Every finding on record at Sterling Care Rockville Nursing

Based on medical record reviews, staff interviews, and observations, it was determined that the facility failed to 1) ensure that residents received treatment and care necessary to promote well-being and 2) follow physician's medication order and directions. This was evident for 1 (Resident #6) of 2 residents reviewed for Urinary Tract Infection (UTI) and for 2 of the 26 medication administrations observed during the facility task. The findings include: 1) A review of Resident #6's medical records on 4/02/26 at 9:17 AM revealed a positive test for a UTI on 3/04/26. Further review of the Medication Administration Record (MAR) showed an initial order for Nitrofurantoin (an antibiotic) 100mg by mouth twice daily (BID). The resident received two doses on 3/04/26 and one dose on the morning of 3/05/26. This order was discontinued starting with the 3/05/26 afternoon dose. A new order was placed for Nitrofurantoin 100mg by mouth once daily (QD) for chronic UTI prophylaxis, scheduled for daily administration for seven days every 4 weeks. The MAR indicated that this medication was only administered on 3/06, 3/07, and 3/08 (total of three doses). During an interview on 4/02/26 at 10:00 AM, the Director of Nursing (DON) stated that the facility's Infectious Disease physician had changed the order from BID to QD. The DON explained that the intent was to administer the medication once daily for one week per month, for a duration of three months. Upon reviewing the MAR with the surveyor, it was confirmed that Resident #6 only received three doses of the QD regimen (from 3/06/26 to 3/08/26). The DON validated that the resident did not receive the full course as intended by the physician. 2a) On 04/02/2026 at 09:34 AM, the surveyor observed Certified Medication Aide (CMA) #9 administer scheduled morning medications to Resident #17. The medication label for a inhaler, administered once per day for pulmonary disease, instructed the resident to Rinse mouth with water without swallowing after using it to help reduce the chance of getting thrush. CMA #9 administered the inhaler but failed to educate the resident to rinse without swallowing after use, as ordered. The CMA then administered the remaining pills with a cup of water.On 04/02/2026 at approximately 09:38 AM, the surveyor notified CMA #9 of her failure to ensure the resident rinsed after using the inhaler, as prescribed. The surveyor showed CMA #9 the administration instructions written on the medication package, and she verbally acknowledged the findings.2b) On 04/02/2026 at 09:53 AM, the surveyor observed CMA #9 administering medication to Resident #70. CMA #9 poured MedPass (a high-calorie/high-protein supplement) into an unmeasured clear cup, which was approximately three-quarters full. When the surveyor asked CMA #9 how she ensured the resident received the ordered supplement amount, she explained that her long experience gave her an idea of the correct dosage. She further explained that she typically fills the cup but, knowing Resident #70 often does not drink the full amount, she did not fill the cup to the top. CMA #9 indicated that 30ml medication cups are sometimes used for measuring liquids and admitted she should have measured the supplement before pouring it.On 04/02/2026 at approximately 03:00 PM a review of the physician's order revealed that Resident#70 had an order for MedPass three times a day for malnutrition 4 oz./120ml. On 04/02/2026 at 03:15 PM, the surveyor interviewed the Assistant Director of Nursing (ADON) regarding the capacity of the large white plastic cup on the medication cart. The ADON verified that the cup held 9 ounces of fluid and presented it to the surveyor for verification. The Assistant Director of Nursing (ADON) was subsequently asked about the facility's expectation for measuring medications/supplements, such as MedPass. The DON explained that staff are expected to use the small medication cups with measurements printed on the container. The ADON was informed of the findings: that CMA #9 failed to measure the nutritional supplement and she administered an unmeasured amount of MedPass to Resident #70, potentially not giving the appropriate amount as ordered.The ADON was notified that CMA#9 failed to administer medication according to the physician's order and or direction on 2 separate occasions during the medication administration facility task.

Based on observation, record review and interview, it was determined that the facility failed to provide necessary personal hygiene to dependent resident. This was evident for 1 (Resident #8) of 1 resident reviewed for ADL care during the recertification survey.The findings include:Activities of Daily Living (ADLs) is a term used collectively to describe fundamental skills required to independently care for oneself, such as eating, bathing, and mobility. Minimum Data Set (MDS) is a core set of screening, clinical, and functional status data elements, including common definitions and coding categories, which form the foundation of a comprehensive assessment for all residents of nursing homes certified to participate in Medicare or Medicaid. A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess, and evaluate the effectiveness of the resident's care. On 4/01/2026 at:47 AM, Resident #8 was observed with facial hair on the chin and expressed a desire for staff assistance with shaving. On 4/02/2026 10:40 AM, a review of Resident #8's medical record indicated a BIMS (Brief Interview for Mental Status) score of 6/15 which indicated severe cognitive impairment. A review of the Quarterly MDS with an Assessment Reference Date (ARD) of 12/22/2025 confirmed that Resident #8 was classified as Dependent (helper does all of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity) for personal hygiene (the ability to maintain personal hygiene, including combing hair, shaving, applying makeup, washing/drying face and hands- excludes baths, showers, and oral hygiene). Resident #8's ADL care plan outlined the following: Has deficit in activities of daily living related to weakness and cognitive deficit. Date Initiated: 04/07/2025 Will receive the appropriate staff support with bed mobility, transfers, eating, dressing, toilet use, personal hygiene, through next review.Date Initiated: 10/19/2025 On 4/02/2026 at 11:06 AM, during a follow up visit, facial hair was still observed on Resident #8's chin. On 4/02/2026 at 11:09 AM, in an interview with Geriatric Nurse Assistant (GNA #5), he/she confirmed that when providing shower or bath to dependent residents, nursing staff were expected to clean/trim fingernails, shave facial hair for both male and female residents. On 4/02/2026 at 11:18 AM, the surveyor notified the Director of Nursing (DON) of the concern. On 4/02/2026 at 11:38 AM, the DON confirmed that after becoming aware of the concern, she visited Resident #8 to offer assistance with shaving, however, the resident declined. The DON further confirmed that the care plan was updated on 4/2/26 following the surveyor's intervention, to reflect the refusal to trim facial hair.

