Every finding on record at Vivo Healthcare Fort Pierce

Based on record review and interview, the facility failed to honor shower preferences and schedules for 1 of 2 sampled residents reviewed for choices, Resident #87. The findings included:Record review revealed Resident # 87 was admitted to the facility on [DATE] with a diagnosis to include Unspecified Dementia, Hypertension, Rheumatoid Arthritis, Chronic Kidney Disease, and Need for Assistance with Personal Care. Review of the quarterly MDS (Minimum Data Set) assessment dated [DATE] revealed he has a BIMS (Brief Interview for Mental Status) score of a 3 indicating cognition is severely impaired. Review of the Task sheet for showers revealed Resident #87's shower days are Tuesday, Thursdays and Saturdays on the 3:00 PM-11:00 PM shift. Further review of the Task sheet for showers for the last 30 days revealed the resident did not have any showers, nor does it show that he refused any. The task sheet shows that he only had a sponge bath. Under GG, it documents he needs substantial/maximal assistant with showers/bathes. There was no care plan for ADLs (Activities of Daily Living).Review of the care plans dated 07/03/25-07/23/26 did not show documentation related to ADL's.During a telephone interview on 06/30/2026 at 9:12 AM with a family member, she stated that she comes in to sponge bath him. She wants him showered.During an interview on 07/01/26 at 8:55 AM with Staff N, CNA (Certified Nursing Assistant), she was asked about this resident. She stated she is a floater and doesn't usually have this resident. When asked where she documents showers, she stated in the POC-Tasks for showers. When asked how to determine who needs a shower, she stated that it is on the back of the shower door. We went to the shower door and stated 'bed A has showers from 7-3 and B bed gets showers on 3-11. He is scheduled Tuesdays, Thursdays, Saturdays on the 3-11 shift.' When asked if a resident wants a shower, would they give it to them, she stated absolutely. When asked if Resident #87 got out of bed, she stated she hadn't gotten him up in a while.During an interview on 07/01/26 at 4:05 PM with Staff O, CNA, she was asked about this resident. She stated she is a floater and doesn't know this resident.During the interview with Staff O on 07/01/26 at 4:06 PM, Resident #87 roommate (Resident #75) was sitting in the hallway and stated that a CNA would come in and just sponge bath him. He has never had a shower that he is aware of.

Based on record review and interview, the facility failed to complete baseline care plans in the required time frame for 1 of 9 sampled residents reviewed, Resident #93. The findings included:Record review revealed Resident #93 was admitted on [DATE] with a diagnosis to include Right Femur Fracture, Muscle Wasting and Atrophy, Essential Hypertension, and Benign Prostatic Hyperplasia without Lower urinary Tract Symptoms. Review of Resident #93 baseline care plan revealed that as of 07/01/26, the baseline care plan had not been completed and had been due by 06/28/26. During an interview on 07/01/26 at 12:05 PM with the Director of Nursing (DON) she was asked to locate Resident #93's baseline care plan. She acknowledged that it had not been done yet and that it was 3 days overdue.

Based on observations, record review and interviews, the facility failed to develop and implement care plans related to Oxygen for 1 of 39 sampled residents, Resident #32; and failed to develop and implement care plans related to bed rails for 3 of 39 sampled residents, Resident #87, #82, #19, The findings included: 1. Record review revealed Resident #32 was admitted to the facility on [DATE] with a diagnosis to include Chronic Obstructive Pulmonary Disease (COPD), Chronic Respiratory Disease with Hypoxia, Emphysema, Type II Diabetes, Major Depressive Disorder, [NAME] Matter Disease, and Generalized Anxiety Disorder. Review of the physicians' orders revealed she was ordered Oxygen at 2 LPM (liters per minute) via nasal cannula with a start date of 05/23/26. Review of Resident #32's care plan did not document an oxygen care plan and did not mention oxygen in any other care plan.During an interview on 07/02/26 at 12:50 PM with MDS Coordinator (Minimum Data Set) she reviewed Resident #32 care plan, she stated she is missing the oxygen care plan. She acknowledged that she did not put a care plan for oxygen in for her. 2. Record review revealed Resident #82 was admitted on [DATE] with a readmission from the hospital on [DATE]. The resident was placed under Hospice services on 06/17/26 with a diagnosis to include Epilepsy, Unspecified Intellectual Disabilities, Peripheral Autonomic Neuropathy, Dementia with Behavioral Disturbances, Major Depressive Disorder, and Parkinson's Disease. Review of the care plans for Resident #82 revealed there was no care plan for ADL (Activities of Daily Living), and no mention in other care plans regarding the residents having side rail enablers.Observations were made on 07/01/26 at 3:28 PM of Resident #82 having bilateral bed rails. 3. Observations were made on 07/02/26 at 7:38 AM of Resident #87 having bilateral bed rails on his bed.Review of Resident #87 medical records revealed resident #87 was admitted to the facility on [DATE] with a diagnosis to include Obstructive and Reflux Uropathy, Essential Hypertension, Rheumatoid Arthritis, Dementia, Chronic Kidney Disease, and a History of Falling, A review of Resident # 87 Care Plan dated 07/03/25-07/23/26 a care plan for ADLs was not found. Multiple other care plans were missing as well for Hypertension, Pain, Hypothyroidism, Cholesterol. Resident #87 has bilateral side rails on his bed used for enablers.4. Observations were made on 07/02/26 at 7:33 AM of Resident #19 having bilateral side rails on her bed.Record review revealed Resident #19 was admitted to the facility on [DATE] with the most recent readmission from hospital on [DATE]. The resident's diagnoses included Chronic Obstructive Pulmonary Disease (COPD), Essential Hypertension, Heart Failure, Hypothyroidism, and Major Depressive Disorder. A review of Resident #19 care plan revealed this resident did not have a care plan for ADLs. It does not mention in any of the care plans regarding her having bed rails.During an interview on 07/02/26 at 12:50 PM with MDS Coordinator (Minimum Data Set) she was asked to review the care plans for Resident #19, #82 and #87. She stated that she would put the care plan for enablers under ADLs. She said she looks at the nursing assessment quarterly or admission / readmission to see if they have bed rails. She acknowledged that none of the three residents had care plans for the bed rails / enablers.

Based on observation, interview, and record review, the facility failed to ensure the comprehensive care plan was updated to accurately reflect the resident's current wound status for 1 of 2 sampled residents reviewed for wound care, Resident #87. The findings included:Record review revealed Resident #87 was admitted to the facility on [DATE] with diagnoses including non-Alzheimer's dementia.Review of the physician orders showed the following progression of the resident's right heel wound:a. On 10/05/2025 - directed staff to apply skin prep to the right heel every shift for redness.b. On 12/26/2025 - directed staff to paint the right heel with Betadine and apply a heel protector every shift for a deep tissue injury (DTI). This order was discontinued on 01/13/2026.c. On 04/12/2026, an order was initiated that directed staff to cleanse the right heel with normal saline, pat dry, apply Betadine-moistened gauze, and cover with Kerlix every night shift for an unstageable pressure ulcer.d. The most current physician order, dated 06/26/2026, directed staff to cleanse the right heel unstageable pressure ulcer with Dakin's solution, pat dry, apply collagen, and cover with Kerlix.Review of the nutrition assessment dated [DATE] documented Resident #87 had an unstageable pressure injury to the right heel measuring 1.4 cm x 1.3 cm x 0.2 cm that was improving with delayed wound closure.Review of wound evaluations revealed:On 12/31/2025, the right heel wound measured 7.0 cm x 5.0 cm and was identified as a deep tissue injury (DTI).On 01/30/2026, the wound measured 6.5 cm x 5.0 cm and was identified as an unstageable pressure ulcer.The most recent wound evaluation, dated 06/26/2026, documented the wound measured 1.4 cm x 1.3 cm and remained an unstageable pressure ulcer.Review of the resident's care plan, last reviewed by the facility on 04/24/2026, identified a deep tissue injury (DTI) pressure ulcer to the right heel/potential for pressure ulcer development related to immobility. The care plan had not been revised to reflect the resident's current diagnosis of an unstageable pressure ulcer, despite documentation showing the wound status had changed months earlier.On 07/01/2026 at 9:28 AM, during wound care observation, Resident #87 was observed with an open wound approximately the size of a quarter on the right lateral heel.On 07/02/2026 at 12:14 PM, during a side-by-side record review and interview, Staff D, the MDS Coordinator, acknowledged the resident's care plan continued to identify the wound as a deep tissue injury and did not reflect the current unstageable pressure ulcer. After the surveyor identified the discrepancy, Staff D updated the care plan to reflect the resident's current wound status.

