neglect to the state agency for 1 of 1 residents reviewed for neglect (Resident #1).

Inspectors wroteBased on record review and staff interviews, the facility failed to ensure a medical record was accurate regarding post fall documentation. This was for 1 of 5 sampled residents whose medical record was reviewed for documentation (Resident #1).

Inspectors wroteBased on observations, record review, and staff and Nurse Practitioner (NP) interviews, the facility failed to implement a broad-based approach COVID-19 testing for staff and residents on 10/13/24 when residents tested positive for COVID-19 on two resident halls. The facility had been in outbreak status since 10/08/24 when a staff member tested positive and only residents/staff with symptoms, roommates of residents that tested positive and staff that requested or were symptomatic tested for COVID-19. Broad-based COVID-19 testing per the Centers for Disease Control and Prevention (CDC) guidance was not implemented until 10/23/24. Before broad-based testing was implemented on 10/23/24, a total of 4 staff members and 22 residents had tested positive for COVID-19. [...]

Inspectors wroteBased on record reviews and staff interviews, the facility failed to have licensed nursing coverage 24 hours/day in the facility for 17 out of 120 days reviewed for staffing. The failure to have a licensed nurse in the facility at all times had a high likelihood of impacting every resident in the facility.

Inspectors wroteBased on record reviews and staff interviews, the facility failed to provide Registered Nurse (RN) coverage at least 8 consecutive hours per day, 7 days per week for 17 out of 120 days reviewed for staffing.

Inspectors wroteBased on observations, staff interviews and record reviews, the facility failed to prevent a significant medication error when a nurse failed to administer insulin before a meal as scheduled as specified in the physician's order. This occurred for 1 of 1 sampled resident (Resident #25).

Inspectors wroteBased on observations, record review, and resident and staff interviews, the facility's interdisciplinary team failed to assess and document the ability of a resident to self-administer medications for 2 of 2 residents (Resident #6 and Resident #12) who were reviewed for medication self-administration.

Inspectors wroteBased on medical record review and staff interview, the facility failed to complete a Significant Change in Status Minimum Data Set (MDS) assessment for 1 of 2 residents (Residents #15) reviewed for hospice services.

Inspectors wroteBased on observations, record reviews and staff interviews, the facility failed to accurately code the minimum data set (MDS) assessments in the areas of falls (Resident #42), range of motion (Resident # 59) and failed to assess (Resident #69) and code the MDS assessment for cognition, mood, behavior, functional abilities, bowel and bladder continence, and oral/dental status. This was for 3 of 30 sampled residents reviewed for MDS accuracy.

Inspectors wroteBased on observations, record reviews and staff interviews, the facility failed to apply the right-hand grip splinting device as recommended by the occupational therapist for 1 of 1 sampled resident (Resident #59) with a contracture of his right hand.

Inspectors wroteBased on observations, record review, and staff and Nurse Practitioner interviews, the facility failed to administer oxygen at the physician prescribed rate for 1 of 1 resident sampled for respiratory care (Resident #14).

Inspectors wroteBased on staff interviews and record review, the facility failed to maintain a complete medical record in the area of diagnoses for 1 of 5 residents (Resident #42) reviewed for unnecessary medications.

Inspectors wroteBased on observations and staff interviews, the facility failed to maintain the walls in the residents' rooms in good repair for 8 of 11 sampled residents' rooms: 3206, 3217, 3222, 3251, 3242, 3243, 3214 and 3225.

Inspectors wroteBased on record reviews, and interviews with the responsible party (RP) and Administrator, the facility failed to maintain documentation of the results of grievances reported by the RP for 1 of 1 sampled resident (Resident #190).

Inspectors wroteBased on record review and interviews with family, hospice nurse, and facility staff, the facility failed to treat terminal agitation in 1 of 1 (Resident #3) resident reviewed for hospice.

Inspectors wroteBased on observations, interviews with staff and the consultant Registered Dietitian (RD), and record review, the facility failed to provide a nourishing evening snack when more than 14 hours elapsed between the provision of a substantial evening meal and breakfast the following day for residents residing on 7 of 7 resident hallways (700 Hall, 200 Hall, 3200 Hall, 300 Hall, 400 Hall, 500 Hall and 600 Hall).

Inspectors wroteBased on observations, interviews with staff and the consultant Registered Dietitian (RD), and record reviews, the facility failed to: 1) Seal, label/date, and/or discard expired food items in 1 of 1 walk-in cooler; 2) Seal and label/date opened food items in 1 of 1 Dry Storage area; 3) Label/date opened food items stored in the kitchen preparation / cooking area; and 4) Label/date opened food items in 1 of 1 Nourishment Room observed (200 Hall). These practices had the potential to affect food served and distributed to all residents.

