**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record review, facility document review, facility policy review, the facility failed to ensure employment of a full-time Director of Nursing to manage the nursing department and provide oversight of care and planning to all residents; and to ensure a registered nurse was available in the building for 8 consecutive hours a day for resident needs. It was determined the facility's non-compliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The Immediate Jeopardy (IJ) situation was related to State Operation Manual, Appendix PP, 483.35 (Nursing Services) at a scope and severity of L. The IJ began on 02/17/2025 after review of; employee files, timecard reports; Resident #33 TAR; Resident #184's lack of Minimum Data Sheet (MDS) assessments, comprehensive care plan with interventions, and interview; Resident #85's lack of MDS assessment, comprehensive care plan with interventions, and basic care plan; Resident #135's lack of MDS assessment, stage 2 pressure ulcer assessment, EBP implementation for a urinary catheter, and a comprehensive care plan. The Administrator was notified of the IJ on 04/23/2025 at 5:20 PM. A Removal Plan was requested. An IJ removal plan must include all the actions the facility has taken or will take to immediately address the noncompliance that resulted in or made serious injury, serious harm, serious impairment or death likely. On 04/25/2025 at 9:51 AM an acceptable Immediate Jeopardy removal plan was accepted in accordance with Appendix Q. The IJ was not removed prior to exit; the survey team was unable to validate the plan of removal. The IJ was cleared on 05/09/2025 at a subsequent survey. Findings include: A review of the facility's undated Facility Assessment with an Addendum attached 08/24/2024 stated, a Director of Nursing (DON) was on staff, but no self-assessed staffing guidelines were identified and no mention of Registered Nurse (RN) coverage. A review of an undated facility document titled, Director of Nursing Job Description, indicated, DON must process the clinical and managerial skills to direct and lead a nursing department. It is vital that the person communicate [communicates] clearly to residents, their families, nurses and all nursing home personnel. The DON must lead the nursing staff in taking positive action to continually upgrade the quality of physical, social, emotional and spiritual care given. Professional requirements included, a willingness to study, learn and implement continuously changing state and federal regulations. Be a role model of professionalism and teamwork. Leadership ability. Responsibilities included, Plan, organize and direct the administration of all nursing units and patient care given based on established goals and objectives, standards, policies and procedures of the company and facility. Put into effect the administrative policies of the company. Maintain records. Review, update and revise policies including OBRA [Omnibus Budget Reconciliation Act] procedures to meet current objectives and state and federal regulations. Regularly inspect the facility, nursing practices and documentation for compliance with federal, state, and local standards and regulations. Insure [Ensure] that all shifts are adequately covered for nursing services following state and federal policies as well as patient needs. Oversee agenda preparation for medical staff and utilization review meetings. Function as the liaison between state and federal agencies in regard to Medicaid, Medicare and any and all other insurances. Complete any required documentation in a timely manner. Meet daily with critical core team members regarding admission, placement, or discharge of patients. In addition, participates in coordination of patient services through departmental staff meetings and assists in the development of patient's care plans. Oversee the complete and timely completion of care plans. Attend department head/administrative meetings. Review all infection control reports, medications incident reports and I&A reports. With appropriate staff, develop [a] corrective action plan. Study all weekly reports such as level of care reports, dietary and pharmacy consultant reports. Meet monthly with staff on each shift. Provide in-services to all shifts as necessary to maintain a quality nursing program. Maintain all required records. Meet monthly with the nursing staff regarding chart audits and physician orders. Perform in-house quality assurance surveys on a quarterly basis and maintain all quality assurance requirements and recommendations. Is on call for all emergencies that other supervisory personnel cannot handle. Stay up to date on state and federal regulations and policies. Plan, organize and direct all patient care. A review of the facility's employee file for the Former DON [Facility Name] New Hire/Stats Change Form, indicated, the Former DON was hired on 07/10/2023 and was terminated 02/16/2025; reason cited was quit without notice. She was an RN and full-time DON/MDS (Minimum Data Sheet) nurse. No acknowledgement of the facility's DON job description was noted signed or otherwise in the employee file. A review of the facility's employee file for the Former DON #8 [Facility Name] New Hire/Stats Change Form, indicated, the Former DON #8 was hired on 03/20/2025 and was terminated on 04/15/2025 reason cited was inability to perform job duties. She was an RN and the full-time DON/MDS nurse. No acknowledgement of the facility's DON job description was noted signed or otherwise in the employee file. During an interview on 04/22/2025 at 4:25 PM, Licensed Practical Nurse (LPN) #7 stated corporate reported Former DON #8 had not done any Minimum Data Sheet (MDS) assessments while employed, this meant no care plans had been developed. A review of the facility's employee file for the RN #4 revealed on a RN license verification for the state of Arkansas and an Arkansas Department of Human Services request for adult maltreatment registry information signed 04/22/2025. Per the Administrator on 04/23/2025 RN #4 was named as an Interim DON, no paperwork in the employee ' s file indicated this. RN #4 worked during the survey a partial 8-hour shift on 4/22/205, then worked 8 hours on 04/23/2025 and 04/24/2025. She was not at the facility again during the survey. The facility had one RN on staff who worked part-time, RN #2 who did not routinely work 8-hour shifts. A review of the Employee Timecard Report 02/16/2025-04/22/2025 and Human Resources identified dates worked by the DON revealed the facility was without 8 consecutive hours of RN coverage on 02/17/2025-02/18/2025, 02/20/2025-03/20/2025, 03/22/2025, 03/23/2025, 03/27/2025, 03/29/2025, 04/01/2025-04/06/2025, 04/09/2025, 04/13/2025-04/22/2025 which was 53 out of 65 days. As a result of no RN coverage or nurse management oversight the following occurred; Resident #25 had two major falls with injury due to lack of care plan re-evaluation and escalation of interventions, Resident #33's Peripherally Inserted Central Catheter (PICC) line was not assessed for 18 days by an RN and intravenous (IV) medications and flushes were administered by a non-IV certified LPN. Resident #85, #135, and #184 received no assessments and had no care plan implemented for care interventions for 26 days, 31 days, and 24 days respectively. A review of the Physician ' s Orders, indicated the facility admitted Resident #25 on 12/18/23 with diagnoses which included dementia, hypertension, insomnia, major depressive disorder with chronic anxiety, atrial fibrillation, dizziness and giddiness. A review of the quarterly MDS, with an Assessment Reference Date (ARD) of 03/16/25 revealed Resident #25's Brief Interview for Mental Status (BIMS) was 00, which indicated severe cognitive impairment. Section GG, functional abilities, revealed Resident # 25 required substantial/maximal assistance for mobility. A review of Resident #25's Care Plan dated 12/17/24, indicated the resident was at a very high risk for falls, lacked safety awareness and was weaker since a hospitalization. Resident #25 did not use call light nor know how. The facility developed interventions which included keeping the bed in the lowest position, attempting to keep gripper socks or shoes on when the resident is up, and to keep the resident room door open so staff could observe them as they walked down the hall. A review of Nursing Fall Risk Evaluation dated 03/24/25, revealed Resident # 25 had 3 or more falls in the last 90 days, no cognitive status changed in last 90 days, eliminated with assistance, was confined to a chair and used bedrails, the resident was not able to balance without physical help, had 3 or more risk factors related to falls on Resident Assessment Instrument (RAI) user's manual, and scored 24 on this. With a score of 10 or higher, the evaluation recommended staff should consider environmental risk factors in the resident's interventions. This form was completed by the Director of Nursing (DON). A review of Nursing Notes for Resident #25 on 03/13/25 at 2140 noted an X-ray of left wrist after an unwitnessed fall. A Radiology Results Report dated on 03/13/25, revealed Resident #25 had an impacted and comminuted distal left radius fracture and probable distal ulnar fracture to the left arm. An ace wrap applied to the left arm/wrist by the nurse. Resident #25 was a direct admitted to hospital for surgery on left arm. Resident #25 was discharged from the hospital on [DATE] post surgery with a cast in place to their left arm. The cast was removed by the resident twice. Per a review of Nursing Notes, on 03/26/25 Resident #25 was found on the floor in their room after an unwitnessed fall with complaints of pain to the right arm. An X-ray was performed on 03/28/25 which diagnosed a fracture to the right arm. Neither the Resident's closet care plan nor comprehensive care plan was updated with interventions for the resident's falls. A review of Incident and Accident Report (I&A) dated 03/26/25, indicated Resident #25 was found in the floor by a Certified Nursing Assistant (CNA). The witness statement stated the resident's left cast was off and on the other side of the bed and the resident was on the floor. No interventions were noted on I&A. A review of Radiology Results Report dated on 03/28/25, revealed Resident #25 had an impacted fracture of the right radial head. A review of a Hospital Orthopedic Record dated 03/26/25, revealed Resident #25 was