Tiffany Springs Rehabilitation & Health Care Cente

Inspectors wroteBased on interview and record review the facility failed to follow their Cardiopulmonary Resuscitation (CPR) Policy and failed to follow the documented wishes for Resident #1, when a Licensed Practical Nurse (LPN) performed CPR on the resident when the resident had a documented and physician signed Do Not Resuscitate (DNR) order. The facility census was 111. Review of the facility policy titled, Cardiopulmonary Resuscitation, dated 03/2025 showed if a resident was found unresponsive and no breathing normally, a clinical staff member will verify code status using the clinical record. If the resident is a DNR, per medical record, notify the attending provider. Review of the facility policy titled, Resident Rights, dated 12/2024 showed each resident residing in this community has the right and will be afforded the right to a dignified existence, and self determination. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to prevent the development of an unstageable pressure injury (a severe, full-thickness wound where the base is completely covered by dead tissue) for one resident (Resident #2), of 6 sampled residents, when the facility failed to periodically check the resident's skin under a removable medical device for more than 20 days and the resident required surgery to clean the wound. The facility census was 115. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed promote each resident's right to self-determination when the facility failed to provide services to maintain good grooming and personal hygiene in accordance with resident preferences for two residents (Resident #76 and #92) out of 24 sampled residents. The facility census was 116. Review showed the facility did not provide a policy related to showers.1. Review of Resident #76's Quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 10/30/25, showed:- The resident was cognitively intact;- Required assistance with showering, bathing, and toileting;- Diagnoses included: seizures, diabetes, and heart failure. [...]

Inspectors wroteBased on interview and record review, the facility failed to implement policies and procedures to ensure resident's trust fund accounts were not allowed to go into a negative balance which affected one resident (Resident #28) and when the facility failed to refund resident funds within 30 days of discharge for six residents (Residents #123, #124, #125, #126, #127, and #128). The facility census was 116. Review of facility policy Resident Trust Fund Policy, revised [DATE], showed:- Refund checks for discharged or expired residents must be completed within 5 business days of the resident discharge. Per state regulations, a completed discharge/trust fund accounting form reflecting discharge date and monies disbursed must be sent to the caseworker within 5 business days.- The Resident Fund bank account must be reconciled monthly immediately upon receipt of the bank statement. [...]

