Based on interview, record review, and review of the facility's policy, the facility failed to have a system in place to account for residents' funds or provide residents with a monthly statement of their funds for one of five sampled residents (R1). Based on interview, record review, and review of the facility's policy, the facility failed to have a system in place to account for residents' funds or provide residents with a monthly statement of their funds for one of five sampled residents (Resident 1 (R1).The findings include: Interview on 06/04/2025 at 10:36 AM, with the Interim Administrator, revealed the facility did not have a policy related to staff acting as a resident's payee. Review of the facility's policy titled, Patients' Rights and Responsibilities, undated, revealed upon written authorization of a resident, the facility must hold, safeguard, manage and account for the personal funds of the residents.Review of Resident (R) 1's medical record revealed a diagnosis of quadriplegia, unspecified. (Quadriplegia is a condition where all limbs are paralyzed.) Review of the resident's Quarterly Assessment, dated 11/19/2024, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 14/15. This score indicated R1 was cognitively intact.Review of two direct deposit forms, both dated 03/15/2013, revealed the former Administrator was listed as a payee on the resident's bank accounts for Social Security and Workers Compensation - Black Lung.In an interview, on 06/25/2025 at 3:22 PM, Kentucky State Police (KSP) Officer 1 stated the KSP had completed their investigation into the misappropriation of resident funds and had concluded that the former Administrator had taken more than $8,300.00, from R1. KSP Officer 1 stated that the case was pending with the Grand Jury. During an interview with the Business Office Supervisor, on 06/04/2025 at 1:30 PM, she stated that the former Administrator had complete control of the residents' funds and no one else monitored them. She stated that the Business Office did not supply any type of financial statement to R1 accounting for her personal funds. The Business Office Supervisor stated there was no policy/procedure in place regarding the accounting of residents' personnel funds.In interview on 06/04/2025 at 1:45 PM, Registered Nurse (RN) 1 stated she had taken R1 shopping on 05/21/2024 and had been told by the former Administrator to not allow the resident to spend more than $200.00. She stated the former Administrator told her R1 did not have additional funds available. RN1 stated in March 2025, R1 requested a pink Apple iPad (brand of tablet) and a protective case be purchased for her. She stated based on the amount of money R1 received monthly, she estimated the resident should have around $720.00 in her personal account because the resident had not spent any money since the shopping trip in 2024. RN1 explained that the purchase price of the iPad would be approximately $350.00. RN1 stated when she told the former Administrator about R1's request to buy the iPad, the former Administrator told her the resident did not currently have the funds to make the purchase.In interview on 06/04/2025 at 10:36 AM, the Interim Administrator stated there were no logs being kept by the facility recording how R1's funds were being spent. She stated she was not aware of the facility giving R1 monthly or quarterly statements accounting for her personal funds. The Interim Administrator stated if the facility had been keeping logs they could have identified the misappropriation of R1's personal funds sooner.In interview on 06/04/2025 at 1:05 PM, R1 stated she had never given the former Administrator or any other facility staff member permission to spend her money on anything, unless it was for her own use. R1 stated she was not given any type of monthly or quarterly statement from the facility accounting for her personal funds and expenditures.In interview with the former Administrator on 06/05/2025 at 8:53 AM, she stated the facility had not maintained any type of ledgers tracking the spending of the residents' funds. She stated that nothing was tracked correctly. The former Administrator stated the facility did not give R1 any statements accounting for her personal funds. She stated, Keeping up with the resident's (R1's) money was the farthest thing on her list of things to do.

Based on interview, record review, and review of the facility's policy, the facility failed to ensure residents were free from misappropriation of resident's property for one of five sampled residents (Resident (R)1), who were investigated for misappropriation. As the representative payee for the resident, the facility failed to properly manage the resident's account. It was determined through a Kentucky State Police (KPS) and Adult Protective Services (APS) investigations that the former Administrator had stolen more than $8,300.00 from Resident (R) 1's personal funds. The findings include:Review of the facility's policy titled, Patients' Rights and Responsibilities, undated, revealed upon written authorization of a resident, the facility must hold, safeguard, manage and account for the personal funds of the resident. Review of the facility's policy titled, Abuse, Neglect, Exploitation, of Patients and Reporting, adopted 05/2017, revealed exploitation included the misappropriation of an individual's property. Per policy review, misappropriation included deliberate misplacement, mistreatment, or wrongful, temporary, or permanent use of an individual's belongings or money without the individual's consent. Review of two direct deposit forms (for R1), both dated 03/15/2013, revealed the facility's former Administrator was listed as a payee on the resident's bank accounts for Social Security (SS) and Workers Compensation - Black Lung. Review of bank statements revealed that the former Administrator, who was the only person authorized to withdraw money from the residents' personal account, had withdrawn money from R1's account after the money was deposited by Social Security and Workers Compensation.Review of facility document titled Performance Guidelines and Expectations, dated 03/10/2025 revealed the former Administrator was placed on a progressive discipline and Performance Improvement Plan. The areas of concern were listed as: Management of Department, Time Management, Mandatory Reporting of Unknown Incident Source, Employee Conduct and Professionalism, and Adhering to Company Policies and Procedures. Continued review of the document revealed the former Administrator signed stating that she acknowledged that she had read and understood the facility's policies on Abuse Recognition, Abuse Reporting, and Abuse Investigation on 03/10/2025.Review of the Adult Protective Services (APS) investigation, dated 06/02/2025, revealed APS had substantiated the allegation that the former Administrator did not pay R1's patient liability on time monthly, and there was money that was withdrawn that was unaccounted for. APS interviewed R1 and she stated that she never received any cash or personal items purchased from the former Administrator. Interview with Human Resources on 06/04/2025 at 3:01 PM, Risk and Compliance Officer on 06/04/2025 at 3:01 PM, and the Chief of Nursing Officer (CNO), on 06/04/2025 at 9:05 AM, revealed the facility completed their investigation; however, the facility's legal team advised them not to turn over their investigation in case they made an error. The Human Resources Manager stated they were able to estimate more than $5767.95 was unaccounted for from Resident (1)'s personal funds. The state survey agency (SSA) surveyor requested R1's accounting records; however, the Interim Administrator provided documentation on 06/16/2025 at 2:08 PM, by way of electronic mail, of R1's monthly income. The document was dated June 16, 2025, and signed by the Interim Administrator, adding this was the only accounting records they could provide.Review of R1's medical record revealed diagnoses that included quadriplegia, unspecified (paralysis of all limbs) and aphasic (a language disorder that affects the ability to communicate). Review of R1's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/19/2024, revealed the facility assessed R1 to have a Brief Interview for Mental Status (BIMS) score of 14 out of 15, indicating the resident was cognitively intact. Review of R1's Comprehensive Care Plan, dated 11/19/2024, revealed R1 was aphasic, but could effectively communicate her needs and preferences to staff using a communication board.In an interview with R1, using her communication board, on 06/04/2025 at 1:05 PM, R1 stated she had never given the Former Administrator or any other staff member permission to spend her money on anything, unless it was for her. R1 stated she wanted a new pink Apple iPad (a brand of tablet computers manufactured by Apple) so she could watch movies and use applications that her current iPad was unable to download, due to its age. R1 revealed she was told by staff she could not have the iPad as she did not have enough money in her account. Later, she stated the facility informed her that the former Administrator had taken her personal funds, and this was the reason why she did not have enough money to purchase her requested items. The resident discontinued or stopped responding to the surveyor's questions as she became frustrated with having to spell out her words on her communication device. In an interview, on 06/25/2025 at 3:22 PM, the Kentucky State Police (KSP) Officer 1 stated the KSP had completed their investigation into the misappropriation of resident funds and concluded that the former Administrator had taken more than $8,300.00, from R1. KSP Officer 1 stated the case was pending with the Grand Jury. Registered Nurse (RN) 1 stated in interview on 06/04/2025 at 1:45 PM, that she had taken the resident shopping on 05/21/2024 and was told by the former Administrator not to allow the resident to spend more than $200.00, because the resident did not have any additional funds available. RN1 stated the total spent while shopping with the resident was $246.25. RN1 revealed she personally paid for the overage of $46.25 and was reimbursed half of the overage within a week and the other half took a month or two to be paid back, by the resident's payee/former Administrator. The RN stated in March 2025 (exact date unknown) R1 requested that a pink Apple iPad and a protective case be purchased. RN1 stated R1 received $40.00 monthly until January of 2025, then she started receiving $60.00 a month (for personal expenses). Based on that, she stated the resident should have had around $720.00 in her personal account. She further stated the resident had not spent any of her personal money since the 2024 shopping trip. RN1 stated the purchase price of the Apple iPad was approximately $350.00. She stated she told the former Administrator about the residents' request to purchase the iPad, and the former Administrator told RN1 the resident did not have the funds to make the purchase. In an interview on 06/04/2025 at 9:09 AM, the Human Resource (HR) Manager stated that three staff members, (the Interim Administrator, Interim Director of Nursing (DON), and Registered Nurse (RN) 1) voiced concerns to her regarding the misappropriation of Resident (R)1's personal funds by the former Administrator. The HR Manager stated the facility was conducting an ongoing internal investigation regarding the misappropriation of R1's personal funds by the former Administrator. According to the HR Manager an estimated $5767.95 was missing and unaccounted for from R1's personal funds account. During an interview with the Business Office Supervisor, on 06/04/2025 at 1:30 PM, the Business Office Supervisor stated that the former Administrator had complete control of the residents' funds and no one else monitored them. Further, she stated the resident would have past due balances on her account, as the resident's fee for residing in the facility was often late and unpaid. She stated her bosses would inquire as to why R1 had past due balances. She revealed she would bring the past due balances to the attention of the former Administrator, and she would eventually send the money to cover the resident's fees. She stated this would happen so often that everyone got use to the sporadic payments. In interview with the Interim Administrator on 06/04/2025 at 10:36 AM, she stated the former Administrator had started to get behind on going to the bank and monitoring the residents' personal funds. She stated that she would take Cashier Checks from the former Administrator to the Business Office to pay R1's room and board fees. In April of 2025 (exact date unknown) the Interim Administrator stated she opened R1's bank statement and the account had over $10,800.00 in it. The interim Administrator stated that there was no policy on how frequently the payee was expected to withdraw money from R1's account, but leaving too much money would jeopardize R1's medical insurance. The Interim Administrator stated a log tracking who requested funds to make purchases on a resident's behalf, was not kept. She further stated she felt if spending logs had been maintained the issue would have been identified sooner. In an additional interview, with the Interim Administrator (also Social Service Director), on 06/04/2025 at 3:24 PM, she stated that a psychosocial evaluation had not been performed on R1. In an interview with the Interim Director of Nursing (DON), on 06/04/2025 at 3:05 PM, she stated there were numerous instances where the former Administrator would not go to the bank to withdraw R1's personal funds to pay for the resident's expenses at the nursing home or to obtain the resident's $60.00 personal spending allowance. According to the Interim DON, the former Administrator would tell staff the resident did not have any funds when the resident requested staff to purchase items for R1. The Interim DON stated she did not have any way to check or monitor the resident's funds, but when the resident wanted to buy an iPad, and the former Administrator said the resident did not have the funds available it set off red flags. The Interim DON further stated that she could have gone to members of the Governing Body with this information but did not because she never thought the former Administrator would have stolen money. In an interview with the former Administrator, on 06/05/2025 at 8:53 AM, she stated that she became the resident's payee when she stepped into the role of Administrator, on 03/15/2013. Per the interview, she stated she kept the resident's personal funds in an unlocked lock box in her office. She stated the box, and her office, remained unlocked most of the time. Continued interview with the former Administrator revealed that she was not tracking the resident's funds accurately and was unaware that any of the resident's funds was missing.