discharged from the hospital with a diagnosis of markedly displaced and comminuted left distal radius and ulna fracture with significant soft tissue swelling status post stabilization with Open Reduction and Internal Fixation (ORIF) and casting by an orthopedic surgeon. During an interview on 04/21/25 at 12:25 PM, Resident #25's family member stated Resident #25 fell about a month ago and had to go to the hospital for surgery on their left wrist. Upon return from the hospital, Resident #25 kept removing their cast and fell 2-3 days later and sustained a new fracture to the right elbow. Resident #33, who according to the Medication Administration Record (MAR)/Treatment Administration Record (TAR) was admitted on [DATE] with a PICC line in place to receive IV antibiotics and flushed with saline and an anticoagulant twice a day, had no RN assessment or care of the line on 02/18/2025, 02/20/2025-02/23/2025, 02/27/2028-03/02/2025, 03/06/2025-03/09/2025, 03/13/2025-03/17/2025 which was 18 days. 17 doses of IV antibiotics were administered from 02/14/2025-02/28/2025 by the Med Records/LPN Charge Nurse, LPN #7, LPN #11, and LPN #12. During an interview on 04/25/2025 at 10:08 AM LPN #9 stated she was never asked for documentation of her IV certification by the facility, but she was certified as an optional part of her LPN curriculum and the certification shows when her license is verified. She stated prior to using Resident #33 PICC line she would assess for redness or swelling at the site and see if the resident could complete range of motion in the affected arm without pain. During an interview on 04/25/2025 the Administrator stated she did not ask the LPNs if they were IV certified and she did not track it. The Administrator stated there was no IV training in the facility. During an interview on 04/25/2025 at 10:32 AM, the Medical Record LPN stated they would assess the PICC line with every administration by looking for warmth, redness, pain, swelling, and signs and symptoms of infection and touch around the site too. The Medical Record LPN stated the scope of practice for LPNs assessing depended on your home state and she was originally licensed in New Mexico. During an interview on 04/25/2025 at 10:32 AM LPN #9 stated they did admission assessments as an LPN, indicating it was in their scope of practice. A review of a Face Sheet revealed Resident #85 was admitted on [DATE], a review of Resident #85 chart revealed no MDS assessment, a comprehensive care plan, or a basic closet care plan completed as of 04/23/2025. A review of Resident #85's MDS Admission, submitted late, revealed it was signed off by RN #4 on 04/24/2025 and a comprehensive care plan was initiated 04/24/2025. A review of a Face Sheet revealed Resident #135 was admitted on [DATE], a review of Resident #135 chart revealed no MDS assessment, or a comprehensive care plan completed as of 04/23/2025. A review of Resident #135's MDS Admission, submitted late, revealed it was signed off by RN #4 on 04/24/2025 and a comprehensive care plan was initiated 04/24/2025. A review of Resident #184 Face Sheet revealed Resident #184 was admitted [DATE], a review of Resident #184's chart revealed no MDS assessment, or a comprehensive care plan was completed as of 04/23/2025. A review of Resident #184's MDS Admission, submitted late, revealed it was signed off by RN #4 on 04/24/2024 and a comprehensive care plan was initiated 04/25/2025. During an interview on 04/25/2025 at 1:55 PM, the Certified Nursing Assistant (CNA) #1 stated, if a resident had fallen or was declining, she would notify Med Records LPN, and she would assess them if there was no RN available. The Medical Records LPN would tell us to keep an eye on them and update the residents' care plan. If the Medical Records LPN couldn't take care of it, she would notify the DON, if we had one. During an interview on 04/29/2025 at 9:42 AM, the Assistant Director of Nursing (ADON) stated, there is no DON, but as ADON she did not assume the job duties of the DON. She stated she had to work bedside every day and had other work to do. Nobody had assumed those responsibilities, and I was not aware the MDSs, and care plans had not been done. On 04/25/2025 at 9:51 AM an acceptable Immediate Jeopardy removal plan was accepted in accordance with Appendix Q: 1. Interim Registered Nurse/Director of Nursing was hired on 4/22/2025. Registered Nurse to provide weekend coverage and replace Director of Nurses in event of a call in. Schedule will be updated to reflect Registered Nurse Coverage. Registered nurse coverage is considered 8 consecutive hours daily. 