Inspectors wroteBased on interview and record review, the facility failed to notify four residents (Resident #16, #23, #75, and #106) when they were within $200.00 of the Social Security Income (SSI) limit ($6,068.80) or when the resident's account was over the SSI limit. This affected four of 24 residents sampled. Facility census was 116. Review of the facility policy, Facility Resident Trust Fund Policy, revised May 2012, showed any individual Resident Trust Account that is nearing the state specified maximum balance will require notification to the Resident/Responsible part via Form letter.1. Review of Resident #16's Quarterly Minimum Data Set (MDS, a federally mandated assessment tool completed by facility staff), dated 12/30/25, showed:- Resident was cognitively intact;- Diagnoses: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide services or care that adhere to accepted standards of quality when the facility failed to properly manage pain, provide medication as ordered by a physician, failed to notify physician of unavailability of pain medication, failed to obtain medication from emergency medication kit on site for one Resident (Resident #100), and failed to follow physician's orders for Residents #9, #94, #113 and failed to implement Diabetes management for Resident #9. This affected four sampled residents out of 24 sampled. The facility census was 116. Review of the facility's Medication Administration Policy dated May 2019, showed staff to administer all medications to overcome illness and to relieve and prevent symptoms as per physician order. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure dependent residents who were unable to carry out their own activities of daily living (ADLs) received the necessary services to maintain good personal hygiene when staff did not provide complete perineal care for two sampled residents, (Resident #13 and #6). This affected two of 24 sampled residents (Resident #13, and #6). The facility census was 116. Review of the facility's Activities of Daily Living Policy dated, 09/04/25, showed this facility provides each resident with care according to the resident's care plan and the resident's ability to perform activities of daily living including bathing, dressing, grooming and toileting. 1. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents were served food that was palatable, safe, and at an appetizing temperature during meal service. This affected 2 of 24 sampled residents (Residents #22 and #95). The facility census was 116. Request for facility policy on cooking and dining food temperatures was not provided for review.1. Review of Resident #22's Quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 11/17/25, showed:- Resident was cognitively intact;- Diagnoses: heart failure, Parkinson's Disease, anxiety disorder, depression, and respiratory failure;During an interview on 1/20/26 at 9:27 A.M., the Resident said the food is cold and this can happen at all meal times. Some of the food is very spicy, he/she normally eats in his/her room. [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure the bathroom exhaust vents were free of excess dust in residents' rooms. This affected 11 rooms. The facility census was 116. Observation on 1/20/26 starting at 11:17 A.M., showed the bathroom exhaust vents covered in dirt in:- room [ROOM NUMBER];- room [ROOM NUMBER];- room [ROOM NUMBER];- room [ROOM NUMBER];- room [ROOM NUMBER];- room [ROOM NUMBER];- room [ROOM NUMBER];- room [ROOM NUMBER];- room [ROOM NUMBER];- room [ROOM NUMBER];- room [ROOM NUMBER]. During an interview on 1/21/26 at 3:08 P.M., the Maintenance Director said they cleaned the bathroom exhaust vent twice a year. It was last done in July to August in 2025. He thought the maintenance staff may have started and then got called away to other jobs and not completed the task for all exhaust vents, that was why some of them had so much dirt on them.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop a baseline care plan for one resident (Resident #113), when staff did not care plan pain control. This affected one of 24 sampled residents. The facility census was 116. Review of the facility's Care Plan Policy dated 12/2024, showed: The purpose is to assess strengths, weakness and care needs for each resident that will assist the staff and resident in achieving and maintaining the highest practical level of mental functioning, physical functioning, and wellbeing as possible.1. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to implement and monitor interventions put into place for one resident with significant unplanned weight loss (Resident #97) to prevent the resident from further weight loss when staff failed to offer Super Cereal (a highly nutritious, calorie-dense food to prevent malnutrition) and a Magic Cup (a high-protein nutritional treat designed to fight malnutrition) and when the staff failed document in the resident's medical record that the prescribed diet had not been consumed. Staff additionally failed to notify the resident's physician and the Registered Dietitian (RD) when the prescribed diet had not been consumed. This affected one of 24 sampled residents. The facility census was 116. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe and sanitary environment when facility staff did not apply Personal Protective Equipment (PPE) when they provided care and treatment for one resident (Resident #13). This affected one of 24 sampled residents (Resident #13). The facility census was 116. Review of the facility's undated, Enhanced Barrier Precautions policy, showed:-Enhanced barrier precautions (EPB) are recommended for residents with any of the following: o Wounds; o Indwelling medical devices; o High contact care activities;-High contact care activities when a gown and gloves should be worn include: o Bathing/showering; o Changing bed linens; o Changing briefs; o Assisting with toileting. 1. [...]

Inspectors wroteBased on interviews and record review the facility failed to honor a resident's choice for a Do Not Resuscitate (DNR) advanced directive when the facility staff performed Cardiopulmonary Resuscitation (CPR), an emergency lifesaving procedure performed when the heart stops beating, and notified EMS (Emergency Medical Services) to complete all life saving measures because the facility failed to ensure the DNR had been entered into the resident's physician orders and medical record accurately. The facility census was 108. On [DATE], the Administrator was notified of the past noncompliance incident which occurred on [DATE]. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure three residents (Resident #1, #2, and #5) received treatment and care in accordance with professional standards of practice when the facility failed to provide timely lab testing with results. Two residents (Resident #2 & #5) were admitted to the hospital with septic shock. The facility also failed to obtain lab testing for one resident (Resident #1) who was without his/her psychotropic medication for fourteen days when the pharmacy would not provide the medication without lab results. The facility also failed to follow physician's orders for the resident when they did not administer psychotropic medication. The sample size was six residents. The facility census was 111. A policy regarding professional standards of care was requested but not provided. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide necessary laboratory services for residents when they did not ensure residents needs were met with timely collection and reporting of laboratory results. This occurred when the facility failed to obtain lab testing for one resident (Resident #1) who was without his/her psychotropic medication for fourteen days when the pharmacy would not provide the medication without lab results. The facility also failed to ensure urine cultures for residents with potential urinary tract infections (UTI) were collected by the laboratory company, tested, and results received by the facility so the physician's could properly treat infections Residents #1, #2, #3, #4, #5, and #6 for signs and symptoms of UTI. The facility additionally failed to provide timely lab testing with results for two residents (Resident #2 & #5). [...]