Based on observation, interview, and record review, the facility failed to ensure appropriate care and services for 6 of 39 sampled residents as evidenced by the failure to ensure documentation of administration and or refusal of medications for Residents #68, #97 and #66; failure to follow medication administration policy regarding pre-pouring of medications for Residents #8 and #35; and failure to only use Resident #93's individualized prescribed medication.The findings included: Review of the policy titled, Medication Administration, updated 01/2026, documented in part, Policy Explanation and Compliance Guidelines: . 10. Ensure that the six rights of medication administration are followed: a. right resident. 12. Compare medication source (bubble pack, vial, etc.) with MAR (Medication Administration Record) to verify resident name, medication name, form, dose, route, and time. 1. During the medication administration observation beginning on 06/30/26 at 4:30 PM for Resident #68, Staff A, Licensed Practical Nurse (LPN), prepared one metformin tablet (a medication for diabetes) by crushing it and mixing it with applesauce. Upon entering the resident's room, Resident #68 refused the medication. Upon reconciliation of the medication for Resident #68, review of the Medication Administration Record (MAR) revealed Staff A had signed off the medication as administered. During an interview on 06/30/36 at 6:53 PM, when asked why the metformin was documented as administered to Resident #68, Staff A was unaware of the error and stated, I'm gonna fix that. Upon review of the MAR by any staff, the staff would assume the metformin had been administered. 2. During the medication administration observation beginning on 06/30/26 at 4:12 PM, Staff A, LPN, stated Resident #97 had come to her at the beginning of her shift asking for pain medication. The LPN obtained one Colace 100 mg (milligrams) tablet (a stool softener) and one Percocet 10/325 mg tablet (a narcotic pain medication) from the medication cart and administered them to Resident #97. During a side-by-side record review of the MAR with the Regional Nurse Consultant on 06/30/26 at 6:16 PM, it was noted neither medication was signed out on the MAR as administered. The Medication Monitoring / Control Record for Resident #97 documented the LPN signed out the Percocet at 4:25 PM. The Regional Nurse Consultant agreed with the findings. Upon review of the MAR by any staff, the staff would not know the medications had been provided to Resident #97. 3. A medication administration observation was made with Staff B, LPN, beginning on 06/29/26 at 9:31 AM for Resident #66. Review of the physician orders after administration of five other medications revealed Colace 100 mg tablet was due at that time. During an interview on 06/30/26 at 11:35 AM, when asked about the Colace, the LPN stated, I never give her Colace as she always refuses it. During a side-by-side review of the MAR for Resident #66, the LPN had documented she gave the Colace on 06/29/26. The LPN stated, I don't know why I did that. Further review of the June 2026 MAR revealed Staff B documented the administration of the Colace 13 additional times in June 2026. 4. During the medication administration observation beginning on 06/30/26 at 4:04 PM, while marking two small medication cups with 401A and 401B, along with the first name of each resident in that room, Staff A, LPN, stated, I normally try to go into the room just one time, so I pull meds for both patients at the same time, but label each med cup with their room number and name. The LPN realized 401B did not have any medication due at that time and discarded the cup. The LPN proceeded to the next room on 06/30/26 at 4:09 PM and while at the medication cart she labeled two medication cups using a black marker for Resident #35 and #8. The LPN placed two tablets into the medication cup for Resident #35. The LPN proceeded to pour 30 ml of ProStat (a protein supplement) into a third medication cup that she had labeled with the first name of Resident #8. Stating that she had another liquid for Resident #8, the LPN took the medication cup for Resident #35 and the ProStat for Resident #8 into the room. The LPN gave Resident #35 her two pills, then went to Resident #8 and left the ProStat at the bedside. The LPN returned to the medication cart and obtained the other liquid which was Lactulose. She poured 15 ml of the Lactulose, documented on the label to administer it three times daily for liver cirrhosis, and returned to Resident #8 and administered the ProStat. Resident #8 questioned the Lactulose stating she had already had a bowel movement, and the LPN stated, So you don't want it? The LPN failed to explain the medication was for her liver cirrhosis and not specifically to assist her with bowel movements. On 06/30/26 at 4:22 PM, Staff A, LPN went to the third room, marked a medication cup with Resident #97's room number and explained that her roommate did not have any medications due at that time, so she didn't need the second medication cup. During an interview on 06/30/26 at 4:39 PM, in the presence of the Director of Nursing (DON), when asked why she prepped two resident medications at one time, the LPN stated, 'to save time'. When asked if that was a safe practice, the LPN stated it was not as the medications could be confused between residents. 5. Record review revealed Resident #93 was admitted to the facility on [DATE] with diagnoses to include Fracture of Right Femur, Essential Hypertension, Cardiac Pacemaker, and Benign Prostatic Hyperplasia. A review of the physician's orders documented the resident is on Methocarbamol Oral Tablet (Robaxin) 500 MG Give 500 mg by mouth every 6 hours for Muscle spasms start date 06/26/26 at 6:00 PM. A review of Resident #93's MAR (Medication Administration Record) documented that the day he was admitted he had an order for Methocarbamol Oral Tablet 500 MG Give 500 mg by mouth every 6 hours for Muscle spasms. The first dose, at 6:00 PM, documented it was given. The next dose at midnight documents with a 9 meaning to see progress notes. The progress notes document that the prescription had not arrived yet from pharmacy and therefore was not given. From 06/26/26 to 06/30/26 in the MAR, it showed the medication was given one time on 06/26/26 at 6:00 PM and then again given on 06/27/26 at 6:00 AM, 12:00 PM and 6:00 PM. On 06/28/26 and 06/29/26, it documented that the resident received all 4 doses (12:00 midnight, 06:00 AM, 12:00 Noon and 6:00 PM). On 06/30/26, the MAR documented he received the medication at midnight and the 6:00 AM dose. The surveyor requested a list of medications in the Omnicell. The Omnicell is an automated medication dispensing system that stores medications for emergency use and for administration when medications are not yet available from the pharmacy. The Methocarbamol was not one of the medications listed in the Omnicell. During an observation on 06/30/26 at 2:55 PM with Staff O, Unit Manager, she was asked to show the surveyor Resident #93's medication for the Methocarbamol Oral Tablet (Robaxin) 500 MG. The medication cart revealed he had two bubble packs which were both open: One bubble pack with 30 tablets has 6 tablets that were given. The other bubble pack has 28 tablets that had 3 given. This equaled 9 tablets that were given. When you count the number of times this medication was given in the MAR, it shows 14 times. During an anonymous interview on 06/30/26 at 9:34 AM with a nurse, she stated that when a new resident comes in and the medication has not arrived from pharmacy the nurses will take the same medication from another resident to give to that resident. During an interview on 06/30/26 at 3:06 PM with the Director of Nursing (DON), she was asked to review Resident #93's MAR and orders. She counted 9 days missing and 14 days the medication was given. She acknowledged the concerns and stated if the prescription is not in, the nurses should not be using another resident's medication. They should be calling the physician for either a substitute or a new order date. During an interview on 06/30/26 at 3:20 PM with Staff B, LPN (Licensed Practical Nurse), she was asked what the process is if a medication has not arrived from the pharmacy. She stated we would take it from the E-Kit/Omnicell or call pharmacy and would let them know when it comes in. She went to the medication cart and pulled the resident's Methocarbamol and acknowledged that only 9 meds were missing. She repeatedly stated there is no way he has had 14 doses and counted the days he should have had the medication. She then stated she thinks he was only taking a 1/2 tab and that there was another bubble pack for that medication that was missing. The surveyor asked her to please review the orders and was asked if there was an order for 1/2 tablet and she confirmed she could not locate it. At this time, the next shift nurse, Staff M (LPN) arrived. Staff M was the staff that worked the night the resident came in. During an interview on 06/30/26 at 3:35 PM with Staff M, LPN, he confirmed he worked that night of 06/26/26 and those were his initials on the MAR for 06/26/26 at 6:00 PM. He was asked to review the MAR and was asked if the resident's medication had arrived. He said he could not remember. He was asked if he pulled the medication from another resident's packet if the medication had not arrived. He had no response to that question.

Based on policy review, observation, interviews, and record review, the facility failed to follow treatment and services for pressure ulcers for 2 of 2 sampled residents, Residents #95 and #87, reviewed for not the following physicians' orders or recommendations for low air loss mattresses for pressure relief. The findings included: Review of the policy, Wound Treatment Management, implemented on 09/2023 and revised on 01/2026, documented, in part, 1. Wound treatments will be provided in accordance with physician orders, 2. In the absence of a treatment order, the licensed nurse will notify physician to obtain treatment orders. 1. Record review revealed Resident #95 was admitted to the facility on [DATE] with a recent readmission on [DATE]. Review of the Nursing weekly pressure ulcer wound note, dated 06/26/26, documented, in part: date of wound 06/19/26 as a Stage III (Full thickness tissue loss) sacrum pressure ulcer that was present upon admission. During an initial observation on 06/29/26 at 10:38 AM, Resident #95 was in bed sleeping on her left side. Her mattress did not have a control pump at the foot of the bed and did not have any connected air hoses. Review of the physicians' skin and wound progress note dated 06/26/26 documented, in part, that Resident #95 had a sacral pressure injury (PI) stage III that was present on admission and recommended an alternating low air loss mattress for pressure redistribution. An interview was conducted on 06/30/26 at 7:53 AM with the Director of Nursing (DON) who stated that all the mattresses in the facility are pressure-reducing mattresses and if a resident has a Stage III pressure ulcer they would be provided with an alternating low air loss mattress. An interview was conducted on 07/01/26 with Staff D, Licensed Practical Nurse (LPN), who stated that she does wound care rounds with the Physician on Fridays. Staff D was asked how recommendations from the Wound Care Physician get ordered, Staff D stated that the wound care Physician prefers that the attending Physician writes the order based on the Wound Care Physicians' recommendation and that she is the intermediary between the Wound Care Physician and the attending Physician. Staff D then stated that if a resident has a Stage III pressure injury, an alternating low air mattress would automatically be ordered. Staff D reviewed the Physician's progress note for Resident #95 dated 06/26/26 and agreed that the physician recommendation for the alternating low air loss mattress should have been ordered for Resident #95 and was not ordered. Review of Physicians' orders revealed an order dated 07/01/26 for an Alternating Pressure Mattress (APM) for Resident #95 after surveyor intervention. 2. Record review revealed Resident #87 was admitted to the facility on [DATE] with a diagnosis to include Obstructive and Reflux Uropathy, Essential Hypertension, Rheumatoid Arthritis, Dementia, Chronic Kidney Disease. Review of the physician's orders documented that an APM (Air Pressure Mattress) to bed for pressure injury was ordered 06/05/26. Further review of the resident's records revealed he has had multiple pressure ulcers that included one to his coccyx which was resolved but currently has one on his heel. Observations of Resident #87's bed on 06/30/26 at 1:00 PM, revealed there was no observed air pressure mattress on Resident #87's bed. During an interview on 07/01/26 at 9:40 AM with the ADON (Assistant Director of Nursing), she was asked if this resident is supposed to have an air mattress. She stated yes. The surveyor informed her he did not have an APM on his bed and she stated he needs one and she would have it taken care of right away.

Based on policy review, interview, observation and record review, the facility failed to provide care and services to prevent accidents for 1 of 1 sampled resident, reviewed for smoking, as evidenced by failure to maintain smoking materials in designated area for Resident #22.The findings included:Review of the policy titled, Resident Smoking, implemented on 09/01/23 and revised on 01/2026, documented, in part, #8. Any resident will be allowed to smoke in designated smoking areas at designated times in accordance with the care plan. #14. Residents noted to fail to adhere to the safe smoking policy, including returning lighters may be issued a 30-day notice of discharge #16. Smoking materials for all residents will be maintained by nursing staff or designated areas.Review of the record revealed Resident #22 was admitted to the facility on [DATE]. Review of the care plan initiated on 02/07/25 and revised on 03/19/26 revealed Resident #22 is a smoker with interventions that included to notify the charge nurse immediately if it is suspected resident has violated the smoking policy.During an initial interview on 06/29/26 at 8:15AM, Resident #22 was asked about the smoking schedule in the facility. He stated he keeps his own cigarettes and lighter in his room and does not follow the rules and will go outside to have a cigarette anytime he wants to as long as he does not use the main door.During an observation of the smoking area on 07/01/26 during the 9:00 AM scheduled time, Staff F, Certified Nursing Assistant (CNA), stated that she supervises the smoking area about twice a month. Staff F was carrying an orange toolbox that had the residents' cigarettes, 2 lighters and a brand-new unwrapped smoking apron. Review of the cigarette packages that were labeled with residents' names revealed that there were no cigarettes labeled with Residents #22's name in the toolbox. When Staff F was asked what types of things she is looking for while supervising the smokers, she could not verbalize any safety issues to look out for and was under the impression that a resident would let her know if they needed to use the smoking apron. At 9:15 AM, Resident #22 was observed walking to the smoking area while carrying a small black bag and he sat down in the smoking area while staff was supervising 4 other residents who were smoking, Resident #22 pulled his cigarettes out of the bag and lit a cigarette with his lighter. Staff F did not seem to notice or identify that Resident #22 had his own cigarettes and his own lighter and that he did not get the cigarettes from the orange toolbox that she was overseeing.An interview was conducted on 07/01/26 at 9:46 AM with the Assistant Director of Nursing (ADON) who was asked if Resident #22 was allowed to keep his own cigarettes and lighter in his room and the ADON stated, no. The ADON stated residents should not have access to cigarettes and lighters as per the facilities smoking policy. The ADON was asked if staff that supervise smoking are trained in what to look for with smoking safety and she stated, yes and they sign off after reviewing the training. The ADON stated that she was not made aware that Resident #22 had his own smoking supplies and was not made aware that he was not adhering to the smoking policy and agreed with the findings.

