Based on observation, interview, and record review, the facility failed to identify, assess and provide supportive interventions for one resident (Resident #8) with a diagnosis of post-traumatic stress disorder (PTSD - a mental health condition triggered by a terrifying event - either experiencing it or witnessing it; symptoms may include flashbacks, nightmares and severe anxiety, as well as uncontrollable thoughts to the event) out of one sampled resident. The facility's census was 59. Review of the facility's policy titled, Trauma Informed Care, undated, showed: - It is the policy of this facility to provide care and services which, in addition to meeting professional standards, are delivered using approaches which are culturally-competent, account for experiences and preferences, and address the needs of trauma survivors by minimizing triggers and/or re-traumatization; - The facility will work to facilitate the principles of trauma informed care which includes collaboration between resident and/or his or her representative, and all staff and disciplines involved in the resident's care in developing the plan of care; - The facility will ask the resident about triggers that may be stressors or may prompt recall of a previous traumatic event, as well as screening and assessment tools; - The facility will identify triggers which may re-traumatize resident with a history of trauma, trigger specific interventions will identify ways to decrease the resident's exposure to triggers; - Trauma-specific care plan interventions will recognize the interrelation between trauma and symptoms of trauma such as substance abuse, eating disorders, depression, and anxiety; - The facility will evaluate whether the interventions have been able to mitigate (or reduce) the impact of identified triggers; - In situations where a trauma survivor is reluctant to share their history, the facility will still try to identify triggers which may re-traumatize the resident and develop care plan interventions which minimize or eliminate the effect of the trigger on the resident. 1. Review of Resident #8's medical record showed: - admission date of 02/17/15; - Diagnoses of PTSD, depression (a serious medical illness that negatively affects how you feel, the way you think and how you act), insomnia (difficulty falling or staying asleep, resulting in poor sleep quality), and anxiety disorder (persistent worry and fear about everyday situations); - No trauma informed care assessment. Review of the resident's Physician's Order Sheet (POS), dated February 2025, showed: - An order for Lexapro (an antidepressant medication) 10 milligrams (mg) by mouth at bedtime for depression, dated 12/20/22; - An order for trazodone (an antidepressant medication) 100 mg by mouth at bedtime for insomnia, dated 03/06/24; - An order for psychological services, dated 01/21/2021. Review of the resident's comprehensive care plan, last revised 02/18/25, showed: - PTSD not addressed; - No goals to maintain the resident's psychosocial and mental health; - No documentation of the resident's past trauma, or any triggers that would cause the resident trauma; - No interventions for how the facility would address the behaviors if they occurred or how the facility would provide support to the resident. During an interview on 02/24/25 at 2:30 P.M., the resident said he/she has experienced trauma, a heat stroke, and gets upset if he/she hears people talking about him/her. During an interview on 02/25/25 at 3:06 P.M., the Minimum Data Set (MDS - a federally mandated assessment completed by facility staff) Coordinator said PTSD should be on the care plan if it is active. During an interview on 02/26/25 at 9:55 A.M., the Social Service Designee (SSD) said he/she was unaware of any triggers for the resident, if someone asks him/her to go outside when it is hot outside, the resident will say no, due to having a heat stroke in the past. During an interview on 02/27/25 at 12:14 P.M., the Director of Nursing (DON) and the Administrator said PTSD and triggers should be on the care plan if it is active.

Based on observation, interview, and record review, the facility failed to maintain an error rate of less than five percent (%) during medication administration. There were 27 opportunities with two errors made, for an error rate of 7.41%, which affected one resident (Resident #4) out of three sampled residents. The facility's census was 59. Review of the facility's policy titled, Administering Oral Medications, reviewed May 2019, showed: - Check the label on the medication and confirm the medication name and dose with the Medication Administration Record (MAR); - Check the medication dose, re-check to confirm the proper dose. Review of the facility's policy titled, Adverse Consequences and Medication Errors, reviewed May 2019, showed: - A medication error is defined as the preparation or administration of drugs or biological which is not in accordance with physician's orders, manufacturer specifications, or accepted professional standards and principles of the professional providing services; - Examples of medication errors includes wrong dose and wrong dosage form. 1. Review of Resident #4's Physician's Order Sheet (POS), dated February 2025, showed: - An order for aspirin 81 milligrams (mg) chewable in the morning, dated 11/26/24; - An order for Fluticasone Propionate Nasal Suspension (a medication used to treat inflammation of the nasal passages) 50 micrograms (mcg) per actuation (ACT), two sprays in both nostrils in the morning, dated 11/26/24. Observation of the resident's medication administration on 02/26/25 at 7:58 A.M. showed: - Registered Nurse (RN) E administered aspirin 81 mg enteric coated to the resident; - RN E administered Fluticasone Propionate Nasal Suspension one spray in both nostrils to the resident. During an interview on 02/26/25 at 8:15 A.M., RN E said he/she should have confirmed the dosage of nasal spray before giving it and should have given the chewable form of aspirin instead of the enteric coated tablet. During an interview on 02/27/25 at 1:14 P.M., the Administrator and the Director of Nursing (DON) said they expect to have a medication error rate less than five percent.

