Based on medical record review, observation, staff interview, review of the facility policy, and review of online guidelines per the National Pressure Ulcer Advisory Panel (NPUAP), the facility failed to implement treatment once the pressure ulcers were identified. This resulted in Actual Harm for Resident #34, who was admitted to the facility without pressure ulcers and developed pressure ulcers to her right antecubital and left antecubital space (inside of the elbows), which were not identified and treated until they had developed into stage IV ulcers with exposed tendon. This affected one (Resident #34) of five residents reviewed for pressure ulcers. The facility census was 67 residents. Findings include:Review of the medical record for Resident #34 revealed an admission date of 04/25/24 with diagnoses including chronic respiratory failure, encephalopathy, and epilepsy. Review of the pressure ulcer risk assessment for Resident #34 dated 04/25/24 revealed the resident was at high risk for the development of pressure ulcers. Review of the physician’s orders for Resident #34 revealed an order dated 04/25/24 for the resident to have weekly skin checks per a licensed nurse. Review of the care plan for Resident #34, dated 04/26/24 revealed the resident had the potential for alteration in skin integrity and required protective/preventative skin care maintenance related to bladder incontinence, bowel incontinence, decreased mobility, history of previous skin breakdown, Impaired cognition. Interventions included the following: encourage the resident to float heels as tolerated, encourage to turn and reposition every two hours and as needed as tolerated, inspect for any reddened areas during daily care, pressure reducing cushion to chair to promote comfort and prevent skin breakdown, pressure reducing mattress on bed to promote comfort and prevent skin breakdown, monitor skin prior to and after placing bilateral hand splints. Review of the care plan for Resident #34, dated 04/26/24, revealed the resident needed assistance with activities of daily living (ADL) related to cognitive impairment, hemiparesis, immobility, and due to the resident being in a persistent vegetative state. Interventions included the following: inspect skin condition daily during personal care and report any impaired areas to the charge nurse, staff to anticipate needs, staff to perform ADL as the resident was totally dependent and did not participate in any aspect of the care task Review of the progress note for Resident #34 dated 03/06/25 revealed the facility met with the resident’s family to discuss the resident’s appropriateness for palliative care services, and the family was in agreement. The resident’s provider gave an order to admit the resident to palliative care services for acute respiratory failure. Review of the Minimum Data Set (MDS) assessment for Resident #34, dated 04/30/25, revealed the resident had impaired cognition and was dependent on staff for assistance with all ADL and received 100 percent of her nutrition via tube feeding. Review of the pressure ulcer risk assessment for Resident #34 dated 05/08/25 revealed the resident was at high risk for the development of pressure ulcers. Review of the weekly skin checks for Resident #34 dated 05/06/25, 05/13/25, 05/20/25, and 05/27/25, revealed the resident had no open areas. Review of the shower sheet for Resident #34 dated 05/23/25 completed by Certified Nursing Assistant (CNA) #48 and signed by Registered Nurse (RN) #89, revealed the aide noted two open areas to the inside of the resident’s right and left elbows. Review of the medical record for Resident #34 dated 05/23/25 to 05/28/25 revealed the record did not include documentation of open areas to the resident’s right and left inner elbows. Review of the skin assessment for Resident #34 dated 05/29/25, revealed there was a pressure ulcer to the resident’s right antecubital space which measured 1.0 centimeter (cm) in length by 2.0 cm in width by 0.5 cm in depth. The wound bed had full tendon exposure with 100 percent granulation tissue (new connective tissue). The resident also had a pressure ulcer to the left antecubital space which measured 1.0 cm in length by 1.0 cm in width by 0.3 cm in depth. The wound bed had full tendon exposure with 100 percent granulation tissue. Review of the physician’s order for Resident #34, dated 05/29/25, was to cleanse bilateral inner elbows with normal saline (NS), pat dry, apply calcium alginate to the wound beds, cover with an abdominal dressing (ABD), and loosely wrap with Kerlix (gauze roll), complete every night shift. Review of the care plan for Resident #34, dated 05/29/25, revealed the resident had an actual area of skin impairment of pressure related to contractures to the bilateral arms. Interventions included the following: initiate wound treatment, continue treatment as ordered by the physician, nursing to observe the wound dressing daily to ensure that the dressing remained