Inspectors wroteBased on observations, staff interviews, and record review, the facility failed to ensure safe food handling practices, food was labeled, dated, and sealed in cold storage, and the kitchen was kept in a clean and sanitary manner. These failures had the potential to increase the prevalence and spread of foodborne illness and infection among all 116 facility residents. The facility census was 116.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure pain medication and timely interventions were provided for three of three residents (Residents (R) 107, R82, and R4) reviewed for pain management of 27 sample residents. This failure placed residents at risk of harm when pain was not assessed, monitored, with timely interventions provided. The facility census was 116.

Inspectors wroteBased on observations, record review, interviews, and policy review, the facility failed to ensure residents who received a pureed diet of 116 total residents were served foods prepared in a pureed form to meet their needs. This failure had the potential to cause choking, aspiration [inhalation of food into the lungs], malnutrition, weight loss, or dissatisfaction with meals. The facility census was 116.

Inspectors wroteBased on record review and interviews, the facility failed to ensure the physician was notified when pain medications were unavailable to be administered per physician's order for one of three residents (Resident (R) 4) reviewed for pain of 27 sample residents. This failure had the potential to contribute to uncontrolled pain and fall risk. The facility census was 116.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident who had a negative Preadmission Screening and Resident Review (PASARR) Level I and then later had a significant change in status with a new serious mental illness diagnosis was accurately and timely referred for a PASARR Level II for one of two residents (Resident (R) 29) reviewed for PASARRs out of 27 sample residents. This failure placed the residents at risk of qualifying for specialized services but not receiving the services due to the inaccuracy of the PASARR Level I. The facility census was 116.

Inspectors wroteBased on interview and record review, the facility failed to develop a comprehensive patient centered care plan related to an Implantable Cardioverter Defibrillator (ICD) device one of 27 sample residents (Resident (R) 82) reviewed for care plans. The failure to update care plans to reflect the residents' needs can result in potential harm.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to maintain current abilities for one of one resident (Resident (R) 80) reviewed for activities of daily living (ADL) of 27 sample residents. Failure of the facility to provide proper assistance for a resident that has ADL decline could result in psychological and physical harm. The facility census was 116.

Inspectors wroteBased on observation, interview, and record review, the facility failed to safely store an oxygen emergency tank (e-tank) for one of three (Residents (R) 272) reviewed for respiratory care of 27 sample residents. This failure placed the residents at risk of injury. The facility census was 116.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure an occlusive, peripherally inserted central catheter (PICC) line was changed every seven days, as required for one of one resident (Resident (R) 108) reviewed for intravenous (IV) antibiotic use of 27 sample residents. This failure placed the residents at risk of increased infection and complications. The facility census was 116.

Inspectors wroteBased on interviews and record review, the facility failed to ensure one of 27 sample residents (Resident (R) 4) medications were ordered and received for timely administration. This put residents at risk of complications from not receiving their medications. The facility census was 116.

Inspectors wroteBased on interview, record review, and review of facility policy, the facility failed to document the death of a resident and include a physician order to release the body for one of one resident (Resident (R) 115) reviewed for death of 27 sample residents. This failure had the potential for residents to have a medical record that did not reflect care provided by the facility. The facility census was 116.