Based on observation, interview, and record review, facility staff failed to maintain appropriate infection control practices by not performing proper hand hygiene and glove changing techniques during incontinent care and medication administration for two residents (Resident #27 and #214) out of 15 sampled residents and two residents (Resident #4 and #37) outside the sample and failed to provide infection prevention precautions by not following enhanced barrier precautions (EBP) for one resident (Resident #15) out of six sampled residents. The facility's census was 59. Review of the facility's policy titled, Personal Protective Equipment, dated May 2024, showed: - Change gloves and perform hand hygiene between clean and dirty tasks and when moving from one body part to another; - Perform hand hygiene before donning gloves and after removal. Review of the facility's policy titled, Perineal Care, dated May 2019, showed: - Wash perineal area, wiping from front to back; - Continue to wash the perineum moving from inside outward; - Do not reuse the same washcloth or water to clean the urethra; - After washing perineal area, wash the rectal area thoroughly. Review of the facility's policy titled, Suprapubic Catheter Care, dated May 2019, showed: - Wash around the catheter site with soap and water or peri wash; - If the resident has a drainage sponge around the stoma site, remove the drainage sponge before washing with soap and water. Review of the facility's policy titled Enhanced Barrier Precautions, last revised on 11/25/24, showed: - All staff receive training on enhanced barrier precautions upon hire and at least annually and are expected to comply with all designated precautions; - An order for enhanced barrier precautions will be obtained for residents with wounds and/or indwelling devices; - Personal Protective Equipment (PPE) for enhanced barrier precautions is only necessary when performing high-contact care activities; - High-contact care activities include: dressing, bathing, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care, and wound care. 1. Observation on 02/26/25 at 7:58 A.M. of Resident #4's medication administration showed: - Registered Nurse (RN) E dropped a Jardiance (a medication used to control blood sugar) pill onto the top of the medication cart, picked up the dropped pill with bare fingers, and placed the pill into medication cup, contaminating the medication and the other medications in the cup; - RN E dropped a methocarbamol (a muscle relaxant medication) pill onto the top of the medication cart, picked up the dropped pill with bare fingers, and placed the pill into the medication cup, contaminating the medication and the other medications in the cup; - RN E administered the contaminated medications to the resident; - RN E checked the resident's blood pressure; - RN E checked for swelling of the resident's legs, by placing his/her bare hand on the resident's lower legs; - RN E left the room, documented the blood pressure reading in the computer and began the next medication administration without performing hand hygiene. 2. Observation on 02/26/25 at 8:09 A.M. of Resident #214's medication administration showed: - RN E, without performing hand hygiene, placed the resident's medications into a medication cup; - RN E handed the resident his/her glasses; - RN E removed the resident's straw from one cup and placed it into a cup of water with his/her bare fingers without performing hand hygiene or wearing gloves; - RN E repositioned the resident in bed; - RN E gave the resident his/her medications and drink, and left the room; - RN E touched the medication cart and computer without performing hand hygiene. 3. Observation on 02/27/25 at 10:00 A.M. of Resident #27's catheter care showed: - Certified Nurse Aide (CNA) A and CNA B washed hands and donned gowns and gloves; - CNA A opened clean bed protector and laid it across the bedside table; - CNA B made one basin of soapy water and one basin of clean water and sat them on top of the bed protector; - CNA B put clean wash cloths in each basin and left some dry cloths in a bag sitting on the bed protector; - CNA A took a cloth from the soapy water basin, wrang out, and wiped outer perineal area front to back on each side, folding cloth each time; - CNA A placed the soiled cloth in the dirty linen bag; - Without changing gloves or performing hand hygiene, CNA A reached into the clean soapy water, pulled out another cloth and wrang it out over the basin; - CNA A wiped the area around the catheter, folded cloth, and wiped peri area from side to side; - CNA A placed the soiled cloth in the dirty linen bag; - Without changing gloves or performing hand hygiene, CNA A reached into the clean soapy water and pulled out another cloth and wrang it out over the basin; - CNA A wiped the catheter starting closest to the insertion point and wiped away from the body approximately four inches, folded cloth and repeated; - CNA A placed the soiled cloth in the dirty linen bag; - Without changing gloves or performing hand hygiene, CNA A reached into the clean soapy water, pulled out another cloth and wrang it out over the