Based on observations, policy review, record review and interview, the facility failed to properly complete assessments, care plans, consent forms and maintenance service for bedrails / enablers for 3 of 3 sampled residents, Residents #87, #82, #19. The findings included:Review of the policy titled, Proper Use of Bed Rails, implemented date 09/23 with a revised date of 01/26 revealed the policy stated, it is the policy of this facility to utilize person-centered approach when determining the use of bed rails. Appropriate alternative approaches are attempted prior to installing or using bed rails. If bed rails are used, the facility ensures correct installation, use and maintenance of the rails.The definition of bed rails that is in their policy documents, bed rails are adjustable metal or rigid plastic bars that attach to the bed. They are available in a variety of types, shapes, and sizes ranging from full to one-half, one-quarter, or one-eighth lengths. Examples of bed rails include but are not limited to side rails, bed side rails, safety rails, grab bars and assist bars. The Resident Assessment documents that part of the resident's comprehensive assessment, there are 12 components when considering in determining the resident needs and whether the use of bed rails meets those needs. The resident assessment must include an evaluation of the alternatives that were attempted prior to the installation or use of the bed rail and how the alternative failed to meet the resident's assessed needs as well as the risk from using the bed rails. Informed consent from the resident or resident representative must be obtained after appropriate alternatives have been attempted prior to installation and use of the bed rails. Upon receiving informed consent, the facility will obtain a physician's order for use of the specified bed rail, medical diagnosis, condition, symptoms or functional reason for the use of the bed rail. The facility will ensure the correct installation and maintenance of bed rails prior to use. The facility will continue to provide necessary treatment and care to the residents who have bed rails. This should be evidenced in the residents' records including their care plan. Responsibilities of ongoing monitoring and supervision include a nurse assigned to the resident will complete reassessments but not less than quarterly, upon a significant change in status or change in type of bed/mattress or/rail. The maintenance director, or designee, is responsible for adhering to a routine maintenance and inspection schedule for all bed frames, mattresses, and bed rails.1. Observations were made on 07/01/26 at 3:28 PM of Resident #82 having bilateral bed rails. Record review revealed Resident #82 was admitted on [DATE] with a readmission from the hospital on [DATE] and placed under Hospice services on 06/17/26 with diagnoses to include Epilepsy, Unspecified Intellectual Disabilities, Peripheral Autonomic Neuropathy, Dementia with Behavioral Disturbances, Major Depressive Disorder, and Parkinson's Disease. Review of the care plans for Resident #82 did not have an ADL (Activities of Daily Living) Care Plan, nor did they mention about the resident having enablers.Review of the admission / readmission Nursing assessment dated [DATE] documents under section H1, Side rails recommendations the Resident will not utilize side rails and alternatives will be initiated. A Quarterly Nursing assessment dated [DATE] under section H1 documents, Side rails recommendations the Resident will not utilize side rails and alternatives will be initiated. A document in Resident #82 records named Bed Rail Evaluation/Consent dated 11/15/2024 documents other for alternative tried. Under Bed Rail Intervention Recommendations documents, Bed Rails to be used as enablers for bed mobility and repositioning. At the bottom, there is a section for the residents or representatives to sign consent, but it is blank. Resident #82 currently has bilateral side rails on bed. 2. Observations were made on 07/02/26 at 7:38 AM of Resident #87 having bilateral bed rails on his bed.Record review revealed Resident #87 was admitted to the facility on [DATE] with diagnoses to include Obstructive and Reflux Uropathy, Essential Hypertension, Rheumatoid Arthritis, Dementia, Chronic Kidney Disease, and a History of Falling, Review of Resident #87's quarterly MDS (Minimum Data Set) assessment dated [DATE] documents a BIMS (Brief Interview for Mental Status) score of 3, indicating cognition is severely impaired. Review of Resident #87's care plans dated 07/03/25-07/23/26 revealed a care plan for ADLs was not found. Multiple other care plans were missing as well for Hypertension, Pain, Hypothyroidism, Cholesterol. Resident #87 has bilateral side rails on his bed used for enablers.Review of Resident #87 quarterly Nursing Evaluation dated 04/08/26 Section H1 documents that the resident or representative expressed a desire to have an assistive device to aid in bed mobility, safety and comfort. It documents that a trapeze bar was attempted as an alternative. It had a yes next to the resident and our representative for the use of alternatives and the risk for side rails. Under #7, it documents the recommendations the Resident will not utilize side rails and alternatives will be initiated. No consent was found for this resident. Resident #87 currently has bilateral side rails on bed. 3) Observations were made on 07/02/26 at 7:33 AM of Resident #19 having bilateral side rails on her bed.Record review revealed Resident #19 was admitted to the facility on [DATE] with the most recent readmission from hospital on [DATE]. Her diagnosis included Chronic Obstructive Pulmonary Disease (COPD), Essential Hypertension, Heart Failure, Hypothyroidism, and Major Depressive Disorder. Review of Resident #19's Annual MDS documents a BIMS score of 2 indicating cognition is severely impaired. Review of Resident #19's care plan revealed this resident did not have a care plan for ADLs. There was no care plan in the record related to her having bed rails.Review of Resident #19 quarterly Nursing Assessment for bed rails dated 06/16/26 documents under section H1 that Resident #19 is non ambulatory and is incontinent. She or her representative has not expressed a desire for the residents to have bed rails. It had a 'no' next to the resident's and or representative has not been educated about the use of alternatives and the risk for side rails. Under #7, it documents the recommendations is that the Resident will not utilize side rails and alternatives will be initiated. Resident #19 has bilateral side rails on her bed. On 07/01/26 at 12:30 PM, the DON (Director of Nursing and the ADON (Assistant Director of Nursing), was asked about a Bed Rail Policy. The DON then stated, we don't have bed rails. The surveyor then read her the definition from their consent documents, Bed rails are defined as adjustable metal or rigid plastic bars that attach to a bed. There are many types of bed rails available for use in a variety of shapes and sizes. Sizes range from full to one-half, one-quarter, and one-eighth lengths. Some bed rails are not designed to be part of the bed by the manufacturer. These types of rails are installed on or used along the side of the bed.When the surveyor enquired of a policy and assessment of the Administrator, she reiterated that they did not think they had bed rails in facility, so they didn't have a policy on them. She then stated that Resident #82's bed was brought in by Hospice.During an interview on 07/01/26 at 4:03 PM with the Maintenance Director, he was asked if he does rounds to check the bed rails/enablers on the bed and to make sure they follow manufacturers' guidelines. He stated he doesn't document any of it, and they only check them if the nurse tells them one needs to be fixed.During a secondary interview with the DON on 07/02/26 at 1:25 PM, she stated the reason they all say, they will not utilize side rails is that no one considered using a side rail/bed rail.

Based on observations and interviews, the facility failed to ensure daily staffing was accurate and current for 2 of 6 days. The findings included:Upon entrance into the facility on Monday 06/29/26 at 6:12 AM, the staff posting was dated Friday 06/26/26 and the required number of licensed nurses was not updated prior to the night shift. An interview was conducted with the Staffing Coordinator on 07/02/26 at 8:42 AM and she was asked who posts the staffing sheet. She stated that she posts it every morning Monday through Friday. When the Staffing Coordinator was asked who posts it over the weekend, she stated that she leaves blank copies at the reception desk, but she was not sure if the receptionists know how to fill it out. The Staffing Coordinator was advised that the staff posting on Monday morning was dated Friday 06/26/26 and she agreed with the findings.The Staffing Coordinator was then asked why there was only one licensed nurse listed for the night shift on Friday 06/26/26 when the census was 75. She stated that on Friday 06/26/26 she had a nurse call out and did not update the staff posting prior to the shift to show that 2 licensed nurses worked the night shift.

Based on observation, interview, and record review, the facility failed to ensure accurate accountability and documentation of controlled substances for 2 of 4 sampled residents, Residents #84 and #58. This failure resulted in discrepancies between the medication monitoring control records and the Medication Administration Records (MARs), including undocumented narcotic removals, documented removals without corresponding MAR documentation, MAR documentation without corresponding narcotic control record entries, and failure to ensure medication administration was consistent with the physician's order. The findings included:1. Record review revealed Resident #84 was prescribed Oxycodone 5/325 mg by mouth every 8 hours as needed for pain for 7 days. It was revealed that the facility received the medication from pharmacy on 06/12/26. Review of the medication monitoring control record and the June 2026 MAR revealed the following discrepancies. The control record documented removal of Oxycodone on 06/26/26 at 12:52 AM, 8:45 AM, and 10:15 PM; however, the MAR only reflected administration at 10:15 PM, with no documentation supporting the other two removals.The MAR documented Oxycodone administration on 06/27/26 at 12:00 AM, 10:17 AM, and 11:58 PM; however, the narcotic control record only documented removal at 12:00 AM, and lacked documentation supporting the other two administrations.The narcotic control record documented Oxycodone removals on 06/28/26 at 12:00 AM, 1:15 AM, and 9:15 AM, which did not correspond with the ordered every 8-hour interval and indicated the medication continued beyond the physician-ordered 7-day duration. 2. Record review reveled Resident #58 had a physician order for Tramadol 50 mg, one tablet by mouth every 12 hours as needed for moderate to severe pain. Review of the medication monitoring control record and the June 2026 MAR revealed the following discrepancies: The narcotic control record documented Tramadol removal on 06/13/26 at 5:00 AM; however, there was no corresponding MAR documentation. The narcotic control record documented two removals on 06/14/26 at 10:32 AM and 9:00 PM, while the MAR only documented administration at 10:32 AM. The MAR documented Tramadol administration on 06/19/26 without corresponding narcotic control record documentation. The narcotic control record documented removal on 06/20/26 at 1:35 PM without corresponding MAR documentation.On 07/02/26 at 12:04 PM, a side-by-side review and interview were conducted with the Director of Nursing (DON) and Assistant Director of Nursing (ADON). The DON and ADON acknowledged the discrepancies between the narcotic medication monitoring control records and the MARs.