Inspectors wroteBased on interview and record review, the facility failed to ensure one staff maintained one sampled residents right to personal privacy for one resident (Resident #1) when Certified Nurse's Aide (CNA) A used his/her personal cell phone to record a two separate videos without the residents consent. One video showed Resident #1 lying in bed and and second video showed the resident with his/her glasses on upside down on his her face. The facility census was 119. The facility did not provide the requested policy regarding Resident Rights. The facilty did not provide the requested policy in regards to video recording of residents. [...]

Inspectors wroteBased on interview and record review, the facility failed to perform life saving measures to include Cardio-pulmonary resuscitation (CPR) for one sampled resident (Resident #1) when staff found the full code resident without a pulse or respirations. Additionally, the facility failed to ensure the staff knew safety protocols and emergency procedures when Licensed Practical Nurse (LPN) A did not know where to locate the crash cart (a cart that contains emergency equipment). The facility census was 117. The administrator was notified on [DATE] at 4:51 P.M. of an Immediate Jeopardy (IJ) which began on [DATE]. The IJ was removed on [DATE] as confirmed by surveyor on-site verification. Review of the facility's Emergency Procedures/Cardio-Pulmonary Resuscitation Policy, revised, February 2022, showed: -Any unnecessary interruptions in chest compressions decreases the effectiveness of CPR; [...]

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure staff provided care in a manner to preserve and enhance residents dignity when staff utilized cell phones while provided resident cares to two of eight residents (Resident #3 and #4 ), and when staff did not provide adequate supplies for residents incontinent care needs (residents #3 and #4). This affected four of eight sampled residents. The facility census was 117. Facility did not provide policy on call lights or dignity. Review of facility policy, use of cell phones and other portable communication devices, undated, showed: -The use of cellular phones, pagers, or other portable communication devices is strictly prohibited while on duty except during scheduled rest and meal periods. -Use of these devices will be restricted to the break room or outside of the community; [...]

Inspectors wroteBased on record review, the facility failed to provide care and treatment in accordance with professional standards of practice when oxygen tubing was not changed and dated according to physician's orders weekly (Residents #3, #5, and #7) and when daily weights were not taken on one resident (resident #5 ). This affected three of eight sampled residents. The facility census was 117. Review of oxygen administration policy, dated October 2010, showed: -Verify that there is a physician's order for the procedure of oxygen administration. -Check the tubing connected to the oxygen cylinder or concentratior to assure that it is free of kinks. -Replenish water in humidifying jar as needed; -After completing the oxygen setup or adjustment, the following information should be recorded in the resident's medical record: -The date and time that the procedure was performed. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure they cared for residents in a dignified manner when staff failed to respond to call lights in a timely manner for residents with incontinence for five of the 21 sampled residents (Residents #85, #306, #4, #37, #42). The facility also failed to ensure staff cared for residents in a dignified manner when staff left one resident (Resident # 85) sitting in a wheelchair in only a t-shirt and an incontinent brief with his/her genitalia exposed outside of the brief, in an open hallway in view of other people and failed to change one resident's (Resident #22) bed sheet that had two brown golf ball sized stains on it that were visible from the the hall. [...]

Inspectors wrote4. Review of Resident #18's follow up question and report for snacks at bedtime for June, 2023 , showed the resident did not get offered a snack at bedtime on the following dates: - 6/3/23; 6/5/23; 6/6/23; 6/7/23; 6/8/23; 6/9/23; 6/10/23; 6/11/23; 6/12/23; 6/13/23; 6/14/23; 6/16/23; 6/17/23; 6/18/23; 6/20/23; 6/23/23; and 6/28/23. Review of the resident's follow up question and report for snacks at bedtime for July, 2023 , showed the resident did not get offered a snack at bedtime on the following dates: - 7/1/23; 7/2/23; 7/4/23; 7/7/23; 7/8/23; 7/12/23; 7/13/23; 7/19/23; 7/21/23; 7/22/23; 7/23/23; 7/25/23; 7/26/23; and 7/27/23. Review of Resident #18's quarterly MDS, dated [DATE] showed: - Cognitive skills severely impaired; - Independent with set up only for bed mobility, transfers, and toilet use; - Independent with eating; - Lower extremity impaired on one side; [...]