intact and that there were no signs or symptoms of infection or increased drainage, observe and document character of wound weekly, observe for clinical changes, such as infection and/or worsening of wound, skin observation and document on bath/shower days, charge nurse to notify the wound nurse, physician and family of any new areas Review of the wound visit note for Resident #34 dated 06/04/25, per Wound Doctor (WD) #150 revealed the resident had a stage IV pressure area to the right antecubital space which measured 0.8 cm in length by 1.3 cm in width by 0.6 cm in depth. There was a moderate amount of exudate (drainage) from the wound with exposed underlying structure and 100 percent granulation tissue within the wound bed. The resident had a stage IV pressure area to the left antecubital space which measured 0.7 cm in length by 1.1 cm in width by 0.5 cm in depth. There was a moderate amount of exudate from the wound with exposed underlying structure and100 percent granulation tissue within the wound bed. The resident was at high risk for development of wounds due to encephalopathy, generalize muscle weakness, epilepsy, persistent vegetative state, and respiratory failure with tracheostomy status. During an observation of Resident #34’s skin on 07/24/25 at 11:09 A.M., Licensed Practical Nurse (LPN) #92 revealed the resident had a nickel sized open area to the right and left antecubital spaces which appeared to be approximately 0.5 cm in depth. Both areas had red wound beds, with the peri wound area intact, and no signs of infection. The wounds were healing. During an interview on 07/24/25 at 2:31 P.M., LPN #92 stated she functioned as the unit manager and the wound nurse for the facility, and she expected staff to notify her of any changes to the resident’s skin integrity and initiate treatment for new impaired skin areas immediately. LPN #92 said she did not recall how or when she was notified of the open areas for Resident #34. LPN #92 stated CNA #48 first identified open areas to Resident #34’s bilateral antecubital spaces on 05/23/25, but the facility did not initiate treatment until 05/29/25 when the areas were assessed to be stage IV pressure ulcers. During an interview on 07/24/25 at 2:35 P.M., the Director of Nursing (DON) stated Resident #34’s clinical condition was compromised due to acute respiratory failure and worsening bilateral arm contractures. Resident #34 had recently been ordered to receive palliative care services, the facility did not obtain timely treatment for the pressure ulcers. During an interview on 07/24/25 at 2:59 P.M., CNA #48 stated she observed small red open areas to the inside of Resident #34’s right and left elbows on 05/23/25 during a shower and she notified the nurse on duty immediately. Multiple attempts to reach RN #89 for a phone interview on 07/24/25 were unsuccessful. Review of the facility policy titled “Pressure Injury Prevention and Management”, dated 03/05/25, revealed that licensed nurses would conduct a full body skin assessment on all residents upon admission/readmission, weekly, and after any newly identified pressure injury. Findings will be documented in the medical record. Assessments of pressure injuries would be performed by a licensed nurse and documented in the resident’s medical record. The staging of pressure injuries would be clearly identified to ensure correct coding on the MDS. Nursing assistants would inspect the resident’s skin during bathing and would report any concerns to the resident’s nurse immediately after the task. Review of online guidelines per the NPUAP, dated 2014 pages 70-71 at https://npiap.com/general/custom.asp?page=2014Guidelines, revealed facilities should educate health professionals on how to undertake a comprehensive skin assessment that included the techniques for identifying blanching response, localized heat, edema, and induration. Further review of the guidelines revealed ongoing assessment of the skin was necessary in order to detect early signs of pressure damage. Visual assessment for erythema (redness of the skin) was the first component of every skin inspection. Skin redness and tissue edema resulting from capillary occlusion was a response to pressure, especially over bony prominences. Staff should conduct a head-to-toe assessment with particular focus on skin overlying bony prominences including the sacrum, ischial tuberosities, greater trochanters and heels and each time the patient was repositioned was an opportunity to conduct a brief skin assessment. This deficiency represents noncompliance investigated under Complaint Number OH00165854 (iQIES 1308588) and Complaint Number OH00163312 (iQIES 1308586) and Complaint Number OH163016 (iQIES 1308585.)