**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility staff failed to complete the required Minimum Data Set (MDS), a federally mandated resident assessment, within the required timeframe for two of three sampled residents (Residents #2 and #162). The facility census was 10. 1. Review of the facility's MDS Automation policy, revised April 2021, showed: -The MDS will be completed on a timely basis as mandated by Centers for Medicare Services (CMS); -Discharge tracking forms are completed on every resident within five days of dismissal; -The MDS assessments as required are sent to the state through electronic submission every 7-10 days. Review of the Resident Assessment Instrument (RAI) manual 3.0 version 1.18.11, dated October 2023, showed discharge assessment time frames for a resident must be completed no later than 14 days from the date of discharge and submitted by the MDS completion date plus 14 calendar days. 2. Review of Resident #2's admission MDS, dated [DATE], did not contain a completed discharge assessment within the required time frame. Review of the resident's medical record showed staff documented the resident discharged on 10/01/23. 3. Review of Resident #162's admission MDS, dated [DATE], did not contain a completed discharge assessment within the required time frame. Review of the resident's medical record showed staff documented the resident discharged on 07/18/23. 4. During an interview on 12/28/23 at 10:46 A.M., the MDS Coordinator said currently he/she is responsible for MDS. He/She said during weekly meetings he/she sets the dates of upcoming due MDS assessments. He/She said when residents are discharged on the weekends their name may fall off the resident list and will fall through the cracks. The MDS Coordinator said if it was not a weekend discharge he/she would need to do research as to why it was not completed. He/She said he/she did not have access to the Internet Quality Improvement and Evaluation System (IQIES), communication system from facility to CMS, until recently and did not know the missing assessment report was available. During an interview on 12/28/23 at 10:52 A.M., the Director of Nursing (DON) said his/her expectation is the MDS be completed timely. He/She was not aware there were late assessments.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, facility staff failed to complete entrapment assessments for the use of bed rails for 6 residents (Resident #2, #6, #209, #211, #212, and #214). The facility census was 10. 1. Review of the facility policies provided showed the facility did not have a policy for bedrails/mobility assist devices. Review of the facility's VersaCare Bed Service Manual, revision 5, undated, showed the manual did not address risk of resident entrapment. 2. Review of Resident #2's admission Minimum Data Set (MDS), a federally mandated resident assessment, dated 1/12/23, showed staff assessed the resident as follows: -Cognitively intact; -Required extensive, one person assistance with mobility, transfer, and toileting; -Impairment on one side lower extremity. Review of the resident's medical record, showed the record did not contain the required entrapment assessment specific to the resident. Observation on 1/18/23 at 1:50 P.M., showed the resident in bed, with a quarter side rail on the right side of bed, and a full side rail on the left side in the upright position. Observation on 1/19/23 at 10:30 A.M., showed the resident in bed, with a quarter side rail on the right side of bed, and a full side rail on the left side in the upright position. 3. Review of Resident #6's admission MDS, dated [DATE], showed the staff assessed the resident as follows: -Required extensive, two person assistance with bed mobility, transfers, and toileting; -Required the use of a walker and wheelchair; -Did not use bedrails; -Diagnosis of weakness. Review of the resident's medical record, showed the record did not contain the required entrapment assessment specific to the resident. Observation on 1/17/23 at 1:57 P.M., showed the resident in bed with quarter-length bilateral bed rails in the upright position. Observation on 1/18/23 at 1:50 P.M., showed the resident in bed with quarter-length bilateral bed rails in the upright position. 4. Review of Resident #209's admission record showed staff assessed the resident as follows: -admission date of 1/17/23; -Cognitively intact; -Required extensive, two person assistance with mobility and toileting; -Required extensive, one person assistance with transfers. Review of the resident's medical record, showed the record did not contain the required entrapment assessment specific to the resident. Observation on 1/17/23 at 11:45 A.M., showed the resident in bed, with quarter-length bilateral bed rails in the upright position. Observation on 1/18/23 at 9:15 A.M., showed the resident in bed, with quarter-length bilateral bed rails in the upright position. Observation on 1/18/23 at 2:00 P.M., showed the resident in bed, with quarter-length bilateral bed rails in the upright position. Observation on 1/19/23 at 10:30 A.M., showed the resident in bed, with quarter-length bilateral bed rails in the upright position. 5. Review of Resident #211's admission record showed staff assessed the resident as follows: -admission date of 1/11/23; -Diagnosis of weakness, fracture of the left femur (a break in the bone of the thigh), and fracture of the carpal bone (a break in the bone of the wrist). Review of the resident's medical record, showed the record did not contain the required entrapment assessment specific to the resident. Observation on 1/17/23 01:37 P.M., showed the resident in bed with quarter-length bilateral bed rails in the upright position. Observation on 1/18/23 1:50 P.M., showed the resident in bed with quarter-length bilateral bed rails in the upright position. Observation on 1/19/23 10:29 A.M., showed the resident in bed with quarter-length bilateral bed rails in the upright position. During an interview on 1/18/23 at 1:50 P.M., the resident said he/she always has his/her side rails up. The button controls for the bed are on the side rails. Without them up he/she wouldn't be able to reach them. 6. Review of Resident # 212's admission record showed staff assessed the resident as follows: -admission date of 1/16/23; -Diagnosis of a complicated urinary tract infection, which caused significant weakness. Review of the resident's medical record, showed the record did not contain the required entrapment assessment specific to the resident. Observation on 1/17/23 at 12:48 P.M., showed the resident in bed with bilateral upper quarter side rails in the upright position. Observation on 1/18/23 at 3:45 P.M., showed the resident in bed with bilateral upper quarter side rails in the upright position. Observation on 1/19/23 at 10:33 A.M., showed the resident in bed with bilateral upper quarter side rails in the upright position. During an interview on 1/19/23 at 10:33 A.M., the resident said he/she does not use the side rails for anything. 7. Review of Resident # 214's admission record showed staff assessed the resident as follows: -admission date of 1/4/23; -Diagnoses of amputation of the toe of the right foot, diabetic infection of the left foot, diabetic ulcer of the left heel, and abscess of the right foot. Review of the resident's medical record, showed the record did not contain the required entrapment assessment specific to the resident. Observation on 1/18/23 at 10:45 A.M., showed the resident in bed with bilateral upper quarter side rails in the upright position. Observation on 1/18/23 at 2:14 P.M., showed the resident in bed with bilateral upper quarter side rails in the upright position. During an interview on 1/19/23 at 10:30 A.M., the resident said he/she does not use the side rails for anything. 8. During an interview on 1/18/23 at 12:56 P.M., the MDS Coordinator said the bed rails are manufactured with the side rails so they do not come off, and patients cannot become entrapped. During an interview on 1/19/23 at 10:25 A.M., Certified Nurse Assistant (CNA) A said all of their residents use side rails. They use them for the control buttons located on the side of the rails. The buttons help the resident move their head, feet, and bed up and down. CNA A said the side rails do not come off the bed, but can lowered when needed. During an interview on 1/19/23 at 10:45 A.M., the MDS Coordinator said if a resident was really small, there might be a risk of entrapment however there have not been any residents admitted that might have this risk. During an interview on 1/19/23 at 10:47 A.M., the Director of Nursing said it was his/her understanding that the beds purchased by the facility have manufactured safety features to prevent entrapment so residents could not be entrapped.