Inspectors wroteBased on observations and interviews, the facility failed to maintain a safe, clean and comfortable homelike environment. This affected four Residents (Residents #37, #42, #43 and #73). The facility census was 104. The facility did not provide the requested policy regarding the environment. 1. Review of Resident #37's quarterly MDS, (MDS) A federally mandated assessment instrument completed by facility staff, dated 8/15/23, showed: -Resident has moderate cognitive impairment; -Resident is independent with ADL's; (Activities of Daily Living) -Resident requires supervision for transfers; -Diagnoses included, kidney failure, diabetes mellitus and high blood pressure. A review of the resident's care plan, dated 5/25/23, showed: -Resident has an ADL self-care performance related to impaired balance; -Resident has limited physical mobility. Observation on 8/15/23, at 2:55 P.M., showed: [...]

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure staff failed to follow physician orders for three out of 21 sampled residents when they failed to follow the physician's order for oxygen therapy for one resident (Resident #89) failed to transcribe a diagnosis of dementia for one resident (Resident #99) and failed to obtain an order to obtain Resident #9's blood glucose prior to obtaining the blood glucose. The facility census was 104. The facility did not provide a policy regarding following physicians orders. Review of the facility's Oxygen Administration policy, dated 1/2017 showed: - Verify there is a physician's order for this procedure for oxygen administration; - After completing the oxygen set up or adjustment, the following information should be recorded in the resident's medical record: - Date and time the procedure was performed; [...]

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure dependent residents who were unable to carry out activities of daily living (ADLs) received the necessary services to maintain good personal hygiene when staff did not provide complete perineal care which affected three of 21 sampled residents, (Resident #43, #64, and #91), failed to ensure showers were completed for Resident #43, #59 #22 and #37 and failed to ensure shaving was completed for residents, (Resident #89 #254, #22. #37 and #27). The facility census was 104. The facility did not provide a policy for peri care and did not provide a policy for showers or shaving residents. 1. Review of Resident #43's significant change in status Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 8/6/23 showed: - Cognitive skills intact; [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure staff used proper techniques to reduce the possibility of accidents or injuries when transferring three sampled residents (Resident #33, #91 and Resident #43) during the use of a mechanical lift transfer. The facility census was 104. Review of the manufacture's instructions for the Medline mechanical lift, dated 2016, showed: -Open the legs of the lift when lifting the patient; -Close the legs of the lift before moving patient ; -Open the legs of the lift for stability before lowering the patient. -When raising and lowering the resident, apply the brakes in both rear casters. 1. Review of Resident #33's significant change MDS (a federally mandated assessment tool completed by facility staff), dated 7/6/23, showed: -Severe cognitive impairment; [...]

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure staff provided proper respiratory care when staff failed to follow physician orders for oxygen therapy for one resident (Resident #89) and failed to ensure oxygen concentrators had filters in them for one resident (Resident #306) out of 21 sampled residents. The facility census was 104. Review of the facility's Oxygen Administration policy, dated 1/2017 showed: - Verify there is a physician's order for this procedure for oxygen administration; - After completing the oxygen set up or adjustment, the following information should be recorded in the resident's medical record: - Date and time the procedure was performed; - Rate of oxygen flow; - The reason for PRN (as needed) administration. 1. [...]