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, staff interview, review of facility policy, and review of guidelines from the National Pressure Ulcer Advisory Panel (NPUAP), the facility failed to thoroughly assess the resident's skin and failed to timely identify a resident's pressure ulcer until it reached an advanced stage which resulted in actual harm to Resident #44 who developed an unstageable pressure ulcer to the left flank which required sharp debridement. The facility also failed to develop and implement a care plan to prevent skin breakdown which placed the resident (#74) at risk for more than potential harm that was not actual harm. This affected two (Residents #44 and #74) of three residents reviewed for pressure ulcers. The facility census was 73. Findings include: 1. Review of the medical record for Resident #44 revealed an admission date of 03/31/18 with diagnoses including chronic obstructive pulmonary disease (COPD), diffuse traumatic brain injury (TBI), chronic respiratory failure with hypoxia, and protein calorie malnutrition. Review of the nurse's weekly skin observation dated 06/02/23 for Resident #44, revealed there were no new areas of skin impairment noted. There was no documented evidence a weekly skin observation for Resident #44 was completed on 06/09/23 and 06/16/23. Review of the care plan dated 06/04/23 for Resident #44, revealed the resident had a potential for impairment to skin integrity related to decreased mobility, dependence on staff for all activities of daily living (ADLs), bowel and bladder incontinence, and receiving enteral nutrition. Interventions included the following: educate resident/family on skin breakdown risk factors and preventative measures, encourage, and assist to float heel as tolerated, encourage, and assist to turn and reposition often, evaluate resident's specific risk factors, provide low air loss mattress-setting per weight and comfort, once weekly skin assessment, pressure reducing cushion to chair, and provide assistance with hygiene, including peri care as needed. Review of the shower sheets dated 06/04/23, 06/07/23, 06/11/23, and 06/14/23 for Resident #44, revealed there were no new areas noted to the resident's skin. Review of the Minimum Data Set (MDS) assessment dated [DATE] for Resident #44, revealed the resident was cognitively impaired and was totally dependent on the assistance of one to two staff with activities of daily living (ADLs.) Resident #44 was assessed as not having the presence of any pressure ulcers. Review of the pressure ulcer risk assessment dated [DATE] for Resident #44, revealed the resident was at risk for the development of pressure ulcers. Review of the nurse's skin grid dated 06/17/23 for Resident #44, revealed an unstageable pressure (full thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough [dead, yellowish tissue] or eschar [dry, back hard necrotic tissue] and if the slough or eschar is removed, a Stage III or Stage IV will be revealed) to the resident's left flank which measured 9.0 centimeters (cm) in length by 5.0 cm in width with depth unable to be determined. The wound bed had green and yellow slough in the middle. Review of the nurse's skid grid dated 06/19/23 for Resident #44, revealed an unstageable pressure ulcer to the resident's left flank first identified on 06/17/23 which measured 3.0 cm in length by 3.7 cm in width with depth unable to be determined. The wound bed consisted of 10 percent (%) granulation tissue, 10% slough, and 80% eschar. The wound had approximated edges, a moderate amount of tan and green and yellow colored drainage. Review of the wound physician progress note dated 06/21/23 for Resident #44, revealed the resident had a newly identified unstageable pressure ulcer to the left flank first identified on 06/17/23 which measured 3.4 cm. in length by 5.2 cm. in width with depth unable to be determined. The composition of the wound bed tissue at the beginning of the visit was 50% granulation, 15% slough, and 35 % eschar. The wound physician performed a sharp debridement (surgical procedure of the wound with sharp instruments where devitalized tissue is removed) at the bedside using a curette to remove eschar and slough tissue and used benzocaine spray to control resident's pain during the procedure. Following the debridement procedure, the unstageable pressure area was recategorized as a stage III pressure ulcer (full thickness loss of skin, in which fat tissue is visible.) Observation of wound care on 08/01/23 at 9:11 A.M. for Resident #44 per Licensed Practical Nurse (LPN) #392, revealed the resident was resting on a pressure reduction mattress. Observation revealed the resident had a dime-sized healing pressure ulcer to the left flank. Interview with LPN #630 on 08/01/23 at 2:39 P.M. confirmed she participated in wound rounds with the wound physician, and she completed the skin grid for Resident #44 on 06/19/23. LPN #630 confirmed skin observations should be performed weekly by a licensed nurse, and Resident #44 had no skin observations recorded from 06/02/23 until 06/17/23 when the resident was found to have an unstageable pressure ulcer to his left flank. LPN #630 confirmed the pressure ulcer should have been identified