Based on interview, record review, review of the facility's Position Descriptions, and review of the facility's policies and procedures, the facility failed to be administered in a manner that enabled effective use of its resources to attain and maintain the highest practicable physical, mental, and psychosocial well-being of each resident. This practice affected one of five sampled residents (Resident 1 (R1)). Refer to F602. The findings include:Review of the facility's document, titled Nursing Home Administrator Job Description, last edited 07/12/2023, revealed the primary purpose of the Administrator was to manage the facility in accordance with current applicable federal, state, and local standards guidelines, and regulations that govern long-term care facilities to ensure the highest degree of quality care was always provided to residents.Review of the facility's document, titled Director of Nursing Services Job Description, last modified 11/06/2024, revealed the Director of Nursing (DON) was required to oversee all departmental health administration needs and requirements as directed by upper management. Review of two direct deposit forms, both dated 03/15/2013, revealed the former Administrator, who also served as the DON, was listed as a payee on R1's bank accounts. R1's deposits included Social Security and Workers Compensation - Black Lung checks.In an interview, on 06/25/2025 at 3:22 PM, Kentucky State Police (KSP) Officer 1 stated the KSP had completed their investigation into the misappropriation of R1's funds. He stated the investigation concluded that the former Administrator had taken more than $8,300.00, from R1. KSP Officer 1 stated that the case was pending with the Grand Jury. In an interview with the Interim Administrator, on 06/04/2025 at 10:36 AM, she stated that the former Administrator had started getting behind on going to the bank for the resident three or four years ago. She stated the facility had no logs to monitor the residents' funds and this was at the direction of the former Administrator. The Interim Administrator stated that she and the Interim DON had concerns about the residents' funds in December 2024. However, there were no logs for them to review to determine if their concerns were valid. She stated that there was no written policy for the payee process or responsibilities. The Interim Administrator stated that if policies had been in place, the facility could have caught the misappropriation of R1's funds sooner.In an interview with the Business Office Supervisor, on 06/04/2025 at 1:30 PM, the Business Office Supervisor stated that the former Administrator had complete control of the residents' funds and no one else monitored them. The Business Officer Supervisor stated that there were no policies for her to follow related to the former Administrator being a payee for a resident.In an interview with the Interim DON, on 06/04/2025 at 3:05 PM, she stated that she did not go to the Governing Body with the above information because she never dreamed the former Administrator would have stolen money. The DON stated that the facility had no checks and balances for the current acting Payee. She stated the lack of policies prevented her from being able to ensure the residents' funds were used appropriately.In an interview with the former Administrator, on 06/05/2025 at 8:53 AM, she stated that she was overwhelmed in her role and was not able to give any task one hundred percent. She stated that there was a lack of leadership and communication from the Governing Body. She stated she did not receive the help she asked for, and this prevented her from doing her job effectively. The former Administrator stated the residents' funds were not tracked accurately and managing the residents' funds was the last thing on her to-do list.

Based on interview, record review, and facility policy/document review, the facility's Governing Body failed to provide effective oversight to ensure the facility implemented policies to prevent the misappropriation of resident funds. This had the potential to affect all the facility's residents. The findings include:Review of the facility's policy titled, Patients' Rights and Responsibilities, undated, revealed upon written authorization of a resident, the facility must hold, safeguard, manage and account for the personal funds of the resident.Review of the facility's document, titled Nursing Home Administrator Job Description, last edited 07/12/2023, revealed the primary purpose of the Administrator is to manage the facility in accordance with current applicable federal, state, and local standards guidelines, and regulations that govern long-term care facilities. To ensure the highest degree of quality care is always provided to residents.Review of two Direct Deposit sign-up forms, both dated 03/15/2013, revealed the previous Administrator was listed as a payee on R1's bank accounts for Social Security and Workers Compensation - Black Lung.In an interview, on 06/25/2025 at 3:22 PM, Kentucky State Police (KSP) Officer 1 stated the KSP had completed their investigation into the misappropriation of resident funds and had concluded that the former Administrator had taken more than $8,300.00, from R1. KSP Officer 1 continued to state that the case was pending with the Grand Jury. In an interview, on 06/04/2025 at 10:36 AM, the Interim Administrator stated that there were no policies or procedures in place regarding staff members serving as payees for residents. Current practice was based on how the process was done in the past, without written guidelines to direct staff responsibilities or oversight. In continued interview, the interim Administrator stated that if the facility had policies in place, it was likely that the facility would have caught the misappropriation of resident funds sooner.In an interview, on 06/04/2025 at 3:01 PM, the Human Resources (HR) Manager stated there was no policies in place to govern what responsibilities a facility staff member acting as a payee on behalf of a resident should follow. Additionally, the HR Manager stated the facility did not offer any type of trainings regarding financial responsibility for resident personal funds. In an interview, on 06/04/2025 at 3:01 PM, the Director of Risk and Compliance stated that the Risk and Compliance department oversees conducting a monthly audit for resident personal funds, but the policy has not been put in place.In an interview, on 06/05/2025 at 8:53 AM, the former Administrator stated there was never any policies written to govern staff members acting as payee. The former Administrator stated that there was a lack of leadership and communication from the administrative team, and she did not receive the help or guidance she asked for and this prevented her from doing her job effectively.In an interview, on 06/05/2025 at 1:42 PM, the interim Administrator and interim DON stated that they had taken over the responsibility of payee for the resident, but no policies or procedures had been written to govern their roles.

Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive, person-centered care plan for one (1) of eighteen (18) sampled residents (R)13. A review of R13's care plan for Potential for Injury Related to Non-Compliance with No Smoking Policy, dated 06/11/2025, indicated that R13 should smoke in an area visible to staff. However, as outlined in the care plan and facility policies, the facility failed to provide supervision. The findings include: A review of the facility's policy, Care Plan Process, undated, revealed that the MDS coordinator would revise each resident's comprehensive care plan as identified and quarterly. A review of the facility's policy, Patient Supervision and Monitoring in the Medical Units, dated 03/19/2024, revealed that within eyesight supervision required staff to have a direct line of sight of the resident. A review of R13's admission Face Sheet revealed the facility admitted the resident on 11/03/2022 with diagnoses that included biliary cirrhosis, osteoarthritis, and anxiety. A review of R13's Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/19/2025, revealed the facility assessed R 13 to have a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident was cognitively intact. A review of R13's care plan, revised on 06/11/2025, listed the problem of Potential for Nonadherence with Smoking Policy. The goal was for the resident to remain injury-free for 90 days. One of the listed interventions included that R 13 would smoke in an area well visualized by staff. However, the facility failed to provide R 13 supervision during smoking within the staff's eyesight. A review of the facility form Tug Valley Skilled Nursing Facility Smoking Assessment dated 06/13/2025 revealed that R 13 required general supervision while smoking. Observation on 06/16/2025 at 2:40 PM revealed that R 13 was outside of the facility and not within the staff's eyesight while smoking. An observation on 06/17/2025 at 1:00 PM revealed that R 13 was smoking outside the facility, again not within the staff's line of sight. During an interview on 06/17/2025 at 11:12 AM, R 13 stated that staff never came to the door or outside to check on her while she smoked. During an interview, on 06/17/2025 at 11:20 AM, State Registered Nurse Aide (SRNA)1 stated R13 required no supervision while smoking. During an interview on 06/17/2025 at 11:25 AM, SRNA 2 stated R 13 was independent with smoking and required no assistance or supervision by staff during smoke breaks. During an interview on 06/17/2025 at 2:30 PM, the Medical Director stated staff should supervise R 13 during smoking to prevent any smoking-related injury. During an interview on 06/17/2025 at 2:36 PM, the Director of Nursing (DON) stated that R 13 required supervision during smoking and that the staff should check on R 13 every 15 minutes. However, the care plan intervention only stated the resident should smoke in an area visible to staff. The DON confirmed that staff could not visualize the area where R 13 smoked. During an interview on 05/17/2025 at 2:50 PM, the Administrator stated the facility failed to educate R 13 to smoke only in an area that staff could visualize during scheduled smoke breaks. The Administrator further noted that if R 13 experienced complications while smoking outside of the staff's eyesight, the staff would not be able to respond promptly.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and review of facility policy it was determined the facility failed to revise the Comprehensive Care Plan for one (1) of eight (8) sampled resident, Resident #16. The facility failed to review Resident #16's care plan to address the resident's safety and smoking needs. The findings include: Review a of the facility's resident demographic document for Resident #16 revealed the facility admitted the resident with diagnoses that included Anxiety Disorder, Traumatic Subdural Hemorrhage (brain bleed), and left Clavicle Fracture. Review of the facility's Quarterly Minimum Data Set (MDS) assessment dated [DATE], for Resident #16 revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of fourteen (14), which indicated the resident was cognitively intact. Review of Resident #16's Interdisciplinary Plan of Care dated 11/03/2022 and revised 02/03/2023, revealed the facility care planned the resident as at risk for respiratory distress and Depression related to smoking. Continued review of the care plan revealed interventions which addressed the resident's respiratory status; however, there was no documented evidence of interventions that addressed the resident's safety/needs when smoking. Observation on 02/28/2023 at 4:36 PM, revealed Resident #16 outside sitting in a wheelchair with a blanket covering his/her legs, and with no staff supervision while he/she was smoking. Interview with Resident #16 at the time of observation revealed he/she told the State Survey Agency (SSA) Surveyor, he/she got his/her cigarettes from a drawer at the nurses' station. Interview on 02/28/2023 at 2:40 PM, with Certified Nursing Assistant (CNA) #1 revealed Resident #16 went outside alone all the time to smoke. CNA #1 further stated Resident #16 liked to smoke four (4) cigarettes per day, one (1) cigarette after each meal and one (1) cigarette in the afternoon. Interview on 02/28/2023 at 2:51 PM, with Licensed Practical Nurse (LPN) #2 revealed Resident #16 came to the nurses' station to get his/her cigarettes before going outside alone to smoke. Interview on 03/03/2023 at 1:11 PM, with the MDS Coordinator revealed Resident #16 did not have a care plan for smoking; however, should have had one (1). Interview on 03/03/2023 at 3:45 PM, with the Administrator, who was also the facility's Director of Nursing (DON), revealed her expectations were for a care plan to be initiated for residents who smoked, with the care plan updated regularly.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and facility policy review, it was determined, the facility failed to ensure residents received adequate supervision and remained as free of accident hazards as possible for one (1) of ten (10), Resident #16. Resident #16 was observed sitting in a wheelchair with a blanket covering his/her legs outside the facility smoking without staff's supervision. Interview revealed the facility failed to develop and implement policies to ensure the assessment and safety of residents who smoked. The findings include: Review of the facility's policy titled, Smoking dated 07/26/1991, and review of the facility's undated resident admission agreement, revealed the facility's Smoking Policy was to prohibit smoking and to discourage other use of tobacco, among its employees, residents and visitors. Further review of the resident admission agreement revealed there would be no exceptions to the NO SMOKING POLICY for residents, employees, or family members. Review of the resident demographic document for Resident #16 revealed the facility admitted the resident on ??/??/????, with diagnoses that included Traumatic Subdural Hemorrhage, Anxiety Disorder, and Left Clavicle Fracture. Review of Resident #16's admission Data/Social History dated 11/03/2022, revealed the resident smoked cigarettes every day. Review of Resident #16's Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of fourteen (14), which was indicative of the resident being intact cognitively. Review of Resident #16's Interdisciplinary Plan of Care dated 11/03/2022 and revised 02/03/2023, revealed the facility's care plans for the resident included he/she being at risk for respiratory distress and depression related to smoking. Interview on 02/27/2023 at 1:57 PM, with Resident #16 revealed the resident was allowed to go smoke, alone outside the facility. Interview on 02/28/2023 at 2:40 PM, with Certified Nursing Assistant (CNA) #1 revealed the facility allowed Resident #16 to go outside alone to smoke. Per CNA #1, Resident #16 smoked four (4) cigarettes per day, a cigarette after each meal and one (1) in the afternoon. Interview with CNA #1 revealed after finishing smoking, Resident #16 rang a doorbell to let staff know he/she needed assistance to get back inside the facility. In addition, CNA #1 stated in order for a resident to be able to go outside to smoke, he/she must be able to go outside by himself/herself and could not use oxygen. Interview on 02/28/2023 at 2:51 PM,with Licensed Practical Nurse (LPN) #2 revealed when Resident #16 wanted to smoke, he/she came to the nurses' station to get his/her cigarettes, and then went outside to smoke. According to LPN #2, in order for a resident to be able allowed to smoke, he/she had to be able to go outside on his/her own as there was not enough staff to go outside with a resident while he/she smoked. Interview further revealed LPN #2 was not sure if the facility had a policy available for residents who wished to smoke. Interview on 02/28/2023 at 3:02 PM, with the Administrator, also the facility's Director of Nursing (DON, revealed the facility did not have any other policy (than the policy referenced above) related to residents who smoked. Interview further revealed for residents who were alert and oriented, the facility was their home and staff could not tell the resident they could not smoke if the resident had the ability to go outside alone. Interview on 02/28/2023 at 3:10 PM, with the Social Worker revealed the facility did not routinely evaluate residents for smoking. Observation on 02/28/2023 at 4:36 PM, of Resident #16 revealed the resident was sitting in a wheelchair with his/her legs covered by a blanket, smoking outside alone. Interview with Resident #16, at the time of observation, revealed he/she obtained his/her cigarettes from a drawer at the nurse's station. Interview on 03/02/2023 at 8:51 AM, with the facility's Director of Risk and Compliance revealed the facility was smoke-free and she was not aware of any residents in the facility who smoked. Per the Director of Risk and Compliance, it was the facility's expectation for all staff, and nursing facility residents to follow the facility's policy. Interview on 03/02/2023 at 3:09 PM, with LPN #3 stated Resident #16 was allowed to go out to smoke. Per LPN #3, Resident #16 pressed the doorbell when they finished smoking so staff could assist the resident back inside. LPN #3 stated she was unaware of any smoking assessments for Resident #16. A follow-up interview on 03/03/2023 at 8:51 AM, with Resident #16 revealed he/she had not been evaluated by staff for his/her safety while smoking. Further interview revealed other residents sometimes also went outside; however, there was no one else who smoked. Resident #16 additionally stated staff sometimes came outside while he/she was smoking; however, that did not happen often. Interview on 03/03/2023 at 1:11 PM, with the MDS Coordinator revealed the facility had not documented a smoking assessment for Resident #16. Further interview revealed however, staff looked at the resident and talked about his/her ability to smoke. The MDS Coordinator further stated Resident #16 did not have a care plan for smoking; however, should have had one (1) to address smoking. Interview on 03/03/2023 at 3:45 PM, with the Administrator, also the facility's Director of Nursing (DON), revealed her expectations for a resident who smoked, was for a care plan to be initiated for residents who smoked with regular updates made to the care plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and facility policy review, it was determined the facility failed to conduct regular inspections of all resident bed frames, mattresses, and bed rails, to identify any risk of entrapment for three (3) of nine (9) sampled residents reviewed for accidents (Residents #2, #3, and #8). The findings include: Review of an undated, unlabeled typed document on facility letterhead revealed, Checks beds for electronic and mechanical functionality according to the specific manufacturer's bed recommendation. Further review revealed the checks were to be performed every six (6) months and as needed with any issues with the bed. 1. Review of the facility's resident demographic document for Resident #2 revealed the facility admitted Resident #2 with diagnoses that included Dementia, Urinary Tract Infections (UTIs), and Peripheral Vascular Disease. Review of Resident #2's Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of ten (10), which indicated moderate cognitive impairment. Further review of the MDS Assessment revealed the facility assessed Resident #2 to require extensive assistance with bed mobility and transfers. Review of Resident #2's Interdisciplinary Plan of Care dated 01/24/2023, revealed the facility care planned the resident to use side rails for bed mobility, and as not attempting to get out of bed unassisted. Further review of the care plan revealed interventions which included staff to provide frequent clinical monitoring for any problems or injuries. Observation on 02/27/2023 at 10:28 AM, revealed Resident #2 lying on his/her bed with a mattress which was too short for the bedframe. Further observation revealed a bath blanket placed in the gap between the mattress and the end of the bedframe, which failed to keep the mattress from sliding. 