**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, facility investigation review, and interviews, the facility failed to ensure 1 resident (Residents #51) was free from physical abuse when 1 resident (Resident #84) hit Resident #51 on the left arm of 81 residents sampled for abuse. The findings include: Review of the facility's policy titled, Patient Protection and Response policy for Allegation/Incidents of Abuse, Neglect, Misappropriation of Property and Exploitation, dated 2/1/2023, revealed .Abuse .will not be tolerated by anyone .including .patients .The patient has the right to be free from abuse .Abuse .includes .physical abuse .Willful .as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm .Physical Abuse .includes hitting .slapping . Review of the medical record revealed Resident #51 was admitted to the facility on [DATE], with diagnoses including Dementia, Adult Failure to Thrive, Anemia, and Palliative Care. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #51 scored a 12 on the Brief Interview for Mental Status (BIMS) assessment, which indicated the resident had moderate cognitive impairment. Further review of the quarterly MDS assessment revealed Resident #51 utilized a wheelchair for mobility. Review of the Nursing Progress Notes for Resident #51 dated 6/20/2023 at 11:32 PM, revealed .Notified by .[CNA C-certified nursing assistant] .the resident [Resident #51] was in her room when another resident [Resident #84] came in to get .shoes [Resident #84 thought Resident #51 had taken her shoes] .when [Resident #51] refused to give [Resident #84] the shoe [Resident #84] hit [Resident #51] on the left arm .Assessed resident for injury .Resident denies any pain . Review of the Nursing Progress Notes for Resident #51 dated 6/21/2023 at 1:50 PM, revealed .Left arm w/ [with] no bruising .no c/o [complaints] of pain or discomfort . Review of the medical record revealed Resident #84 was admitted to the facility on [DATE], with diagnoses including Adult Failure to Thrive, Altered Mental Status, Depression, Adjustment Disorder, Dementia with Severe Agitation, Mood Disturbance, and Anxiety. Review of a quarterly MDS assessment dated [DATE], revealed Resident #84 scored an 11 on the BIMS assessment which indicated the resident had moderate cognitive impairment. Further review revealed Resident #84 utilized a wheelchair for mobility and exhibited no behaviors. Review of a comprehensive care plan for Resident #84 dated 4/27/2023, revealed .Behavioral Symptoms .Wandering in hallway and [in] other patients [patients'] rooms .Approach [intervention] .Direct resident to safe activities .Guide patient back .if she is self-propelling in a wheelchair . Review of the Nursing Progress Notes for Resident #84 dated 6/20/2023 at 10:00 PM, revealed .[CNA C] .reported that she was in [Resident #51's room] when [Resident #84] came into [Resident #51's room] accused [Resident #51] of taking her [Resident #84] shoes and hit her [Resident #51] on the left arm .Promptly removed .[Resident #84] from [Resident #51's] room . Review of a witness statement dated 6/20/2023, revealed .[Resident #51] was sitting in her wheelchair in her room .[Resident #84] was very aggravated about her [Resident #84's] shoes came in [Resident #51's room] saying [Resident #51] had her shoes .and smacked [Resident #51] on her left arm . Further review revealed CNA C signed the witness statement. Review of the Nursing Progress Notes for Resident #84 dated 6/20/2023 at 10:00 PM, revealed .Resident transported to [name of hospital] for evaluation . Resident #84 was placed in 1 on 1 supervision until transferred to the hospital. Review of the Hospital Progress Note for Resident #84 dated 6/21/2023 at 2:04 PM, revealed the resident presented to the Emergency Department (ED) with agressive behaviors. While in the ED, Resident #84 was diagnosed with an Urinary Tract Infection (UTI), treated with antibiotics, and once her behaviors stabilized was transferred back to the long term care facility. Review of the Nursing Progress Notes for Resident #84 dated 6/21/2023 at 11:51 PM, revealed .Returned to facility .order for Cephalexin [medication used to treat UTI] 500 mg [milligram] every 8 hours for 5 days for UTI . Review of the Nurse Practitioner Progress Notes for Resident #84 dated 6/22/2023 at 1:43 PM, revealed Resident #84 was evaluated after a return visit from the ED for agressive behaviors and hitting Resident #51. During an interview on 12/11/2024 at 9:15 AM, Licensed Practical Nurse (LPN E) stated she was familiar with Resident #84 and recalled the resident versus resident altercation between Residents #51 and #84 which occurred on 6/20/2023, but did not witness the altercation. LPN E stated CNA C reported Resident #84 wandered into Resident #51's room and swatted Resident #51 on the left arm. LPN E stated Resident #51 recalled the event the night of the incident and denied pain after the altercation. LPN E stated Resident #84 was placed with 1 on 1 supervision until Emergency Medical Services (EMS) arrived to transport the resident to the hospital. LPN E stated Resident #84 did not exhibit behaviors towards other residents prior to or after the incident on 6/20/2023. During an interview on 12/11/2024 at 11:10 AM, the Administrator stated he was aware of a resident-versus-resident altercation between Resident #51 and Resident #84. The facility initiated an investigation and based on CNA C's witness statement the resident-versus-resident altercation between Resident #51 and Resident #84 had occurred.