basin; - CNA A wiped down the resident's left inner thigh, folded cloth, and wiped the right inner thigh; - Without changing gloves or performing hand hygiene, CNA A reached into the clean water, pulled out a cloth and wrang it out over the basin; - CNA A wiped the area around the catheter, folded cloth, and wiped peri area front to back from the outside in, folding the cloth with each pass; - CNA A placed the soiled cloth in the dirty linen bag; - Without changing gloves or performing hand hygiene, CNA A reached into the clean water, pulled out another cloth and wrang it out over the basin; - CNA A wiped down the catheter starting from the insertion point and moving outward, folded cloth and repeated; - CNA A placed the soiled cloth in the dirty linen bag; - CNA B handed CNA A a clean dry cloth; - CNA A dried the resident's peri area moving front to back; - Without changing gloves or performing hand hygiene, CNA A without changing gloves or performing hand hygiene, reached into the clean bag and pulled out a clean dry cloth; - CNA A dried the resident's inner thighs and then pulled the covers up to the resident's waist; - Without changing gloves or performing hand hygiene, CNA A reached into the soapy water, pulled out a cloth, wrang it out over the basin and handed it to the resident to wash his/her hands; - CNA B took a clean dry cloth, wet it in the sink and handed it to the resident to rinse his/her hands; - CNA A removed gloves; - Without performing hand hygiene, CNA A pulled a clean dry cloth from the bag and handed it to the resident to dry his/her hands; - CNA B emptied the basins into the sink, removed gown and gloves, and washed hands with soap and water; - CNA A removed gown and placed in trash can, gathered trash and dirty linens and left the room; - CNA B cleaned the bed side table with a wet soapy paper towel, then a wet paper towel; - CNA B dried the bed side table with a paper towel, placed the resident's cup and phone on the table and left the room. 4. Observation on 02/27/25 at 12:58 P.M. of Resident #37's perineal care showed: - CNA C made a basin of soapy water and sat it on the resident's bed side table; - Without performing hand hygiene, CNA C donned gloves; - CNA D washed hands and donned gloves; - CNA D placed bed protector on the bed under the resident's hips; - CNA D rolled the resident onto his/her right side, removed the soiled brief, and placed in trash can; - CNA C handed CNA D a clean cloth from the soapy water basin; - CNA D wiped the resident's buttock front to back, folded cloth, wiped front to back, folded cloth, repeated one more time, and placed the soiled cloth in the dirty linen bag; - Without changing gloves or performing hand hygiene, CNA D placed a clean incontinence brief under the resident and rolled the resident onto his/her back; - CNA C handed CNA D a clean cloth from the soapy water basin; - CNA D wiped the resident's perineal area from back to front; - CNA D placed the soiled cloth in the dirty linen bag; - CNA C handed CNA D a clean dry cloth; - Without changing gloves or performing hand hygiene, CNA D used the clean dry cloth to dry the resident's perineal area; - CNA D placed the soiled cloth in the dirty linen bag; - Without changing gloves or performing hand hygiene, CNA D closed resident's incontinence brief; - CNA D removed gloves and washed hands with soap and water; - CNA C removed gloves and placed pants on the resident. 5. Review of Resident #15's medical record showed; - An admission date of 07/18/24; - An order to clean lumbar wound with wound cleanser and cover with Mepilex (absorbent dressing) until healed, every day shift, dated 02/24/25. Observation of the resident on 02/26/25 at 11:56 A.M. showed: - A sign on the resident's name plate by the door stating EBP; - CNA A and CNA B entered the room, did not perform hand hygiene, and did not don gloves or gowns; - CNA A placed the resident's upper mechanical lift sling straps on the mechanical lift, touching the bed with his/her clothes; - CNA B placed the lower mechanical lift sling straps on the mechanical lift, touching the bed with his/her clothes; - CNA B placed socks on the resident; - CNA A raised the mechanical lift and positioned the resident over the wheelchair; - CNA B positioned the resident in the wheelchair; - CNA A brushed the resident's hair; - CNA B made the resident's bed; - CNA B transferred the resident to the dining room. During an interview on 02/26/25 at 8:15 A.M., RN E said he/she should have performed hand hygiene between residents and should have destroyed the dropped medications and administered new medications. During an interview on 02/26/25 at 12:10 P.M., CNA A and CNA B said they should have worn gloves and a gown during the care of the resident who required EBP. During an interview on 02/27/25 at 1:10 P.M., CNA D said gloves should be changed and hand hygiene performed before going from dirty activity to clean activity. He/She said perineal care should be performed from front to back. During an interview on 02/27/25 at 2:14 P.M., the Director of Nursing (DON) and Administrator both said they would expect staff to follow EBP during high contact resident care activities, gloves to be changed and hand hygiene to be performed when going from dirty to clean, and for perineal care to be performed from front to back.