2. Review of the facility's resident demographic document for Resident #3 revealed the facility admitted Resident #3 with diagnoses that included Dementia, Parkinson's Disease, and Alzheimer's Disease. Review of Resident #3's Quarterly MDS assessment dated [DATE], revealed the facility assessed the resident to have a BIMS score of eight (8) which indicated he/she had moderate cognitive impairment. Further review revealed the facility assessed Resident #3 to require extensive assistance with bed mobility and transfers. Review of Resident #3's Interdisciplinary Plan of Care dated 08/16/2022, revealed the facility care planned the resident as using side rails per his/her choice for mobility and he/she did not attempt to get of bed unassisted. Further review revealed care plan interventions which included staff to provide frequent clinical monitoring for any problems or injuries. Observation on 02/27/2023 at 9:33 AM, revealed Resident #3 was observed in bed with four (4) side rails in a raised position. 3. Review of the facility's resident demographic document for Resident #8 revealed the facility admitted Resident #8 with diagnoses that included Encephalopathy (a brain altering disease), Malaise (general feeling of discomfort), and Heart Failure. Review of Resident #8's Quarterly MDS assessment dated [DATE], revealed the facility assessed the resident as having a BIMS score of twelve (12) which indicated the resident had moderate cognitive impairment. Further review of the MDS Assessment revealed the facility assessed Resident #8 to require extensive assistance with bed mobility. A review of Resident #8's Interdisciplinary Plan of Care reviewed 12/21/2022, indicated the resident used side rails for bed mobility and did not attempt to get out of bed unassisted. The care plan interventions indicated, the staff would provide frequent clinical monitoring for any problems or injuries. Observation on 03/01/2023 9:47 AM, revealed Resident #8 lying on a low bed with two (2) side rails raised. Interview with Resident #8, at the time of observation, revealed he/she used the side rails for bed mobility. Interview on 03/01/2023 at 11:02 AM, with the Maintenance Supervisor revealed he did not do anything with the residents' beds. Further interview revealed the facility had a contract with an outside company for performance of the inspection and maintenance of residents' beds. Interview on 03/01/2023 at 10:55 AM, with the Administrator (who was also the facility's Director of Nursing), revealed the facility contracted with a company that serviced and inspected all the residents' beds in the facility. Continued interview revealed the Administrator/DON was unaware the contracted company only took care of the hardware portion of residents' beds and did not measure and inspect the beds for entrapment zones. Further interview revealed the Maintenance Supervisor would be instructed to conduct review of all the facility's resident beds right away, yearly, and when there was a change in a resident's mattress.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, it was determined the facility failed to establish smoking policies as required to ensure the safety of one (1) out of ten (10) residents sampled for smoking, Resident #16. Interview on 02/28/2023 at 3:02 PM, with the Administrator (also the facility's Director of Nursing) revealed the facility had no policy regarding resident smoking, smoking areas, or smoking safety. The findings include: Review of the resident demographic document for Resident #16 revealed the facility admitted the resident with diagnoses that included Anxiety Disorder, Left Clavicle Fracture, and Traumatic Subdural Hemorrhage (brain bleed). Review of the facility's admission Data/Social History, dated 11/03/2022, for Resident #16 revealed the resident smoked cigarettes every day. Review of the facility's Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of fourteen (14), indicating intact cognition. Review of Resident #16's Interdisciplinary Plan of Care dated 11/03/2022 and revised 02/03/2023, revealed the facility care planned the resident as at risk for respiratory distress and depression related to smoking. Interview, during the entrance conference on 02/27/2023 at 9:37 PM, with the Administrator/DON revealed Resident #16 was the only resident in the facility who smoked. Per interview, Resident #16 wheeled himself/herself outside on his/her own to smoke after meals. Interview on 02/27/2023 at 1:57 PM, with Resident #16 revealed he/she was able and allowed to go outside alone to smoke. Observation on 02/28/2023 at 4:36 PM, revealed Resident #16 outside the facility unaccompanied by staff while he/she smoked. Further observation revealed Resident #16 was sitting in a wheelchair, with his/her legs covered by a blanket. Interview with Resident #16, at the time of observation, revealed he/she reported getting his/her cigarettes from a drawer at the nurse's station prior to outside to smoke. Interview on 02/28/2023 at 2:51 PM, with Licensed Practical Nurse (LPN) #2 revealed Resident #16 was the only resident in the facility who smoked. Further interview revealed LPN #2 was not sure if there was a facility policy regarding residents who smoked. During an interview on 03/03/2023 at 3:45 PM, the Administrator/DON stated no policies regarding resident smoking were in place but were needed. The Administrator/DON noted that, when the hospital went smoke free several years prior, the facility failed to consider developing their own policies.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and facility policy review, it was determined the facility failed to ensure the Comprehensive Care Plan interventions related to side rail use were consistently implemented to maintain safety for eight (8) out of nine (9) sampled residents reviewed for use of side rails, Residents #1, #2, #3, #4, #5, #7, #8, and #15. Observations conducted throughout the survey revealed the side rails for the residents in question were raised while the residents were in bed. Use of the side rails was not reflected in the respective residents' care plans to direct staff regarding the type of side rails to be utilized or their expected and safe deployment. The findings include: Review of the facility policy titled, Side Rail Assessment, dated as reviewed 03/2018, revealed, Upon admission, all residents will be assessed using the Skilled Nursing Side Rail Assessment form. Continued review revealed the Skilled Nursing Side Rail Assessment was to be mapped on the side rail decision tree for determining side rail use and was to be re-evaluated quarterly and if a significant change had occurred. 1. Review of the Patient Information sheet, dated 06/28/2022, for Resident #1 revealed the facility admitted the resident with diagnoses that included Cerebral Palsy (a neurological disorder affecting movement, muscle tone, and posture), Legal Blindness, and Intellectual Disabilities. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed Resident #1 as having severe cognitive impairment in regard to mental status. Continued review of the MDS Assessment revealed Resident #1 was totally dependent on two (2) or more people for bed mobility and had not transferred during the assessment period. According to the MDS review, Resident #1 had functional limitations in range of motion to his/her upper and lower extremities on both sides, and bed rails were not being utilized as a restraint. Review of Resident #1's Interdisciplinary Plan of Care, with initiated date of 11/15/2022, revealed the facility care planned the resident for safety related to a seizure disorder and uncontrolled spastic movements of the upper and lower extremities. Continued review revealed the interventions included utilization of four (4) padded non-restrictive side rails for his/her safety, and for staff to complete a side rail assessment quarterly. Continued review of Resident #1's medical record revealed the facility completed a Side Rail Evaluation on 09/19/2019. Review further revealed however, no documented evidence a quarterly assessment of Resident #1's side rails had been completed since 09/19/2022. Observation on 02/27/2023 at 10:06 AM revealed Resident #1 had two half side rails raised on both sides of the bed. Each half rail was padded with a blanket and secured. 2. Review of the Patient Information sheet for Resident #7 revealed diagnoses that included Quadriplegia (paralysis of all four limbs), Traumatic Brain Injury (TBI), and Aphasia (a disorder affecting the ability to communicate due to damage or injury in the brain). Review of the Quarterly MDS assessment dated [DATE], revealed the facility assessed Resident #7 to have severe cognitive impairment in mental status. Continued review revealed the facility assessed Resident #7 as being dependent on two (2) or more people with bed mobility and transfer. Review further revealed the facility assessed Resident #7 to have functional limitation in range of motion to the upper and lower extremities on both sides. In addition, review of the MDS Assessment revealed the facility assessed the side rails on Resident #7's bed as not being used as a restraint. Review of the Interdisciplinary Plan of Care, dated 11/15/2022, for Resident #7 revealed the facility care planned the resident for safety due to uncontrolled movements of the upper and lower extremities. Continued review revealed the care plan interventions included utilization of four, padded non-restrictive side rails for Resident #7, and for staff to complete a side rail assessment quarterly. Review of the facility's Side Rail Evaluation dated 08/30/2019, for Resident #7 revealed the facility assessed the resident as: not physically able to release the side rails; unable to use the rails for bed mobility; unable to voluntarily move their body; and having involuntary movement of the upper and lower extremities. Further medical record review revealed no documented evidence a quarterly side rail assessment of Resident #7's side rails had been completed since 08/30/2019. Observation on 02/28/2023 at 9:12 AM revealed Resident #7 had two half side rails raised on both sides of the bed. Each half rail was padded with a blanket and secured. 