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, facility documentation review, and interviews, the facility failed to protect the resident's right to be free from misappropriation and/or exploitation when a staff member deliberately used a resident's personal monetary funds without consent for personal gain for 1 resident (Resident #287) of 81 sampled residents reviewed for misappropriation of personal funds. The findings include: Review of the facility's policy titled, Patient Protection and Response Policy for Allegations/Incidents of Abuse, Neglect, Misappropriation of Property and Exploitation, dated 2/1/2023, revealed .the patient had the right to be free from abuse .misappropriation of property .definitions .misappropriation of property: the deliberate misplacement .temporary or permanent use of a patient's belongings or money without the patient's consent . Review of the medical record revealed Resident #287 was admitted to the facility on [DATE] with diagnoses including Muscle Weakness, Chronic Kidney Disease, and Malnutrition. Further review revealed the resident discharged home on [DATE]. Review of the Activities of Daily Living (ADL) documentation for Resident #287 dated 12/15/2022 through 12/22/2022, revealed Certified Nursing Assistant (CNA) A cared for Resident #287 on the following dates: 12/16/2022, 12/20/2022, 12/21/2022, and 12/22/2022. Review of a 5-day Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #287 scored a 14 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident was cognitively intact. Review of the facility's documentation dated 1/24/2023, revealed the facility reported the following information to the state designated authority: .allegation type .misappropriation of resident property .staff became aware of the incident .1/24/2023 at 1:00 PM .alleged victim [Resident #287] .alleged perpetrator [CNA A] .relationship to the alleged victim .caregiver .date and time when alleged incident occurred .12/20/2022 at 2:17 PM [date and time checks were cashed/deposited] .victim [Resident #287] called the facility today with a representative from her bank to report that two checks [amount unknown] had been cashed and the name on the check was a staff member [CNA A] . Review of a police report dated 1/24/2023, revealed .offenses .theft from building .complainant [Resident #287] .suspects [CNA A] .properties .check .value: $525.00 .case notes .on 1/24/2023 .complainant .report [reported] that two checks were stolen out of her purse .the victim was at [facility name] from 12/15/2022 to 12/22/2022 .the suspect [CNA A] was the victim's CNA and had been in the room multiple times .at one point the suspect told the victim her [Resident #287's] purse had fallen off the table and she [CNA A] had picked up the contents and put it back [inside the purse] .the victim was notified by her bank that two of her checks were deposited at [bank name] .made out to the suspect [CNA A] . Review of the facility's investigation summary dated 1/27/2023, revealed .patient [Resident #287] discharged from facility on 12/22/2022 .on 1/24/2023 [bank representative and Resident #287] called [the Administrator] about 2 checks that were written and fraudulent in nature while [Resident #287 was a patient at the facility] .the employee involved [CNA A] was immediately placed on administrative leave .on 1/27/2023 [CNA A] resigned via [by way of] phone call with [the] Administrator . Review of a Facility Action and Abuse Report dated 5/2023, revealed CNA A was added to the abuse registry for abuse: exploitation. During an interview on 12/11/2024 at 8:28 AM, the Administrator stated Resident #287 and her bank representative called the facility on 1/24/2023 (specific time unknown) to inform the facility of an occurrence of check fraud which involved a staff member. The bank representative stated Resident #287 had 2 personal checks written out to CNA A and was cashed. The Administrator stated the bank reimbursed the resident the money stolen by CNA A. The Administrator stated CNA A was placed on administrative leave pending investigation however she called the Administrator back on 1/27/2023 to immediately resign. The Administrator stated during