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to notify the resident and/or the resident's representative in writing of a facility-initiated transfer to a hospital, including the reasons for the transfer for five residents (Resident #5, #11, #16, #28 and #38) out of 15 sampled residents. The facility's census was 58. The facility did not provide a facility-initiated transfer policy. 1. Review of Resident #5's medical record showed: - Facility-initiated transfer and admitted to the hospital on [DATE], and readmitted to the facility on [DATE]; - Facility-initiated transfer and admitted to the hospital on [DATE], and readmitted to the facility on [DATE]; - No documentation the resident and/or the resident representative was informed in writing of the transfer and the reason for the transfer to the hospital. 2. Review of Resident #11's medical record showed: - Facility-initiated transfer to the hospital on [DATE], and readmitted back to the facility on [DATE]; - No documentation the resident and/or the resident representative was informed in writing of the transfer and the reason for the transfer to the hospital. 3. Review of Resident #16's medical record showed: - Facility-initiated transfer and admitted to the hospital 05/28/23, and readmitted to the facility on [DATE]; - No documentation the resident and/or the resident representative was informed in writing of the transfer and the reason for the transfer to the hospital. 4. Review of Resident #28's medical record showed: - Facility-initiated transfer and admitted to the hospital on [DATE], and readmitted to the facility on [DATE]; - No documentation the resident and/or the resident representative was informed in writing of the transfer and the reason for the transfer to the hospital. 5. Review of Resident #38's medical record showed: - Facility-initiated transfer to the hospital on [DATE], and readmitted to the facility on [DATE]; - No documentation the resident and/or the resident representative was informed in writing of the transfer and the reason for the transfer to the hospital. During an interview on 01/24/24 at 3:30 P.M., the Director of Nursing (DON) said if the resident needed an evaluation, then she would not expect to do the paperwork for the resident to leave the facility. If the resident gets admitted , then she would expect the appropriate paperwork to be completed and given to the appropriate people. During an interview at 01/25/24 at 2:10 P.M., the Administrator said she would expect the resident or the resident representative to be provided the transfer/discharge forms when sent out of the facility to the hospital.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to inform the resident and/or the legal representative of the bed hold policy at the time of the transfer to the hospital for five residents (Resident #5, #11, #16, #28 and #38) out of 15 sampled residents. The facility's census was 58. Review of the facility's policy titled, Bed Hold Policy, undated, showed: - If the resident's care is paid under the Medicaid Program, Medicaid (a government program that provides health insurance for adults and children) may pay for a certain number of bed hold days; - Resident may request an additional bed hold if days exceed what Medicaid will pay by agreeing to pay the applicable daily rate during the additional bed hold period; - Any private or Medicare (a federal health insurance for anyone age [AGE] and old, and some people under age [AGE] with certain disabilities or conditions) resident may request a bed hold from the facility but may be required to pay a daily rate for the bed held during that period. 1. Review of Resident #5's medical record showed: - Transferred and admitted to the hospital on [DATE], and readmitted to the facility on [DATE]; - Transferred and admitted to the hospital 12/13/23, and readmitted to the facility on [DATE]; - No documentation the resident or the resident representative was informed in writing of the facility bed hold policy at the time of the transfer. 2. Review of Resident #11's medical record showed: - Transferred to the hospital on [DATE] and readmitted to the facility on [DATE]; - No documentation the resident or the resident representative was informed in writing of the facility bed hold policy at the time of the transfer. 3. Review of Resident #16's medical record showed: - Transferred and admitted to the hospital 05/28/23, and readmitted to the facility on [DATE]; - No documentation the resident or the resident representative was informed in writing of the facility bed hold policy at the time of the transfer. 4. Review of Resident #28's medical record showed: - Transferred and admitted to the hospital on [DATE], and readmitted to the facility on [DATE]; - No documentation the resident or the resident representative was informed in writing of the facility bed hold policy at the time of the transfer. 