2. Administrator was in serviced by Regional Director, on registered nurse and director of nursing coverage and requirement to have a full time DON and at least 8 hours of registered nurse coverage 7 days a week. 3. Resident #33 peripherally inserted central catheter (PICC) Line was removed on 3/20/2025, care plan reviewed and updated as needed a. Bedside LPN in serviced 1: 1 by administrator about scope of practice regarding PICC line and site care on April 24, 2025. b. All LPNs/RN's to be in-serviced by phone or in person by director of nurses on Scope of Practice regarding PICC line and site care on April 25,2025 4. All staff will be in serviced by administrator and/or director of nursing in person or by phone on ESP and infection control by 4/25/25. Onsite Verification: During an interview on 04/25/25 at 11:30 AM the Administrator stated she had not heard from the new RN #4 (new interim DON). Neither she nor the Director of Operations could reach her on the phone. The Administrator stated she was not sure if the facility still had a DON. Onsite verification did not continue at this time. The survey team did not observe a RN in the building on 04/25/2025. Onsite verification was attempted on 05/02/2025 at 1:00 PM and could not be completed due to the Administrator verbalizing a Director of Nursing (DON) position had not been permanently filled and Interim DON verbalized being contracted for Registered Nurse (RN) coverage for 4 days and would be leaving the facility on Sunday 05/04/2025 to return to Oklahoma. Onsite verification was attempted on 05/05/2025 at 4:08 PM and could not be completed due to Interim DON verbalized being in Oklahoma and was not working for the facility. Interim DON verbalized only being contracted for four days as weekend RN coverage, not DON. The IJ was removed on 05/09/2025 at 12.56 PM after the survey team performed onsite verification that the Removal Plan had been implemented. Onsite verification of the Removal Plan began on 05/08/2025 at 11:00 AM. Record review included new DON was hired on 05/09/2025 and was present in the facility during the onsite verification. RN coverage was reviewed from 04/22/2025 to 05/09/2025 and verified via interviews. In-services reviewed included requirement of registered nurse and director of nursing coverage and to have a full time DON and at least 8 hours of registered nurse coverage 7 days a week. Resident #33 PICC Line was removed on 3/20/25, the care plan was updated. The Regional Director indicated the facility was no longer admitting residents with a PICC/IV, so there were no IV certifications to review. There were no residents residing in the building that had a PICC/IV. A total of 13 staff interviews were conducted with staff from all shifts to very training had been completed. The staff interviewed included Certified Nursing Assistants, Licensed Practical Nurses, Registered Nurses, Nurse Consultant, Social Services Director, and Assistant Director of Nursing. The staff interviewed verified they had been trained on the RN/DON requirement, scope of practice for LPNs. A review of in-service sheets provided indicated 16 had been provided training. Those staff who were not physically present to receive the in-services were messaged via telephone, with the in-service information provided and the employee acknowledging receipt and voicing understanding.

Based on interview, record review and policy review the administration (governing body) failed to ensure policies were implemented regarding management and operation of the facility to ensure residents were able to attain or maintain the highest practicable physical, mental, and psychosocial well-being. During the survey, the survey team identified no full-time registered nurse (RN) working 8 consecutive hours per day and licensed practical nurses (LPN) were not certified to assess and manage peripherally insert center catheters (PICC). Additionally, the survey team identified bed rails were installed without consent and residents were not assessed for their needs. The survey team identified residents with falls had not received fall assessments and interventions to prevent further falls. Lastly, the survey team identified a newly admitted resident had not been assessed for mobility function, identify interventions, and provide necessary equipment to maintain their most practicable independence. These identified failed practices resulted in Immediate Jeopardy for F727, F726, F700, F689, and F688. These deficient practices have the potential to affect all the residents residing in the facility. It was determined the facility ' s non-compliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The Immediate Jeopardy (IJ) situation was related to State Operation Manual, Appendix PP, §483.70 Administration at a scope and severity of L . The IJ began on 04/29/2025 after the survey team identified five IJs including F726, F727, F700, F688, F689. The Administrator was notified of the IJ on 04/29/2025 at 12:05 PM. A Removal Plan was requested. An IJ removal plan must include all the actions the facility has taken or will take to immediately address the noncompliance that resulted in or made serious injury, serious harm, serious impairment or death likely. On 05/01/2025 at 2:12 PM, an acceptable Immediate Jeopardy removal plan was accepted in accordance with Appendix Q. The findings are: A review of a facility policy titled Administrative Management revised on 10/01/2024, indicated, The facility ' s governing board is the supreme authority and has full legal authority and responsibility for the management and operation of our facility .The governing body is responsible for, but is not limited to: a. Oversight of facility care and services in accordance with professional standards of practice and principles .d. Establishment and ongoing review of all administrative programs governing facility management and operations, including: .