Based on observation, interview and record review, it was determined that the facility failed to review and revise a resident's plan to meet their specific needs. This was evident for 1 (Resident #4) of 23 residents reviewed for care planning during the recertification survey. The findings include: According to CMS (Centers for Medicare and Medicaid Services), in long-term care facilities, patient-centered care plans should be developed, implemented, and regularly updated to reflect changes in a patient's health status, treatments, or medication. Revisions must occur upon significant clinical changes, annually, or when goals are met, ensuring accuracy in care delivery. A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess, and evaluate the effectiveness of the resident's care. Minimum Data Set (MDS) is a core set of screening, clinical, and functional status data elements, including common definitions and coding categories, which form the foundation of a comprehensive assessment for all residents of nursing homes certified to participate in Medicare or Medicaid. Activities of Daily Living (ADLs) is a term used collectively to describe fundamental skills required to independently care for oneself, such as eating, bathing, and mobility. On 4/01/2026 at 10:14 AM, during the initial tour of the facility, Geriatric Nurse Assistant (GNA #5) was observed taking the sit-to-stand lift or a stand assist lift (is a motorized or hydraulic device designed to assist individuals with limited mobility to move from a seated to a standing position) to Resident #4's room. GNA #5 confirmed that the lift was used to transfer Resident #4 from bed to chair. On 4/02/2026 at 7:51 AM, a review of Resident #4's medical record indicated a diagnosis of Hemiplegia (complete paralysis) and hemiparesis (weakness) affecting left non-dominant side. The MDS record with an Assessment Reference Date (ARD) of 1/14/26 revealed that Resident #4 had a functional limitation in range in motion on one side of the upper and lower extremity and was Dependent (helper does all of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity) for the following:a. Sit to stand: The ability to come to a standing position from sitting in a chair, wheelchair, or on the side of the bed.b. Chair/bed-to-chair transfer: The ability to transfer to and from a bed to a chair (or wheelchair). A review of Resident #4's care plan (initiated on 7/24/24 and revised on 3/28/26) indicated, has deficit in Activities of daily living related to weakness, decreased mobility and pain. One of the interventions that was initiated on 11/2/25 specified, Transfer with use of Hoyer Lift (a mechanical device used to safely transfer individuals with limited mobility, such as those who are bed-bound or wheelchair-bound). However, the care plan was not updated to reflect the use of a sit-to-stand lift for transfers. On 4/02/2026 at 11:18 AM, the Director of Nursing (DON) confirmed that care plans were initiated on admission and updated by the supervisor or the Unit Manager during significant changes, new orders, or scheduled MDS assessments. On 4/02/2026 at 11:56 AM, Staff #3 confirmed that Resident #4 was on sit-to-stand lift trial from December to January 2026. On 4/03/2026 at 8:17 AM, Staff # 3 provided the surveyor with a copy of the attendance sheet for sit-to-stand lift education that was conducted on 11/25/25 for GNAs #5 and #23. On 4/03/2026 at 8:24 AM, the DON was notified of the concerns.

Based on a review of the Minimum Data Set (MDS) assessments and interviews with facility staff, it was determined that the facility failed to transmit MDS assessments to the CMS system within the required 14-day timeframe following completion. This deficiency affected two residents (Resident #22 and #86) out of four residents reviewed for resident assessments during the recertification/complaint survey.The findings include:Per the Resident Assessment Instrument (RAI) User's Manual, the MDS is a federally mandated tool used to identify resident strengths and needs to inform care planning. MDS assessments must be encoded within seven days of completion. Furthermore, the facility is required to transmit MDS data to the Centers for Medicare and Medicaid Services (CMS) system within 14 days of the assessment completion date.During the annual survey, the system flagged 'Resident Assessments' due to MDS records exceeding 120 days old.On 4/03/26 at 10:33 AM, a review of the medical records for the flagged residents revealed the following:-Resident #22: The Quarterly MDS assessment (target date 10/11/25) was completed on 10/28/25, which exceeded the 14-day transmission window by three days. A subsequent Quarterly assessment (target date 1/10/26) was completed on 1/26/26, exceeding the window by two days.-Resident #86: The Quarterly MDS assessment (target date 1/09/26) was completed on 1/26/26, exceeding the 14-day transmission window by four days.On 4/03/26 at 12:11 PM, the MDS Coordinator (Staff #16) stated that MDS assessments must be completed and transmitted within 14 days of the Assessment Reference Date (ARD). Upon reviewing the records for Resident #22 and Resident #86 with the surveyor, Staff #16 validated that the assessments were not completed or transmitted in a timely manner.

Based on clinical record review and staff interview it was determined that the facility staff failed to ensure a resident had an Advance Directive and/or failed to offer the appropriate information to formulate one if the resident did not have one. This was evident for 1(Resident #12) out of 24 residents reviewed as part of the initial pool survey task during the recertification/complaint survey.The findings include:This surveyor reviewed Resident #12's clinical record on 4/1/26 at 12:17 PM. The review revealed that the clinical record contained no evidence that the facility staff asked if the resident had an Advance Directive or that the resident, or the Responsible Party (RP), was offered the paperwork to formulate an Advance Directive if the resident did not have one.An interview with the Social Services Assistant (Staff #1) was conducted on 4/1/26 at 1:49 PM. The survey team member asked how does the facility account for an Advance Directive. Staff #1 stated that upon admission we ask the resident if they have an Advance Directive. If the resident was incapable, then we ask the family if they have Power of Attorney (POA) or guardianship. If they are capable, and they say, 'no we do not have an Advance Directive', then the facility staff will offer a copy for them to fill out. The surveyor asked where the Advance Directive and/or documentation would be found. Staff #1 answered that it was documented in the admission note. If the resident had a copy of the Advance Directive or if the facility received a copy from the family, it was uploaded into the electronic health record. The survey team requested information on some residents who needed proof of either having an Advance Directive or having been offered the paperwork to complete an Advance Directive. The Director of Nursing (DON) was interviewed on 4/2/26 at 8:50 AM. She was informed of the findings as well as the importance of having either the Advance Directive or offering it. She said she understood and would investigate. She said she believed the resident does not have one but was not sure if the resident was offered the paperwork to complete one. The Social Worker (Staff #11) was interviewed on 4/6/26 at 9:27 AM. This surveyor asked if she had any information regarding the presented concerns. She confirmed Resident #12 does not have an Advance Directive and then she said Staff #1 called the resident's family member on Friday and the family member claimed to have the Power of Attorney paperwork but has not brought it in.