5. Review of Resident #38's medical record showed: - Transferred to the hospital on [DATE], and readmitted to the facility on [DATE]; - No documentation the resident or the resident representative was informed in writing of the facility bed hold policy at the time of the transfer. During an interview on 01/24/24 at 3:30 P.M., the Director of Nursing (DON) said if the resident needed an evaluation, then she would not expect to do the paperwork for the resident to leave the facility. If a resident gets admitted , then she would expect the appropriate paperwork to be completed and given to the appropriate people. During an interview at 01/25/24 at 2:10 P.M., the Administrator said she would expect the resident or the resident representative to be provided the bed hold notices when sent out of the facility to the hospital.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to assess residents for the use of bed rails and to receive a physician's order prior to installation or use nor did they obtain informed consent from the resident or if applicable, the resident representative for two residents (Resident #16 and #17) out of two sampled residents. The facility's census was 58. Review of the facility policy titled, Proper Use of Bed Rails, undated, showed: - Appropriate alternative approaches are attempted prior to installing or using bed rails; - Medical diagnosis, conditions, symptoms, size and weight, sleep habits, medications, delirium (state of disorientation or confusion), ability to toilet self safely, cognition, communication, mobility, and risk of falling are considered components when determining the resident's needs and whether use of bed rails meets those needs; - Evaluate alternatives prior to installation and how the alternatives failed; - Resident risk such as accident hazards, barrier to residents from safely getting out of bed, physical restraint, decline in status, skin integrity issues, decline in activity of daily living, risk of entrapment, and other potential negative outcomes are part of resident assessment; - The facility will assess to determine if the bed rail meets the definition of a restraint; - A bed rail is considered a restraint if the bed rail keeps a resident from voluntarily getting out of bed in a safe manner to the lower bed rail independently; - Informed consent from the resident/representative must be obtained after appropriate alternatives have been attempted prior to the installation and use of the bed rails and information presented in an understandable manner with consent given voluntarily, free from coercion; - Monitoring the resident with bed rails will be in accordance with professional standards of practice and the resident's choices evidenced by the resident's record and care plan; - A nurse assigned to the resident will complete reassessments at least quarterly, upon a significant change in status, or a change in type of bed/mattress/rail; - Maintenance director, or designee, is responsible for adhering to a routine maintenance and inspection schedule for the bed frames/rails and mattresses. Review of the Federal Drug Administration (FDA) documents entitled, Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment, dated [DATE], showed 413 people died as a result of entrapment events in the United States. Further review revealed those among the most vulnerable for these entrapment type events are elderly patients and residents, especially those who are frail, confused, restless, or who have uncontrolled body movement. Review of the FDA document entitled, Practice Hospital Bed Safety, dated February 2013, showed different potential zones of entrapment. The guidance characterizes the head, neck, and chest as key body parts that are at risk for entrapment. 1. Review of Resident #16's medical record showed: - admitted on [DATE]; - Diagnoses of heart failure (chronic condition where the heart does not pump blood as well it should), renal failure (kidneys do not filter waste products as they should), diabetes mellitus (abnormal blood sugar in the blood), dementia (a disorder marked by memory loss, personality changes, and impaired reasoning that interferes with daily functioning), anxiety (persistent worry and fear about everyday situations), and depression (a serious medical illness that negatively affects how a person feels, thinks, and acts); - No documentation of an order for the bed rails; - No documentation of any attempts made with alternative methods for the bed rail use; - No documentation of an informed consent signed explaining the risks and benefits for the bed rail use; - No documentation of a bed rail assessment completed. Review of the resident's quarterly Minimum Data Set (MDS) (a federally mandated assessment completed by the facility), dated [DATE], showed: - Impaired cognition; - Dependent with bed mobility; - Did not use bed rails. Review of the resident's current care plan, dated [DATE], showed: - Increased risk of falls related to impaired mobility, weakness, on an antidepressant medication, confusion and forgetfulness, actual falls, and incontinence; - Did not address bed rail use. Observations of the resident on [DATE] at 2:12 P.M., and [DATE] at 10:00 A.M., showed the resident lay in bed with