(4) Staff orientation, training and development programs. e. Creation of and participation in the annual (pr as needed) facility-wide assessment; f. Establishment and annual review of policies and procedures governing facility operations . During the survey entrance conference on 04/21/2025 at 10:42 AM the Administrator reported there was no Director of Nursing (DON) on staff, the DON would also fill the role of Minimum Data Sheet (MDS) nurse, a corporate LPN was completing MDSs remotely. A review of the facility ' s employee file for the Former DON [Facility Name] New Hire/Stats Change Form, indicated, the Former DON was hired on 07/10/2023 and was terminated 02/16/2025 reason cited was, quit without notice. She was an RN and full-time DON/MDS (Minimum Data Sheet) nurse. No acknowledgement of the facility ' s DON job description was noted signed or otherwise in the employee file. A review of the facility ' s employee file for the Former DON #8 [Facility Name] New Hire/Stats Change Form, indicated, the Former DON #8 was hired on 03/20/2025 and was terminated on 04/15/2025 reason cited was, inability to perform job duties. She was an RN and the full-time DON/MDS nurse. No acknowledgement of the facility ' s DON job description was noted signed or otherwise in the employee file. During an interview on 04/28/2025 at 9:42 AM, the Assistant Director of Nursing (ADON) verbalized working as the Infection Preventionist (IP) and was not able to pick up the DON duties due to working bedside daily and barely having time to complete the IP job duties. During an interview on 04/22/2025 at 12:50 PM, the Med Records Nurse stated it had been a while since they were able to work in medical records due to working on the floor as a bedside nurse for the last six months. During a phone interview on 04/29/2025 at 9:42 AM, the Assistant Director of Nursing (ADON) verbalized the individual serving as the DON completes the care plans, fall assessments, and MDSs. The ADON continued to state no one has assumed the responsibilities since the facility does not have a DON. The ADON continued to verbalize some residents have one care plan in the closet, and it is not comprehensive, it is mainly about transfers, incontinence, or how they eat. A review of a facility policy titled, Central Venous and Midline Catheter Flushing, revised April 2016, indicated, The facility should consult the [state laws and regulations] for RN/LPN scope of practice and function and Insertion site assessment should be done as part of the flushing process to monitor for complications. During an interview on 04/25/2025 the Administrator verbalized, not asking the LPNs who was IV certified and reported they did not track which LPNs were IV certified. The Administrator stated there was no IV training in the facility. During an interview on 04/27/2025 at 01:02 PM, Registered Nurse (RN) #2 revealed there were no bed rail assessments. During an interview on 04/27/2025 at 01:12 PM, Licensed Practical Nurse (LPN) #9 revealed she was unsure of where bed rail assessments or documentation would be in the medical record and the facility usually just asks the residents what their preference was on having bed rails or not. During an interview on 04/27/2025 at 1:31 PM, the Housekeeping/Maintenance (Hskp/Maint) Supervisor verbalized being responsible for putting the bed rails on the beds and taking the bed rails off the beds. The Hskp/Maint Supervisor verbalized most of the beds in the facility have bedrails except for the residents who did not want them on. Hskp/Maint Supervisor revealed there are 3 types of bed rails, but that they (Hskp/Maint Supervisor) does not measure the beds to ensure proper fitment. The Hskp/Maint Supervisor reported being able to look at the bed and know which bedrail goes on the beds. She reported the facility had manufacture guidelines to the bed rails and beds but was unsure where they were at the time of interview, but she would find them. The Hskp/Maint Supervisor stated she had not read the manufacture guidelines. Hskp/Maint Supervisor revealed she checked the high and low beds at least weekly, but some of the beds every couple of days because the bed rails got really loose and must be tightened. When asked how she knew which bed rails to check she replied she just knew. The Hskp/Maint Supervisor revealed there were no forms or logs kept on bed rails. She reported if the bedrails were loose, they were not safe and would not be stable for the residents to use. She revealed the nurses were the ones who determined who got bed rails and who did not, and they would inform her. She revealed they have a standard size mattress in use in the facility. She revealed the facility also had a concave mattress and two types of bariatric size mattresses in use. She revealed it didn 't make a difference on the size of the mattress; it just made the bed rails closer to the mattress, so the mattress didn ' t slide. A review of Falls-Clinical Protocol policy, with a revision date of April 2024, revealed that, based off assessments, staff should identify pertinent interventions to prevent subsequent falls, and to address the risks of clinically significant consequences of falling. Staff