Based on observation, interview and record review, the medication error rate was 10.34% percent. Three medication errors were identified while observing a total of 29 opportunities, affecting 2 of 9 residents observed, Residents #66 and #8. The findings included:Review of the policy, titled, Medication Administration, updated 01/2026, documented in part, Policy Explanation and Compliance Guidelines: . 10. Ensure that the six rights of medication administration are followed: . c. right dosage . e. right time . 20. Sign MAR (Medication Administration Record) after administered.1. A medication administration observation was made beginning on 06/30/26 at 9:23 AM for Resident #66. Staff B, Licensed Practical Nurse (LPN), obtained the resident's blood pressure and the result was 152/100. Staff B obtained five pills from the medication cart to include gabapentin (an anticonvulsant), amlodipine (a medication to lower blood pressure), bumetanide (a diuretic given for excess fluids), hydralazine (for blood pressure and heart failure), and clopidogrel (an anti-platelet medication). The LPN verified she had five pills and that was all that was due at the time.Review of the physician orders revealed a Colace 100 mg tablet was due at that time. Further review of the physician orders revealed the medication clonidine 0.1 mg was to be administered every 8 hours as needed for a blood pressure of 140/90. Review of the Medication Administration Record (MAR) documented the Colace had been given and lacked any administration of the clonidine for Resident #66 on 06/29/26.During an interview on 06/30/26 at 11:35 AM, when asked about the Colace for Resident #66, the LPN stated, I never give her Colace as she always refuses it. During a side-by-side review of the MAR for Resident #66, the LPN had documented she gave the Colace. The LPN stated, I don't know why I did that. During the continued interview, when asked when she would administer the clonidine to Resident #66, Staff B stated she would do so when the blood pressure was high, further stating she thought the parameters were if the systolic (top) blood pressure number was greater than 140. The LPN volunteered that she gave the clonidine to Resident #66 at lunch time. During the side-by-side review the LPN agreed there was no documented evidence of the administration of the clonidine. The LPN stated, Around lunch when I was reviewing the blood pressure for Resident #66, I noticed it was high, so I gave her a clonidine. The LPN again agreed to the lack of documentation and failure to administer it during the medication pass on 06/29/26 at 9:23 AM.2. During the medication administration observation on 06/30/26 beginning at 4:12 PM for Resident #8, Staff A, Licensed Practical Nurse (LPN), obtained a large bottle of Lactulose in the concentration of 10 gm (grams) per 15 ml (milliliters). The LPN proceeded to pour 15 ml of Lactulose into a small medication cup. When asked how much Lactulose she had poured to administer to Resident #8, the LPN confirmed 15 ml. Although the resident refused the medication, Staff A entered the room with the intent to give the 15 ml of Lactulose.Review of the physician order documented Lactulose 10 gm/15 ml solution and for the nurse to give 30 ml (20 grams) three times daily for liver cirrhosis.During a side-by-side review of the record and interview on 06/30/26 at 6:51 PM, Staff A, LPN, agreed she had only poured 15 ml of Lactulose to administer to Resident #8, and the order was for 30 ml.

Based on observation, record review, and interview, the facility failed to ensure safe and appropriate storage of medications for 2 of 9 sampled residents observed during the medication administration pass as evidence by throwing the refused medication of Resident #68 in the trash and leaving the medication cart unlocked and unattended during the medication administration for Resident #8, and as evidenced by the pre-pouring of medications for Resident #4 found in 1 of 2 medication carts (100 unit). The findings included:Review of the policy, titled, Medication Storage, updated 01/2026, documented in part, Policy Explanation and Compliance Guidelines: 1. General Guidelines: a. All drugs and biologicals will be stored in locked compartments . c. during a medication pass, medications must be under the direct observation of the person administering medications or locked in the medication storage area/cart.1. During the medication (med) administration observation beginning on 06/30/26 at 4:30 PM for Resident #68, Staff A, Licensed Practical Nurse (LPN), prepared one metformin tablet (a medication for diabetes) by crushing it and mixing it with applesauce. Upon entering the resident's room, Resident #68 refused the medication. The LPN, in the presence of the Director of Nursing (DON), threw the small medication cup with the applesauce and metformin in the small trash bin attached to the medication cart.During an interview on 06/30/26 at 4:39 PM, in the presence of the DON, when asked where she disposed of the refused medication for Resident #68, the LPN confirmed she threw it in the trash container on the side of the medication cart. When asked if that was a safe and secure way to dispose of medications, the LPN stated it was not as any confused resident could get to it. When asked about the facility's process on how to dispose of medications, the LPN did not answer. The DON stated every medication cart was stocked with a secure container to dispose of the medication, in which the medication will dissolve in the container. The DON was also made aware the LPN had left the medication cart unlocked and unattended during the medication pass observation and agreed with the findings. 2. During a medication administration observation on 06/30/26 at 4:09 PM, while at the medication cart, Staff A, Licensed Practical Nurse (LPN) labeled two med cups using a black marker for Resident #35 and #8. The LPN placed two tablets into the medication cup for Resident #35. The LPN proceeded to pour 30 ml of ProStat (a protein supplement) into a third medication cup that she then labeled with the first name of Resident #8. Stating that she had another liquid for Resident #8, the LPN took the medication cup for Resident #35 and the ProStat for Resident #8 into the room, leaving the medication cart unlocked and unattended. The LPN gave Resident #35 her two pills, then went to Resident #8 and left the ProStat at the bedside stating, She won't touch it. Don't worry. The LPN returned to the medication cart and obtained the other liquid which was Lactulose. The LPN did not notice the medication cart had been left unlocked and unattended.During an interview on 06/30/26 at approximately 5:40 PM, when told of the observation, the DON agreed with the findings. 3. During observation of the 100-unit medication cart 07/01/26 at 10:57 AM, a small medication cup with five pre-poured medications was found in the bottom of the medication cart drawer. When asked about the medications, Staff G, Registered Nurse (RN), first stated while she was at her medication cart, she was interrupted by the DON who needed to see her. When asked specifically when she had poured the medication in relation to when the DON arrived, the RN stated she had poured the morning medication, but the resident was outside with therapy and then outside to smoke, and she again was interrupted by the DON.During an interview on 07/01/26 at 11:12 AM, when asked if she had spoken with Staff G, RN, that morning, the DON stated she had and explained the RN was leaving a resident's room as she had been in the room with the CNA (Certified Nursing Assistant). The DON stated she made sure that the RN was done with care as she never wants to leave a resident unattended. When asked again if the RN was at the medication cart, the DON stated she was not.

Based on observation, interview and record review the facility failure to ensure pureed foods were prepared appropriately for 1 of 1 sampled resident in the main dining room who was served pureed foods, Resident #59, with the potential to affect 5 residents in the facility who consumed pureed food at the time of the survey.The findings included:Review of the policy, titled, Puree Food Preparation, updated 01/2026, documented in part, Puree means that all food has been ground, pressed and/or strained to a consistency of a soft, smooth, thick paste similar to a thick pudding.1. After observation of the breakfast tray line on 06/29/26 at 8:25 AM, the pureed sausage was tasted and had a fine gritty texture throughout. When asked if she tasted the pureed sausage, Staff C, cook, stated she had. When the pureed sausage was described as having a gritty texture, the cook stated, I understand.During a supplemental stating of the pureed sausage the next day on 06/30/26 at 8:36 AM, it was noted to have a very smooth pudding-like texture. When asked if the pureed sausage from yesterday and today had been tasted, both the cook and the Certified Dietary Manager (CDM) stated they tasted both and agreed the texture was gritty on 06/29/26.During an interview on 06/30/26 at 9:14 AM, when asked the definition of pureed food, the Speech Language Pathologist (SLP) stated the pureed food should be a smooth texture, maybe a little gritty, but overall smooth. When told the pureed sausage on Monday was very gritty and after speaking with the staff, this morning's sausage was very smooth, the SLP stated, Well there you are.2. An observation of the lunch tray for Resident #59 on 06/30/26 at 12:04 PM revealed four scoops of pureed foods. The pureed zucchini and rice appeared very glossy. Upon completion of the tray line at 12:35 PM, a pureed test tray was requested. Observation of the pureed zucchini and rice appeared very glossy. The texture of both the pureed zucchini and rice was very gummy and sticky. The red sauce provided to the surveyor that was observed over the rice and meat to the residents on pureed diets contained small pieces of the meatballs that had broken off into the sauce. The CDM was asked to taste the zucchini and rice and described it as sticky, almost like peanut butter. When asked where they obtained the sauce for the pureed lunches, the cook and CDM stated from the large pan of meatballs with sauce. The cook confirmed she did not strain the sauce to ensure a lack of meat chunks.

Based on observation, interview, and record review the facility failed to maintain cleaning and sanitizing bucket in in the kitchen during 2 of 2 observations (Monday 06/29/26 and Tuesday 06/30/26). The facility also failed to maintain the nourishment refrigerator.The findings included:1) Review of the Inservice Training: Use of Red and [NAME] Sanitizing Buckets, not dated, and provided to the surveyor as the process for the sanitizing buckets, documented in part, 1. Importance of Color-Coded Buckets . Red Bucket: Designated for sanitizing only. It contains an approved sanitizing solution used after surfaces have been cleaned. [NAME] bucket: Designed for cleaning (detergent use). It is used to remove visible dirt, food particles, and grease before sanitizing. Using color-coded buckets helps prevent cross-contamination and ensures food-contact surfaces are properly maintained. Change water and solution frequently, or when visibly soiled. 4. Sanitizer Concentration and Monitoring . Use test strips to verify that sanitizer is within the correct PPM (parts per million) range: Quaternary (used for red buckets) Ammonia: 150-400 ppm. Test the sanitizer at the beginning of each shift and when replacing the solution.During the initial tour and subsequent breakfast tray line on 06/29/26 beginning at 6:56 AM there were no green buckets noted in the kitchen area.During an additional kitchen observation on 06/30/26 at 2:08 PM, no green buckets were noted, and two red buckets were available for staff use. The CDM was asked to test the two buckets for chemical levels. The CDM tested the first bucket and the test strip turned from tan to yellow. When held against the test strip color gauge there was no yellow, indicating the chemical level was less than 0 ppm. The CDM tested the same bucket again, and the second bucket that was located under the prep area, and a third time filling one of the buckets with fresh sanitation water. Each time the CDM held the test strip in the bucket, moving it around and each observation revealed below optimal levels of chemicals as per the chemical test strip color gauge, on the 0 to 500 scale. When asked how they know how much chemical to put in the red bucket, the CDM explained it is automatically pumped in the water so there was no measuring. The Senior Dietary Manager joined the observation and directed the CDM to call the water sanitation company.On 06/30/26 at approximately 2:30 PM the Senior Dietary Manager provided the Inservice Training: Use of Red and [NAME] Sanitizing Buckets. During a side-by-side review of this process with the Sr. Dietary Manager, it was revealed the dietary staff were to use a green bucket with detergent for general cleaning to remove visible dirt, food particles, and grease before sanitizing with the red bucket sanitizing solution. When asked if she had seen any green buckets in use the Sr. Dietary Manager stated she did not. The Sr. Dietary Manager confirmed the test strip for the sanitizing solution should read between 150 - 400 ppm as per the manufacturer's instructions. The Sr. Dietary Manager stated the service man was on his way.On 06/30/26 at approximately 3:30 PM the service man had discovered a dislodged part in the sanitizing solution tubing, that was clogging the sanitizer and stated this could happen very easily. The Executive Director was present at the time and agreed the staff should have identified the issue prior to surveyor intervention.

