Based on interviews and record review, the facility failed to ensure the physician and family were notified after a resident's fall for 1 (#1) of 1 resident reviewed for falls. Findings: Review of the facility's fall prevention program dated 01/01/2025 revealed when any resident experienced a fall the facility will assess the resident, complete an incident report, notify the physician and family and document all assessments and actions. Review of resident #1's medical record revealed diagnoses which included depression, anxiety, dementia, repeated falls and a non-displaced fracture of the shaft of the right clavicle. On 03/11/2025 at 3:10 p.m., interview with S4Certified Nursing Assistant (CNA) revealed shortly before 10:00 p.m., on 02/16/2025 she heard a housekeeper yell out that resident #1 was on the floor. S4CNA and another CNA ran to the resident's room and found the resident sitting on the floor. S3Licensed Practical Nurse (LPN) entered the room immediately after them. The nurse assessed the resident found no injuries and then the 2 CNAs assisted resident #1 to bed. The resident did not complain of pain at that time. On 03/12/2025 at 11:05 a.m., interview with S5CNA revealed on 02/16/25 near 10:00 p.m., she heard a housekeeper say that resident #1 was on the floor. S5CNA and S4CNA ran to the resident's room and found the resident sitting on the floor with her legs extended. S5CNA reported S3LPN entered the room right behind them and assessed the resident. After the S3LPN assessed the resident, S4CNA and S5CNA assisted resident #1 with getting dressed for bed and then helped her to bed. S5CNA reported resident #1 never voiced any pain. On 03/12/2025 at 12:20 p.m., interview with S3LPN revealed on the evening of 02/16/2025 a housekeeper called down the hall that resident #1 was on the floor. Two CNAs ran to the resident #1's room and she entered behind them. The resident was on the floor. She assessed the resident and found no injuries. The resident voiced no pain or injury and displayed no non-verbal indication of pain or injury. S3LPN confirmed she did not contact the physician and family regarding the fall. Review of resident #1's record revealed there was no documented evidence of the family or the physician notifications on 02/16/2025 following resident #1's fall. On 03/11/2025 at 1:30 p.m., interview with S1Administrator and S2Director of Nursing (DON) confirmed S3LPN should have contacted the physician and family regarding resident #1's fall.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure a resident received treatment and care in accordance with professional standards of practice when the nursing staff failed to document a post fall assessment and complete an incident report as stated in the facility's fall prevention program policy for 1 (#1) of 1 residents reviewed for accidents that experienced a fall. Findings: Review of the facility's fall prevention program dated 01/01/2025 revealed when any resident experienced a fall the facility will assess the resident, complete an incident report, notify the physician and family and document all assessments and actions. Review of resident #1's medical record revealed diagnoses which included depression, anxiety, dementia, repeated falls and a non-displaced fracture of the shaft of the right clavicle. Review of the 03/05/2025 quarterly Minimum Data Set assessment revealed the resident was independent with indoor mobility. Resident #1 scored a 3 on her Brief Interview for Mental Status assessment indicating severe cognitive impairment. Review of the Fall Risk assessment dated [DATE] revealed the resident scored a 13 indicating she was at risk for falls. Review of the progress notes of resident #1 revealed on 02/17/2025 at 9:38 a.m. resident #1 was found to have fresh bruising over the right collar bone. The resident voiced only soreness. The progress notes also stated there had been no reports of falls and that the nurse practitioner was in the facility. The nurse practitioner examined the resident and orders were given to send resident #1 to the emergency room for evaluation. Review of the hospital's computed tomography (CT) scan revealed the resident had a subtle non-displaced fracture of the left clavicular neck. Review of resident #1's record failed to reveal a progress note documenting a post fall assessment on 02/16/2025 or an incident report regarding a fall on 02/16/2025. Review of the facility's investigation dated 02/17/2025 regarding the fresh bruising over the right collar bone of resident #1 revealed on 02/16/2025 two Certified Nurse Aides (CNA) were called to the room of resident #1 when another staff saw resident #1 on the floor. Written statements from S4CNA and S5CNA indicated they entered the room and found resident #1 sitting upright on the floor. On 03/11/2025 at 3:10 p.m., interview with S4CNA revealed shortly before 10:00 p.m., on 02/16/2025 she heard a housekeeper yell out that resident #1 was on the floor. S4CNA and another CNA ran to the resident's room and found the resident sitting on the floor. S3Licensed Practical Nurse (LPN) entered the room immediately after them. The nurse assessed the resident found no injuries and then the 2 CNAs assisted resident #1 to bed. The resident did not complain of pain at that time. On 03/12/2025 at 11:05 a.m., interview with S5CNA revealed on 02/16/2025 near 10:00 p.m. she heard a housekeeper say that resident #1 was on the floor. S5CNA and S4CNA ran to the resident's room and found the resident sitting on the floor with her legs extended. S5CNA reported S3LPN entered the room right behind them and assessed the resident. After the S3LPN assessed the resident, S4CNA and S5CNA assisted resident #1 with getting dressed for bed then helped her to bed. She reported resident #1 never voiced any pain. On 03/12/2025 at 12:20 p.m., interview with S3LPN revealed on the evening of 02/16/2025 a housekeeper called down the hall that resident #1 was on the floor. Two CNAs ran to resident #1's room and she entered behind them. The resident was on the floor. She assessed the resident and found no injuries. The resident voiced no pain or injury and displayed no non-verbal indication of pain or injury. S3LPN confirmed she did not complete an incident report or document a post fall assessment regarding the fall. On 03/11/2025 at 1:30 p.m., interview with S1Administrator and S2Director of Nursing (DON) revealed S3LPN failed to complete an incident report on the fall and failed to document a post fall assessment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to ensure that residents received care, consistent with professional standards of practice, to prevent pressure ulcers for 1 (#4) of 3 (#1, #4, #43) residents reviewed for pressure ulcers. The facility failed to provide a pressure relieving device as ordered for the resident. Findings: Review of the medical record for resident #4 revealed an admission date of 04/19/2013 with diagnosis of atrial fibrillation, cerebrovascular accident, edema, muscle wasting, dysphagia, hypertension, vascular dementia, history of urinary tract infection, history of stage 3 pressure ulcer to the left heel, depressive disorder, and contracture to the left elbow. Review of the Annual Minimum Data Set assessment dated [DATE] revealed the resident had a Brief Interview for mental Status score of 6 which indicated severe cognitive impairment. Further review revealed the resident needed maximum assistance with all activities of daily living. Review of resident #4's December 2024 physician's orders revealed an order for heel protectors to be worn at all times with a start date of 06/06/2024. Review of resident #4's current care plan dated 05/15/2024 revealed he had an un-stageable pressure ulcer to the left heel. Further