3. Review of the Patient Information sheet for Resident #4 revealed the facility admitted the resident with diagnoses which included Anxiety, Quadriplegia, Chronic Obstructive Pulmonary Disease (COPD), and Cerebrovascular Accident (CVA). Review of the Quarterly MDS assessment dated [DATE], revealed the facility assessed Resident #4 as not speaking; however, as usually understood and as usually understanding others. Continued review of the MDS Assessment revealed the facility assessed Resident #4 to require extensive assistance of one (1) person with bed mobility and limited assistance of one (1) person for transfers. Further review revealed the facility assessed Resident #4 to have functional limitation in range of motion to the upper and lower extremities on both sides. Additionally, review of the MDS Assessment revealed the facility assessed side rails as not a restraint for Resident #4. Review of the Interdisciplinary Plan of Care dated 08/31/2022, for Resident #4 revealed the facility care plan interventions included the resident to utilize three (3) padded side rails per resident's choice, and for staff to complete a side rail assessment quarterly. Review of the facility's Side Rail Evaluation dated 10/11/2019, for Resident #4 revealed side rails were currently in use at the time of the assessment. Further review revealed however, no documented evidence a quarterly assessment of Resident #4's side rails had been completed since 10/11/2019. Observation on 02/27/2023 at 11:09 AM, revealed Resident #4 lying on his/her bed with four (4) side rails in use and up. (Which was not as per the resident's care plan for three [3] side rails). 4. Review of the Patient Information sheet for Resident #5 revealed the facility admitted the resident with diagnoses of Alzheimer's disease, Weakness, Heart Failure, and Diabetes with Kidney Disease. Review of the Quarterly MDS assessment dated [DATE], revealed the facility assessed Resident #5 to have a Brief Interview for Mental Status (BIMS) score of eleven (11), which indicated moderate cognitive impairment. Continued review of the MDS revealed the facility assessed Resident #5 to require extensive assistance of one (1) person for bed mobility and to have transferred only once or twice during the assessment period with limited assistance of one (1) person. Further review of the MDS Assessment revealed the facility assessed Resident #5 to have functional limitation in range of motion to both lower extremities. Review of the MDS Assessment further revealed the facility assessed Resident #5 as not using side rails as a restraint. Review of Resident #5's Interdisciplinary Plan of Care, dated 11/15/2022, revealed the facility's care plan interventions included two (2) to four (4) side rails to be utilized per the resident's choice for mobility. Further review of the care plan interventions revealed staff were to complete a side rail assessment upon admission and quarterly. Review of the facility's Side Rail Evaluation dated 10/10/2019, for Resident #5 revealed the facility's interdisciplinary team (IDT) recommended upper side rails for the resident to assist with his/her bed mobility. Further review revealed no documented evidence the facility completed a quarterly side rail assessment following the assessment completed on 10/10/2019. Observation on 02/27/2023 at 11:16 AM, revealed Resident #5 had two (2) half rails in use located at the head of the bed. 5. Review of the Patient Information sheet for Resident #3 revealed the facility admitted the resident with diagnoses which included Dementia, Psychotic Disturbance, Anxiety, Parkinson's Disease, and Heart Failure. Review of the Quarterly MDS assessment dated [DATE], for Resident #3 revealed the facility assessed the resident to have a BIMS score of eight (8), which indicated moderate cognitive impairment. Continued review of the MDS Assessment revealed the facility assessed Resident #3 to require extensive assistance of one (1) person with bed mobility and transfers. Further review revealed the facility assessed Resident #3 to have no functional limitations in range of motion. Review further revealed the facility assessed side rails as not a restraint for Resident #3. Review of Resident #3's Interdisciplinary Plan of Care, dated 08/16/2022, revealed the facility care planned the resident with interventions which included two (2) side rails in use, and for staff required to complete a side rail assessment quarterly. Review of Resident #3's electronic medical record (EMR) further revealed an admission assessment dated [DATE], which included a Side Rail Assessment. Continued review of the Side Rail Assessment revealed Resident #3 had severely impaired decision-making skills and the resident and family requested side rails for his/her bed. Review further revealed however, no documented evidence the facility completed a quarterly Side Rail Assessment after the 08/16/2022 Assessment. Observation on 02/27/2023 at 9:33 AM and 2:17 PM, and on 02/28/2023 at 4:36 PM, revealed Resident #3 was lying on his/her bed with two (2) side rails elevated on each side of the head of the bed, and one (1) side rail elevated at the foot of the bed. 6. Review of the Patient Information sheet for Resident #15 revealed the facility admitted the resident with diagnoses which included CVA with Hemiplegia and Hemiparesis (paralysis and weakness of a side of the body), Muscle Weakness, and history of TBI. Review of the Quarterly MDS assessment dated [DATE], revealed the facility assessed Resident #15 as severely impaired cognitively for mental status. Continued review of the MDS Assessment revealed the facility assessed Resident #15 to require extensive assistance of two (2) or more people with bed mobility. Further review of the MDS Assessment revealed the facility assessed Resident #15 to have functional limitation in range of motion to the upper and lower extremities of one (1) side of the body. Further review revealed the facility assessed Resident #15 as not using side rails as a restraint. Review of Resident #15's Interdisciplinary Plan of Care, dated 05/05/2022, revealed the facility care planned the resident as utilizing two (2) or three (3) padded non-restrictive side rails per resident choice for mobility. Continued review of the Care Plan revealed the facility's care planned Resident #15 as not attempting to get out of bed, and to point at the bottom side rail requesting staff raise the rail to rest the resident's foot during muscle spasms. Further review of Resident #15's Care Plan interventions revealed staff were to complete a Side Rail Assessment quarterly. Continued review of Resident #15's EMR revealed a Side Rail Assessment completed with the admission assessment on 05/05/2022. Continued review of the Side Rail Assessment revealed the resident had moderately impaired decision making and the family requested side rail use for him/her. Review further revealed no documented evidence a Side Rail Assessment had been completed quarterly since 05/05/2022. Observation on 02/27/2023 at 2:19 PM, revealed Resident #15 lying on his/her bed with padded half side rails elevated on both sides of the head of the bed. 7. Review of the facility's Team Conference sheet for Resident #2 revealed the resident had diagnoses which included Diabetes, Dementia, Heart Failure, and Chronic Kidney Disease. Review of the admission MDS assessment dated [DATE], for Resident #2 revealed the facility assessed the resident to have a BIMS score of ten (10) which indicated moderate cognitive impairment. Continued review revealed the facility assessed Resident #2 to require extensive assistance of two (2) or more people with bed mobility and transfers. Further review revealed the facility assessed Resident #2 to have no functional limitation in range of motion, and as not using bed rails as a restraint. Review of the Interdisciplinary Plan of Care, dated 01/24/2023, for Resident #2 revealed interventions which included two (2) side rails were in use per resident's choice. Continued review of the Care Plan revealed Resident #2 used the side rails for bed mobility and he/she did not attempt to get out of bed unassisted. Further review revealed the interventions additionally included Resident #2 used side rails to turn from side to side in bed and to lower the head of the bed. Observation on 02/27/2023 at 10:28 AM and 1:34 PM, and on 03/01/2023 at 9:20 AM, revealed Resident #2 was lying on his/her bed with four (4) side rails raised, (he/she was care planned for only two [2] side rails). Further observation on 02/28/2023 at 1:18 PM, revealed Resident #2 lying on his/her bed with the two (2) top half side rails raised and the bottom right side rail also raised. 8. Review of a Team Conference form, dated 02/28/2023, revealed the facility admitted Resident #8 with diagnoses which included Encephalopathy, Diabetes, and Heart Failure. Review of a Patient Information document revealed the facility admitted Resident #8 on 03/21/2022. Review of the Quarterly MDS assessment dated [DATE], revealed the facility assessed Resident #8 as having a BIMS score of twelve (12), which indicated moderate cognitive impairment. Continued review revealed the facility assessed Resident #8 to require extensive assistance of one (1) person with bed mobility, and as having no functional limitation in range of motion. Review further revealed the facility assessed Resident #3 as not utilizing bed rails as a restraint. Review of the Interdisciplinary Plan of Care, dated 03/21/2022, for Resident #8 revealed the facility care planned the resident to have use of two (2) side rails raised per resident's choice for mobility. Further review of the care plan interventions revealed staff were required to complete a side rail assessment quarterly. Continued review of Resident #8's EMR revealed an electronic admission assessment dated [DATE], with the Side Rail Assessment which was conducted as a part of the admission assessment. Continued review of the Side Rail Assessment revealed Resident #8 had some difficulty with decision-making; however, had requested to use side rails. Further review of Resident #8's EMR revealed no documented evidence the facility completed a Side Rail Assessment quarterly as required after the 03/21/2022 assessment. Observation on 03/01/23 at 9:20 AM, revealed Resident #8 lying on his/her low bed with two (2) side rails in the raised position at the top of his/her bed and one (1) bottom right side rail in the raised position, instead of the two (2) side rails as care planned by the facility. Interview on 02/28/2023 at 9:15 AM, with the MDS Registered Nurse (RN) revealed the facility completed side rail assessments upon a resident's admission to the facility. Continued review revealed however, for quarterly side rail assessments, she did not document a side rail assessment. She further stated she reviewed the facility's side rail decision tree that was attached to the original assessment quarterly to make sure everything still applied. During an interview on 02/28/2023 at 9:15 AM, MDS/Assistant Clinical Nurse Manager RN stated the resident had a side rail assessment on admission, then quarterly