before it had reached an advanced stage. LPN #630 confirmed she assisted the wound physician on 06/21/23 when he had to perform a sharp debridement on Resident #44 in order to remove the eschar and slough tissue from the wound. Interview with LPN #630 on 08/01/23 at 3:15 P.M. confirmed the State Tested Nursing Assistants (STNAs) had showered and completed the shower sheets for Resident #44 during the time period of 06/02/23 to 06/17/23 and the STNAs did not identify any new skin areas for the resident. LPN #630 confirmed the shower sheets did not take the place of a nurse's assessment for the resident's skin. 2. Review of the closed medical record for Resident #74 revealed an admission date of 07/07/23 with diagnoses including diabetes mellitus (DM), cerebral infarction, acute respiratory failure with hypoxia, asthma, hypertension, sleep apnea, atherosclerotic heart disease, and recent acute myocardial infarction and a discharge date of 07/14/23. Review of the admission assessment/baseline care plan dated 07/07/23 for Resident #74, revealed the resident had no areas of skin impairment and there were no documented interventions for the prevention of skin breakdown for resident. Review of the pressure ulcer risk assessment dated [DATE] for Resident #74, revealed the resident was at very high risk for the development of pressure ulcers. Review of the July 2023 Treatment Administration Record (TAR) for Resident #74, revealed it included weekly skin check for resident signed off as completed on 07/09/23; however, there were no other interventions or treatments included in the TAR for prevention of skin breakdown. Review of the nurse's weekly skin observation dated 07/09/23 for Resident #74, revealed the resident had no areas of skin impairment. Review of the MDS assessment dated [DATE] for Resident #74, revealed the resident was cognitively impaired, required extensive assistance of staff with ADLs, and was assessed as having a stage II pressure ulcer (partial thickness loss of skin with exposed dermis) which was not present upon admission. Review of the comprehensive care plan dated 07/14/23 for Resident #74, created after the resident had discharged , revealed the resident had an actual area of skin impairment related to pressure ulcer. The care plan goals and interventions had not been entered at the time of resident's discharge from the facility. Review of the nurse progress note dated 07/14/23 for Resident #74, revealed the resident was noted with a new superficial open area to his right buttock. Review of the nurse's skin grid dated 07/14/23 for Resident #74, revealed the resident had a stage II pressure ulcer to his left buttock which measured 1.4 cm in length by 1.4 cm in width by 0.1 cm in depth. The pressure ulcer was described as a superficial open, reddened area without drainage. Interview with LPN #554 on 08/01/23 at 8:40 A.M. confirmed Resident #74 was assessed upon admission as being at very high risk for the development of pressure ulcers. LPN #554 confirmed the resident's admission skin assessment indicated resident had no skin breakdown, and the resident's baseline care plan had no documented interventions implemented to prevent skin breakdown. LPN #554 indicated the care plan included an update on 07/14/23 indicating the resident had developed a Stage II pressure ulcer. LPN #554 confirmed the facility had conducted a weekly skin observation for Resident #74 on 07/09/23, but also confirmed the facility conducted weekly skin observations per licensed nurses for all residents, and resident #74 had no individualized interventions put in place related to his very high risk of pressure ulcer development. Review of the facility policy titled Pressure Injury Prevention and Management dated 08/20/22 revealed the facility was committed to the prevention of avoidable pressure injuries. The facility defined avoidable as the resident developed a pressure ulcer/injury and that the facility did not do one or more of the following: evaluate the resident's clinical condition and risk factors; define and implement interventions that are consistent with resident needs, resident goals, and professional standards of practice; monitor and evaluate the impact of the intervention and revise the interventions as appropriate. Licensed nurses would conduct full body skin assessments for all residents weekly. Evidence-based interventions for prevention would be implemented for all residents who were assessed at risk or who had a pressure injury present. Review of the NPUAP guidelines dated 2014 pages 70-71 at (https://npiap.com/general/custom.asp?page=2014Guidelines) revealed facilities should educate health professionals on how to undertake a comprehensive skin assessment that includes the techniques for identifying blanching response, localized heat, edema, and induration. Further review of the guidelines revealed ongoing assessment of the skin was necessary in order to detect early signs of pressure damage. Visual assessment for erythema (redness of the skin) was the first component of every skin inspection. Skin redness and tissue edema resulting from capillary occlusion was a response to pressure, especially over bony prominences. Staff should conduct a head-to-toe assessment with particular focus on skin overlying bony prominences including the sacrum, ischial tuberosities, greater trochanters and heels and each time the patient was repositioned was an opportunity to conduct a brief skin assessment. This deficiency represents non-compliance investigated under Complaint Numbers OH00144957 and OH00144740.