Based on observation, interviews and record reviews, it was determined that the facility failed to ensure that a call bell was kept within resident's reach. This was evident for 1 (Resident #8) of 88 residents observed during the recertification survey.The findings include: A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess, and evaluate the effectiveness of the resident's care. Minimum Data Set (MDS) is a core set of screening, clinical, and functional status data elements, including common definitions and coding categories, which form the foundation of a comprehensive assessment for all residents of nursing homes certified to participate in Medicare or Medicaid. The data elements (also referred to as items) in the MDS standardize communication about resident problems and conditions within nursing homes, between nursing homes, and outside agencies. On 4/01/2026 at 9:55 AM, during the initial tour of the facility, Resident #8's call bell was observed on the floor. At 10:04 AM, the surveyor notified Licensed Practical Nurse (LPN #6) of the finding. On 4/02/2026 at 10:40 AM, a review of Resident #8's medical record revealed a diagnosis of muscle weakness and abnormalities of gait and mobility. The Quarterly MDS Section GG- Functional abilities, with an Assessment Reference Date (ARD) of 12/22/2025 coded Resident #8 as Dependent (helper does ALL of the effort. Resident does none of the effort to complete the activity. Or the assistance of 2 or more helpers is required for the resident to complete the activities) for the following:a. Bed mobility-Roll left and right: the ability to roll from lying on back to left and right side and return to lying on back on the bed.b. Transfer-Chair/bed-to-chair transfer: the ability to transfer to and from a bed to a chair.c. Personal hygiene: The ability to maintain personal hygiene, including combing hair, shaving, applying makeup, washing/drying face and hands (excludes baths, showers, and oral hygiene). A review of Resident #8's care plan, initiated on 4/7/2025 specified to Have commonly used articles within easy reach i.e. call bell, TV remote control, etc. On 4/02/2026 at 10:56 AM, Licensed Practical Nurse (LPN #4) confirmed that nursing staff were expected to place the call bells within reach. On 4/02/2026 at 11:18 AM, the Director of Nursing (DON) was notified of the concern and verbalized understanding.

Based on a review of medical records and staff interviews, it was determined that the facility staff failed to provide treatment and care in a timely manner for a resident with a urinary tract infection (UTI). This was evident for one resident (Resident #2) of three reviewed for urinary catheter care during this recertification/complaint survey.The findings include:A review of Resident #2's medical record on 4/06/26 at 7:37 AM revealed that the resident tested positive for a urinary tract infection (UTI) on 3/30/26. A further review of the resident's progress notes indicated that the results were reported to the attending provider on 3/30/26; however, no new orders were received at that time. A review of the Medication Administration Record (MAR) showed that five days later, on 4/05/26, Resident #2 began receiving Methenamine Hippurate (antibiotic) 1g twice daily for seven days to treat the UTI.In an interview on 4/06/26 at 8:10 AM, the Director of Nursing (DON) stated that the facility staff should contact Staff #22 (in- house Infectious Disease doctor) as soon as a resident is identified with a UTI and must follow their prescribed interventions.On 4/06/26 at 8:23 AM, the surveyor interviewed the Assistant Director of Nursing (ADON). ADON confirmed that Resident #2's UTI was reported to the attending physician on 3/30/26 without a new order. She subsequently contacted Staff #22 to establish a treatment plan, which resulted in the resident starting antibiotics on 4/05/26. Staff #22's consultation note, found in the electronic medical record and dated 4/03/26, recommended changing the foley catheter as soon as possible and starting Methenamine. The foley catheter was changed on 3/31/26.The surveyor asked the ADON why the medication was started on 4/05/26-two days after Staff #22 placed the order and five days after the initial positive result was reported. The ADON stated that she needed to clarify the frequency of the medication with Staff #22, which caused a delay. She added, Since the medication was for UTI prophylaxis, no urgent use was required.In a follow-up interview on 4/06/26 at 8:44 AM, the surveyor shared concerns with the DON regarding the failure to address Resident #2's UTI treatment in a timely manner. The DON validated these concerns.

Based on interviews with residents and staff, and a review of facility documentation, it was determined that the facility failed to make prompt efforts to resolve resident grievances. This deficiency was evident for one resident (Resident #6) out of 24 residents reviewed for grievances during the recertification/complaint survey.The findings include:During an interview on 4/01/26 at 10:49 AM, Resident #6 reported that a new, unopened package of T-shirts, and a pair of eyeglasses went missing during his/her recent hospitalization in February 2026.On 4/02/26 at approximately 10:00 AM, the surveyor inquired if the facility had a formal grievance on file for Resident #6 regarding these missing items.On 4/03/26 at 11:09 AM, the Director of Nursing (DON) confirmed that no grievance form had been completed for Resident #6. The surveyor informed the DON of the resident's concerns regarding the missing property. The DON stated, The resident mentioned telling a nurse, but we did not have a [formal] grievance filed for that. The Social Worker is now speaking with the resident and has initiated the case. The surveyor shared the concern that the facility failed to initiate grievance until prompted by the surveyor, and the DON validated the finding.

Based on observations and interviews, it was determined that the facility failed to provide necessary respiratory care services. This was evident for 1 (Residents #4) of 2 residents reviewed for respiratory care during the recertification survey.The findings include: CPAP (Continuous Positive Airway Pressure) machine is a device that uses a hose and mask to deliver steady, gentle air pressure to keep airways open. The system includes a motor, air filter, tubing, and a mask. On 4/01/2026 at 10:01AM, during the initial tour of the facility, Resident #4's CPAP mask was observed on the floor, and the tubing was dated 1/10/26. At 10:04 AM, Licensed Practical Nurse (LPN #6) was notified of the findings. On 4/02/2026 at 8:19 AM, a review of Resident #4's medical record indicated a diagnosis of Obstructive Sleep Apnea or OSA (is a common sleep disorder where breathing repeatedly stops and starts because throat muscles relax and blocks the airway.)Further review of the medical record confirmed the following orders:a. Apply CPAP at bedtime and remove in the morning as tolerated. Settings: 4 centimeters water every evening and night shift for OSAb. Oxygen tubing: change weekly and as needed. (Used for CPAP) as needed for hygiene, label with initials /date / time.c. Oxygen tubing change weekly and as needed.(Used for CPAP) every night shift every Friday for hygiene. Label with initials / date / time.d. Respiratory: Wash the CPAP water chamber and filter with warm water and mild detergent every week while in use. Dry completely before use every evening shift every Wednesday for infection Control. On 4/02/2026 at 10:56 AM, LPN #4 confirmed that nurses were expected to change and label the oxygen tubing weekly and that masks must be washed, dried, and stored in clear bags after each use. The facility's oxygen policy dated 1/20/26 required that oxygen tubing and mask/cannula be changed weekly and as needed when soiled or contaminated, and that delivery devices be stored in plastic bags when not in use. On 4/02/2026 at 11:18 AM, the Director of Nursing (DON) was notified of these findings and acknowledged the concerns.