review revealed an intervention to provide heel protectors to bilateral feet. Review of the Braden Scale for predicting pressure ulcer risk evaluation dated 11/27/2024 revealed the resident was at moderate risk due to a history of a pressure ulcer to the left heel. Review of the skin and wound evaluation dated 9/24/2024 revealed the resident had a stage III (full-thickness skin loss) to the left heel acquired in the facility. The surrounding skin was fragile skin that was at risk for breakdown. Additional care was heel suspension/protection device. Progress: pressure ulcer resolved will continue with preventative measures. An observation on 12/16/2024 at 11:00 a.m., revealed sample resident #4 was sitting in his Geri chair in the lobby the resident did not have any heel protectors on. An observation on 12/17/2024 at 8:30 a.m., revealed the resident was sitting in the Geri chair in his room. The resident was dressed and had socks on his feet and the heel protectors were lying in the chair not on the resident. An observation on 12/17/2024 at 2:50 p.m., revealed resident #4 was sitting in his Geri chair in the lobby. The resident was dressed and had socks on but did not have heel protectors on as ordered. On 12/18/2024 at 8:00 a.m., the resident had been placed on isolation in his room due to a positive COVID test dated 12/18/2024. An observation revealed the resident was lying in bed eating breakfast and he did not have his heel protectors on. An interview on 12/18/2024 at 10:15 a.m., with S4Licensed Practical Nurse confirmed sample resident #4 was at high risk for pressure ulcers and had a physician's order to wear heel protectors at all times. She was not sure if the resident had them on or not. She stated the Certified Nurse Assistants (CNAs) that get them up every morning are responsible for making sure the resident had them on. An interview on 12/18/2024 at 10:30 a.m., with S5CNA revealed she had been taking care of resident #4 the last few days and she had not placed the heel protectors on the resident. An interview on 12/18/2024 at 1:40 p.m., with S3Assistant Director of Nursing confirmed resident #4 should have had the heel protectors on as ordered due to him being at risk for pressure ulcers.

Based on observation, record review and interview, the facility failed to maintain an infection control program to help prevent the development and transmission of communicable diseases and infections by failing to implement its policy for enhanced barrier precautions for 1 (#37) of 1 residents reviewed for transmission based precautions. Findings: On 12/16/2024 at 8:45 a.m., observation of resident #37 revealed she had a Foley catheter. Observation of resident #37's door revealed there was no signage regarding Enhanced Barrier Precaution and there were no personal protective equipment supplies located nearby resident #37's room. Review of the facility's Enhanced Barrier Precautions policy dated 11/01/2024 revealed catheters were a qualifying condition for the implementation of enhanced barrier precautions. The policy also read Clear signage will be posted on the door or wall outside of the resident room indicating the type of precautions, required personal protective equipment (PPE), and the high-contact resident care activities that require the use of gown and gloves. The policy also indicated gowns and gloves should be available immediately outside the resident's room. On 12/17/2024 at 9:10 a.m., interview with S3Assistant Director of Nursing confirmed the facility did not implement their enhanced barrier precautions policy by failing to place signage and PPE near the door of resident #37's room.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews, the facility failed to ensure residents were free from physical restraints imposed for the purpose of discipline or convenience for 1 (#20) of 1 (#20) resident reviewed for restraints. Findings: Review of the facility Restraint Free Environment policy revised 12/02/2024 revealed the following, in part: Policy: It is the policy of this facility that each resident shall attain and maintain his/her highest practicable well-being in an environment that prohibits the use of restraints for discipline or convenience and limits restraint use to circumstances in which the resident has medical symptoms that warrant the use of restraints. Definitions: Physical Restraint refers to any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body. Physical restraints may include, but are not limited to applying leg or arm restraints that the resident cannot remove. Review of resident #20's medical record revealed she was admitted to the facility on [DATE] with diagnoses of cognitive communication deficit, Alzheimer's disease, generalized anxiety disorder, major depressive disorder, unspecified pruritus, and polyneuropathy. Review of resident #20's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed she had a Brief Interview for Mental Status score of 99, which indicated the interview was not successful. Resident #20 required extensive assistance for most activities of daily living. Further review revealed there was no documentation the resident had a restraint. Review of resident #20's medical record revealed her current care plan revealed she was at a high risk for skin tears due to the resident scratching herself. Further review revealed an approach for resident #20 to wear socks or gloves on her hands to keep her from scratching herself. Further review of resident #20's medical record revealed no documented evidence of a pre-restraint assessment, restraint consent, nor monitoring for the limb restraint use (socks on her hands). On 12/16/2024 at 9:40 a.m., an observation revealed resident # 20 was in her wheelchair in her room and she had socks on her hands. The resident was nonverbal and could not inform surveyor why she had socks on her hands. On 12/16/2024 at 11:10 a.m., an interview with S9Certified Nursing Assistant (CNA) revealed they put socks on the resident's hands because she scratches herself. S9CNA reported resident #20 cannot take the socks off her hands by herself. On 12/18/2024 at 8:28 a.m., an observation revealed resident # 20 was in her wheelchair in her room and she had socks on her hands. On 12/18/2024 at 1:13 p.m., an interview with S7Licensed Practical Nurse (LPN) revealed they have been using socks on the resident's hands due to she scratches herself. S7LPN confirmed the resident cannot take the socks off her hands without help. On 12/18/2024 at 1:40 p.m., an interview with S3Assistant Director of Nursing and S8LPN/MDS Nurse confirmed the facility failed to obtain a pre-restraint assessment and restraint consent; and there was no monitoring for the socks being used on the resident's hands.

Based on observation, interviews and record review, the facility failed to implement a comprehensive person-centered care plan for each resident for 1 (#41) of 1 residents reviewed for anticoagulants. Findings: On 12/16/2024 at 10:00 a.m., observation of the resident #41's hands revealed she had bruising to the back of both hands. Resident #41 reported she took a blood thinner. Review of the medical record revealed resident received the blood thinning medication Eliquis 2.5 milligrams (mg) twice daily. Review of the care plan revealed it addressed anti-coagulant use with an intervention to monitor for bruising. Review of the Medication Administration Record (MAR) revealed the nursing staff were to monitor for bruising each shift. Review of the December 2024 MAR revealed every entry indicated resident #41 had no bruising. On 12/17/2024 at 1:05 p.m., interview with S3Assistant Director of Nursing confirmed resident #41 had bruising to her hands and the nursing staff failed to document the bruising on the MAR.