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, staff interview, review of hospital records, review of the Food and Drug Administration's guidelines, review of manufacturer's guidelines, and review of facility policy, the facility failed to ensure residents were assessed for appropriateness of bed rail use prior to the installation of bed rails. The facility also failed to assess bed rails for possible areas of entrapment. This resulted in actual harm for one (#14) of three residents reviewed for bed rails when the facility installed grab bars to the resident's bed without conducting an assessment for their use and failed to assess the rails for entrapment risk. The resident subsequently had a fall from bed in which his head became stuck between the mattress and the grab bar. Resident #14 sustained a one-inch laceration to his neck and was transferred to the hospital where they discovered an injury to a cervical ligament which required inpatient hospital treatment. The facility identified 38 residents with half rails or grab bars. The census was 71. Findings include: Review of the medical record for Resident #14 revealed an admission date of 01/24/23 with diagnoses including malignant neoplasm of the prostate and bone, diabetes mellitus (DM), metabolic encephalopathy, affective mood disorder, and hypertension (HTN). Review of the comprehensive significant change Minimum Data Set (MDS) assessment for Resident #14 dated 01/26/23 revealed the resident was cognitively impaired and required extensive assistance of one staff with bed mobility. The resident was coded as negative for use of bed rails. Review of the care plan for Resident #14 dated 10/17/22 revealed the resident needed assistance with activities of daily living (ADLs) due to cognitive impairment, immobility, pain, status post fracture of the right hip, had a history of falls, a diagnosis of prostate cancer with metastasis to bone, was incontinent, and had multiple other co-morbidities. Interventions bilateral grab bars to increase independence, assist with bed mobility, transfers, turning and repositioning, and the resident required independence to extensive assistance for bed mobility. Review of physical therapy (PT) assessment for Resident #14 dated 03/13/23 revealed the resident was assessed by PT, and was determined to have a recent significant decline in functional mobility due to illness including COVID-19. Review of a PT treatment note for Resident #14 dated 03/16/23 revealed the resident's current level of functioning indicated maximum assistance of one staff was required with bed mobility including rolling side to side and using grab bars to assist with positioning. Review of a nurse progress note for Resident #14 dated 03/24/23 at 8:05 A.M. per Licensed Practical Nurse (LPN) #105 revealed a nurse aide notified the nurse of the resident's fall. Upon entry to room, Resident #14 was partially on floor and partially on the bed with his head positioned on the lateral portion of the bed with the bed's grab bar touching face and neck. Due to the resident's position, he was unable to speak. Staff repositioned Resident #14 on the floor for comfort and ease of breathing. The unit manager called 911. While awaiting emergency personnel arrival, the resident was alert, speaking, and answering questions appropriately. Resident #14's vital signs were taken and were within normal limits. Review of the March 2023 monthly physician's orders for Resident #14 revealed an order dated 03/24/23 at 1:23 P.M. for the resident to have bilateral grab bars to his bed. Review of the side rail assessment for Resident #14 dated 03/24/23 at 1:32 P.M. revealed resident had bilateral grab bars to his bed to assist with mobility. The side rail assessment was completed after Resident #14 had been transferred to the hospital due to his head becoming entrapped between the mattress and the grab bar. The assessment did not include an alternative to the use of grab bars was attempted nor did it address the risk of entrapment. Review of the hospital notes for Resident #14 dated 03/24/23 through 03/31/233 revealed the resident was admitted to the hospital on [DATE] with an admitting diagnosis of trauma and penetrating injury to the neck. Resident #14 presented in the emergency department from the facility after a fall in which the resident was reported to have been found