Based on observation, interview, and record review, the facility failed to ensure required clinical documentation was completed and maintained for 2 of 2 sampled residents reviewed, related to dialysis communication records and colostomy care documentation for Resident #95 and Resident #84. The findings included: 1. Record review revealed Resident #95 was admitted to the facility on [DATE] and readmitted on [DATE] with a diagnosis of end-stage renal disease (ESRD). Progress notes dated 06/12/26 documented the dialysis center notified the facility of a change in dialysis schedule to Tuesdays, Thursdays, and Saturdays. The care plan dated 06/01/26 included interventions for Resident #95 to complete dialysis communication forms for scheduled dialysis treatments. Review of the electronic clinical record under miscellaneous documentation revealed no dialysis communication forms were maintained. During an interview on 07/02/26 at 9:09 AM, the Director of Nursing (DON) stated the forms should be located in baskets at the nursing stations; however, no forms were located during the search. At 12:33 PM, the DON provided three dialysis communication forms dated 06/23/26, 06/25/26, and 06/30/26. At 2:34 PM, the DON provided two additional forms dated 06/18/26 and 06/20/26 but was unable to provide dialysis communication forms for 06/16/26 and 06/27/26. The DON continued searching for the missing forms and was unable to provide evidence they were completed or maintained. 2. Record review revealed Resident #84 was admitted to the facility on [DATE]. Review of Physician orders with a start date of 07/11/25 documented to observe colostomy/ileostomy site for signs/symptoms of infection or irritation, report abnormalities every shift for colostomy care, and to change colostomy pouch/appliance every 24 hours as needed for leakage, soiled. During an initial interview on 06/29/2026 at 11:00 AM, Resident #84 stated that staff change her colostomy bag, keep it clean and that she has not had any issues with it. Review of the Medication Administration Record (MAR) for June 2026 revealed that licensed nurses were documenting under the Physician's order to observe colostomy/ileostomy site for signs/symptoms of infection or irritation, report abnormalities every shift for colostomy care but did not document when the colostomy pouch/appliance was changed. An interview was conducted on 07/01/26 at 2:00 PM with Staff E, Licensed Practical Nurse (LPN), who was asked if she changed Resident 84's colostomy pouch and she stated, yes. When Staff E was asked where in the MAR did it show that the colostomy pouch was changed, she showed the surveyor the MAR with the initials and check marks under the Physician Order observe colostomy/ileostomy site for signs/symptoms of infection or irritation, report abnormalities every shift for colostomy care. Staff C was asked how would other licensed staff know if the colostomy bag was changed. She was unable to tell based on the MAR and agreed that documenting under the Physician Order change colostomy pouch/appliance every 24 hours as needed for leakage, soiled would show that the colostomy bag was changed and not just observed. An interview was conducted on 07/01/26 at 2:57 PM with the Assistant Director of Nursing (ADON) who reviewed the MAR for Resident #84 and agreed with the findings that staff are not documenting when they change the colostomy bag.

Based on observation, record review and interview, the facility failed to ensure appropriate infection control practices to help prevent the transmission of communicable diseases and infections for 6 of 9 sampled residents observed during the medication administration observations (Residents #8, #11, #35, #68, #97, and #66) as evidenced by improper hand hygiene by 2 of 6 staff observed (Staff A & B), and by Staff A touching pills during the medication administration observations for Residents #8, #11, #35, #68, #97; failure to maintain the laundry room in a clean manner as evidenced by 4 of 4 ceiling vents with a black substance on the white vents along with dust laden water drip areas, and 2 of 2 dryer drums stained and with debris; failure to maintain 4 of 4 clean linen carts; failure to maintain clean refrigerator and sink in the medication storage room; failure to maintain clean gauze during wound care for Resident #87; and two random observations of improper cleanliness and use of ice coolers.The findings included: Review of the CDC (Centers for Disease Control and Prevention) Hand Hygiene for Healthcare workers, updated 02/27/2024, documented in part, Know how to use alcohol-based hand sanitizer: 1. Put product on hands and rub hands together. 2. Cover all surfaces and rub until hands feel dry. This should take around 20 seconds. 3. Pay attention to the areas providers frequently miss: thumbs, fingertips, and between fingers. Know how to wash hands with soap and water: 1. Wet hands with water. 2. Apply soap. 3. Rub hands together vigorously for at least 15 seconds, covering all surfaces of the hands and fingers. 4. Rinse hands with water and use disposable towels to dry. Use a towel to turn off the faucet. 1. During the medication administration observation on 06/30/26 beginning at 4:04 PM, Staff A, Licensed Practical Nurse (LPN), put hand sanitizer into her hand, did one swipe back and forth with her hands, grabbed a tissue and dried her hands. The LPN proceeded to hand sanitize in this manner during the entire medication pass with Residents #8, #11, #35, #68, and #97. The LPN stated, I don't like the feel of the hand sanitizer, so I normally go and wash my hands. The LPN proceeded into the shower room at the beginning of the hall, ran water for less than 10 seconds, returned to the medication cart and dried her hands with tissues. After the administration of medication for Resident #97 at 4:29 PM, the LPN again washed her hands in the shower room. Upon entering the shower room, she was unable to get any paper towels from the dispenser. The LPN asked another staff who assisted her, showing her how to press the bar below the dispenser, as the LPN was waving her hand as if it was a touchless dispenser. The LPN washed her hands for 2 or 3 seconds and turned off the faucet with her bare hands. During an interview on 06/30/26 at 4:39 PM, in the presence of the Director of Nursing (DON), when asked how long she should wash her hands, Staff A stated, While I sing Happy Birthday. When asked if she sang Happy Birthday while washing her hands during this medication pass the LPN stated, No, but I used hand sanitizer. When asked the proper way to hand sanitize the LPN described rubbing the sanitizer on her hands and drying with a tissue. The DON was made aware of the minimal hand-washing time, failure to use paper towels to turn off the faucets and stated there should be a 15 second air dry after thoroughly rubbing the hand sanitizer into her hands. 2. A medication administration observation was made with Staff A, LPN, on 06/30/26 beginning at 4:04 PM. The LPN gave medications to a total of five residents, including Resident #8, #11, #35, #68, and #97. While popping all the pills, the LPN would pop the back of the bubble pack to open the area that contained the pill and touched the pill while dropping it into the medication cup, instead of pushing the pill through the top of the bubble pack directly into the cup. During an interview on 06/30/26 at approximately 5:40 PM, when told of the observation, the Assistant Director of Nursing (ADON) who was also the Infection Control Preventionist (ICP), agreed with the findings. 3. A medication administration observation was made beginning on 06/30/26 at 9:23 AM for Resident #66. Staff B, LPN, obtained the blood sugar level and blood pressure for Resident #8. Upon completion, the LPN went into the bathroom and washed her hands, running the water for less than 10 seconds. The LPN then turned off the faucets using her bare hands. She did not do any hand sanitation at that time. During an interview on 06/30/26 at 11:35 AM, when asked how long she should wash her hands, Staff B stated, Happy Birthday twice . about 3 minutes or so. When asked to describe the process the LPN included turning off the faucet with a paper towel. When told her hand washing was less than 10 seconds and she failed to use the paper towel, the LPN stated, Oh. 4. An observation of the laundry area was made on 06/30/25 at 12:25 PM with the Environmental Director. Four white ceiling vents were noted with black residue covering about 25 to 50% of the vent. Below each vent was a black box with a black piece of foam and connected piping, that had dust hanging along the edges of the boxes. As per the Environmental Director, the black boxes were installed to catch condensation from the ceiling vents. During the continued tour of the laundry, observation of both dryers revealed stained areas along with brown and white debris on the inside of the dryer drums. The Environmental Director agreed with the findings. 5. Observations of all four linen carts, located on the four hallways, revealed all linen cart covers were stained, especially on the tops of each cart. The stains varied from white, to red, to dark shadowing. Besides the stains, the cart on the 100 hall had a clean hospital gown hanging out of the side of the cart. The cart on the 300 hall was not covering the linens in the lower right-hand corner, with a blue hospital gown and bed linens showing. The ICP and DON were made aware of the findings on 07/01/26 at 11:55 AM and agreed with the findings. 6. An observation of the medication room was made on 07/02/26 at 11:34 AM with the Unit Manager. A large refrigerator was noted with ice packs in the freezer area and numerous medications that needed refrigeration in the lower refrigerated section, to include in part insulin, intravenous antibiotics, and narcotics. The bottom of the freezer was stained and contained dark brown debris. The top and front of the refrigerator door was stained and had brown and black debris in the imbedded handle area of the top of the door. Upon turning on the sink faucet in the medication room, only a small stream of water was noted. The sink itself was stained on the bottom surface and along the rim. The Unit Manager agreed with the findings. 7. During a random observation on 06/29/26 at 1:31 PM, the ice cooler was noted on the 200 unit. The top of the cooler had a black substance on the white lid. The bottom tray of the cart was stained and dirty. 8. On 06/29/26 at 6:15 AM, observation on Hall 4 revealed an ice igloo containing ice that was left open and unattended. At 6:19 AM, a male staff member entered Hall 4 from another area of the facility, obtained ice from the unattended ice igloo, placed the ice into Styrofoam cups, and distributed the ice to residents located at the back of Hall 4. 9. On 06/29/26 at 6:16 AM, observation on Hall 4 revealed the linen cart was not covered, exposing linens and towels. On 06/30/26 at 9:14 AM, observation on Hall 1 revealed the linen cart was not fully covered, exposing linens and towels. On 07/01/26 at 11:46 AM, an interview was conducted with the Director of Nursing (DON). The DON was made aware of the infection control concerns related to the ice igloo being left open and unattended with ice available for staff distribution and the uncovered linen carts exposing linens and towels. The DON acknowledged the concerns. 10. Record review revealed Resident #87 was admitted on [DATE] with diagnoses including Non-Alzheimer's Dementia. Review of the Physician orders dated 06/26/26 indicated treatment for a right heel unstageable pressure ulcer requiring cleansing with Dakin's solution, application of collagen, and dressing with Kerlix. On 07/01/26 at 9:28 AM, during wound care observation for Resident #87, the Unit Manager (UM) was observed preparing and performing wound care. The UM obtained gauze from the treatment cart and placed the gauze directly on top of the treatment cart before applying collagen powder. The UM then used the gauze with Dakin's solution to cleanse the resident's right heel wound. After cleansing the wound, the UM applied gauze with collagen powder onto the wound bed and secured the dressing with Kerlix. The gauze placed directly on the treatment cart was not protected by a clean barrier, creating the potential for contamination prior to use on the resident's open wound. During an interview on 07/01/26 at 9:55 AM, the UM acknowledged the finding and stated she should have disinfected the treatment cart or applied a clean barrier before placing the gauze on the cart. On 07/01/26 at 10:02 AM, an interview was conducted with the Director of Nursing (DON). When asked if she had discussed the wound care observation with the UM, the DON stated she had. When asked what the UM reported, the DON stated the UM said she became nervous and placed the gauze directly on the treatment cart. The DON stated that the gauze should not have been placed directly on the cart and a clean barrier should have been used before placing the gauze. The DON was informed that during the interview, the UM did not state she had cleaned the treatment cart prior to placing the gauze on the surface.