the bed rails in the upright position on both sides of the bed. 2. Review of Resident #17's medical record showed: - admitted on [DATE]; - Diagnoses of obesity (a disorder involving excessive body fat that increases the risk of health problems), hemiplegia (paralysis of one side of the body) and hemiparesis (muscle weakness or partial paralysis on one side of the body) following a cerebral infarction (an area of necrotic tissue in the brain caused by disrupted blood supply and restricted oxygen supply) affecting the left non-dominant side, cerebrovascualr disease ( a group of disorders that affect the blood vessels and blood supply to the brain), and generalized muscle weakness; - No documentation of an order for bed rails; - No documentation of any attempts made with alternative methods for the bed rail use; - No documentation of an informed consent signed explaining the risks and benefits for the bed rail use; - No documentation of a bed rail assessment completed. Review of the resident's quarterly MDS, dated [DATE], showed: - No cognitive impairment; - Dependent for bed mobility; - Did not use bed rails. Review of the resident's care plan, revised on [DATE], showed: - Resident was a fall risk with a history of actual falls; - Bed rail on the right side of the bed for repositioning; - Resident required extensive assistance with activities of daily living (ADLs). Observations of the resident on [DATE] at 9:47 A.M., and [DATE] at 9:24 A.M., showed the resident sat in a wheelchair in his/her room with the bed rail in the upright position on the right side of the bed. During an interview on [DATE] at 9:24 A.M., Resident #17 said he/she used the bed rail to assist with bed mobility. During an interview on [DATE] at 9:17 A.M., the Director of Nursing (DON) said nursing and therapy assessed and went over the risks and benefits of the bed rail with the resident. Maintenance then would be informed of the bed rail information that was needed to apply the bed rails. Once the bed rail was added, housekeeping and other staff assessed weekly if there was anything that needed to be fixed. If something needed addressed, then maintenance was informed. During an interview on [DATE] at 2:05 P.M., the Administrator said she would expect the bed rail use risks and benefits to be discussed with the resident or their representative and their understanding of these risks and benefits to be documented in the medical record. She would expect bed rail use to be assessed on a regular basis.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, facility staff failed to conduct regular inspections of all bed frames, mattresses and bed rails as part of a regular maintenance program for two residents with bed rails (Residents #16 and #17) out of two sampled residents. The facility's census was 58. Review of the facility policy titled, Proper Use of Bed Rails, undated, showed: - Maintenance director, or designee, is responsible for adhering to a routine maintenance and inspection schedule for bed frames/rails and mattresses; - The facility will assure the correct installation and maintenance of bed rails prior to use. Review of the Federal Drug Administration (FDA) documents entitled, Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment, dated [DATE], showed 413 people died as a result of entrapment events in the United States. Further review revealed those among the most vulnerable for these entrapment type events are elderly patients and residents, especially those who are frail, confused, restless, or who have uncontrolled body movement. Review of the FDA document entitled, Practice Hospital Bed Safety, dated February 2013, showed different potential zones of entrapment. The guidance characterizes the head, neck, and chest as key body parts that are at risk for entrapment. 1. Review of Resident #16's medical record showed: - admitted on [DATE]; - No documentation of maintenance assessments for the bed rails. Observations of the resident on [DATE] at 2:12 P.M., and [DATE] at 10:00 A.M., showed the resident lay in bed with bed rails in the upright position on both sides of the bed. 2. Review of Resident #17's medical record showed: - admitted on [DATE]; - No documentation of maintenance assessments for the bed rails. Observations of the resident on [DATE] at 9:47 A.M., and [DATE] at 9:24 A.M., showed the resident sat in a wheelchair in his/her room with the bed rail in the upright position on the right side of the bed. During an interview on [DATE] at 9:24 A.M., the resident said that he/she used the bed rail to assist with bed mobility. During an interview on [DATE] at 11:15 A.M., the Maintenance Supervisor said he/she got approval from therapy and nursing if a bed rail was needed and what needed to happen. He/She relied on the housekeeping and nursing staff to let him/her know if a bed rail needed to be fixed or adjusted. He/She only added or removed bed rails after confirming with therapy and nursing staff that the bed rails were needed or not needed anymore. During an interview on [DATE] at 2:05 P.M., the Administrator said she would expect the bed rail use to be assessed on a regular basis.