between the railing of his bed after a fall. Results of magnetic resonance imaging (MRI) performed on 03/25/23 indicated Resident #14 sustained an injury to the interior longitudinal ligament at the cervical (C6-C7) disc interspace without spinal cord injury which the hospital physician believed was sustained during the fall on 03/24/23. Neurosurgery was consulted while Resident #14 was in the hospital and recommended non-operative management of the injury. Resident #14 wore a hard cervical collar which was ordered to be maintained for two weeks, and then he was to follow up with neurosurgery. While in the hospital, Resident #14 had a gastrostomy tube (a tube placed directly into the stomach) placed and was a nothing by mouth (NPO) status due to concern for esophageal injury. Review of the facility's investigation of Resident #14's fall on 03/24/23 revealed Maintenance Director (MD) #100 assessed Resident #14's bed on 03/24/23 at 9:00 A.M., and determined it was in working order with no malfunctioning of equipment noted. Further review of the investigation revealed it did not address assessment of Resident #14's beds for entrapment risk. Review of a written statement for State Tested Nursing Assistant (STNA) #125 dated 03/24/22 revealed the aide entered Resident #14's room on 03/24/23 at approximately 8:00 A.M. and noted the resident's head was stuck in the side rail and his body was on the floor. Further review of statement revealed STNA #125 saw blood on Resident #14's face and he was shaking, wet, and cold, and the nurse aide called the nurse who assisted in moving the resident. Review of a written statement for STNA #385 dated 03/24/23 revealed at approximately 8:00 A.M. Resident #14's call light was sounding, and she entered the room and found the resident with his body on the ground and his head stuck in the bed rail. STNA #385 called for STNA #125 and the nurse and the nurse aides assisted with repositioning Resident #14's body on the floor while the nurse removed the resident's head from the bed. STNA #385 confirmed Resident #14 was gurgling and she was concerned about Resident #14 choking while waiting for 911 to arrive. Review of a written statement for LPN #105 dated 03/24/23 revealed the nurse aides called her to Resident #14's room on 03/24/23 at approximately 8:00 A.M., and the resident was found with his body on the floor and his head between the bed and the grab bar. Resident #14 complained of hip pain and there was a one inch laceration noted to his neck with a small amount of blood. The nurse and nurse aides assisted the resident to the floor and 911 was called. Interview on 03/31/23 at 9:31 A.M., with LPN #105 confirmed on 03/24/23 at approximately 8:00 A.M. the nurse aide told her Resident #14 was on the floor. LPN #105 entered the resident's room and found Resident #14 with his head on the grab bar on the left side of the bed and his body was on the ground. LPN #105 confirmed she lifted Resident #14's head up and placed it on a pillow on the floor while the nurse aides repositioned Resident #14's body. Resident #14 had a small laceration to the right side of his neck that was bleeding. The unit manager, LPN #150, called 911. Resident #14 complained of hip pain and his vital signs were stable. Interview on 03/31/23 at 9:40 A.M., with LPN #150 confirmed she called 911 on 03/24/23 because she was told Resident #14 got his head stuck between his side rail and the mattress. LPN #150 confirmed when she entered Resident #14's room on 03/24/23 at approximately 8:05 A.M., another nurse and two nurse aides were with him, and he was lying on the floor on his left side with his head on a pillow. LPN #150 confirmed she was unsure when the grab bars were installed on the resident's bed. LPN #150 confirmed the physician's order for grab bars and the side rail assessment for Resident #14 were completed on 03/24/23 after Resident #14 had been taken to the hospital. Interview on 03/31/23 at 10:00 A.M., with the Director of Nursing (DON) confirmed Resident #14 had a fall on 03/24/23 in which his head was wedged between the mattress and the grab bar. DON confirmed the resident was sent to the hospital on [DATE] via 911, and Resident #14 was admitted to the hospital. DON further confirmed she was unsure of Resident #14's admitting diagnosis or if he had sustained any injuries related to the incident. DON confirmed she heard Resident #14 planned to discharge back to the facility on [DATE]. Interview on 03/31/23 at 10:05 A.M., with MD #100 confirmed he assessed Resident #14's bed on 03/24/23 at approximately 9:00 A.M. per the Administrator's request because he heard the resident got stuck between the mattress and the grab bar of his bed. MD #100 confirmed he installed the grab bars to Resident #14's bed approximately one week prior to incident on 03/24/23. MD #100 confirmed when he inspected Resident #14's bed he determined the bed was in good working order, the grab bars were compatible with the resident's