a follow up phone call with Resident #287, the resident had told him she remembered CNA A one night (date and time unknown) awakened and observed CNA A looking through her purse. The resident stated she asked CNA A what she was doing, and CNA A responded to Resident #287 that her [Resident #287's] purse fell onto the floor, and she (CNA A) was placing the contents back inside the purse. The Administrator stated Resident #287's two personal checks were stolen and cashed by CNA A sometime during the resident's stay in December 2022 however the resident was not aware of the missing funds until she received her bank statement in January 2023. The Administrator stated Resident #287 recognized the employee's name [CNA A] when the bank representative told her the name the checks were written out to and initiated a fraud alert on her bank account. The Administrator confirmed the facility failed to protect Resident #287 from a deliberate act of misappropriation of property when CNA A had taken 2 personal checks for personal gain without Resident #287's consent. Interview with the Administrator on 12/11/2024 at 9:18 AM, confirmed the facility had identified the misappropriation of property to Resident #287 and had taken actions to correct the non-compliance. A plan of correction was developed from 1/24/2023-2/1/2023 to address the deficient practice identified. The corrective actions were validated on-site by the surveyor on 12/9/2024-12/11/2024 through interviews and review of facility documents. The facility's Plan of Correction for the Freedom of Abuse, Neglect, and Exploitation dated 1/27/2023, was presented to the survey team and documented the following corrective actions were implemented: On 1/24/2023, interviews were conducted by the Social Services Director and with all residents (and or their responsible parties) to inquire for any items that may have been lost or stolen. Results concluded no other patients were identified as having any checks or money missing. On 1/24/2023-2/1/2023, the 75 active employees received education to address financial exploitation and misappropriation of resident property. Audits for any allegation of misappropriation of property of sampled residents were completed by the Administrator or designee on 3/2023-6/2023 and confirmed there were no issues observed with misappropriation of property. 1. Surveyor interviewed the Administrator on 12/11/2024 at 9:18 AM, in the Administrator's office. Interview confirmed there had not been any further incidents involving misappropriation of resident property or exploitation. 2. Surveyor interviewed multiple staff members (in various departments) from 12/9/2024-12/11/2024 for knowledge of the in-services provided in the corrective action plan, and no knowledge deficits were identified. The deficient practice was cited as past noncompliance for F-602 and the facility is not required to submit a plan of correction.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, observations, and interviews the facility failed to implement a comprehensive care plan for fall interventions for 1 resident (Resident #60) of 5 residents reviewed for falls and failed to develop a comprehensive care plan for anticoagulant medication for 1 resident (Resident #23) of 18 residents reviewed for care plans. The findings include: Review of the facility's policy titled, Section VII: Patient Care Plans, dated 11/2023, revealed .The center will ensure an interdisciplinary and comprehensive approach to the development of the patient's care plan of care .goals for care .Problems are patient care conditions .Approaches serve as instructions for patient care .Approaches [interventions] Care Plan Approaches are specific individualized steps partners and Patients will take together to assist the patient .Approaches serve as instructions for patient care and provide for continuity of care by all partners . Review of the medical record revealed Resident #60 was admitted to the facility on [DATE], with diagnoses including History of Falls, Orthostatic Hypotension, Anemia, and Anxiety. Review of the comprehensive care plan for Resident #60 dated 1/22/2024, revealed the resident was care planned for falls with interventions to include a tab alarm [an alarm attached to resident's clothing that monitors patient movement and alerts facility staff when patients leave their beds] effective 5/9/2024, a low bed [a specialty bed which lowers to the floor] effective 6/8/2024, and 2 fall mats effective 10/19/2024. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #60 scored a 7 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident had moderate cognitive impairment. Further review of the quarterly MDS assessment revealed Resident #60 had multiple falls. During an observation on 12/9/2024 at 10:17 AM, Resident #60 was observed lying in a regular bed which was not in the lowest position. Further observation revealed the resident had 1 fall mat which was placed on the resident's right side and a tab alarm was in place and was not attached to the resident's clothing. During an interview and observation on 12/10/2024 at 1:20 PM, Certified Nursing Assistant (CNA) F stated Resident #60 was at risk for falls. The CNA stated Resident #60's bed was not a low bed and the regular bed was not in the lowest position. CNA F stated Resident #60 had 1 fall mat in place, was not sure if the resident required 2 fall mats or required a low bed. During an interview on 12/10/2024 at 1:50 PM, Licensed Practical Nurse (LPN) G stated Resident #60 was a a high risk for falls. LPN G stated the resident did not require a low bed and only required 1 fall mat. LPN G stated tab alarms were used for residents with falls, and the alarms were to be clipped to the resident's clothing. During an observation on 12/11/2024 at 9:50 AM, Resident #60 was observed lying in a regular bed which was not in the lowest position. Further observation revealed the resident had 1 fall mat which was placed on the resident's right side, a tab alarm was in place and was not attached to the resident's clothing. During an observation and interview in Resident #60's room on 12/11/2024 at 10:00 AM, CNA H stated Resident #60's bed was not a low bed, and stated the regular bed was not in the lowest position. CNA H stated she was not aware if Resident #60 required more than 1 fall mat. During an observation, record review, and interview in Resident #60's room on 12/11/2024 at 10:05 AM, with the Assistant Director of Nursing (ADON) revealed Resident #60 lying in bed with 1 fall mat placed on Resident #60's right side of bed, the tab alarm was in place; not attached to the resident's clothing, and the regular bed was not in the lowest position. The ADON reviewed Resident #60's comprehensive care plan, confirmed the resident was a falls risk and the resident had the following interventions care planned, a tab alarm, 2 fall mats, and a low bed. The ADON confirmed Resident #60's tab alarm was not attached to the resident's clothing, and the resident had 1 fall mat in use and not the 2 as developed on the care plan. The ADON confirmed the resident was lying in a regular bed and the bed was not in the lowest position. Review of the medical record revealed Resident #23 was admitted to the facility on [DATE], with diagnoses including Congestive Heart Failure, Anxiety, and Dementia. Review of a comprehensive care plan for Resident #23 initiated 11/26/2024, revealed the resident did not have a care plan for anticoagulant medication (blood thinning medication). Review of the Physician's Order for Resident #23 dated 11/26/2024, revealed .warfarin [a blood thinning medication] 2 mg [milligram] tablet at bedtime on Thursday .warfarin 4mg tablet at bedtime on Sunday, Monday, Tuesday, Wednesday, Friday, and Saturday . Review of an admission MDS assessment dated [DATE], revealed Resident #23 scored a 7 on the BIMS assessment which indicated the resident had severe cognitive impairment. Further record review revealed the resident received an anticoagulant medication. During an interview on 12/11/2024 at 12:30 PM, MDS Coordinator B confirmed Resident #23's care plan had not been developed to include anticoagulant medication.

Based on facility policy review, facility documentation review, and interview, the facility failed to ensure the Infection Preventionist attended the 11 scheduled Quality Assurance and Performance Improvement (QAPI) meetings from 2/16/2021-2/15/2022. The findings include: Review of facility documentation titled, QUALITY IMPROVEMENT COMMITTEE MEMBERS, undated, revealed the Infection Preventionist was not a member of the committee. Continued review showed the QAPI meetings were held on the 3rd Tuesday of each month. Review of the facility policy titled, QAPI PLAN, undated, revealed the Infection Preventionist was not a member of the QAPI leadership or committee. Continued review showed .All Department Managers will be educated on the QAPI Plan and expectations for leadership in the process. All partners will be educated on the QAPI concepts and empowered to participate in PIPs [Performance Improvement Plans] which directly impact their area of care . Review of the QAPI Committee Minutes dated 2/16/2021, 3/16/2021, 4/20/2021, 5/18/2021, 6/15/2021, 7/20/2021, 8/17/2021, 9/21/2021, 10/19/2021, 11/16/2021, and 2/15/2022 showed the signature lines for the Infection Preventionist was blank which indicated the Infection Preventionist had not attended the 11 scheduled QAPI meetings. During an interview on 3/22/2022 at 8:29 AM, the Infection Preventionist stated she had been the Infection Preventionist since 12/2021 and had not attended any QAPI meetings. During an interview on 3/23/2022 at 1:30 PM, the Administrator stated he was not aware the Infection Preventionist was required to attend the QAPI meetings. Continued interview revealed a part time Infection Preventionist had been employed at the facility since 11/27/2018 and a full time Infection Preventionist had been employed in that position since 12/2021. The Administrator further confirmed neither Infection Preventionists had attended the 11 scheduled QAPI meetings for the past 12 months.