Inspectors wroteBased on observation, interviews and record review, the facility failed to ensure staff administered medications with a medication error rate of less than 5%. Facility staff made six medication errors out of 25 opportunities for error which resulted in a medication error rate of 24%, which affected six out of 21 sampled residents, (Resident #5, #9, #18, #20, #37 and #88). The facility census was 104. The facility did not provide a policy for administration of medications, administration of eye drops or administration of insulin. Review of the website, www.webmd.com for administration of artificial tears showed: - Tilt the head back, look up and pull down the lower eyelid to make a pouch; - Place the dropper directly over the eye and squeeze out one or two drops as needed; - Look down and gently close your eye for one or two minutes; [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure staff provided a safe and effective medication administration system that was free of significant medication errors when staff failed to [NAME] insulin pens prior to administering insulin which affected three of 21 sampled residents, ( Resident #9, #18 and #20). The facility census was 104. The facility did not provide a policy for administration of insulin. Review of the manufacturer's guidelines for Novolog (fast acting) flexpen insulin, revised 8/22 showed, in part: - Should eat a meal within five to ten minutes after taking it; - Wipe the rubber end of the pen with an alcohol swab; - Remove the seal from the new pen needle and attach it to the end of the pen; - Turn the knob on the pen to a dose of two units; - Hold the pen with the needle straight up. [...]

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to meet the nutritional choices of two resident's and failed to be prepared in advance to ensure there was enough food available for the designated menus and supplements. This effected two of 21 sampled residents (Resident #42 and #13). The facility census was 104. Review of the facility's undated policy on resident meal cards, showed: - Residents shall have a tray card on file indicating significant food preference, including any religious or cultural preferences, diet orders, food allergies, and any other nutritional needs. - Resident tray cards shall be utilized by dining services staff to identify and provide accurate meal service for the individual, while honoring their dining needs and preferences. 1. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents received meals that were nutritive in value and palatable when residents were served cold food which affected three residents (Resident #67, #43 and #59) out of 21 sampled residents. This also had the potential to affect all residents residing in the facility. The facility census was 104. Review of the facility's undated policy for Monitoring Food Temperatures for Meal Service, showed: - Food temperatures will be monitored to ensure foods are served at palatable temperatures. Review of the facility's undated dietary aide job description form showed: - Serve meals that are palatable and appetizing in appearance; - Assist with serving meals as necessary and on a timely basis; - Set up meal trays, food carts, dining room, etc. as instructed; - Deliver food carts, trays, etc. to designated areas. 1. [...]

Inspectors wroteBased on observation, record review and interviews, the facility failed to ensure they provided meals to residents at regular times comparable to normal mealtimes and at the posted times which affected five of 21 sampled residents (Residents #154, #13, #75, #254, #89 ). The facility census was 104. Review of the facilities posted meal times showed: - Breakfast 8:00-9:30 A.M.; - Lunch 12:00-1:30 P.M.; - Dinner 5:00-6:30 P.M. Review of the facility's undated policy on meal time observation for food acceptance and food replacement showed: - Residents will be observed during meal times to monitor acceptance and intake of food and beverage items, and offered food replacements of similar nutritive value or other food selections the resident might enjoy; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain the kitchen in a sanitary manner when staff failed to ensure the blinds were free from dust build up and the oven was free from food particles and debris. Additionally, the facility failed to ensure food items were properly dated, labeled and expired food items were discarded. These have the potential to affect all residents residing within the facility. The facility census was 104. Review of the facility's undated Labeling and Dating Foods policy showed: - All foods stored will be properly labeled according to the following guidelines. - Food items that are unopened will be dated with the date the case was received into the facility; - Once a case of food is opened, the individual food items from the case are dated with the date the item was received into the facility; [...]

Inspectors wroteBased on observation, interview and record review the facility failed to maintain an effective pest control program to prevent gnats from swarming the residents and landing on them. This affected the comfort of four sampled residents (Resident #22, #37, #42 and #43). The facility census was 104. The facility did not provide the requested policy for pest control. 1. Review of Resident #22's quarterly (MDS), a federally mandated assessment instrument completed by facility staff, dated 8/15/23, showed: -Resident has moderate cognative impairment; -Resident is independent with ADLs; -Resident requires supervision for transfers; -Diagnoses included, kidney failure, diabetes mellitus and high blood pressure. A review of the resident's care plan, dated 5/25/23, showed: -Resident has an ADL self-care performance related to impaired balance; -Resident has limited physical mobility. [...]