Based on observations and interviews, the facility failed to ensure the resident enviornment remained as free of accident hazards as possible by failing to ensure resident rooms maintained a water temperature of less than 120 degrees for 4 (#19, 37, 41, 66) of 4 residents whose rooms were assessed for water temperatures. Findings: On 12/16/2024 at 9:00 a.m., a check of the water temperatures in the residents' rooms was done with the S2Maintenance Supervisor. The water temperature for resident #41's room was 127.0 degrees. The water temperature for resident #66's room was 127.2 degrees. The water temperature for resident #19's room was 127.8 degrees. The water temperature for resident #37's room was 127.2 degrees. S1Maintenance Supervisor confirmed the water temperatures were in excess of 120 degrees. On 12/16/2024 at 9:30 a.m., S1Assistant Administrator confirmed the water temperatures in the residents' rooms should not be in excess of 120 degrees.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interviews, the facility failed to treat each resident with respect and dignity in a manor and in an environment that promotes maintenance or enhancement of his or her quality of life for 1 (#1) of 3 (#1, #2, #3) sampled residents reviewed. This failed practice occurred when S4Certified Nursing Assistant (CNA) did not assist resident #1 to the restroom after resident #1 requested to go to the restroom. Findings: Record review revealed resident #1 was admitted to the facility on [DATE] with diagnoses that included dementia unspecified severity with anxiety, encephalopathy unspecified, chronic systolic congestive heart failure, chronic obstructive pulmonary disease with acute exacerbation, seizures, insomnia, generalized muscle weakness, other lack of coordination, other abnormalities of gait and mobility, major depressive disorder recurrent, essential hypertension, atrial fibrillation, hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting right dominant side, aphasia following cerebral infarction, needs for assistance with personal care, and cognitive communication deficit. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 01 which indicated resident #1 was severely cognitive impaired for daily decision making. Further review revealed resident #1 required limited physical assistance by one staff with bed mobility, transfers, eating, and toilet use. Resident #1 was occasionally incontinent of bowel and bladder. Resident #1 was unable to walk and used manual wheelchair for ambulation. Further record review revealed resident #1 had an active care plan care for self-care and mobility deficit and required assistance from staff with bathing, dressing, feeding, hygiene, and toileting. Intervention included to provide resident #1 with assistance with Activities of Daily Living (ADLs) as needed. During an interview on 09/23/2024 at 12:05 p.m., resident #1's family member reported she had reviewed the video camera footage from resident #1's room and observed S4CNA refuse to take resident #1 to the bathroom and told her to go ahead and use it or hold it because she was wearing a brief. Resident #1's family member allowed surveyor to review the video footage recordings on her cell phone. The video footage included audio and were dated and time stamped with the start of each video. Review of the video recordings revealed the following: On 08/26/2024 around 4:30 a.m., resident #1 was lying in the bed and S4CNA was noted to tell resident #1, better not get your butt back up as she covered resident #1's lower extremities and torso with a blanket. Resident #1 was noted to say, I need to go to the bathroom. S4CNA was noted tell resident #1, you have a pamper on, go ahead and use it or just hold it. On 09/24/2024 at 12:40 p.m., an interview with S1Administrator confirmed S4CNA should have assisted resident #1 to the rest room after resident #1 reported she needed to go to the bathroom. S1Administrator further confirmed S4CNA should not have told resident #1 to go ahead and use it because she was wearing a brief or to just hold it.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the provider failed to ensure an alleged violation involving verbal and physical abuse that was reported to the Administrator by resident #1's family member was reported immediately, but no later than 2 hours after being made aware, to the State Survey Agency in accordance with State Laws for 1 (#1) of 3 (#1, #2, #3) sampled residents. Findings: Review of the facility's Abuse, Neglect and Exploitation Policy, dated 07/31/2024, revealed in-part: Policy: It is the policy of this facility to provide for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Definitions: Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish, which can include staff to resident abuse and certain resident to resident altercations. Abuse also includes the depravation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental and psychological well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain, or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. Physical Abuse includes, but not limited to hitting, slapping, punching, biting, and kicking. It also includes controlling behavior through corporal punishment. Verbal Abuse means the use of oral, written or gestured communication or sounds that willfully includes disparaging or derogatory terms to residents or their families, or within their hearing distance regardless of their age, ability to comprehend, or disability. Reporting/Response A. The facility will have written procedures that include: 1. Reporting of all alleged violations to the administrator, state agency, adult protection services and to all other required agencies (e.g. law enforcement when applicable) within specified timeframes: a. Immediately, but no later than 2 hours after the allegation is made, if the event that cause the allegation involve abuse or result in serious bodily injury, or b. Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. Record review revealed resident #1 was admitted to the facility on [DATE] with diagnoses that included dementia unspecified severity with anxiety, encephalopathy unspecified, chronic systolic congestive heart failure, chronic obstructive pulmonary disease with acute exacerbation, seizures, insomnia, generalized muscle weakness, other lack of coordination, other abnormalities of gait and mobility, major depressive disorder recurrent, essential hypertension, atrial fibrillation, hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting right dominant side, aphasia following cerebral infarction, needs for assistance with personal care, and cognitive communication deficit. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 01 which indicated resident #1 was severely cognitive impaired for daily decision making. Further review revealed resident #1 required limited physical assistance by one staff with bed mobility, transfers, eating, and toilet use. Resident #1 was occasionally incontinent of bowel and bladder. Resident #1 was unable to walk and used manual wheelchair for ambulation. During an interview on 09/23/2024 at 9:30 a.m., S1Administrator revealed resident #1's family member came to the facility on [DATE] at 4:00 p.m. and informed her and S2Assistant Administrator that she did not like how S4 Certified Nursing Assistant (CNA) treated resident #1 while providing care during the early hours of 08/26/2024. Resident #1's family member reported S4CNA made rude comments and handled resident #1 roughly while she performed her care. S1Admininstrator and S2Asssistant Administrator viewed the video footage dated 08/26/2024 from 2 video cameras placed in resident #1's room by the family on resident #1's family member's cell phone. Review of the dated and time stamped video recordings revealed the following: On 08/26/2024 at 2:28 a.m., resident #1 was sitting in manual wheelchair and S4CNA was in resident #1's room providing1:1 observation. S4CNA tells resident #1, Get your butt over in that bed and stay in it. S4CNA was noted to be pushing resident #1's wheelchair backwards by holding on to the front wheelchair armrest. Resident #1 placed her hands on top of S4CNA's hands that were on the wheelchair armrest. S4CNA was noted to repeatedly tell resident #1 Get your hands off me. Resident #1 raised her left foot up off the foot rest and extended slowly towards S4CNA's legs. S4CNA was noted to repeatedly tell resident #1 don't you kick me as S4CNA was pushing resident #1 backwards in her manual wheelchair to the bed. Resident #1 raised her left leg up to put distance between them. S4CNA was noted to tell resident #1, woman if you kick me I will beat your ass, get up. S4CNA then stated, trying to help you and you trying to act stupid, gonna get you in the bed and you gonna stay there. S4CNA positioned the wheelchair next to the bed and stated, you want to get in the bed or not. Resident #1 did not appear to want to go to bed. S4CNA was noted to reposition resident #1 up in the wheelchair and allowed her to stay in the wheelchair and continued to provide 1:1 monitoring. Resident #1 did not attempt to hit or kick S4CNA. On 08/26/2024 at 4:12 a.m., S4CNA was noted to tell resident #1, sit up you, you gonna fall out of the wheelchair as she physically assisted resident #1 up in the wheelchair by lifting resident #1 under her arms. Resident #1 was noted to say, Leave me alone. On 08/26/2024 at 4:27 a.m., S4CNA positioned resident #1's wheelchair against her bed and assisted resident #1 to a standing position by holding on to her left arm. S4CNA was noted to tell resident #1, Sit down, don't you feel better now you are in bed. Resident #1 had sat upright on the side of the bed with her feet resting on the floor. S4CNA was noted to yell at resident #1, lay down! On 08/26/2024 at 4:28 a.m., S4CNA was noted to yell at resident #1 again, lay down as S4CNA physically pushed back resident #1's left shoulder to get her to lay down in the bed. Resident #1 did not appear to want to lay down and did not lay back. S4CNA was observed to grab resident #1 by the ankles and forcefully lifted them up and put both of her lower extremities in the bed. This caused resident #1 to fall backward on the left side of the bed and resident #1 was noted to hit her left/back side of her head against the cinder block wall located next to the bed. Resident #1 responded by saying, you son of a bitch. S4CNA was noted to tell resident #1, better not get your butt back up as she covered resident #1's lower extremities and torso with a blanket. During an interview on 09/25/2024 at 1:25 p.m., S1Administrator confirmed S4CNA verbally and physically abused resident #1 on 08/26/2024. Review of the incident investigation report to State Survey Agency revealed S1Amininstrator submitted the report on 08/28/2024 at 5:51 p.m. The incident occurred on 08/26/2024 at 3:30 a.m. The incident was discovered on 08/27/2024 at 4:00 p.m. On 09/24/2024 at 12:32 p.m., an interview with S1Administrator confirmed she did not submit the incident investigation report to the State Survey Agency until 08/28/2024 at 5:51 p.m. and not within 2 hours of being informed of the alleged abuse allegation.

Based on record review and interviews, the facility failed to ensure a comprehensive person-centered care plan was implemented for 1 (#56) of 1 (#56) residents investigated for pressure ulcers. The facility failed to ensure resident #56 had a pressure relieving device in the seat of his wheelchair, as he was at risk for pressure ulcers and dependent upon the wheelchair for his mobility. Findings: Review of the medical record revealed resident #56 was admitted to the facility on the date of 02/09/2022. Further review revealed the residents' diagnoses included in part, peripheral vascular disease, severe intellectual disabilities, cognitive communication deficit, muscle wasting and atrophy multiple sites, abnormalities of gait and mobility, Type 2 diabetes mellitus, mental disorder, history of pressure ulcers, and abnormal weight loss. Review of the quarterly MDS (Minimum Data Set) dated 10/12/2023 revealed resident #56 a brief interview for mental status score of 99. Further review of the MDS revealed that a score of 99 indicated that resident #56 was unable to complete the interview. Review of MDS Section M0150-Risk for Pressure Ulcers/Injuries, revealed resident #56 was at risk for developing pressure ulcers/injuries. Review of resident #56's plan of care revealed resident #56 was at risk for impaired skin integrity. On 12/04/2023 at 10:09 a.m., an observation revealed resident #56 sitting in his wheelchair in front lobby, watching television. Further review revealed there was no pressure relieving device in the seat of his wheelchair. On 12/05/2023 at 10:10 a.m., an observation revealed resident #56 sitting in his wheelchair, in his room. Further observation revealed there was no pressure relieving device in the seat of his wheelchair. On 12/05/2023 at 12:53 p.m., an observation revealed resident #56 sitting in his wheelchair, in his room. Further observation revealed there was no pressure relieving device in the seat of his wheelchair. On 12/06/2023 at approximately 10:20 a.m., S5LPN (Licensed Practical Nurse) was notified of the findings regarding resident #56 not having a pressure relieving device in the seat of his wheelchair during observations on the dates of 12/04/2023 and 12/05/2023. S5LPN reported that all residents using a wheelchair were to have a cushion in the seat of their wheelchair as a preventative measure for pressure ulcers. On 12/06/2023 at 2:15 p.m., S6WCN (Wound Care Nurse) was notified of the findings regarding the observations of resident #56 not having a pressure relieving device in the seat of his wheelchair on the dates of 12/04/2023 and 12/05/2023. S6WCN reported that resident #56 was at risk for pressure ulcers to his buttocks as the resident was dependent on a wheelchair for his mobility. She confirmed resident #56 was to have a cushion applied at all times to the seat of his wheelchair, as part of his plan of care for pressure ulcer prevention. On 12/06/2023 at 2:45 p.m., S2DON (Director of Nursing) was notified of the findings regarding resident #56 not having a pressure relieving device to the seat of his wheelchair during observations on the dates of 12/04/2023 and 12/05/2023. S2DON confirmed resident #56 did not have a pressure relieving device applied to the seat of his wheelchair, in accordance with resident #56's plan of care for pressure ulcer prevention. On 12/06/2023 at 5:30 p.m., S1Administrator was notified of the above findings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to conduct regular inspections of all bed rails for 1 (#53) of 6 (#1, #6, #36, #42, #53, and #54) residents investigated for accidents. The facility failed to identify that resident #53's bed rail was not properly secured to the resident's bed. Findings: Review of the medical record revealed resident #53 was admitted to the facility on [DATE] with diagnoses including in part, cerebral infarction, muscle weakness (generalized), Alzheimer's disease, dementia, unspecified severity with other behavioral disturbance, spondylolisthesis, and spondylosis with radiculopathy, lumbosacral region. Review of the care plan dated 09/15/2023 revealed resident #53 had a terminal prognosis related to Alzheimer's disease and was admitted to hospice services. Further review revealed resident #53's family had requested side rails due to resident #53 having