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, observations, and interviews, the facility failed to ensure medical information was not visible for 10 residents (#2, #17, #18, #25, #33, #52, #63, #67, #183, and #185) of 77 residents reviewed for dignity. The findings include: Review of the facility policy titled, PATIENTS RIGHTS, dated 6/2006, showed .The rights of patients are codified in both federal and state statutes with the intent of further protecting each patient's civil, religious, and human rights while they reside in a health care center. Health care centers that receive federal funds must comply, at a minimum with the federal regulations .The right to respect and dignity are requirements of partners .Protection of confidentiality is a requirement of partners . Review of the medical record showed Resident #2 was admitted to the facility on [DATE] with diagnoses including Presence of Artificial Hip Joint, Peripheral Vascular Disease, and Congestive Heart Failure. Review of the 5-day Minimum Data Set (MDS) assessment dated [DATE], showed the resident had moderate cognitive impairment. During observations on 3/21/2022 at 9:55 AM and 3/22/2022 at 10:00 AM, 1 sign was posted above Resident #2's bed that read, Heel Protectors While in Bed. The signage was visible to anyone who entered the room. During an observation and interview on 3/22/2022 at 4:56 PM, in Resident #2's room, the Director of Nursing (DON) confirmed the signage was present above Resident #2's bed and was visible to anyone who entered the room. Review of the medical record showed Resident #17 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Hemiplegia and Hemiparesis following Cerebral Infarction, Dysphagia, Gastrostomy, Aphasia, and Severe Protein-Calorie Malnutrition. Review of the quarterly MDS assessment dated [DATE], showed Resident #17 had severe cognitive impairment. During observations on 3/21/2022 at 11:03 AM and 3/22/2022 at 8:12 AM, 4 signs were posted above Resident #17's bed. The 1st sign read, Please keep water where [Resident #17's name] can reach it. Thank You. The 2nd sign read, 605B Dentures need to be taken off @ [at] Bedtime + [and] need to be cleaned! The 3rd sign read, Heel Protectors while in Bed. The 4th sign read, Please put food trays on patient's right side for meals. The signs were visible to anyone who entered the room. During an observation and interview on 3/22/2022 at 4:50 PM, in Resident #17's room, the DON confirmed the signage was present above Resident #17's bed and was visible to anyone who entered the room. Review of the medical record revealed Resident #18 was admitted to the facility on [DATE] with diagnoses including Parkinsonism, Dysphagia, Adult Failure to Thrive, Anorexia, Generalized Anxiety Disorder, Unspecified Dementia, and Age-Related Osteoporosis. Review of the quarterly MDS assessment dated [DATE], showed Resident #18 was cognitively intact. During an observation on 3/22/2022 at 3:30 PM, 2 signs were posted at the head of Resident #18's bed. The 1st sign read, Ms. [Resident #18's name] is a dependent diner, and requires tray set up and feeding by staff. Please make sure to encourage and assist resident with feeding at all meals. Thank You! 3/15/22 [3/15/2022]. The 2nd sign read, Heel Protectors While in Bed. The signs were visible to anyone who entered the room. During an observation and interview on 3/22/2022 at 4:47 PM, in Resident #18's room, the DON confirmed the signage was present above Resident #18's bed and was visible to anyone who entered the room. Review of the medical record showed Resident #25 was admitted to the facility on [DATE] with diagnoses including Displaced Fracture of Second and Third Cervical Vertebra, Implantable Cardiac Defibrillator, and History of Falling. Review of the 5-day MDS assessment dated [DATE], showed Resident #25 had severe cognitive impairment. During observations on 3/21/2022 at 10:35 AM and 3/22/2022 at 11:00 AM, 1 sign was posted above Resident #25's bed that read, HEEL PROTECTORS WHILE IN BED PLEASE. The sign was visible to anyone who entered the room. During an observation and interview on 3/22/2022 at 4:58 PM, in Resident #25's room, the DON confirmed the signage was present above Resident #25's bed and was visible to anyone who entered the room. Review of the medical record showed Resident #33 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Aphasia, Dysphagia, Gastrostomy, Chronic Obstructive Pulmonary Disease, Hypertensive Chronic Kidney Disease Stage 3, and Anxiety Disorder. Review of the quarterly MDS assessment dated [DATE], showed Resident #33 had severely impaired cognitive skills for daily decision making. During an observation on 3/22/2022 at 3:35 PM, 3 signs were posted at the head of Resident #33's bed. The 1st sign read, KEEP HEAD OF BED AT 30 DEGREES OR GREATER AT ALL TIMES. ABDOMINAL BINDER MUST BE ON AT ALL TIMES. The 2nd sign read, PLEASE HAVE MRS.