Based on medical record reviews, observations, and staff interviews, it was determined that the facility failed to ensure that medical records were maintained in a complete and accurate manner. This was evident for 3 (Resident #63, #106, #57) of 43 residents reviewed during the recertification/complaint survey. The findings include: 1) A review of Resident #63's medical record on 4/01/26 at 11:24 AM revealed a significant weight gain documented on 10/22/25. According to the record, the resident's weight was 155 lbs. (pound) on 10/14/25; eight days later, on 10/22/25, it was documented as 164 lbs. - a 9 lb. (5.81%) gain. During an interview on 4/03/26 at 11:15 AM, Staff #8 (Dietitian) stated, When a resident has significant weight changes, I write a note, provide an intervention, and report it to the nurses. The surveyor reviewed Staff #8's note dated 10/23/25 in the electronic medical record (EMR). However, the note lacked evidence that the provider and the responsible party had been notified of Resident #63's significant weight gain. Staff #8 stated that the SBAR (Situation, Background, Assessment, Recommendation) documentation - a structured communication framework—contained the notification of the provider and responsible parties. A further review of Resident #63's medical record revealed an SBAR dated 10/20/25, which included details of provider notification and a recommendation to re-weigh the resident. However, Resident #63's body weight for 10/20/25 was struck out in the electronic record with a comment from [Nurse's Name] on 10/22/25 at 12:44 PM stating, typing error. In an interview with the Director of Nursing (DON) and Staff #8 on 4/03/26 at 11:58 AM, Staff #8 stated that Resident #63's weight gain was reported on 10/20/25, as evidenced by the SBAR. The surveyor reviewed the resident's body weight record, which remained struck out with an error message, resulting in inaccurate records. The DON validated these concerns. 2) A Port-a-Cath also known as a port, is an implanted device that is surgically inserted beneath the skin in the chest area. The port allows for easy access to a patient's veins to receive medications, such as chemotherapy on a frequent basis. On 04/01/2026 at 11:27 AM, during the screening portion of the survey, Resident #106 stated that she/he would like a private room because she/he is receiving chemotherapy. Resident #106's medical record was reviewed on 4/2/2026 at 0730 AM, it was found that the resident had been admitted on [DATE] and was started on intravenous chemotherapy on 3/31/2026. During the review, it was noted that the resident signed informed consent for treatment from the oncologist for the following medication: FOPLFIRINOX (Modified) Q14D (3 mo.) Cycle Length: 14 Number Cycles: 6 Start: C1D1 on 3/31/2026 Assoc DX: Primary pancreatic cancer LOT: Neoadjuvant Stage: IV 03/30/2026 C2 D1. The medication, also known as 5-FU consists of Irinotecan, Oxaliplatin, Leucovorin, Fluorouracil, and Atropine. Review of the resident's skilled Medication Administration Record (MAR) and the Treatment Administration Record (TAR) revealed that there was no documentation that resident was receiving this medication and no documentation of monitoring for the specific side effects for the medication. Unit Manager (UM) was interviewed on 4/2/2026 at 08:20 AM, and during the interview, the surveyor asked how the pharmacist would know what chemotherapy medication the resident is getting, and how staff would know what specific side effects to monitor if there are no orders to document on the MAR. The Unit Manger stated that the resident started chemotherapy on 3/31/2026 and she was going to add the orders to the MAR. The surveyor also asked if resident could have a private room. The Unit Manager stated that there is no need for a private room at this time, but if the resident became immunocompromised then Resident #106 will be placed in a private room. On 4/2/2026 at 09:45 AM, the Director of Nursing (DON) provided copies of the skilled MAR that had been updated with the following: Monitor IV Chemotherapy infusion via Right Chest Port: FOLFIRINOX chemotherapy combination (5-FU, leucovorin, irinotecan, oxaliplatin) for pancreatic Cancer. Notify MD/NP and Oncologist for any leakage, complications. every shift for Routine Monitoring Monitor Side effects of Chemotherapy: FOLFIRINOX chemotherapy combination (5-FU, leucovorin, irinotecan, oxaliplatin) for pancreatic Cancer, frequently causing side effects like severe diarrhea, fatigue, nausea, vomiting, mouth sores, hair loss, and low blood cell counts, unique side effect acute cold sensitivity (numbness, throat spasms). Notify MD/NP if any side effects are noted. Notify Oncologist, every shift for Routine Monitoring. On 4/2/2026 at 09:47 AM, The DON was made aware that these updates should have been on the MAR after Resident #106 returned from the Oncologist on 3/31/26 and not after the surveyor's intervention. The DON agreed with the findings. 3) This surveyor reviewed Resident #57's clinical record on 4/3/26 and 4/6/26. A review of the resident's Medication Administration Records (MAR) and Wound Treatment Administration Record (WTAR) for the months of January, February, and March of 2026 revealed nursing staff failed to completely document the administration of medications. A review of the January WTAR revealed the resident's primary physician ordered Ammonium Lactate External Lotion 12% to be applied to the resident's Left Lower Leg. The nursing staff failed to document administering it on 1/1/26,1/8/26, 1/10/26, 1/12/26, 1/13/26. A review of the January WTAR revealed the resident's primary physician ordered Ammonium Lactate External Lotion 12% to be applied to the resident's Right Lower Leg. The nursing staff failed to document administering it on 1/2/26, 1/7/26, 1/8/26, 1/9/26, 1/10/26, 1/12/26, 1/20/26, and 1/29/26. A review of the February WTAR revealed the resident's primary physician ordered Ammonium Lactate External Lotion 12% to be applied to the resident's Left Lower Leg. The nursing staff failed to document the administration of it on 2/5/26, 2/19/26, 2/23/26 A review of the February WTAR revealed the resident's primary physician ordered Ammonium Lactate External Lotion 12% to be applied to the resident's Right Lower Leg. The nursing staff failed to document the administration of it on 2/3/26, 2/4/26, 2/5/26, 2/6/26, 2/7/26, 2/8/26, 2/12/26, 2/13/26, 2/16/26, 2/17/26, 2/18/26, 2/29/26, 2/21/26, and 2/23/26. A review of the February WTAR revealed the resident's primary physician ordered Dakin's external solution to be applied to the left posterior lower leg. The nursing staff failed to document the administration of it on 2/23/26. A review of the February WTAR revealed the resident's primary physician ordered Santyl external solution 250 unit/GM to be applied to the left posterior lower leg. The nursing staff failed to document the administration of it on 2/23/26. A review of the March WTAR revealed the resident's primary physician ordered Ammonium Lactate External Lotion 12% to be applied to the resident's Left Lower Leg. The nursing staff failed to document administration of it on 3/5/26, 3/12/26, 3/14/26, and 3/19/26. A review of the March WTAR revealed that the resident's primary physician ordered Ammonium Lactate External Lotion 12% to be applied to the resident's Right Lower Leg. The nursing staff failed to document the administration of it on 3/3/26, 3/5/26, 3/7/26, 3/8/26, 3/11/26, 3/12/26, 3/14/26, 3/15/26, 3/17/26, 3/18/26, 3/19/26, 3/21/26, 3/24/26, and 3/28/26. A review of the March WTAR revealed the resident's primary physician ordered Dakin's external solution to be applied to the left posterior lower leg. The nursing staff failed to document administration of it on 3/5/26, 3/12/26, 3/14/26, and 3/19/26. A review of the March WTAR revealed the resident's primary physician ordered Greer's [NAME] to be applied to the resident's sacrum. The nursing staff failed to document administration of it on 3/5/26, 3/12/26, 3/13/26, 3/14/26, 3/15/26, and 3/19/26. A review of the March WTAR revealed the resident's primary physician ordered Santyl external solution 250 unit/GM to be applied to the left posterior lower leg. The nursing staff failed to document the administration of it on 3/5/26, 3/12/26, 3/14/26, and 3/19/26. A review of the March WTAR revealed the resident's primary physician ordered Santyl external solution 250 unit/GM to be applied to the right lower leg. The nursing staff failed to document the administration of it on 3/14/26 and 3/19/26. The Director of Nursing (DON) was interviewed on 4/3/26 at 11:59 AM. She was shown the WTAR's and the gaps which suggested that the medications were not administered. She said some of those days were the wound round days and she did not understand why the wound care nurse did not sign that the medications were administered. She said she thought the medications were administered but she was not sure if she could show that they were documented elsewhere. She said she understood the gaps being cited.