she only reviewed a side rail decision tree that was attached to the original paper assessment and determined if the information was still applicable. The MDS RN stated she did not produce a document from the quarterly review. During an interview on 03/02/2023 at 12:28 PM, the Director of Nursing (DON)/Administrator reported she expected a resident's care plan to address the resident's care needs. The DON/Administrator added that a resident with side rails should have evidence of a quarterly assessment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and review of the facility's policies and documents, it was determined the facility failed to ensure: (a) resident-appropriate alternatives were attempted prior to installing side rails on residents' beds: side rail assessments were consistently conducted and documented; (b) resident-specific risks and benefits of side rail use were evaluated and discussed with the residents and/or their responsible parties; (c) and informed consents were obtained for nine (9) of nine (9) sampled residents (Residents #1, #2, #3, #4, #5, #7, #8, #14, and #15) reviewed for the use of side rails. The findings include: Review of a facility policy titled, Side Rail Assessment, dated as reviewed 03/2018, revealed when admitted all residents were to be assessed using the Skilled Nursing Side Rail Assessment form. Continued review revealed the Skilled Nursing Side Rail Assessment was to be mapped on the side rail decision tree for determining the use of side rails. Further review of the policy revealed side rail use was to be re-evaluated quarterly and with a significant change. Review further revealed the policy did not address reviewing the risks and benefits of side rail usage with the resident and/or his/her resident representative and obtaining informed consent prior to installation of side rails. Review of the facility's Side Rail Evaluation form, undated, revealed the facility must justify the need for bed rails and, when the bed rails were to be used, such as only at night, at all times when in bed, or only with an illness, etc. Continued review revealed the side rail evaluation information must be entered into the resident's care plan and re-evaluated after every occurrence, change of condition and quarterly. Review further revealed there was to be informed consent signed for use of restraints, and the facility was to ensure residents and/or their families were aware of all risks regarding the use of side rails (risk examples included strangulation, broken bones, immobility, pressure sores, dehydration, incontinence, agitation, muscle atrophy, loss of independence, and visual obstruction). Review of the facility's Side Rails Informed Consent and Release form, undated, revealed the documentation included, I have been informed of the benefits and risks of the use of side rails on my bed. Continued review revealed the risks of side rails entrapment included: through the bars of a side rail; through the space between split side rails; between the side rail and the mattress; and between the headboard or footboard, side rails and the mattress. Further review revealed the use of side rails might also be associated with accidental skin bruising, cuts or scrapes. Review of the form revealed the benefits of side rails included: improved mobility in bed and ability to position self or assisting caregivers repositioning the resident; and improved mobility with the resident's ability to get in and out of bed by transferring self in and out of bed or assisting caregivers with transferring him/her in and out of bed. 1. Review of a Patient Information sheet, dated 06/28/2022, for Resident #1 revealed the facility admitted the resident with Intellectual Disabilities, Cerebral Palsy (developmental neurological disability affecting movement, posture, and coordination), and Legal Blindness. Review of Resident #1's Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed the resident to have severe cognitive impairment regarding mental status. Per review of the MDS, the facility assessed Resident #1 as totally dependent on two (2) or more people for bed mobility and had not transferred during the assessment period. Additional MDS review revealed the facility assessed Resident #1 to have functional limitation in range of motion to his/her upper and lower extremities on both sides. Further review revealed the facility assessed bed rails as not being utilized as a restraint for Resident #1. Review of Resident #1's Interdisciplinary Plan of Care, dated as initiated on 11/15/2022, revealed the facility care planned the resident for self-care deficit due to his/her diagnosis of Cerebral Palsy. Continued review revealed interventions for: staff to encourage and assist Resident #1 as needed with turning every two (2) hours and encourage the resident to participate in activities of daily living (ADLs) to his/her maximum potential. Review further revealed the facility care planned Resident #1 to utilize four (4) padded non-restrictive side rails for safety, related to a seizure disorder and uncontrolled spastic movements of the upper and lower extremities. Additionally, review revealed interventions for staff to complete a side rail assessment quarterly; encourage the resident to exercise the upper and lower extremities on his/her own, with restorative nursing, or with therapy; and encourage the resident to use the call light for assistance to help raise and lower his/her side rails as needed. Review of the Side Rail Evaluation dated 09/19/2019, for Resident #1 revealed the facility evaluated the resident as: not able to release his/her side rails; unable to use the rails for bed mobility; unable to voluntarily move his/her body; and as experiencing involuntary movement of the upper and lower extremities. Per review of the Evaluation, a low bed and bed alarm had been attempted for Resident #1; however, there was no documented evidence noting how the interventions failed to meet the resident's needs. Continued review revealed Resident #1's guardian requested the use of side rails for the resident's safety and fear of the resident falling. Review further revealed however, there was no documented evidence the risks versus benefits of side rail use noted on the Evaluation. Review of the Evaluation also revealed no documented evidence noted regarding whether the resident or family understood the risk of side rail usage. Further review revealed the interdisciplinary team (IDT) recommended the use of four (4) padded side rails for Resident #1's safety, and to assist the resident with bed mobility and transfers (Although, the MDS Assessment noted Resident #1 was dependent on staff for bed mobility and had not transferred during the assessment period). In addition, review of Resident #1's medical revealed no documented evidence a quarterly assessment of Resident #1's side rails was completed after the 09/19/2022 Side Rail Evaluation. Review of the Side Rails Informed Consent and Release, signed by Resident #1's representative on 09/19/2019, revealed the pre-printed risks of entrapment and skin injuries were listed on the consent form. Further review revealed no documented evidence the facility assessed specific risk factors related to side rail use for Resident #1, nor how those risks would be mitigated. Additionally, there was no documented evidence the facility and provided all that information to the resident's representative prior to obtaining consent for the side rails. Further review of Resident #1's medical record revealed no documented evidence the facility attempted to use other alternatives as required prior to installing side rails on the resident's bed. 2. Review of a Team Conference sheet, dated 02/28/2023, revealed Resident #7 had diagnoses which included Anoxic Brain Damage and Quadriplegia (paralysis of all four limbs). Review of Resident #7's Quarterly MDS assessment dated [DATE], revealed the facility assessed the resident to have severe cognitive impairment in regard to mental status. Per MDS Assessment review, the facility assessed Resident #7 as dependent on two (2) or more people with bed mobility and transferring. Review further revealed the facility additionally assessed Resident #7 to have functional limitation in range of motion to his/her bilateral upper and lower extremities. In addition, review of the MDS Assessment revealed the facility assessed side rails as not being used as a restraint for the resident. Review of the Interdisciplinary Plan of Care, dated 11/15/2022, for Resident #7 revealed the facility care planned the resident for self-care deficit related to an anoxic brain injury (injury to the brain due to lack of oxygen) and upper and lower extremity contractures. Continued review revealed the interventions included for staff to encourage and assist Resident #7 as needed with turning every two (2) hours and encourage the resident to participate in activities of daily living to the resident's maximum potential. Review revealed the facility care planned Resident #7 as utilizing four (4), padded non-restrictive side rails for his/her safety related to uncontrolled movements of his/her upper and lower extremities. Further review revealed the facility care planed Resident #7 as not attempting to get out of bed, and with additional interventions which included staff completing a side rail assessment quarterly. Review further revealed other interventions included encouraging Resident #7 to use his/her call light for assistance as needed to help raise and lower the side rails. Review of Resident #7's Side Rail Evaluation dated 08/30/2019, revealed the facility evaluated the resident as: not physically able to release his/her side rails; unable to use the rails for bed mobility; unable to voluntarily move his/her body; and as experiencing involuntary movement of his/her upper and lower extremities. According to review of the Evaluation, there was no documented evidence of alternative interventions attempted, as required, prior to initiating side rail usage for the resident. Continued review revealed documentation noting Resident #7's guardian understood the risks of side rail usage and had requested the use of side rails for fear of the resident falling, and the risks and benefits of side rail usage for Resident #7 were risk of potential injury. Further review revealed however, no documented evidence of Resident #7's specific risks having been assessed. Review of the Evaluation further revealed the facility's IDT recommended use of four (4) padded side rails for Resident #7's safety concerns. In addition, review of the Evaluation also revealed no documented evidence a quarterly assessment of Resident #1's side rails had been completed after the 08/30/2019 side rail evaluation. Review of Resident #7's Side Rails Informed Consent and Release, form signed by the resident's representative on 08/30/2019, revealed pre-printed risks noted as entrapment and skin injuries listed on the Form. Continued review revealed however, there was no documented evidence the facility assessed Resident #7's specific risk factors related to side rail use or how those risks would be mitigated. In addition, review further revealed no documented evidence the specific risk factor information was discussed with the resident's representative prior to obtaining the consent for side rail usage for Resident #7. Further review of Resident #7's medical record revealed no documented evidence the facility attempted to use other alternatives as required prior to installing