Based on observation, interview, and record review, the facility failed to treat one resident (Resident #25) out of 13 sampled residents in a dignified manner as staff pushed the partially clothed resident, covered with a blanket, in a shower chair throughout the facility. The facility census was 51. Record review of the facility's Shower/Tub policy, revised 2010, showed: - When transporting the resident to and from the bath area, ensure the resident covered and his/her privacy maintained; - Never take the resident outside of his/her room without clothes or appropriate covering. 1. Observation on 8/28/22 at 11:13 A.M., showed: - Resident #25 sat on a shower/potty chair (a chair the resident sits on when in the shower, with a container under it to collect urine and fecal material) pushed from the Main Street hallway, through the facility television/common area, the facility lobby, and to the shower room on Park Avenue Hall; - The resident did not have any clothes on from the waist down; - The front of the resident covered by a bath blanket; - The sides of the resident's hips could be seen as the resident transferred to the shower room. Record review of the resident's quarterly Minimum Data Set, (MDS), a federally mandated assessment to be filled out by the facility staff, dated 8/22/22, showed: - The resident totally dependent on facility staff for bathing/shower. During an interview on 8/29/22 at 4:00 P.M., Resident #25 said if he/she was headed to the shower, undressed from the waist down, and not fully covered, it would bother him/her. The resident said he/she always asks the staff to make sure he/she was covered when taken to the shower. During an interview on 8/31/22 at 9:35 A.M., Certified Nursing Assistant (CNA)/shower aide A said residents who were transferred by a Hoyer lift (a type of lift used to move residents from one surface to another) were partially undressed in their rooms and placed on the shower chair, covered and taken to the shower room. There was not enough room in the shower rooms to safely transfer residents from their wheelchairs to the shower chair. The residents were supposed to be totally covered when they were transported to the shower room. No part of the resident's skin was to be seen. During an interview on 8/31/22 at 11:30 A.M., the Director of Nursing (DON) said the residents were supposed to be totally covered when they were transported to the shower room. She said the facility had shower/bath covers to cover the residents as they were transported through the halls to the shower rooms. The staff should make sure the residents were totally covered when they were transported to the shower rooms.

Based on interview and record review, the facility failed to maintain the bond amount for at least one and one-half times the average monthly balance of the residents' personal funds for the last twelve consecutive months from August 2021 through July 2022. The facility census was 51. Record review of the facility's Surety Bond policy, dated March 2017, showed: - The facility with a current surety bond or provides self-insurance to assure the security of all residents' personal funds deposited with the facility; - The purpose of the surety bond will be to guarantee the facility will pay the resident for losses occurring from any failure by the facility to hold, safeguard, manage, and account for the residents' funds. 1. Record review of the residents' personal funds account for the last 12 consecutive months from August 2021 through July 2022, showed: - The facility's current approved bond amount equaled $43,500.00; - The average monthly balance for the residents' personal funds equaled $30,485.98; - An average monthly balance of $30,485.98 required a bond of at least $45,000.00. During an interview on 8/31/22 at 9:20 A.M., the Business Office Manager (BOM) said he/she did not realize the bond amount was not high enough. He/she did not realize the bond was insufficient until he/she saw the calculated formula for the bond. He/she thought the bond amount had recently been increased. The BOM also said the residents were allowed to have more money in their accounts now. During an interview on 8/31/22 at 9:30 A.M., the Administrator said the bond amount should be adequate and did not realize it wasn't.