Inspectors wroteBased on observations, record review, resident and staff interviews, the facility's Quality Assessment and Assurance (QAA) committee failed to maintain implemented procedures and monitor interventions the committee put into place following the recertification and complaint survey dated 6/21/2021 and 8/4/2022, and the complaint survey dated 10/11/2022. This was for nine deficiencies that were cited in the areas of resident rights (F550), formulate advanced directives (F578), safe/clean/homelike environment (F584), accuracy of assessments (F641), care plan timing and revision (F657), treatment and services to prevent/heal pressure ulcers (F686), free from unnecessary psychotropic medications and as needed use (F758), label and store drugs and biologicals (F761), and food procurement (F812). The nine areas were recited on the current recertification and complaint survey of 5/25/2023. [...]

Inspectors wroteBased on observations and interviews with residents and staff, the facility failed to ensure cigarettes were disposed of in a non-combustible container (courtyard), failed to properly label and store personal care equipment in shared bathroom (rooms [ROOM NUMBERS]); failed to repair the linoleum around the base of the toilet (room [ROOM NUMBER]); failed to maintain walls and baseboards in good repair (rooms 602, 605, 606, and 611); failed to repair loose fitting sink faucets (rooms [ROOM NUMBERS]); failed to maintain toilet paper holders in good repair (room [ROOM NUMBER] and 603); failed to maintain properly attached call bell wall sockets (room [ROOM NUMBER]); failed to maintain window blinds in good repair (room [ROOM NUMBER]); maintain night stand in good repair (room [ROOM NUMBER]). This occurred for a courtyard and 7 of 11 rooms reviewed for a clean, safe, and homelike environment.

Inspectors wroteBased on staff interviews and record reviews, the facility failed to offer the opportunity to be vaccinated with the Prevnar 20 (pneumococcal conjugate vaccine (PCV) 20) in accordance with nationally recognized standards for 4 of 5 residents reviewed for pneumococcal immunizations (Resident #58, #53, #70, and #3).

Inspectors wroteBased on observation, record review, staff and resident interviews, the facility failed to promote dignity when, 1) a staff member transported a resident (Resident #84) into a public area with the back of their gown open, exposing the backside of the resident and 2) by not shaving a female resident's face (Resident #49) that was dependent on staff for activities of daily living (ADL) care needs. This occurred for 2 of 17 residents reviewed for Dignity and respect.

Inspectors wroteBased on resident and staff interviews and medical record reviews, the facility failed to invite a cognitively intact resident to participate in the planning of the resident's care for 2 of 4 residents (Resident #27 and Resident #55) reviewed for participation in care plans.

Inspectors wroteBased on record reviews, resident and staff interviews, the facility failed to accurately transcribe the Advance Directive of 1 of the 2 sampled residents reviewed (Resident #13).

Inspectors wrote2. Resident #55 was admitted to the facility on [DATE]. Diagnoses included, in part, gastroesophageal reflux disease and coronary artery disease. On 9/28/22, the resident was seen at the facility by the dentist. The comprehensive examination note read, in part, Chief Complaint/Dental Concern: broken and missing teeth. The annual MDS assessment dated [DATE], and completed by MDS Nurse #3, revealed Resident #55 had no dental issues. An observation of Resident #55's mouth was completed with MDS Nurse #1 on 5/23/23 at 1:24 PM. During the observation, MDS Nurse #1 reported the resident had missing and broken teeth. On 5/24/23 at 10:06 AM, an interview was conducted with MDS Nurse #3. She verified she completed the MDS assessment dated [DATE]. She explained when she coded the dental section on the MDS, she looked in Resident #55's mouth before she coded dental status. [...]

Inspectors wroteBased on staff interviews and record reviews, the facility failed to develop a baseline care plan within 48 hours of the resident's admission for 2 of 16 newly admitted residents reviewed (Resident #39, Resident #87, and and Resident #98).

Inspectors wroteBased on observations, record reviews, resident and staff interviews, the facility failed to revise the care plan of 1 of 1 sampled resident (Resident #88) reviewed for range of motion and contractures.

Inspectors wroteBased on observations, record review, staff interviews, and the Wound Physician interview, the facility failed to follow a physician order for a wound dressing change for 1 of 4 (Resident #569) sample residents reviewed for pressure ulcers.

Inspectors wroteBased on observations, record reviews, resident and staff interviews, the facility failed to consistently provide the functional management program recommended by the occupational therapist for 1 of 1 sampled resident (Resident #88) reviewed for contractures.

Inspectors wroteBased on interviews with staff, the consultant pharmacist and Medical Director, and record reviews, the facility failed to limit the use of psychotropic medications (any drug that affects brain activities associated with mental processes and behavior) ordered on an as needed (PRN) basis to 14 days and/or indicate the duration for the PRN order to be extended beyond 14 days, when appropriate. This occurred for 1 of 5 residents (Resident #569) reviewed for unnecessary medications.

Inspectors wroteBased on observation, resident and staff interviews and record review, the facility failed to secure medications for 1 of 1 resident (Resident #88) observed with medications at bedside.

Inspectors wroteBased on observation, resident and staff interviews, interview with the Dental Practice Administrator, and record review, the facility failed to reschedule a follow up dental care appointment for recommended extractions for 1 of 3 residents (Resident #55) reviewed for dental services.