side rails on the resident's bed. 3. Review of a Patient Information sheet, dated 11/22/2022, revealed the facility admitted Resident #4 with diagnoses of Sepsis. Review of a Team Conference document, dated 02/28/2023, revealed Resident #4's diagnoses included Cerebrovascular Disease, Anxiety Disorder, and Quadriplegia. Review of the Quarterly MDS assessment dated [DATE], for Resident #4 revealed the facility assessed the resident as not speaking; however, was usually understood and usually understood others. Per the MDS, Resident #4 had a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. Continued review of the MDS Assessment revealed the facility assessed Resident #4 as requiring extensive assistance of one (1) person with bed mobility and limited assistance of one (1) person for transferring. Review further revealed the facility assessed Resident #4 as having functional limitation in range of motion to his/her bilateral upper and lower extremities. In addition, review of the MDS Assessment also revealed the facility assessed the use of side rails as not a restraint for Resident #4. Review of Resident #4's Interdisciplinary Plan of Care, dated 08/31/2022, revealed the facility care planned the resident as requiring assistance with his/her ADLs, with interventions which included staff to encourage and assist the resident with turning every two (2) hours. Continued review revealed the facility care planned Resident #4 to have three (3) padded side rails per resident's choice. Review further revealed additional interventions which included staff to: complete a side rail assessment quarterly; encourage Resident #4 to exercise his/her upper and lower extremities/joints with a certified nurse aide, or with therapy; and encourage the resident to use the call light for assistance as needed to help raise and lower the side rails. Review of Resident #4's Side Rail Evaluation dated 10/11/2019, revealed side rails were currently in use at the time of the assessment. Continued review revealed the facility evaluated Resident #4 as not able to release his/her side rails; however, was able to use the side rails for bed mobility. Per review of the Evaluation, a low bed had been used unsuccessfully as an alternative to side rails for Resident #4; however, there was no documented evidence of how the intervention failed to meet the resident's needs. Further review of the Side Rail Evaluation revealed Resident #4's guardian was noted to have understood the risks of side rail usage and to have requested the use of side rails for the resident's safety due to a fear of the resident falling and to increase the resident's bed mobility. Review further revealed the Evaluation noted the risk of side rail use was a, risk of injury with use. In addition, review revealed no documented evidence of assessment of resident-specific risks related to side rail use for Resident #4, nor of a quarterly assessment of the resident's side rails completed after the 10/11/2019 Side Rail Evaluation. Review of Resident #4's Side Rails Informed Consent and Release, signed by the resident's representative on 10/11/2019, revealed pre-printed risks of entrapment and skin injuries were listed on the consent form. Further review revealed however, no documented evidence the facility assessed Resident #4's specific risk factors related to side rail use or how those risks would be mitigated. In addition, there was no documented evidence the facility provided the information to the resident's representative prior to obtaining consent. Further review of Resident #4's medical record revealed no documented evidence the facility attempted to use other alternatives as required prior to installing side rails on the resident's bed. Observation on 02/27/2023 at 11:09 AM, revealed Resident #4 had four (4) half side rails elevated, two (2) at the head of the bed and two (2) at the foot of the bed; however, the facility care planned the resident for only three (3) side rails. 4. Review of the Patient Information sheet dated 11/24/2020, revealed the facility admitted Resident #5 with diagnoses which included Weakness, Alzheimer's Disease, Heart Failure, and Diabetes with Chronic Kidney Disease. Review of the Quarterly MDS Assessment for Resident #5 dated 11/25/2022, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of eleven (11) which indicated moderate cognitive impairment. Continued review revealed the facility assessed the resident to require extensive assistance of one (1) person for bed mobility and he/she had transferred only once or twice during the assessment period with limited assistance of one (1) person. Review further revealed the facility assessed the resident with functional limitation in range of motion to both lower extremities. Additionally, the facility assessed the use of side rails was not a restraint for Resident #4. Review of the Interdisciplinary Plan of Care, dated 11/15/2022, revealed Resident #5 had a self-care deficit related to debility and general weakness. The planned interventions directed staff to encourage and assist the resident as needed to turn every two hours and to encourage participation in activities of daily living to the resident's maximum potential. Further review revealed the resident was to have two or four side rails in use per resident's choice. The care plan indicated the resident used the side rails for bed mobility and did not attempt to get out of bed. According to the care plan, the resident requested all four side rails up at times due to fear of falling out of bed. The planned interventions directed staff to complete a side rail assessment quarterly; to encourage the resident to exercise the upper and lower extremities/joints on their own, with a certified nurse aide, or with therapy; and to encourage the resident to use the call light for assistance as needed to help raise and lower the side rails. Review of Resident #5's Side Rail Evaluation dated 10/10/2019, revealed the facility evaluated the resident as alert and oriented; however, had safety impairment and poor short-term memory. Per review of the Evaluation, side rails were noted as being used for bed mobility at the time of the assessment. Continued review revealed: Resident #5 was not able to release his/her side rails; used the side rails for bed mobility; was able to voluntarily move his/her body, and did not experience involuntary movements. Review of the Evaluation revealed documentation noting a low bed, personal safety alarm, bed alarm, and floor pads had been attempted as alternatives to side rails for Resident #5; however, there was no documented evidence of how those interventions had failed to meet the resident's needs. Further review revealed the Evaluation noted the side rails increased Resident #5's mobility and there was a risk of injury with the use of side rails. Review revealed however, there was no documentation noting what the risks of injury were with the use of side rails. In addition, review of the Evaluation revealed the resident/family requested the use of side rails for increased bed mobility and risks of the side rails were understood, even though no risks were documented. Review of the Evaluation further revealed the facility's IDT recommended upper side rails to assist the resident with bed mobility; however, there was no documented evidence the facility completed a quarterly Side Rail Evaluation after 10/10/2019. Review of Resident #5's Side Rails Informed Consent and Release, form signed by the resident's representative on 10/10/2019, revealed pre-printed risks for entrapment and skin injuries noted on the consent form. Continued review revealed no documented evidence the facility assessed Resident #5's specific risk factors related to side rail usage or how those risks would be mitigated. In addition, review revealed no documented evidence the facility provided the information regarding Resident #5 specific risk factors for side rail usage to the resident's representative prior to obtaining consent. Observation of Resident #5 on 02/27/2023 at 11:16 AM, revealed the resident had half side rails elevated on each side of the head of the bed. 5. Review of a Team Conference sheet, dated 02/28/2023, revealed the facility admitted Resident #3 with diagnoses which included Parkinson's Disease, Dementia, Anxiety, Insomnia, and Psychotic Disturbance. Review of the Quarterly MDS assessment dated [DATE], revealed the facility assessed Resident #3 as having a BIMS score of eight (8) which indicated moderate cognitive impairment. Continued review of the MDS revealed the facility assessed Resident #3 as requiring extensive assistance of one (1) person with bed mobility and transferring, and to have no functional limitation in range of motion. Review further revealed the facility documented side rails were not a restraint for Resident #3. Review of the Interdisciplinary Plan of Care dated 08/16/2022, for Resident #3 revealed the facility care planned the resident as having a self-care deficit due to Alzheimer's Dementia and decreased mobility. Review revealed interventions which included for staff to encourage and assist the resident as needed with turning every two (2) hours and to encourage the resident to participate in ADLs to his/her maximum potential. Continued review revealed the facility care planned Resident #3 as having two (2) side rails in use per resident's choice for mobility. Per review, the interventions included for staff to complete a side rail assessment quarterly; encourage the resident to exercise the upper and lower extremities/joints with a certified nurse aide, or with therapy; and encourage the resident to use the call light for assistance as needed to help raise and lower the side rails. Further review of the care plan revealed the facility's documented Resident #3 as using the side rails to turn from side to side in bed, to raise and lower the head of the bed, and to help with transfers as needed. In addition, review of the care plan revealed Resident #3 felt safe with the side rails up to serve as a reminder of the parameters of the bed. Continued review of Resident #3's electronic medical record (EMR) revealed an admission assessment dated [DATE], which included a Side Rail Assessment. Review of the Side Rail Assessment revealed Resident #3 had severely impaired decision-making abilities and the resident and family requested the use of side rails. According to review of the Assessment, the facility noted Resident #3 had not attempted to transfer or ambulate independently, had fallen in the last thirty (30) days, and had total loss of the ability to self-balance. Continued review revealed Resident #3 was alert but confused and had random and/or involuntary movements when in bed. Per review, there was no documented evidence of the facility having completed a Side Rail Assessment quarterly after the 08/16/2022 Assessment was completed. Review further revealed no documented evidence the facility assessed the risks and benefits of side rail usage for Resident #3, nor with the resident's representative, and obtained informed consent prior to the installation of side rails. Further review revealed no documented evidence the facility attempted any alternatives prior to the use of side rails. Observation on 02/27/2023 at 9:33 AM and 2:17 PM and on 02/28/2023 at 4:36 PM, revealed Resident #3 was lying on his/her bed with a half rail raised to each side of head of the bed. In addition, observation revealed an additional side rail raised to the right side of the foot of