Based on observation and staff interview it was determined that the facility staff failed to ensure food temperatures were maintained at a safe and palatable level. This was evident for 1 out of 1 test tray observation during the recertification/complaint survey.The findings include:This surveyor arranged for two test trays to be sent to the 3rd floor and for the test trays to be the last ones served. Staff #15 took temperatures of two test lunch trays on 4/3/26 at 1:03 PM. One was a regular diet and the other was a pureed diet. The regular diet tray had milk and juice as beverages. The temperatures were 67 Fahrenheit (F) for the milk and 69F for the juice. The pureed diet tray had milk and tomato juice. The temperatures were 66F for the milk and 49.1F for the tomato juice. This surveyor interviewed Staff #15 on 4/3/26 at 1:06 PM. The temperatures of three of the beverages were above 50F which he agreed were too warm for consumption. He said he would investigate as to the cause of the elevated temperature. He said he was sure the beverages were kept in the coolers until time to be placed on the trays.

Based on medical record reviews and staff interviews, it was determined that the facility failed to ensure that the COVID-19 vaccination status for residents and staff was consistently monitored and documented. This was evident for one of five residents (Resident #22) and one of five staff members (Staff #12) whose records were reviewed during the recertification/complaint survey.The findings include:The COVID-19 vaccine is intended to provide acquired immunity against SARS-CoV-2, the virus that causes COVID-19. On 4/03/26 at 7:22 AM, the surveyor reviewed the employee health file for Staff #12 (hired September 2025 as direct care staff). The review revealed that there was no evidence of the employee's COVID-19 vaccination status. During an interview at 8:13 AM, the Director of Nursing (DON) explained that the Human Resources department screens health records (including childhood immunizations, COVID, Flu, and Hepatitis B). She stated that if a staff member indicates they have been vaccinated, the facility should obtain evidence; if not, the staff member should receive the vaccine. The DON reviewed the record with the surveyor and validated that Staff #12's status was undocumented.On 4/03/26 at 8:00 AM, the surveyor reviewed five randomly selected resident vaccination records. Resident #22, who was originally admitted in June 2025 and readmitted in February 2026, lacked current vaccination documentation. Electronic medical records showed the resident refused the vaccine on 6/20/25, but no record existed for the current admission. At 8:32 AM, the DON confirmed that vaccination status should be updated with each admission.At 9:03 AM on 4/03/26, Staff #13 (a DON from a sister facility) located a paper COVID-19 Vaccination Consent/Declination form in the resident's nursing station chart. While the form was marked as a declination, it was undated. During a follow-up interview on 4/06/26 at 1:00 PM, the DON validated the concern that Resident #22's current COVID-19 vaccination status was not updated.