[Resident #33] UP BY 11AM ON THE FOLLOWING DAYS: SUNDAY TUESDAY THURSDAY HER HUSBAND WILL BE HERE TO SEE AND WOULD LIKE TO HAVE HER UP IN WHEELCHAIR THANK YOU!! The 3rd sign read, RESIDENT IS NPO [nothing by mouth]!!!! ABSOLUTELY NOTHING BY MOUTH!!! The signs were visible to anyone who entered the room. During an observation and interview on 3/22/2022 at 4:45 PM, in Resident #33's room, the DON confirmed the signage was present and visible to anyone who entered the room. Review of the medical record showed Resident #52 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Type 2 Diabetes Mellitus, Dysphagia, Vascular Dementia with Behavioral Disturbance, and Congestive Heart Failure. Review of the quarterly MDS assessment dated [DATE], showed Resident #52 had moderate cognitive impairment. During an observation on 3/22/2022 at 3:40 PM, a sign was posted at the head of Resident #52's bed. The sign read, HEEL PROTECTORS WHILE IN BED THANK YOU. The sign was visible to anyone who entered the room. During an observation and interview on 3/22/2022 at 4:42 PM, in Resident #52's room, the DON confirmed the signage was present and visible to anyone who entered the room. Review of the medical record showed Resident #63 was admitted to the facility on [DATE] with diagnoses including Left Femur Fracture, Peripheral Vascular Disease, Hemiplegia and Hemiparesis. Review of the quarterly MDS assessment dated [DATE], showed Resident #63 had severe cognitive impairment. During a observations on 3/21/2022 at 10:15 AM and 3/22/2022 at 10:45 AM, 1 sign was posted above Resident #33's bed that read, HEEL PROTECTORS WHILE IN BED THANK YOU. The sign was visible to anyone who entered the room. During an observation and interview on 3/22/2022 at 4:57 PM, in Resident #63's room, the DON confirmed the signage was present and visible to anyone who entered the room. Review of the medical record showed Resident #67 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Dementia, History of Falling, Intervertebral Disc Degeneration of the Lumbar Region, Hypertension, and Macular Degeneration. Review of the quarterly MDS assessment dated [DATE], showed Resident #67 had severe cognitive impairment. Observations on 3/21/2022 at 10:00 AM and 3/22/2022 at 8:15 AM, showed 1 sign posted above Resident #67's bed that read, I ALWAYS NEED MY BED ALARM. The sign was visible to anyone who entered the room. During an observation and interview on 3/22/2022 at 4:48 PM, in Resident #67's room, the DON confirmed the signage was present and visible to anyone who entered the room. Review of the medical record showed Resident #183 was admitted to the facility on [DATE] with diagnoses including Displaced Spiral Fracture of Left Femur Shaft, Presence of Left Artificial Knee Joint, and Peripheral Vascular Disease. Review of the 5-day MDS assessment dated [DATE], showed Resident #183 was cognitively intact. During observations on 3/21/2022 at 10:55 AM and 3/22/2022 at 11:35 AM, 1 sign was posted at the head of Resident #183's bed that read, Heel Protectors While in Bed. The sign was visible to anyone who entered the room. During an observation and interview on 3/22/2022 at 4:54 PM, in Resident #183's room, the DON confirmed the signage was present and visible to anyone who entered the room. Review of the medical record showed Resident #185 was admitted to the facility on [DATE] with diagnoses including Bowel Resection, Anorexia, and Bipolar Disorder. Review of the 5-day MDS assessment dated [DATE], showed Resident #185 had moderate cognitive impairment. During observations on 3/21/2022 at 9:30 AM and 3/22/2022 at 7:45 AM, 1 sign was posted on Resident #185's bathroom door that read, Keep Your Head Up AT LEAST 30 Degrees while Tube Feeding is Running. The sign was visible to anyone who entered the room. During an observation and interview on 3/22/2022 at 4:53 PM, in Resident #185's room, the DON confirmed the signage was present and visible to anyone who entered the room. During an interview on 3/23/2022 at 11:19 AM, the DON stated it was the expectation of the facility that signage including resident medical information would not be visibly posted in the resident's rooms unless requested by the resident or family. The DON confirmed no documentation was available to show that Residents #2, #17, #18, #25, #33, #52, #63, #67, #183, and #185 or their families had requested any signage to be placed in their rooms.