Based on observation, record review and interview, the facility failed to ensure monitoring and maintenance of bedrails for entrapment for 3 of 3 sampled residents for Resident #19, #82, #87. The findings included:Review of a policy, titled, Proper Use of Bed Rails, implemented date 09/23 with a revised date of 01/26 revealed that the policy stated it is the policy of this facility to utilize person-centered approach when determining the use of bed rails. Appropriate alternative approaches are attempted prior to installing or using bed rails. If bed rails are used, the facility ensures correct installation, use and maintenance of the rails.The definition of bed rails that is in their policy documents bed rails are adjustable metal or rigid plastic bars that attach to the bed. They are available in a variety of types, shapes, and sizes ranging from full to one-half, one-quarter, or one-eighth lengths. Examples of bed rails include but are not limited to side rails, bed side rails, safety rails, grab bars and assist bars.Resident assessment documents that part of the resident's comprehensive assessment there are 12 components when considering in determining the resident needs and whether the use of bed rails meets those needs. The resident assessment must include an evaluation of the alternatives that were attempted prior to the installation or use of the bed rail and how the alternative failed to meet the resident's assessed needs as well as the risk from using the bed rails.Informed consent from the resident or resident representative must be obtained after appropriate alternatives have been attempted prior to installation and use of the bed rails.Upon receiving informed consent, the facility will obtain a physician's order for use of the specified bed rail, medical diagnosis, condition, symptoms or functional reason for the use of the bed rail.The facility will ensure the correct installation and maintenance of bed rails prior to use.The facility will continue to provide necessary treatment and care to the residents who have bed rails. This should be evidenced in the residents' records including their care plan.Responsibilities of ongoing monitoring and supervision include a nurse assigned to the resident will complete reassessments but not less than quarterly, upon a significant change in status or change in type of bed/mattress or/rail. The maintenance director, or designee, is responsible for adhering to a routine maintenance and inspection schedule for all bed frames, mattresses, and bed rails. 1. Observations were made on 07/01/26 at 3:28 PM of Resident #82 having bilateral bed rails. Record review revealed Resident #82 was admitted on [DATE] with a readmission from the hospital on [DATE] and placed under Hospice services on 06/17/26 with diagnoses to include Epilepsy, Unspecified Intellectual Disabilities, Peripheral Autonomic Neuropathy, Dementia with Behavioral Disturbances, Major Depressive Disorder, and Parkinson's Disease. Resident #82 currently has bilateral side rails on bed. 2. Observations were made on 07/02/26 at 7:38 AM of Resident #87 having bilateral bed rails on his bed.Record review revealed Resident #87 was admitted to the facility on [DATE] with diagnoses to include Obstructive and Reflux Uropathy, Essential Hypertension, Rheumatoid Arthritis, Dementia, Chronic Kidney Disease, and a History of Falling, Review of Resident #87 Quarterly MDS (Minimum Data Set) assessment dated [DATE] documents a BIMS (Brief Interview for Mental Status) score of 3, indicating cognition is severely impaired. Review of Resident # 87 care plan dated 07/03/25-07/23/26 showed that a care plan for ADLs and side rails was not found. Multiple other care plans were missing as well for Hypertension, Pain, Hypothyroidism, Cholesterol. Resident #87 has bilateral side rails on his bed used for enablers.3. Observations were made on 07/02/26 at 7:33 AM of Resident #19 having bilateral side rails on her bed.Record review revealed Resident #19 was admitted to the facility on [DATE] with the most recent readmission from hospital on [DATE]. Her diagnoses included Chronic Obstructive Pulmonary Disease (COPD), Essential Hypertension, Heart Failure, Hypothyroidism, and Major Depressive Disorder. Review of Resident #19 Annual MDS documents a BIMS score of 2 indicating cognition is severely impaired. Resident #19 has bilateral side rails on her bed. On 07/01/26 at 12:30 PM, the surveyor asked the DON (Director of Nursing and the ADON (Assistant Director of Nursing) about a Bed Rail Policy. The DON stated, we don't have bed rails. The surveyor read her the definition from their consent document: Bed rails are defined as adjustable metal or rigid plastic bars that attach to a bed. There are many types of bed rails available for use in a variety of shapes and sizes. Sizes range from full to one-half, one-quarter, and one-eighth lengths. Some bed rails are not designed to be part of the bed by the manufacturer. These types of rails are installed on or used along the side of the bed.When the surveyor requested of the Administrator the policy for side rails and assessments, she reiterated that they did not think they had bed rails in facility, so they didn't have a policy on them. She then stated that Resident #82 bed was brought in by Hospice.During an interview on 07/01/26 at 4:03 PM with the Maintenance Director, he was asked if he did any rounds to check the bed rails and/or enablers on the bed to make sure they follow the manufacturers' guidelines. He stated he doesn't document any of it, then stated they only check them if the nurse tells them one needs to be fixed.During a secondary interview with the DON on 07/02/26 at 1:25 PM, she stated that the reason they all say, will not utilize side rails is that no one considered using a side rail/bed rail. There was no indication the side rails in use for the above residents were monitored, assessed or maintained by the facility.

Based on record review and interview, the facility failed to meet the documentation requirements for the Arbitration Agreement as evidenced by not having the required verbiage on the document; not having the resident or family member acknowledge that they understand the arbitration; and not ensuring the arbitration is explained to the resident or family member so that they can understand. The findings included:A review of the facility's Arbitration Agreement list revealed that the facility does not have anyone to sign the arbitration agreement. Further review of the agreement revealed that it was very difficult to read and understand, that it was very wordy. They use the word Alternate Dispute Resolution. The agreement is supposed to be explained to the resident and his or her representative in a form and manner that he or she understands, including in a language the resident and his or her representative understands; The resident or his or her representative acknowledges that he or she understands the agreement; They are missing the verbiage that the agreement may not contain any language that prohibits or discourages the resident or anyone else from communicating with federal, state, or local officials, including but not limited to, federal and state surveyors, other federal or state health department employees, and representative of the Office of the State Long-Term Care Ombudsman. During an interview on 07/02/26 at 10:55 AM with the Admissions Director, she acknowledged that they do not have any residents that have signed it. She stated she has only been here since 05/29/26. She was asked if she explains to the resident the arbitration agreement. She stated no, I will print out the document and I have them read each page. I don't go through it with them. When asked if she had ever trained in Arbitration, she shook her head side-to-side and stated no.