Based on observations, record reviews, and interviews, it was determined that the facility failed to maintain appropriate infection control practices regarding 1) the proper use and care of respiratory equipment, and 2) a safe and sanitary environment to help prevent the development and transmission of communicable diseases and infections. This was evident for 1 (Resident #4) of 2 residents reviewed for respiratory care and 2 observations (Residents #22 and #58) during the medication administration facility task during the recertification/complaint survey.The findings include: CPAP (Continuous Positive Airway Pressure) machine is a device that uses a hose and mask to deliver steady, gentle air pressure to keep airways open. The system includes a motor, air filter, tubing, and a mask. Enhanced Barrier Precautions are an infection control intervention designed to reduce the transmission of multidrug-resistant organisms (MDROs) in nursing homes. Enhanced Barrier Precautions involve gown and glove use during high-contact resident care activities for residents known to be colonized or infected with a MDRO as well as those at increased risk of MDRO acquisition (e.g., residents with wounds or indwelling medical devices) (CDC website 2025). 1) On 4/01/2026 at 10:01AM, during the initial tour of the facility, Resident #4's CPAP mask was observed on the floor, and the tubing was dated 1/10/26. At 10:04 AM, Licensed Practical Nurse (LPN #6) was notified of the findings. On 4/02/2026 at 8:19 AM, a review of Resident #4's medical record indicated a diagnosis of Obstructive Sleep Apnea or OSA (is a common sleep disorder where breathing repeatedly stops and starts because throat muscles relax and blocks the airway.) Further review of the medical record confirmed the following orders: a. Apply CPAP at bedtime and remove in the morning as tolerated. Settings: 4 centimeters water every evening and night shift for OSA b. Oxygen tubing: change weekly and as needed. (Used for CPAP) as needed for hygiene, label with initials /date / time. c. Oxygen tubing change weekly and as needed.(Used for CPAP) every night shift every Friday for hygiene. Label with initials / date / time. d. Respiratory: Wash the CPAP water chamber and filter with warm water and mild detergent every week while in use. Dry completely before use every evening shift every Wednesday for infection Control. On 4/02/2026 at 10:56 AM, LPN #4 confirmed that nurses were expected to change and label the oxygen tubing weekly and that masks must be washed, dried, and stored in clear bags after each use. The facility's oxygen policy dated 1/20/26 required that oxygen tubing and mask/cannula be changed weekly and as needed when soiled or contaminated, and that delivery devices be stored in plastic bags when not in use. On 4/02/2026 at 11:18 AM, the Director of Nursing (DON) was notified of these findings and acknowledged the concerns. 2a) On 04/02/2026 at 9:15 AM, during medication administration facility task the surveyor observed Certified Medication Aide (CMA) #9 obtain Resident #22's blood pressure with a portable blood pressure machine and reusable blood pressure cuff; and at approximately 09:30 AM CMA#9 used the same portable blood pressure machine and blood pressure cuff to obtain Resident #17 blood pressure. However, CMA #9 failed to clean the blood pressure machine between each resident use, the surveyor also did not observe any sanitizing product on or near the blood pressure machine to indicate cleaning products were readily available to use in between resident use. On 04/02/2026 at 10:06 AM, in an interview with CMA #9, she was informed that she failed to clean the blood pressure machine between resident use. She explained that the cleaning product was removed from the machine and that she would replace it moving forward. 2b) On 04/02/2026 at 1:23 PM, during the medication administration task the surveyor observed License Practical Nurse (LPN) #10. Resident #58 was scheduled to receive an afternoon dose of an intravenous (IV) antibiotic. The surveyor observed an EBP sign posted on Resident #58's door. An orange star sticker was observed next to Resident #58's name, which indicated the resident was on EBP (per LPN #10 , when asked). The posted EBP sign indicated that staff should wear gloves and a gown for high-contact resident care activities including device care or use of a central line, urinary catheter, feeding tube and tracheostomy. Upon entering Resident #58's room, the resident had a single port IV access on the left arm. When asked, the LPN reported that it was a mid-line IV access. Observation of the medication administration revealed that LPN #10 failed to don the required personal protective equipment (gown) prior to administering the resident's IV antibiotics. On 04/02/2026 at approximately 1:40 PM, the nurse was asked about the requirement for EBP when administering IV medication. He explained that gloves and masks were required. When the surveyor asked him about wearing a gown, he reported that gowns were required for contact isolation but not EBP. He was shown the EBP sign posted on the door, which indicates direct care requires a gown and gloves and he verbalized understanding. On 04/02/2026 at approximately 03:20 PM, in an interview with the Assistant Director of Nursing (ADON), she was asked the expectation of staff during IV administration usage. She reported that for residents with central lines, staff should wear gowns and gloves before use. The ADON was informed of the above-mentioned findings and verbalized understanding.

Based on medical record review and staff interview, it was determined the facility staff failed to ensure Minimum Data Set (MDS) assessments were accurately coded. This was evident for 4 (#12, #10, #11, #9) of 5 residents reviewed for MDS assessments during a complaint survey.The findings include: The MDS is part of the Resident Assessment Instrument that was Federally mandated in legislation passed in 1986. The MDS is a set of assessment screening items employed as part of a standardized, reproducible, and comprehensive assessment process that ensures each resident's individual needs are identified, that care is planned based on those individualized needs, and that the care is provided as planned to meet the needs of each resident.1) On 1/12/26 at 10:12 AM a review of Resident #12's medical record was conducted. A review of a 7/14/25 at 12:36 PM care plan update note documented, resident had an unwitnessed fall on 7/11/25 at around 1530. Resident was observed on the floor between the beds by a GNA during rounds.Review of Resident #12's annual MDS assessment with an assessment reference date (ARD) of 10/1/25, Section J1800 Falls, coded that Resident #12 did not have any falls during the previous 3 months. The facility failed to capture the fall on 7/11/25.On 1/13/26 at 12:35 PM an interview was conducted with the MDS Coordinator, RN #16 who confirmed the findings of the MDS errors.2a) On 1/12/26 at 10:52 AM a review of Resident #10's medical record was conducted. A review of nursing progress notes dated 7/30/25 documented that Resident #10 had an unwitnessed fall on 7/30/25 around 6:20 AM. Resident #10 did not sustain any injuries.Review of an 8/1/25 care plan update note documented Resident #10 had an unwitnessed fall on 7/31/25 at 1735 (5:35 PM). There were no noted injuries.Review of Resident #10's MDS assessment with an ARD of 8/22/25, Section 1800 Falls, coded no falls since last assessment. The facility failed to capture the 2 falls.Further review of Resident #10's medical record revealed the August 2025 Medication Administration Record (MAR) which documented Resident #10 received PRN (when needed) Oxycodone for pain on 8/16/25 and 8/18/25. The Treatment Administration Record (TAR) documented that Resident #10 received the antibiotic ointment Bacitracin on 8/15, 8/16, and 8/17/25.Review of Section J0100B received PRN pain medications OR was offered and declined? It was coded 0. The facility failed to capture the PRN use of Oxycodone.Review of Section N Medications, N0415, High-Risk Drug Classes was blank for antibiotic use. The facility failed to capture the use of Bacitracin ointment.2b) Review of Resident #10's care plan update note dated 9/15/25 at 10:10 M documented, had a fall while bathing, no injury noted.Review of the MDS assessment dated [DATE], Section J1800 falls, failed to capture the fall of 9/15/25. On 1/13/26 at 12:35 PM RN #16 confirmed the findings of the MDS errors.3) On 1/12/26 at 11:04 AM a review of Resident #11's medical record was conducted. A review of Resident #11's December 2025 MAR documented Resident #11 received Aspirin (antiplatelet) every morning and Gabapentin (anticonvulsant) every evening.Review of Resident #11's MDS ARD of 12/17/25, Section N Medications, N0415, High-Risk Drug Classes was blank for antiplatelet and anticonvulsant. The facility failed to capture the use of the medications.On 1/13/26 at 12:35 PM RN #16 confirmed the findings.4) On 1/12/26 at 12:05 PM a review of Resident #9's medical record was conducted. Review of Resident #9's February 2025 MAR documented the administration of Tramadol every day for pain 30 minutes before therapy. Resident #9 received the Tramadol on 2/10, 2/11, and 2/12/25. Tramadol is an opioid used for moderate to severe pain.Review of the MDS assessment with an ARD of 2/14/25, Section N Medications, N0415, High-Risk Drug Classes was blank for opioid use. The facility failed to capture the use of opioids. On 1/13/26 at 12:35 PM an interview was conducted with the MDS Coordinator, RN #16 who confirmed the findings.