a decline in condition and being admitted to hospice. On 12/04/2023 at 10:36 a.m., an observation revealed resident #53 was in her room and sitting up in her Geri-chair. Observation of the resident's bed revealed there were two ½ side bed rails. Further observation revealed the right bed rail was loose and wobbly. On 12/05/2023 at 12:49 p.m., an observation revealed resident #53 was in her room and sitting up in her Geri-chair. Observation of the resident's bed revealed the right bed rail was loose and wobbly. On 12/05/2023 at 4:50 p.m., an observation revealed resident #53 was in her room and sitting up in her Geri-chair. Observation revealed the resident's bed revealed that the right bed rail remained loose and wobbly. S2DON (Director of Nursing) was notified of the finding. S2DON assessed resident #53's right bed rail and noted the rail to be loose and wobbly. S2DON confirmed that staff had failed to identify that resident #53's right bed rail was not properly secured to the resident's bed. On 12/06/2023 at 12:13 p.m., S7Maintenance Supervisor was notified of the finding regarding resident #53's right bed rail not being properly secured to the resident's bed. S7Maintenance Supervisor confirmed that he had not received any reports from the staff regarding an issue with resident #53's bed rails being loose and wobbly. On 12/06/2023 at 5:30 p.m., S1Administrator was notified of the above findings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to ensure each resident receives adequate supervision and assistive devices to prevent accidents for 2 (#1 and #42) of 6 (#1, #6, #36, #42, #53, and #54) sampled residents investigated for accidents. The facility failed to implement new interventions after residents #1 and #42 were identified as having a fall. Findings: Resident #1 Review Accidents and Supervision Policy and Procedure revised on 04/12/2023 revealed the following, in part: The resident environment will remain as free of accident hazards as is possible. Each resident will receive adequate supervision and assistive devices to prevent accidents. This includes: 1. Identifying hazard (s) and risk (s). 2. Evaluating and analyzing hazard (s) and risk (s). 3. Implementing interventions to reduce hazard (s) and risk (s). 4. Monitoring for effectiveness and modifying interventions when necessary. Review of the record for resident #1 revealed an admission date of 09/07/2021 with diagnoses including chronic systolic (congestive) heart failure, unspecified convulsions, morbid obesity, diabetic neuropathy, schizoaffective disorder, post-traumatic stress disorder chronic, and anxiety. Review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident requires limited assistance with 1 person physical assistance with transfers, toileting, and bathing. Further review revealed a Brief Interview For Mental Status (BIMS) score of 15 indicating that resident #1 was cognitively intact with daily decision making. Review of the Fall Risk Evaluation dated 10/18/2023 revealed a score of 13 indicating the resident was at high risk for falls. Review of the incident/accident report dated 09/22/2023 revealed resident #1 had a fall in whirlpool room when resident was transferring from wheelchair to the whirlpool chair. Further review of the report revealed no new interventions were implemented after the fall. Review of resident #1's current care plan revealed the resident has had multiple falls related to poor balance, psychoactive drugs, and an unsteady gait. Further review of the care plan revealed no documented evidence that new interventions were implemented after the fall on 09/22/2023. An interview on 12/06/2023 at 8:00 a.m. with S3Licensed Practical Nurse (LPN) revealed that resident #1 was at high risk for falls. S3LPN revealed resident #1 requires assistance for toileting, transferring, and bathing. An interview on 12/06/2023 at 1:30 p.m. with S8Certified Nurse Aide (CNA) revealed resident #1 requires 1 person assist with ADLs including transfers, toileting, and bathing. An interview on 12/06/2023 at 3:45 p.m. with S4LPN/MDS confirmed that resident #1 requires limited assistance with 1 person physical assistance with Activities of Daily Living (ADLs) including transfers, toileting, and bathing. An interview on 12/06/2023 at 2:45 p.m. with S2Director of Nursing (DON) revealed that resident #1 was at high risk for falls. S2DON confirmed that resident #1 did have a fall on 09/22/2023 in whirlpool room and the facility did not implement a new intervention for this fall. Resident #42 Review of the record for resident #42 revealed an admission date of 06/23/2021 with diagnoses including fusion of spine cervical region, Parkinson's disease, chronic obstructive pulmonary disease, pseudobulbar affect, neurosyphillis, and a history of traumatic brain injury. Review of the End of Part A Stay MDS dated [DATE] revealed a Brief Interview For Mental Status (BIMS) score of 6 indicating moderate that resident #42 had severe cognitive impairment. Further review of the MDS revealed the resident required extensive assistance with 1 person physical assistance with transfers, toileting, and bathing. Review of the incident/accident report dated 09/11/2023 revealed resident #42 had a fall in his room and was found sitting on his bottom with his head on the wall. Further review revealed resident was trying to get into his bed by himself and was sent to the hospital for evaluation. Review of the incident/accident report dated 11/14//2023 revealed resident #42 had a fall while reaching for item on meal cart. Further review revealed there were no new interventions implemented after the fall. Review of the Fall Risk Evaluation for resident #42 dated 10/06/2023 revealed a score of 15 indicating the resident was at high risk for falls. Review of the current care plan for resident #42 revealed the resident had falls on 09/11/2023 and 11/14/2023 with no documentation of new interventions implemented for these falls. An interview on 12/06/2023 at 8:00 a.m. with S3LPN revealed that resident #42 had frequent falls and was at high risk for falls. S3LPN reported the resident needed assistance with ADLs including transfers, toileting, and bathing. An interview on 12/06/2023 at 1:30 p.m. with S8CNA revealed resident #42 required assistance for transfers and toileting. An interview on 12/06/2023 at 3:45 p.m. with S4LPN/MDS revealed that resident #42 required extensive assist with 1 person physical assistance with ADLs including transfers, toileting, and bathing. An interview on 12/06/2023 at 2:30 p.m. with S2DON revealed that resident #42 was at high risk for falls and had a fall on 09/11/2023 and 11/14/2023. S2DON confirmed that the facility did not implement new interventions for either of the falls for resident #42.