Based on observation, interview, and record review, the facility failed to ensure a safe, clean, and homelike environment for 6 of 11 rooms observed as evidenced by discolored floors, molding and walls, stained/dirty privacy curtains, peeling wallpaper, damaged drywall, and a damaged/dirty electrical outlet cover in occupied and unoccupied rooms. The census at the time of survey was 72. The bed capacity was 79.The findings included: 1. Record review documented Resident #2 was admitted on [DATE] and discharged on 03/11/26. Review of the grievance report for Resident #2, submitted by the spouse on 02/05/26 about the floor in the resident's room, documented the floor was not clean. Observation of Resident #2's room was conducted on 03/17/26 at 10:40 AM revealed that the room had been deep cleaned as both beds had a dated paper (Bed A was dated 03/13/26 and Bed B 03/15/26) with the housekeeper's name that was placed on top of the mattresses. The observation revealed that Bed B's mattress still had a stained area on the mattress, the privacy curtain was dirty, there was trash in the trash can, paper towels crumpled up on the floor under the privacy curtain, a previous resident's personal items in a labeled bag in the closet, and the floor and wood molding was stained in areas near the closet and bathroom. 2. Record review for Resident #3, who currently resides in the facility, revealed a grievance that was submitted by Resident #3's family member on 02/05/26 that housekeeping failed to clean up a spill and that the floor had not been previously cleaned sufficiently. Observation of this room revealed that the floor appeared clean, but the wallpaper was peeling off behind both A and B beds. 3. Further observations revealed the following:-room [ROOM NUMBER] had discolored floor and walls with damage to drywall.-room [ROOM NUMBER] had discolored and missing part of flooring and area where wall was dirty.-room [ROOM NUMBER] had a sign on both beds to indicate they had been cleaned and appeared to have clean sheets on them (Bed 105-B dated 03/12/26 and Bed 105-A dated 03/11/26). There was an adaptive Reacher, a pad from a wheelchair leg rest and a folded red plastic bag on the countertop next to the television, trash in both of the trashcans in the bedroom and in the bathroom, a hole in the wall under the air conditioner (A/C) unit, the privacy curtain was dirty, and a blue mat with ripped areas was noted behind the bedside table. 4. Record review revealed Resident #1 was admitted to the facility on [DATE] with a diagnosis in part of Acute Respiratory Failure and a discharge date of 12/22/25. In an interview with Resident #1's family member it was noted that the resident's room had appeared unclean on admission, had the previous resident's personal clothing and paperwork left in the closet, mold-like substance was around an electrical outlet and in the air conditioning unit, and there was hair on the bedding.Observation of this room, conducted on 03/17/26 at 10:25 AM, revealed an electrical outlet that appeared to have the drywall open around the outside of the outlet cover, and dark blackish stains on the wood molding around the air conditioning unit. An interview was conducted with the Housekeeping and Laundry Manager on 03/17/26 at 11:13 AM who has worked at the facility for 9 years. The Housekeeping Manager was asked what the process was for cleaning a room after a resident has been discharged . The Housekeeping Manager stated that when the nursing staff advises housekeeping that a room needs to be deep cleaned, the housekeeping staff replace the privacy curtain, wipe down the mattress, the bed frame, the remote control for the bed, the call bell, the bedside table, the nightstand and closets and empty the trashcans. They then place a paper on the bed with the date the bed was cleaned and the name of the housekeeping staff who cleaned it. The Housekeeping Manager confirmed that the paper on the bed means the whole room was deep cleaned and ready for a new resident to move in. The Housekeeping Manager stated that he is made aware of issues in the rooms by the housekeepers, staff that do angel rounds, the Certified Nursing Assistants (CNA's) and the nurses. On 03/17/25 at approximately 11:30 AM, observation was made of Resident #2's room with the Housekeeping Manager who agreed with the findings of the dirty privacy curtain, items in the trash can and on the floor, a mattress that had residue on it with the signed paper this bed was wiped clean on 03/13/26, and the floor and wood moldings that were stained near the closet and bathroom. He stated that he would contact the Maintenance Director if he or his staff were unable to clean the walls, floors or furniture due to the need for repairs. An interview was conducted on 03/17/26 at 1:50 PM with the Director of Maintenance who has worked at the facility for 5 years. The Director of Maintenance was asked if he checks the rooms that are getting cleaned for new residents. He stated he only checks the rooms when he has the opportunity to check them. He was then asked what he would check for and stated, 'making sure the call lights work, the bathroom, the television, and the air conditioner unless it was running and working then would not check it'. He was asked if the air conditioning units get moldy and stated that he does not recall that issue but that some units get dark and dusty on the front grill and can be cleaned. The Director of Maintenance was then shown photographic evidence of the outlet and air conditioning wood molding in Resident #1's room to which he stated, 'it looks like the receptacle needs to be cleaned and the bottom portion of the molding around the air conditioning unit looks like it could have water / condensation but did not think it was mold'. He stated that he is the contact person for the monthly pest control that the facility gets through [company name] and that there are 2 binders in the building, one at the nursing unit and one at the front desk that staff are required to add the location, time date and what type of pest was seen so that they know where to treat during the monthly treatments. He was asked if there is a plan for replacing or fixing the walls, cabinetry and floors and he requested that the surveyor address that with the Administrator. During the exit conference on 03/17/26 at 2:30, the Nursing Home Administrator (NHA) was asked about repairs to the residents' rooms. He stated that it is difficult to get into a resident's room for 2-3 days to make repairs needed due to the census being high. The NHA was advised that there were currently two rooms that appear to have been empty for 2-3 days and have not appeared to have any repairs done. The NHA agreed with the findings. Photographic Evidence Obtained.

Based on observation and interview, the facility failed to ensure timely housekeeping and maintenance in 2 of 4 (100 and 300) resident hallways, affecting Resident #224, #42, #23, and #66; and failed to maintain ceiling vents and common area walls on all four resident units and in the central common area. The findings included: 1. The following environmental and housekeeping concerns were observed during the survey: a) On 02/10/25 at 10:24 AM, Resident #224 stated the window air conditioner in her room was broken, and had been since her admission on 02/07/25. The panel on the air conditioning unit showed a code of E3, indicating an error, and no air was blowing. b) On 02/10/25 at 11:09 AM, the privacy curtains for Resident #42 were noted to be stained on both sides. Photographic Evidence Obtained. There was also a urine odor noted upon entering the room. On 02/11/25 at 10:35 AM and on 02/12/25 at 9:29 AM, the urine odor remained. An observation of the resident's mattress at this time lacked any obvious signs of previous incontinent episodes and during a skin check at this time, the resident's skin lacked any skin impairment which would indicate a lack of incontinence care. Upon further investigation, the privacy curtain had an urine odor as well as the room itself. The baseboard on the wall behind the bed had also pulled away from wall several inches and the laminate trim from the footboard of the bed was missing. The floors were visibly dirty with debris and darkened stains. Photographic Evidence Obtained. c) On 02/10/25 at 11:19 AM, the over-the-bed table for Resident #23 had an open rusted square area on the leg and the headrest area of the recliner had a worn off, and could no longer be effectively cleaned. Photographic Evidence Obtained. d) On 02/10/25 at 10:35 AM, an area of white plaster, approximately 2 feet by 3 feet, was noted on the yellow wall located behind the bed of Resident #66. During a supplemental interview on 02/11/25 at 9:42 AM, the resident stated it had been there ever since she could remember. When asked if it bothered her, the resident stated, Well it's not pretty. During an interview on 02/13/25 at approximately 10:00 AM, when asked the process for ensuring clean privacy curtains, the Housekeeping Director stated the curtains are taken down and replaced monthly when each room is deep cleaned. When asked specifically about the deep cleaning schedule, the Housekeeping Director stated he makes out a monthly calendar and ensures each room and all common areas are deep cleaned monthly. The Housekeeping Director also identified two target rooms that are completed weekly due to urine odors, but did not include the room of Resident #42. When asked if the staff did any type of rounds to identify new areas of concern, the Housekeeping Director stated managers do daily angel rounds and should be reporting any concerns during their morning meetings. An additional observation was made at this time and the Housekeeping Director agreed with the concerns for Residents #42 and #23. During an interview and tour on 02/13/25 at 11:12 AM, when asked the process for repairs, the Maintenance Director stated they had a maintenance book to log needed repairs, and many staff just tell him of needed repairs. The Maintenance Director stated, Remember, I'm the only maintenance person, so I can't always get to things right away. And I do life safety as well. Review of the 100 unit Maintenance Book lacked any entries for 2025. During an observation of the plaster wall in Resident #66's room, with the Maintenance Director, he stated the repair of that wall had been done back in November or December (of 2024), and that he hadn't had a chance to get back and paint the area or the wall. Observation of Resident #244's room revealed a temporary air conditioner. The Maintenance Director stated he had just heard about the issue that morning. When told it had not been working since the resident's admission, the Maintenance Director stated he just heard of the issue that day. 2. Observation of the common area and four hallways on 02/13/25 beginning at approximately 11:30 AM, with Photographic Evidence obtained, revealed the following: a) On the 100 hall, 5 of 6 ceiling vents had a rust-like substance and or were dirty. b) On the 200 hall, 6 of 6 ceiling vents had a rust-like substance and or were dirty. c) On the 300 hall, 6 of 6 ceiling vents had a rust-like substance and or were dirty. There were multiple areas of bubbling and or pealing paint on the walls. d) On the 400 hall, 4 of 6 ceiling vents had a rust-like substance and or were dirty. The walls had areas of bubbling paint. e) In the common central area, 6 of 8 ceiling vents had a rust-like substance and or were dust laden. During an interview on 02/13/25 at approximately 1:00 PM, the Maintenance Director agreed with the findings.