bed, and were installed properly per manufacturer's instructions. MD #100 confirmed his routine maintenance and inspection of beds did not include assessing for possible entrapment risk. Interview on 03/31/23 at 10:18 A.M., with the Administrator confirmed he was not aware if Resident #14 had sustained any injuries related to his fall on 03/24/23. Administrator further confirmed the resident was taken to the hospital via 911 and admitted on [DATE] because he got his head stuck between the bed rail and the mattress. Administrator confirmed Resident #14 was still in the hospital and he heard Resident #14 was possibly going to return to the facility on [DATE]. Interview on 03/31/23 at 10:22 A.M., with STNA #125 confirmed STNA #385 called her to Resident #14's room on 03/24/23 at approximately 8:00 A.M. STNA #125 confirmed the resident was on the floor on the left side of the bed and the mattress was slid over a bit. Resident #14 was gurgling, and he had blood on his face. Resident #14's body was on the floor on the left side of the bed tangled up in a blanket and his head was facing the floor with his head stuck between the grab bar and the mattress. Resident #14 indicated his neck was hurting. The nurse aide did not move the resident but waited for LPN #105 to assess him. The nurse aides assisted with repositioning Resident #14's body on the floor while LPN #105 lifted his head up and placed it on a pillow on the floor. Observation of Resident #14's bed on 03/31/23 at 12:03 P.M., with MD #100, revealed the bed, air mattress, and grab bars were all from the same manufacturer. The air mattress was in place and functioning and was secured to the bed frame with ties provided by the manufacturer. The grab bars were in place to the bilateral upper sides of the bed. When the mattress was pushed to the right side of the bed a three-to-three-and-a-half-inch gap between the mattress and left grab bar was measured. This was confirmed with MD #100 who used a tape measure to take the measurement. Interview on 03/31/23 at 12:03 P.M., with MD #100 confirmed Resident #14's bed had not been altered since he left for the hospital on [DATE]. MD #100 stated the facility planned for Resident #14 to return to the same room with the same bed, air mattress, and grab bars when he was readmitted to the facility. Review of Food and Drug Administration (FDA) document titled, Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment, dated 03/10/06, revealed for 20 years, the FDA had received reports in which vulnerable patients had become entrapped in hospital beds while undergoing care and treatment in health care facilities. The term entrapment described an event in which a resident is caught, trapped, or entangled in the space in or about the bed rail, mattress, or bed frame. Resident entrapments might result in deaths and serious injuries. The population most vulnerable to entrapment was elderly patients and residents, especially those who were frail, confused, restless, or who had uncontrolled body movement. Entrapments have occurred in a variety of patient care settings, including hospitals, nursing homes, and private homes, and long-term care facilities reported the majority of the entrapments. Reducing the risk of entrapment involved a multi-faceted approach that included bed design, clinical assessment and monitoring, as well as meeting the needs for vulnerable residents. Review of manufacturer's guidelines for the bed and grab bars in use for Resident #14 dated 04/01/18 revealed accurate assessment of the resident and monitoring of correct maintenance and equipment use were required to prevent entrapment. Review of the facility policy titled, Proper Use of Bed Rails, dated 10/01/22, revealed alternative approaches should be attempted prior to installing or using bed rails. If bed rails are used, the facility should ensure correct installation, use, and maintenance of the rails. The following components will be considered when determining the resident's needs, and whether or not the use of bed rails meets those needs: medical diagnosis, conditions, symptoms, and or behavioral symptoms, size and weight, sleep habits, medication(s), acute medical or surgical interventions, underlying medical conditions, existence of delirium, ability to toilet self safely, cognition, communication, mobility in and out of bed, risk of falling. The assessment must include an evaluation of the alternatives that were attempted prior to the installation or the use of a bed rail. Examples of potential hazards included entrapment. The facility should inspect and regularly check the mattress and the bed rails for areas of possible entrapment. The facility should ensure the bed frame, bed rail, and mattress do not leave a gap wide enough to entrap a resident's head or body, regardless of mattress width, length, and/or depth. This deficiency represents non-compliance investigated under Master Complaint Number OH00141602 and Complaint Number OH00141506.