will try various relevant interventions until falling reduces or stops or until a reason is identified for its continuation. During an interview on 04/29/2025 at 9:42 AM, the ADON revealed staff look at the time-of-day falls occur. The ADON confirmed fall assessments were completed by the DON and currently the facility does not have a DON. The ADON confirmed that no one has been completing fall assessments and updating care plans when falls occur. The ADON stated the facility utilizes low beds and fall mats for interventions. A facility document review of Facility Assessment Profile, undated, indicated the Director of Nursing pre-screens any new referrals and makes notes based on the information sent and if the facility is able to meet the needs of the resident. The facility provides wheelchairs and has a highlighted list residents regarding mobility. A facility policy review of Resident Assessment Instrument, revision date September 2024, indicated the purpose of the assessment was to describe the resident ' s capability to perform daily life functions and to identify significant impairments in functional capacity. The assessment also derives information from the comprehensive assessment which then helps the staff to plan care that allows the resident to reach his/her highest practicable level of functioning. A policy for Activities of Daily Living/Mobility was not provided by the Administrator when requested on 04/25/2025. An admission Nursing Evaluation, dated 03/31/25, Resident #184s evaluation was not an assessment and was completed by Medical Records/Licensed Practical Nurse, revealing one person assist for bed mobility, dressing, toileting, personal/hygiene, and bathing. It documented two persons assist for transfers with wheelchair use. During an interview on 04/29/2025 at 10:14 AM, the Administrator confirmed the role of the Administrator is to complete decision making for the betterment of the facility. During an interview on 04/25/25 at 11:55 AM, the Director of Operations (DOO) verbalized the role of the DOO is to assist the Administrator with policies and procedures, staffing, and budgets. The DOO verbalized the DOO position reports to the manager of the facility. On 05/01/2025 at 2:12 PM, an acceptable Immediate Jeopardy removal plan was accepted in accordance with Appendix Q: 1. In-service/meeting given via phone by regional director to governing body members (Manager, medical director) and in person to administrator. Administrator in-serviced management staff ( DON, COM, SS, HR, MOS) regarding the following: a. Responsibility of the Governing Body (facility oversight, operations and policy/procedure). b. Survey findings and POR to correct: Fall Clinical Protocol, Registered Nurse requirement, Competent staff, Mobility, Bed rail usage and Supervision to prevent accidents. c. Plan moving forward to improve findings Onsite Verification: Onsite verification was attempted on 05/09/2025 at 12:56 PM and could not be completed at that time due to designated staff not fully educated on the plan of removal. The IJ was removed on 05/15/2025 at 8:13 AM after the survey team performed onsite verification that the Removal Plan had been implemented. Onsite verification of the Removal Plan began on 05/09/2025 after the survey team identified five IJs including F726, F727, F700, F688, F689. Observation of bed rails on beds, care plans for residents in place; in-service provided to Administrator by Regional Director on 04/30/2025; in-service provided to nursing staff regarding policy and procedure of bed rails, assessing, consent to use and physician order required; consent forms for residents with bed rails, bed rail assessments for residents with bed rails. Six (6) residents identified as having bed rails with no assessments / consents. Assessments and consents obtained. Monitoring sheets completed on 05/08/2025 by Administrator and Director of Nursing (DON), 05/12/2025 by Housekeeping Supervisor and 05/13/2025 by Administrator and DON, for bed rail assessment and consents. File containing manufacturer guidelines for bed rails provided. The Housekeeping Supervisor confirmed they were in-serviced by the Administrator regarding bedrails, maintenance, ensuring bedrails are compatible with the bed frame, and has reviewed and will refer to guidelines if needed. Review of the in-service document date 05/02/2025 revealed the regional director in-serviced the governing body by telephone and the Administrator was in-serviced in person regarding responsibility of the governing body, survey findings, plan of removal to correct findings during survey, and plan moving forward to improve findings. A total of 6 staff interviews were conducted with staff from all shifts verifying training had been completed. The staff interviewed included Certified Nursing Assistants, Housekeeping Supervisor. The staff interviewed verified they had been trained on bed rails and enhanced barrier precautions. A review of in-service sheets provided indicated 24 staff were provided with training. Staff who were not physically present to receive the in-services were in-serviced by telephone, with the in-service information provided and the employee acknowledging receipt and voicing understanding.