Based on review of facility reported incidents, medical record review and staff interview, it was determined the facility failed to thoroughly investigate an allegation of abuse . This was evident for 1 (Resident #7) of 9 residents reviewed for Facility Reported Incidents during a complaint survey.The findings include: A review of facility reported incident 367211 was conducted on 1/6/26 regarding an allegation Resident #7 reported to Staff #18 on 5/13/25 that he/she was uncomfortable the way Staff #17 cared for him/her on 5/10/25. On the initial report to OHCQ (Office of Health Care Quality) submitted on 5/13/25 the facility indicated the allegation was physical. Further review of the facility investigation revealed no statement from Staff #18 to include what was reported by Resident #7 and when it was reported. The investigation also did not include a statement from Resident #7 until 5/14/25, the day after the allegation. Review of the statement provided by Resident #7 on 5/14/25 revealed the Resident stated to the Social Services Assistant (SSA) that the Resident saw Staff #17's fingers in his/her private area. Further review of Resident #7's medical record revealed the Resident was seen by Staff #19 (Psychiatric Mental Health Nurse Practitioner) on 5/14/25 who documented the Resident reported the allegation on 5/13/25 to the Dietitian. Review of the facility investigation provided to the Surveyor on 1/12/26 reveals no statement from the Dietitian and no emergency room documentation. After Surveyor intervention on 1/12/26, the facility provided the Surveyor with a copy of Resident #7's emergency room documentation from 5/13/25 that was not in the Resident's medical record. Review of the emergency room physician notes dated 5/13/25 revealed it stated the Chief complaint (in patient's own words) was for a complaint of sexually assaulted by male staff last Saturday at around 8:00 PM. Review of the Facility Reported Incident Follow-Up Investigation Report Form submitted on 5/20/25 by the Administrator did not include the Resident's statement alleging sexual abuse. Interview with the Corporate Nurse on 1/13/26 at 12:05 PM confirmed the investigation for Resident #7's allegation of sexual abuse on 5/13/25 does not include interviews, emergency room documentation and a complete investigation of the Resident's allegation.

Based on medical record review and staff interview it was determined that facility staff failed to develop and initiate a comprehensive, resident centered care plan for a resident with an indwelling urinary catheter. This was evident for 1 (Resident #15) of 5 residents reviewed for urinary catheters during a complaint survey.The findings include: A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess, and evaluate the effectiveness of the resident's care. A foley catheter is a flexible tub placed in the body which is used to empty the bladder and collect urine in a drainage bag. Obstructive uropathy occurs when urine cannot drain through the urinary tract. Urine backs up into the kidney and causes it to become swollen. Reflux nephropathy is a condition in which the kidneys are damaged by the backward flow of urine into the kidney. On 1/13/26 at 12:20 PM observation was made of Resident #15 lying in bed with foley catheter tubing and a drainage bag hanging on the side of the bed. The urinary drainage bag was not in a dignity bag.Review of Resident #15's medical record revealed the resident was admitted to the facility in September 2025 with diagnoses that included but were not limited to obstructive and reflux uropathy, malignant neoplasm of rectum, and benign prostatic hyperplasia.Further review of Resident #15's medical record failed to produce a care plan with measurable goals and interventions for a resident with a foley catheter.On 1/13/26 at 12:35 PM RN #15 was interviewed and stated the resident should have had a care plan for the catheter and she said she would make sure a care plan was put in place.

Based on medical record review, observation, and interview, it was determined the facility failed to ensure that the resident's call light and commonly used items were within reach, per the individualized care plans, to allow access to assistance when needed. This was evident for 1 (Resident #12) of 19 residents reviewed during a complaint survey. The findings include:A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess, and evaluate the effectiveness of the resident's care.On 1/12/26 at 10:12 AM Resident #12's medical record was reviewed and revealed Resident #12 was admitted in November 2024 with diagnoses that included but were not limited to unspecified dementia, repeated falls, and multiple sclerosis. Review of Resident #12's care plan, actual fall and is at risk for falls related to generalized weakness and gait/balance problems that was initiated in November 2024, had the intervention, have commonly used articles within easy reach i.e. call bell, TV remote control, etc. On 1/12/26 at 11:26 AM observation was made of Resident #12 lying in bed covered with a white sheet and white blanket. The gray call bell cord was hanging on the wall and not within reach of the resident. Resident #12's over the bed tray table was next to the window and out of reach of the resident. On the bed tray table was water, sandwiches, and the tv remote control.On 1/12/26 at 11:26 AM an interview was conducted with LPN #4 the Unit Manager of the second floor. LPN #4 was asked where Resident #12's call bell was located. LPN #4 looked around the bed, walked next to the bed and saw the call bell hanging on the wall. LPN #4 took the call bell cord off the wall and placed it on top of the bed. LPN #4 was asked if the tray table should have been within reach for Resident #12 and he said, yes. LPN #4 then pushed the tray table next to the resident's bed.On 1/13/25 at 9:35 AM a second observation was made and on 1/13/26 at 12:25 PM a third observation was made of Resident #12. The gray call bell cord with attached call bell was lying on the floor out of the resident's reach. Staff #14 was shown the concern.On 1/13/25 at 12:35 RN #15 was informed of the concern.