the resident's bed. Interview, at the time of observation, revealed Resident #3 stated he/she had not sustained any falls lately and had not tried to get out of bed on his/her own. Interview further revealed Resident #3 was not able to get up on his/her own and had to call for staff's assistance to do so. 6. Review of a Patient Information sheet, dated 05/09/2022, for Resident #15 revealed the facility admitted the resident with diagnoses of Hemiparesis and Hemiplegia (paralysis and weakness of a side of the body), Muscle Weakness, Cerebral Infarction (Ischemic Stroke), and history of a Traumatic Brain Injury (TBI). Review of the Quarterly MDS assessment dated [DATE] for Resident #15 revealed the facility assessed the resident as severely impaired cognitively regarding mental status. Continued review revealed the facility assessed Resident #15 as requiring extensive assistance of two (2) or more people with bed mobility. Further review revealed additionally assessed Resident #15 as having functional limitation in range of motion of his/her upper and lower extremities on one (1) side of the body. In addition, review of the MDS Assessment revealed the facility assessed the use of side rails as not a restraint for Resident #15. Review of Resident 15's Interdisciplinary Plan of Care, dated 05/05/2022, revealed the facility care planned the resident for self-care deficit related to a TBI and debility. Per review, the care plan interventions included: staff assisting and encouraging Resident #15 with turning every two (2) hours as needed; and encouraging the resident's participation in ADLs to his/her maximum potential. Continued review revealed the facility care planned the resident as utilizing two (2) or three (3) padded non-restrictive side rails per resident choice for mobility; as not attempting to get out of bed; and to point to the bottom rail, requesting it be raised to rest the resident's foot during muscle spasms. Further review revealed additional interventions which included: staff to complete a Side Rail Assessment quarterly; assist the resident with transfers as needed. In addition, review revealed Resident #15 used the side rails to turn from side to side in bed and to raise and lower the head of the bed. Continued review of Resident #15's EMR revealed an admission assessment document which included a Side Rail Assessment completed on 05/05/2022, noting the resident's family requested side rails for the resident. Review of the Side Rail Assessment revealed the facility assessed Resident #15 as having no history of falls, as at low risk for falls, and as able to turn in bed with staff assistance; however, he/she did not seek assistance. Further review of the Side Rail Assessment revealed no documented evidence Side Rail Assessments were completed quarterly after 05/05/2022. Review of Resident #15's EMR further revealed no documented evidence the facility attempted other alternatives prior to initiating side rail use for the resident, nor reviewed the risks and benefits of side rail use with the resident or their representative and obtained informed consent prior to installation of the side rails. Further review of Resident #4's medical record revealed no documented evidence the facility attempted to use other alternatives as required prior to installing side rails on the resident's bed. Observation on 02/27/2023 at 2:19 AM revealed Resident #15 had side rails attached to his/her bed. Observation on 02/27/2023 at 10:06 AM revealed Resident #15 had two half side rails raised on both sides of the bed. Each half rail was padded with a blanket and secured. 7. Review of a Team Conference document for Resident #2, dated 02/28/2023, revealed the facility admitted the resident with diagnoses including Dementia, Heart Failure, and Chronic Kidney Disease. Review of the admission MDS assessment dated [DATE], revealed the facility assessed Resident #2 as having a BIMS score of ten (10) which indicated the resident was moderately cognitively impaired. Continued review of the MDS revealed the facility assessed the resident as requiring extensive assistance of two (2) or more people with bed mobility and transferring. Further review revealed the facility assessed Resident #2 to have no functional limitation in range of motion, and as not using bed rails as a restraint. Review of the Interdisciplinary Plan of Care, dated 01/24/2023, for Resident #2 revealed the facility care planned the resident for self-care deficit related to generalized weakness and cognitive deficits. Per care plan review, the interventions for Resident #2 included for staff to encourage and assist the resident as needed with turning every two (2) hours and encourage him/her to participate in his/her ADLs to his/her maximum potential as tolerated. Continued review revealed the facility also care planned Resident #2 as having two (2) side rails in use per resident's choice, which were used for bed mobility. Further review revealed the facility's interventions for Resident #2 include staff to complete a side rail assessment quarterly; encourage the resident to exercise the upper and lower extremities/joints with a certified nurse aide, or with therapy; and to encourage the resident to use the call light for assistance as needed to help raise and lower the side rails. Continued review of Resident #2's EMR revealed a Side Rail Assessment was completed with the admission assessment dated [DATE], which noted the resident had moderately impaired decision-making ability and the family had requested side rails. Per review of the Side Rail Assessment, Resident #2 had a history of falls in the last six (6) months and was able to turn in bed with the assistance of staff; however, did not seek that assistance. Further review of the EMR revealed no documented evidence of any alternatives to side rails attempted, nor that the risks and benefits of side rail use were discussed with the resident or their representative and informed consent obtained prior to installation of the side rails. Further review of Resident #2's medical record revealed no documented evidence the facility attempted to use other alternatives as required prior to installing side rails on the resident's bed. Observation on 02/27/2023 at 10:28 AM, revealed Resident #2 lying on his/her bed with four (4) side rails in the raised position, with a mattress approximately twelve (12) inches shorter than the resident's bed frame. Continued observation revealed a bath blanket had been placed in the gap between the mattress and the foot of the bed. Further observation on 02/27/2023 at 1:34 PM, revealed Resident #2 lying on his/her bed with four (4) side rails raised; on 02/28/2023, with two (2) top side rails raised and the bottom right-side rail raised; and on 03/01/2023 at 9:20 AM, he/she lying on the bed with four (4) side rails raised. Interview with Resident #2's family member on 02/27/2023 at 11:14 AM, revealed the resident usually had four (4) side rails raised to keep the resident safe. The family member stated the facility had not discussed the risks or benefits of side rails, and the family member denied having signed a consent for the use of side rails. 8. Review of a Team Conference form, dated 02/28/2023, revealed the facility admitted the Resident #8 with diagnoses including Heart Failure, Encephalopathy, Diabetes. Review of the Quarterly MDS assessment dated [DATE], revealed the facility assessed Resident #8 as having a BIMS score of twelve (12) which indicated moderate cognitive impairment. Continued review of the MDS revealed the facility assessed Resident #8 as requiring extensive assistance of one (1) person with bed mobility. Review of the MDS Assessment further revealed the facility assessed Resident #8 as having no functional limitation in range of motion, and as not utilizing bed rails as a restraint. Review of the Interdisciplinary Plan of Care, dated 03/21/2022, revealed the facility care planned Resident #8 for self-care deficit related to Acute Renal Impairment, Encephalopathy, and Congestive Heart Failure. Continued review revealed the interventions included for staff to encourage and assist the resident as needed with turning every two (2) hours and encourage the resident to participate in his/her ADLs to the resident's maximum potential as tolerated. Further review of the care plan dated 03/21/2022 revealed the facility care planned Resident #8 as having two (2) side rails raised per resident's choice for mobility. Further review revealed additional interventions included staff to complete a side rail assessment quarterly; encourage the resident to exercise the upper and lower extremities/joints with a certified nurse aide, or with therapy; and encourage him/her to use the call light for assistance as needed to help raise and lower the side rails. Review of Resident #8's admission assessment dated [DATE] revealed a Side Rail

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and document review, it was determined the facility failed to ensure a Registered Nurse (RN) was designated to serve as the Director of Nursing (DON) on a full-time basis, which had the potential to affect all eighteen (18) residents currently residing in the facility. Per interview, the Administrator was also the facility's Director of Nursing (DON) and the facility had no Assistant Director of Nursing (ADON) in order to devote full time supervision of nursing services. The findings include: Review of the Facility Assessment Tool updated 10/23/2022, revealed the Administrator and the DON were noted as the same person. Interview, during the entrance conference on 02/27/2023 at 9:37 AM, revealed the Administrator/DON stated she oversaw the scheduling and mandatory training of nursing staff as part of her DON duties. The Administrator/DON stated she had a person who assisted with hiring staff and providing staff education and training. She further stated this had been the facility's process since she started working there in 2010. On 03/02/2023 at 3:50 PM, the Administrator/DON provided the State Survey Agency (SSA) Surveyor a copy of a regulatory document titled, 902 [NAME] [Kentucky Administrative Regulations] 20:048, Operation and services; nursing homes. Continued review of the document revealed the facility should have a Director of Nursing who was a Registered Nurse and who worked full time during the day, and devoted full time to the facility's nursing service. Further review revealed if the DON had administrative responsibility for the facility, there was to be an Assistant Director of Nursing (ADON), in order for there to be the equivalent of a full-time DON service. The Administrator/DON stated she spent about fifty percent (50%) of her time as the Administrator and the other 50% of her time as the DON. A follow-up interview on 03/03/2023 at 1:22 PM, with the Administrator/DON revealed she scheduled the nursing staff, performed the COVID reporting and testing, and conducted staff evaluations when the Clinical Nurse Manager was off. Per the Administrator/DON, the Clinical Nurse Manager trained staff and hired new nurses and Certified Nursing Assistants (CNAs). The Administrator/DON further stated the facility did not have an ADON. Interview on 03/03/2023 at 4:17 PM, with the Chief Community Nursing Officer (CCNO) revealed she was the facility's Administrator/DON's supervisor. The CCNO stated the facility did not have an ADON due to the facility being such a small facility. The CCNO further stated she was not aware the DON had to be full-time.