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews the facility failed to ensure Resident #1 was properly transferred using the Vander-Lift by two person assist according to the resident's plan of care for 1 (#1) of 5 (#1, #2, #3, #4, #5) sample residents. The facility implemented corrective actions which were completed prior to the State Agency's investigation, thus it was determined to be Past Noncompliance. Findings: Review of the Safe Resident Handling/Transfers policy revealed in part: Two staff members must be utilized when transferring residents with mechanical lifts. Mechanical lifts may include equipment such as full body lifts, sit to stand lifts, or ceiling track mounted lifts. Review of medical records revealed Resident #1 was admitted to the facility on [DATE]. Resident #1's diagnoses include but not limited to the following: chronic systolic congestive heart failure, atrial fibrillation, peripheral vascular disease, essential hypertension, cognitive communication disorder, lack of coordination, generalized muscle weakness, chronic pain, neuralgia and neuritis unspecified, muscle weakness and atrophy bilateral upper extremities, age related physical disability, and other reduced mobility. Review of Resident #1's quarterly MDS (Minimum Data Set) dated 04/14/2023 revealed a BIMS (Brief Interview Mental Status) score of 12 which indicated the resident was moderately cognitively impaired with daily decision making. Further review revealed she was totally dependent on two person physical assistance with transfers. Review of Resident #1's care plan revealed an ADL (Activities of Daily Living) self-care deficit. Interventions included: Resident requires mechanical lift with two staff assistance for transfers. Review of accident/incident report date 04/19/2023 at 6:10 p.m. reveled Resident #1 was being transferred from her geri-chair to her bed by S5 CNA (Certified Nursing Assistant) using [NAME] mechanical lift by herself. S5 CNA reported that she had resident hooked up on the lift properly and was heading to the bed when all the sudden Resident #1 came out of the lift because Resident #1 kept leaning all of her weight to one side and the whole lift tipped over and landed on the bed and that's when S5 CNA called for help. S11 LPN (Licensed Practical Nurse) was called to room by S5 CNA and found Resident #1 lying on the floor next to the bed. Resident #1 reported that she hit her head. S11 LPN checked Resident #1 for injuries. Range of motion performed on all extremities. Vital signs obtained: temperature 97.8, pulse 101, respirations 20, blood pressure 110/56, oxygen saturation 95%, and pain scale 0. No apparent injuries observed at the time of incident. An ambulance transported Resident #1 to a local hospital emergency room to be checked for injuries. The Physician was notified at 6:20 p.m. and Resident #1's son was notified of incident and transfer to the emergency room at 8:00 p.m. Review of emergency room visit on 04/19/2023 at 6:48 p.m. revealed the following: Patient sent from Nursing Home with complaint of fall while staff were using lift to transfer patient. Patient reports mild pain after hitting floor, denies loss of consciousness. Physical exam: Alert and oriented x3. No acute distress. Head non tender. No swelling of head. Neck painless with range of motion. Heart sound and pulse normal. Breath sounds normal and chest non tender. Abdomen soft and non-tender. CT (Computerized Tomography) scan of cervical spine without contrast and CT scan of brain without contrast were done. Xray report of CT Cervical spine revealed no evidence of acute fracture or listhesis. Xray report of CT brain revealed no evidence of acute intracranial abnormalities. Disposition: discharge back to nursing home. Take over the counter medications according to label instructions and follow up with primary care physician in three days. On 05/22/2023 at 8:55 a.m. an interview with Resident #1 revealed the aide was transferring her with the lift by herself when the fall occurred. Resident #1 revealed she could not recall the aide's name. Resident #1 reported that she hit her head on floor and had a head ache for about an hour. Resident #1 reported they sent her to the emergency room to be evaluated and then she returned to the facility. Resident #1 reported that they have been using two aides when they transfer her since the incident. On 05/22/2023 at 10:25 a.m. an observation revealed S6 CNA, S7 CNA, and S4 CNA Supervisor safely transferred Resident #1 using the Vander-Lift from her bed to geri-chair. On 05/22/2023 at 10:35 a.m. an interview with S4 CNA Supervisor reported that Resident #1 was a two person assist with all transfers using the Vander-Lift. S4 CNA Supervisor revealed she had received training on how to properly use the Vander-Lift to transport residents during her orientation, yearly, and again after Resident #1's accident. S4 CNA Supervisor further revealed that she and S3 ADON (Assistant Director of Nursing) are doing ongoing QA (Quality Assurance) monitoring to make sure there are two CNAs present and they are following proper procedure with resident transfers using mechanical lifts ([NAME] and Vera). On 05/22/2023 at 10:38 a.m. an interview with S6 CNA revealed she had received training on how to properly use the Vander-Lift to transport residents during her orientation, yearly, and again after Resident #1's accident. S6 CNA confirmed that Resident #1 was a two person assist with all transfers using the Vander-Lift. On 05/22/2023 at 10:40 a.m. an interview with S7 CNA revealed he had received training on how to properly use the Vander-Lift to transport residents during his orientation, yearly, and again after Resident #1's accident. S6 CNA confirmed that Resident #1 was a two person assist with all transfers using the Vander-Lift. On 05/22/2023 at 11:50 a.m. an interview S1 Administrator reported their investigation revealed S5 CNA used the proper lift pad, attached the lift pad to the Vander-Lift properly. S5 CNA did not have anyone assisting her during the transfer. During the transfer Resident #1 started to leaning to her side which caused the lift to tilt and her fall during the transfer. S1 Administrator confirmed that it is the facilities policy that all resident transfers using the mechanical lifts have two staff assist. S1Administrator confirmed that S5 CNA did not follow the facilities policy of having two people present to physically assist with transferring Resident #1 on 04/19/2023. S1 Administrator reported on 04/20/2023 S5 CNA received disciplinary write up for not following the facility's policy for having 2 person present while transferring resident with mechanical lift and retraining on proper transfer with two staff with all resident transfers using mechanical lifts by S3 ADON. S1 Administrator revealed S2 DON reported the incident to the state agency on 04/20/2023. S1 Administrator reported on 04/20/2023 CNA's on 300 hall, 100 hall and 200 hall received In-service training on retraining on the proper transfer with two staff with all resident transfers using mechanical lifts by S3 ADON. S1 Administrator revealed that an all staff in-service conducted on 05/05/2023 that included training on proper procedure and having two staff with all resident transfers using mechanical lifts by S2 DON (Director of Nursing) and S3 ADON. S1 Administrator revealed the in-service training was completed on 05/08/2023 for all staff that were not able to attend the training on 05/05/2023. S1 Administrator revealed they implemented QA (Quality Assurance) monitoring of CNA's performing transferring residents using mechanical lifts ([NAME] and Vera) to make sure there are two persons present and proper technique is followed per their policy started on 05/05/2023. QA monitoring is ongoing and being done by S3 ADON and S4 CNA Supervisor. S1 Administrator revealed they have also added this to their Quality Improvement Corrective Action Plan. S1 Administrator confirmed they have not had any other incidents with resident transfers using mechanical lifts ([NAME] or Vera) since incident involving Resident #1 on 04/19/2023. On 05/22/2023 at 12:15 p.m. an interview with S2 DON revealed they plan to continue QA process of observing CNA's to make sure they are following the proper technique and have two staff present with resident transfers with mechanical lifts for the next three months. S2 DON revealed they have added proper body mechanic when lifting and proper use of resident lift/when to use lift to their QAPI (Quality Assurance and Performance Improvement) action plan. S2 DON confirmed thare had not been any further incidents with resident transfers using mechanical lift since incident involving Resident #1 on 