Based on observation and staff interview it was determined that facility staff failed to treat each resident in a dignified manner by failing to place a urinary catheter drainage bag in a dignity bag. This was evident for 2 (#14, #15) of 5 residents reviewed for urinary catheters during a complaint survey.The findings include:1) On 1/13/26 at 12:25 PM observation was made of Resident #14 lying in bed. Resident # 14's foley catheter drainage bag was hanging off the side of the bed frame on the left side of the bed. A foley catheter is a flexible tub placed in the body which is used to empty the bladder and collect urine in a drainage bag. The resident's drainage bag was not placed in a privacy/dignity bag to enhance privacy to the resident.Review of Resident #14's January 2026 Treatment Administration Record (TAR) documented the physician's order, catheter care: ensure dignity foley bag is in use every shift. The order was written on 1/11/26.On 1/13/26 at 12:35 PM RN #15 was informed of the finding.2) On 1/13/26 at 12:27 PM observation was made of Resident #15 lying in bed. Resident #15 had a foley catheter drainage bag hanging off the side of the bed. The drainage bag was not in a dignity bag.On 1/13/26 at 12:35 PM RN #15 was informed of the finding and said it should have been in a privacy bag.

Based on medical record review and interview, the facility staff failed to honor the wishes of a resident's representative (Resident #6). This was evident for 1 of 19 residents reviewed during a complaint survey.The findings include: Review of a complaint on 1/12/26 from Resident #6's representative (RP) sent to OHCQ (Office of Health Care Quality) on 10/29/25 revealed the RP stated he/she received an email from the facility on 10/28/25 stating they would not discharge the Resident on 10/30/25 unless he/she sent a signed AMA (Against Medical Advice) form to the facility. Review of Resident #6's medical record on 1/12/26 revealed the Resident was admitted to the facility on [DATE] from the hospital for rehabilitation. Further review of Resident #6's medical record revealed the Resident had 2 physician certifications that he/she was unable to comprehend information and make decisions on 9/21/25 and 9/23/25. Further review of Resident #6's medical record revealed a Social Services Note on 10/23/25 at 9:56 AM by Staff #6 that stated the Resident's representative reported that he/she would like for the Resident to discharge before the discharge already set by the Director of Rehabilitation due to wanting the Resident to be home. The Resident's RP stated he/she would be in touch with Social Services regarding a discharge date . During interview with Staff #6 on 1/12/26 at 12:18 PM, Staff #6 stated she did tell the RP they needed to sign the Against Medical Advice (AMA) form since the Resident could not and he/she was the RP. Staff #6 provided the AMA form to the Surveyor. Review of the AMA form revealed the RP wrote The facility wrote that if I don't sign this paper, they will not let the Resident leave the facility. It was signed by the RP and Staff #6 on 10/29/25. Review of an email, provided by the facility, sent to Resident #6's RP by Staff #6 on 10/28/25 at 3:31 PM revealed it stated: We can send you the discharge paperwork prior to his/her discharge, but we would need you to sign and send it back in order for us to discharge the Resident on Thursday (10/30/25). Interview with the Corporate Nurse on 1/13/26 at 10:30 AM, the Corporate Nurse confirmed she told Staff #6 via email on 10/30/25 the RP did not need to sign the AMA document. The Surveyor advised the Corporate Nurse at that time the RP had already signed the document on 10/29/25. During interview with Resident #6's RP on 11/14/26 at 11:39 AM, the RP stated he/she had emailed the facility on 10/28/25 to tell them he/she had arranged transportation home for the Resident on 10/30/25. The RP stated at that time Staff #6 emailed him/her back and said he/she could not take the Resident home unless he/she signed the discharge paperwork and included an AMA (Against Medical Advice) document. The RP stated he/she didn't believe the facility could hold the Resident if he/she wanted the Resident to go home. The RP stated he/she did sign the document on 10/29/25 and returned it to the facility but marked on the document the facility he/she was signing because the facility said they would not discharge the Resident unless he/she signed.

Based on record review, observation, and interview, it was determined the facility staff failed to ensure fall mats and the resident's call bell were properly in place for a resident with a history of falls. This was evident for 1 (Resident #12) of 19 residents reviewed during a complaint survey.The findings include: A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess, and evaluate the effectiveness of the resident's care. On 1/12/26 at 10:12 AM a review of Resident #12's medical record revealed Resident #12 had been a resident of the facility since November 2024 and had diagnoses that included but were not limited to unspecified dementia, repeated falls, and multiple sclerosis. Review of a 7/14/25 at 12:36 PM note documented that Resident #12 had an unwitnessed fall on 7/11/25 at around 1530. The resident was observed on the floor between the beds by a GNA (geriatric nursing assistant) during rounds. The fall was reviewed by the interdisciplinary team, and they continued with a plan of care. Review of Resident #12's care plan, actual fall and is at risk for falls related to generalized weakness and gait/balance problems, that was initiated in November 2024, had the intervention, have commonly used articles within easy reach i.e. call bell, TV remote control, etc. and fall mat at bedside when in bed unattended as tolerated. On 1/12/26 at 11:26 AM observation was made of Resident #12 lying in bed covered with a white sheet and white blanket. The gray call bell cord was hanging on the wall and not within reach of the resident. Resident #12's over the bed tray table was next to the window and out of reach of the resident. On the bed tray table was water, sandwiches, and the tv remote control. There were no fall mats on the floor next to the bed.On 1/12/26 at 11:26 AM an interview was conducted with LPN #4 the Unit Manager of the second floor. LPN #4 was asked where Resident #12's call bell was located. LPN #4 looked around the bed, walked next to the bed and saw the call bell hanging on the wall. LPN #4 took the call bell cord off the wall and placed it on top of the bed. LPN #4 was asked if the tray table should have been within reach for Resident #12 and he said, yes. LPN #4 then pushed the tray table next to the resident's bed.On 1/13/26 at 12:25 PM a second observation was made of Resident #12. The gray call bell cord with attached call bell was lying on the floor out of the resident's reach. There were no fall mats on the floor next to the bed. Staff #14 was shown the concern.On 1/13/26 at 12:35 RN #15 was informed of the concern.