Based on observation, record review and interview, the facility failed to provide the necessary supervision to protect a resident identified as high risk for falls from falling for 1 of 3 sampled residents reviewed for falls (Resident # 56). The resident sustained [REDACTED]. The facility failed to complete a thorough investigation of the above fall and failed to implement practices to ensure this practice did not reoccur. The facility also failed to ensure the safety of a random resident on oxygen from the possibility of an accident/injury from cigarette smoking while outside on the patio. The findings include: 1. Review of the clinical record for Resident # 56 revealed the resident sustained [REDACTED]. A 9/13/2010 5:30 PM Nursing Progress note documented, the resident was in the Day Room. He/she got out of the wheelchair and fell . The resident was checked by the nurse. The resident complained of right side leg pain when touching. The Advance Registered Nurse Practitioner (ARNP) prescribed for the resident to be sent to the emergency room for evaluation. At 8:30 PM, the nurse documented the resident was admitted to the hospital for a right femoral fracture. A 7/19/2010 fall risk evaluation identified the resident had a score of 12 indicating the resident was a High Risk for potential falls. A total score of 10 or greater identifies the resident as High Risk for falls. " A prevention protocol should be initiated immediately and documented on the care plan. " Review of the quarterly Minimum Data Set assessment dated [DATE] indicated the resident has short and long term memory impairment and memory recall of the resident is in the nursing home. The resident is moderately impaired for cognitive skills for decision making (decisions poor, cues/supervision required). The resident is usually able to make self understood and understands others, no indicators for depression anxiety or sad mood, no behavior symptoms. The resident is independent for bed mobility, supervision and setup help only (1/1) for transfers; limited assistance of one person (2/2) for walking in the room and corridor, total dependence of one person physical assist (4/2) for locomotion on unit and off unit. The resident was identified as having an unsteady gait as a problem. The resident did not have any pain and had no accidents. An " At risk for falls related to Dementia " care plan was updated on 7/20/2010. The approaches identified on this care plan included the following interventions: Call light within reach every day; answer call light promptly every day; keep bed at lowest position every day; keep area free of hazards every day; monitor for effectiveness of medication and side effects every day; monitor for any declines with transfers every day and as needed; 1:1 supervision as needed; bed/chair alarm as ordered check batteries every 2 weeks and as needed; 1/2 side rails up to promote bed mobility. The resident has [DIAGNOSES REDACTED]. An interview was conducted on 10/7/2010 at 12:47 PM with the Director of Nursing (DON). She initially stated an aide was in the room with the resident because an activity was going on. The surveyor questioned the DON regarding the presence of the staff in the day room and the staff's location in the room in reference to the resident. The surveyor requested to speak with the aide because this information was not documented in the facility's investigation. Furthermore, there was not a statement from the aide in the facility's investigation. The DON later stated she had spoken with the aide whom she had earlier reported was in the Day Room when the resident fell . The DON stated, the aide reminded her there were only two residents in the Day Room at the time of the resident ' s fall. The DON further reported the aide had finished an activity and was transporting residents to the Dining Room (DR). The DON stated the resident was in the Day Room with another resident along with the adult child of the second resident. However, the DON later confirmed there was no facility staff in the Day Room at the time of the resident ' s fall. The DON confirmed the aide was apparently coming back from the DR, when the fall occurred. This was not noted in the facility's investigation. This resident also previously required 1:1 supervision for exit seeking behavior. However, the resident had improved regarding the exit seeking behavior and the 1:1 for exit seeking behavior was discontinued on 8/13/2010. However, the fall risk care plan identified an approach of 1:1 supervision as needed. The resident also no longer had a wander guard, but had a bed and chair alarm for safety. The facility investigation documented the resident removed the clip for the chair alarm off his/her shirt. The DON stated, the type of chair alarm the resident was wearing at the time of his/her fall has a clip which is attached to the resident ' s clothes and the chair alarm box with the magnet connection is attached to the resident ' s chair. When the resident removed the clip off his/her clothes, the string was hanging from the chair. The alarm will not sound until the magnet is disengaged from the alarm. Because the resident had removed the clip, the alarm would not have sounded. She further stated the resident had never attempted to pull the clip off previously. However, upon further discussion, the DON revealed the staff had become creative with the resident regarding placement of the clip for the chair alarm. She stated the staff had begun placing the clip in the back of his/her clothes to prevent the resident from pulling the alarm off. She also stated the staff had begun shortening the string on the chair alarm because the resident would lean forward to determine how far he/she could lean before activating the alarm. She stated, "The resident was smart enough to know what to do with that clip." The facility uses two (2) different types of chair alarms. One type is the clip alarm which attaches to the clothing and the other is a chair pad which will alarm if the resident gets up. The facility utilizes the clip alarm first then they will utilize the chair pads. The surveyor also reviewed the nursing progress notes with the DON which documented, "the resident had attempted numerous times to get out of the chair on 9/11/2010 (2 days before the fall). After much discussion, it was determined the resident was not supervised at the time of the fall. An interview was conducted on 10/7/2010 at approximately 3:30 PM with the aide who allegedly was in Day Room when the fall occurred. The aide confirmed she was not in the Day Room. She was passing in the hall when the fall occurred. When she came into the Day Room, the resident had already fallen and was lying by the wheelchair. The alarm was hanging from the chair. She confirmed she was not assigned to the resident for the evening. She stated she does not recall an aide being in the room before the resident ' s fall. She stated, the other resident in the room told her, Resident # 56 got up from his/her wheelchair and the second resident ' s adult child told the resident to sit down. She further stated she recalls the second resident and his/her adult child was in the room. She reported another aide got to the room before she arrived. The nurse and the administrator were also present. She stated the resident complained of pain on the left side though the resident was lying on the right side. An interview was conducted on 10/7/2010 at 3:40 PM with the aide assigned to the resident. Aide # 2 reported the resident was in the Day Room and he/she fell while there. She stated she was not involved in the resident ' s fall. She was taking care of other residents on the unit at the time. She further reported she too was passing in the hallway after taking another resident to the dining room. Upon returning to the unit, she saw the people in the Day Room. She acknowledged that the resident was a fall risk and had the bed and chair alarms for safety. She reports, the resident would attempt to stand up in his/her wheelchair and make attempts to pull his/her shirt off at times. When she worked with the resident, it took two people to transfer but the resident will attempt to transfer him/herself when he/she wanted to without assistance. The resident will also scoot him/herself in the wheelchair when he/she wanted to. She stated the resident was to be supervised and after an activity, the staff was to put the resident at the desk so the nurse could supervise the resident. " There is always someone at the desk to supervise him/her." An interview was conducted on 10/7/2010 at 4:33 PM with Licensed Practical Nurse involved. He stated the resident required 1:1 supervision at first but the resident improved and that was discontinued. The resident was a fall risk and had a bed and chair alarm. He stated, this was the first time the resident had removed the alarm. He was unaware of the resident making attempts to remove his/her clothing. He stated he was on the unit. The resident fell and the supervisor came to get him. The resident was unable to stretch his/her leg so we called the doctor and sent the resident to the hospital. An interview was conducted on 10/7/2010 at 4:40 PM with the Registered Nurse Evening Supervisor. She stated she was at the nursing station when the family member informed her that the resident had fallen in the Day Room. She stated she went to the Day room and found the resident on the floor. The wheelchair was beside the resident. " The tab alarm went off." She then stated the person who reported the resident's fall to her, stated we quieted the alarm. She believes someone silenced the alarm but she doesn't ' know who. The alarm was hanging off but she doesn't recall if the alarm was hanging off the wheelchair or if the alarm was hanging off the resident. She stated some other visitors were present but they left. She doesn't recall if other staff were present, she stated, " I rushed right to the resident. " She further stated the resident has a history of attempting to get up many times. " We have him/her sit out here (indicating the nursing station) with us, so we can keep an eye on him/her. We have people looking out for him/her. We staff so the residents are not left alone, especially when they attempt to get up. " Furthermore the facility failed to conduct a thorough investigation of the resident ' s fall on 9/13/2010. The facility ' s investigation included written statements by 2 licensed staff who did not witness the incident and the family member who observed the incident. The facility's investigation did not contain statements by the aide who was assisting the resident with activities, the aide assigned to the resident, any residents who were present in the day room at the time of the fall. Additionally, the investigation does not document specific details of the scene, the functioning of the protective devices, the staff who was either present or who was previously present, nor was a thorough evaluation of the resident ' s mental status to determine the resident ' s current need for supervision. The Fall investigation, evaluation and interventions, Incident analysis documented, according to a family member, the resident removed his/her chair alarm attempted to walk and fell on his/her right side. The Summary of investigation documented, the resident was lying on the floor on his/her right side. When the resident was checked by the nurse, the resident complained of right side pain when touching. The corrective action the facility would institute after the fall was to keep resident under staff supervision when out of bed. The following was documented in the facility's documentation: Name of Witness: none noted. Unattended fall was circled; the activity the resident was engaged in when the fall occurred was walking in room, attempted to walk; How loss of balance got up and fell , resident unable to explain, resident alert with confusion, no complaint of pain prior to fall, incontinent of before and after fall, mobility chair bound, shoes, chair alarm circled but does not indicate if the device was functioning at the time of the fall, area was well lighted, floor was clean and dry no falls in the past 30 days and the list of current interventions to prevent falls was the bed and chair alarm. The Investigation had attached statements by the Registered Nurse, Licensed Practical Nurse and the family member as follows: The statement by the Registered Nurse documented, " While at the nursing station a family member approached and stated a resident was laying on the floor. Another nurse and this writer went to investigate and observed resident laying on the floor on his/her right side. Upon assessment, resident touched and complained of pain in leg and hip area. Fall was witnessed by a visitor who stated he/she was visiting with his/her parent and the resident took off his/her alarm (took a loose) and got up attempting to ambulate. The other resident told him/her his/her arm was bleeding so he/she turned and tried to get back to his/her wheelchair and it appeared he/she stumbled and loss his/her balance. The resident was not close enough for me (the visitor) so I could not catch him/her so I came to tell the nurse. " The statement by another Licensed Practical Nurse documented, " According to family member that was in the TV room, the resident removed his/her chair alarm and attempted to walk and fell on his/her right side. The resident was assessed by the nurse. The resident complained of right leg pain when touching. The resident was sent to the emergency room for evaluation. " The statement by the family member documented, " On September 13th at approximately 4:50 PM, I was in the activity room at the facility talking with my parent and client known to me as "stated the resident ' s name " was sitting in a wheelchair in the room also. I observed the resident get up from his/her chair and walk approximately 5 feet to where I was sitting. He/she stood for a moment next to my parent who was talking to him/her. He/she then started to walk back toward his/her chair. Before getting to his/her chair he/she started to stumble when I realized he/she wasn't going to regain his/her balance. I got up. His/her knees buckled and he/she started to stumble to the floor. I caught him/her just as he/she fell to the knee. However, his/her momentum carried him/her over on down to the floor on his/her hip where I instructed him/her not to stand up while I went for help. " An interview was conducted on 10/7/2010 at 4:15 PM with the Administrator, Risk Manager. She stated, the facility did not make additional reports to the state agency because the interdisciplinary team met the following morning (9/14/2010) after the fall and determined the facility could not have done anything to prevent the fall. She stated the resident had a chair alarm in place, the resident had not had a fall since admission and the facility exercised due diligence. The resident removed the alarm and had never removed the alarm previously. The surveyor emphasized to the Administrator the concern of the staff reporting the tendency of the resident to remove the clothing where the clip for the chair alarm was placed and the resident had made numerous attempts of standing prior to the actual fall. Furthermore the resident was care planned on the " risk for falls " and the aide plan of care for 1:1 supervision as needed. She stated, the resident did not require supervision. The surveyor then questioned the Administrator regarding the nursing progress note from 9/11/2010 when the nurse documented the resident had made numerous attempts to get up just 2 days prior to the fall. She then stated, she would not have known this, if it was not reported in the 24 hour report because "she cannot read everyone's chart." Review of the 24 hour report for 9/11/2010 documented on the 3-11 shift, " the resident was agitated most of the shift, uncooperative, restless " ; on 9/12/2010, the resident " scratched his/her arm." On 9/13/2010 the resident was "admitted to the hospital for right femoral fracture." 2) Observation on 10/08/10 at 1:23 PM revealed on the smoking patio a random resident with an oxygen tank secured to his/her wheelchair, with the nasal cannula in place on his/her face, sitting in a wheelchair with a family member next to a resident and a visitor who were actively smoking. The resident was located immediately next to the table where the residents were smoking, approximately 2 feet away. A facility aide was observed sitting at the same table as the smokers, facing the resident who had the portable oxygen. She did not intervene or remove the resident from the area. The surveyors intervened and asked for the resident with the oxygen tank to be moved from the are. The resident's family member took the resident away from the patio and reported that she did not know that it was unsafe for the resident to be in the smoking area. In a subsequent interview with the visitor who was smoking with the residents on 10/08/10 at approximately 1:25 PM, the visitor reported she/he believed she and the family member had believed that the it was appropriate for the resident with the portable oxygen to sit near the smoking residents if "the oxygen was turned off". In an interview conducted on 10/08/10 at 1:44 PM with the Administrator and the DON, the participants reported that the practice was not acceptable at the facility. Interview conducted on 10/08/10 at 1:50 PM with the aide who was observed sitting at the smoking table at the time of the incident, in the presence of the Administrator and the DON, the aide reported that on 10/08/10, she arrived on the smoker's patio after the family member and the resident who had oxygen were already there. She reported that she had questioned their presence on the smoking patio, but reported the Admissions Director told the family that it was acceptable for the resident with portable oxygen to be on the patio if the oxygen "was low". She admitted that she did not check the resident's portable oxygen to verify if it was low. The aide added that she had received education on oxygen safety at an unknown time, as she had been an aide for "a long time", but she reported that when she observed the resident with the portable oxygen next to the resident who was actively smoking she chose to follow the Admissions Director's advice. In an interview conducted on 10/07/10 at 1:55 PM with the Admissions Director, in the presence of the Administrator and the DON, the Admissions Director reported that she did not speak with the aide or any resident or family member about oxygen and smoking. She reported that she went to the smoking patio "earlier today", but there were no residents there at that time.