04/19/2023. On 05/22/2023 at 2:15 p.m. interview with S5 CNA reported she received training on the proper procedure to transfer residents using the mechanical lifts ([NAME] and Vera) during orientation training, and during her annual training. S5 CNA confirmed that she was aware of the facilities policy of having two staff present during all resident transfers using the mechanical lifts. S5 CNA revealed on 04/19/2023 at 6:10 p.m. Resident #1 was wanting to go back to bed. S5 CNA reported that she hooked up the blue lift pad properly to the Vander-Lift and was transferring her from the geri-chair to her bed. S5 CNA reported that she did not have anyone assist her with the transfer. S5 CNA revealed she used the mechanical lift to lift Resident #1 up off the geri-chair and was in the process of moving her with the lift to the bed when Resident #1 began to lean hear body weight to one side. S5 CNA encouraged her to stop leaning. S5 CNA reported that all the sudden the lift started to tilt as Resident #1 continued to lean causing the lift and Resident #1 to fall on to the bed. S5 CNA reported Resident #1 landed on the bed and then slide out of the lift pad and landed on the floor on the right side of the bed. S5 CNA reported that she asked Resident #1 if she was okay and Resident #1 replied she was okay. S5 CNA reported she then activated the call bell and informed S11 LPN what had happened. S5 CNA reported that she had always had another CNA with her when she transferred residents with the mechanical lifts. S5 CNA revealed in her mind she thought it would be okay to go ahead and transfer Resident #1 without any one to assist her. S5 CNA confirmed that she was aware of the policy and procedure of resident transfers using the mechanical lifts requires two staff. S5 CNA confirmed that she should have asked another staff memeber to asssit her. S5 CNA confirmed she received counselling and written up on 04//20/2023 for not following the facilities policy of having two staff present to assist with all resident transfers using mechanical lifts. S5 CNA further confirmed she received retraining with return demonstration of the proper procedure for transferring residents using the mechanical lift on 04/20/2023. Interviews with staff and review of documentation revealed the facility addressed and implemented the following area regarding resident being transferred safely according to the facilities Safe Resident Handling/Transfers policy and procedure: Review of in-service training done 04/20/2023 on the proper technique for lift transfers with return demonstration conducted by S3 ADON revealed 6 CNA's signatures including S5 CNA on the sign in sheet. Review of in-service training 05/05/2023 at 12:00 noon All Staff in-service which included Resident lifts. When to use lift (based on resident preference/determination ADL need) correct way to use lift- determination conducted by S2 DON revealed 33 staff signatures noted on sign in sheet. Review of in-service training 05/08/2023 All Staff in-service which included Resident lift. When to use lift (based on resident preference/determination ADL need) correct way to use lift- determination. Staff that did not attend mandatory in-service. Write up to occur on next occurrence of missing mandatory in-service. Conducted by S3 ADON revealed 30 staff signatures noted on sign in sheet. Review of in-service training 05/08/2023 All Staff in-service which included resident/staff proper lift use When to use lift (based on resident preference/determination ADL need) correct way to use lift- determination. (Night shift employees) conducted by S1 Administrator revealed 5 staff signatures noted on sign in sheet. Review of documentation of S5 CNA received disciplinary action formally written up on 04/20/2023 by S3 ADON for not following the facilities policies and procedures. S5 CNA transferred Resident #1 with the Vander-Lift by her on 04/19/2023. Must have 2 person assist with all resident transfers using mechanical lifts. Review of the monitoring audit tool revealed documentation S3 ADON and S4 CNA Supervisor observed random residents on different halls who required the [NAME] or Vera lifts for transfers. The Audit tool listed the date, name of resident, type of lift used, checked to make sure 2 people were present, and the proper technique was used. The documentation revealed the monitoring began on 05/05/2023. The monitoring occurred several times a week and was still ongoing. Further QA review revealed not problems noted. Review of the Quality Improvement Correction Action Plan Revealed: 04/20/2023 identified the problem- CNA improper lift usage causing lift to tilt and causing resident fall. All resident requiring the use of mechanical lift equipment have the potential to be effected. CNA was disciplined via written disciplinary action on 04/20/2023. CNA was aware of the facilities policy to have 2 staff members present with all resident transfers using mechanical lifts. SIMS report done on 04/20/2023 by S2 DON. All staff received in-service training regarding proper procedure and requirement for two person operation of all resident transfers using mechanical lifts. In-services were performed on 04/20/2023, 05/05/2023 and completed on 05/08/2023. QA including documented observations of compliance with lift policy, implemented on 05/05/2023 and are ongoing at this time. Agency staff will be made aware of the facility specific lift policy prior to providing resident care. Policy will be available for review at all times in the agency orientation binder located at the nurse's station. Audited records will be reviewed by the QAPI interdisciplinary team until such time consistent substantial compliance has been achieved as determined by the committee. The correction date was noted as 05/08/2023; since all investigations, training, and monitoring had been put into place by this date.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to ensure that nurse aides demonstrate competency in skills and techniques necessary to care for residents' needs for 1 (#6) of 1 (#6) residents reviewed for Urinary Tract Infections. The facility failed to ensure CNAs (Certified Nursing Assistant) changed gloves after providing care and becoming soiled. Findings: Review of the medical record revealed resident #6 was admitted to the facility on [DATE]. The resident's diagnoses included personal history of urinary tract infections, disorder of the kidney and ureter, cognitive communication deficit, schizophrenia, and dementia. On 12/12/2022 at 9:40 a.m., an observation revealed S3CNA and S9CNA assisted resident#6 with pericare. During the observation, S3CNA had donned a pair of disposable gloves and was observed wiping the inner folds of the groin areas by wiping from back to front. Further observation revealed S3CNA retrieved and replaced clear plastic bags from inside her jacket pocket and then placed a brief on resident #6. S3CNA did not change her dirty and contaminated gloves after she finished with the pericare procedure. Further observation revealed S3CNA retrieved cleansing wipes from the package with the same dirty and contaminated gloves she used during pericare and wiped the resident's mouth/facial area. She then touched the resident's clothing and the resident's water cup. After the observation was completed, S3CNA was notified of the findings. She reported that she was not aware she had to remove her dirty and contaminated gloves after providing pericare, if the gloves were used for one resident. On 12/14/2022 at 9:52 a.m. S2DON (Director of Nursing) was notified of the finding observed during and after the pericare procedure for resident #6. S2DON confirmed S3CNA should have changed her gloves after they became dirty and contaminated.

Based on record reviews and interviews, the facility failed to ensure criminal background checks and sex offender checks were completed by a Louisiana State Police approved entity prior to 1st day of work at the facility for 2 (S6CNA (Certified Nursing Assistant)/Contracted Staff, and S7CNA/Contracted Staff) of 5 (S3CNA, S4CNA, S5CNA, S6CNA/Contracted Staff, and S7CNA/Contracted Staff) personnel files reviewed. The facility also failed to ensure adverse actions checks were completed upon hire for 5 (S3CNA, S4CNA, S5CNA, S6CNA/Contracted Staff, and S7CNA/Contracted Staff) of 5 CNA's (S3CNA, S4CNA, S5CNA, S6CNA/Contracted Staff, and S7CNA/Contracted Staff) personnel files reviewed. Findings: Review of S6CNA/Contracted Staff's personnel file failed to reveal a criminal background check and sex offender check were completed by a Louisiana State Police approved entity prior to the first day worked on 10/15/2022. The review also failed to reveal an adverse action check was completed. Review of S7CNA/Contracted Staff's personnel file failed to reveal a criminal background check and sex offender check were completed by a Louisiana State Police approved entity prior to the first day worked on 10/09/2022. The review also failed to reveal an adverse action check was completed. An interview on 12/14/2022 at 4:00 p.m. with S1Administrator confirmed that S6CNA/Contracted Staff and S7CNA/Contracted Staff did not have an adverse action check, criminal background check and sex offender check by a Louisiana State Police Authorized Agency prior to 1st day of work at the facility. Review of S3CNA's personnel file revealed a hire date of 09/09/2022 with no adverse action check completed upon hire. Review of S4CNA's personnel file revealed a hire date of 09/09/2022 with no adverse action check completed upon hire. Review of S5CNA's personnel file revealed a hire date of 10/11/2021 with no adverse action check completed upon hire. On 12/14/2022 at 4:00 p.m. an interview with S1Administrator confirmed no adverse action checks obtained for the above 3 staff members.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to conduct regular inspection of all bed frames, mattresses, and bed rails as part of a regular maintenance program to identify areas of possible entrapment for 1 (#6) of 6 (#6, #11, #24, #28, #32, and #45) residents reviewed for accidents. The facility failed to ensure that resident #6's bed mattress was compatible with his bed frame, by having an approximate 6 inch open space area observed between the edge of the bed mattress and the two 1/4 side rails located on the right side of bed. Findings: Review of the Bed Maintenance and Inspection Policy revealed (#3) bed frame, mattress, and bed rail inspections will be conducted upon each item entering the facility during assembly of equipment and as needed during routine maintenance rounds. Review of the medical record revealed resident #6 was admitted to the facility on [DATE]. The resident's diagnoses included cognitive communication deficit, dementia, psychotic disturbance, mood disturbance, anxiety, schizophrenia, glaucoma, and insomnia. Review of the Fall Risk Evaluation dated 11/04/2022 revealed a documented score of 12. According to the fall evaluation assessment, if a score is 10 or greater, the resident should be considered at high risk for potential falls. Further review revealed the level of consciousness/mental state as disoriented x 3 at all times. Review of the physician order dated 10/28/2022 revealed pressure reduction mattress or overlay to bed; verify placement every shift. Review of the December 2022 MAR (Medication Administration Record) revealed documented evidence of staff initials every shift to indicate the pressure reduction mattress placement was verified, however, there was no documented evidence on the MAR of the mattress not properly fitting resident #6's bed. On 12/12/2022 at 9:40 a.m., an observation revealed S3CNA (Certified Nursing Assistant) and S9CNA assisting the resident #6 with pericare. After the task was completed, the resident was repositioned in her bed. There were two ¼ side rails raised and locked to the right side of the resident's bed. Further observation revealed a space between the edge of the bed mattress and the right side rails that was approximately 6 inches in width. S3CNA and S9CNA reported resident #6 scoots in her bed and will try to get out of the bed. On 12/13/2022 at 4:52 p.m., S8Maintenance Supervisor was notified of the findings. S8Maintenance Supervisor went to the room and observed resident #6's bed. During the observation with the supervisor, the folded pillow remained in the space between the mattress and side rails. S8Maintenance Supervisor reported resident #6 originally had a non-electric bed with an air loss mattress in her room, but the family had requested the resident to have an electric bed. He further reported resident #6 did not need an air loss mattress at that time, so he swapped the beds and the mattresses out and placed a pressure reducing mattress on the electric bed frame of the bed resident #6 was currently using. S8Maintenance Supervisor confirmed the current bed mattress was not the correct mattress for the electric bed and it did not properly fit the bedframe of the electric bed. On 12/14/2022 at 2:15 p.m. further interview with S8Maintenance Supervisor revealed he checked the resident beds prior to a resident's admission and again upon admission to the facility. He reported he did make rounds to check for the resident rooms being cluttered, their lighting, and plugins only. S8Maintanence Supervisor confirmed he did not have documented evidence of making rounds and checking resident beds, he did not make rounds with the Quality Assurance team or any other staff. S8Maintenance Supervisor further confirmed the pressure reducing mattress currently on resident #6's electric bed was the incorrect mattress and it did not properly fit the bed. 12/14/2022 at 9:52 a.m., S1Administrator and S2Director of Nursing were notified of the findings regarding resident #6's bed mattress not properly fitting the electric bed the resident was currently using.