**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure PRN orders for psychotropic drugs were limited to 14 days unless the attending physician or prescribing practitioner believed that it was appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record, and indicate the duration for the PRN order for 1 of 3 residents (Resident #11) reviewed for pharmacy services . The facility failed to ensure Resident #11 had a stop date for PRN Alprazolam (a medicine used to treat the symptoms of anxiety) This failure could affect residents who received antipsychotic/psychoactive medications and could place residents at risk of receiving unnecessary psychotropic medications. The findings included: Record review of Resident #11's face sheet dated 9/19/24 revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included: [Anxiety] a feeling of fear, dread, and uneasiness, [Hypertension], also known as high blood pressure, is a condition where the pressure in your blood vessels is too high. It's defined as a blood pressure of 140/90 or higher and [Hyperlipidemia] is a condition where there are high levels of lipids, or fats, in the blood. Record review of Resident #11's most recent comprehensive MDS assessment, dated 8/21/24 revealed the resident was moderately cognitively impaired for daily decision-making skills and was treated with anti-anxiety medications. Record review of Resident #11's comprehensive care plan dated 8/14/24 revealed the resident had a diagnosis of anxiety and used antianxiety medication as ordered by the physician. Record review of Resident #11's Order Summary Report, dated 9/19/24 revealed the following: - Alprazolam Oral Tablet 0.25 MG (Alprazolam) Give 1 tablet by mouth every 24 hours as needed for anxiety disorder, with start date 8/12/24 and no stop date. Record review of Resident #1's Medication Administration Record for August 2024 revealed the following: - Alprazolam 0.25 mg was administered prn on 8/21/24. During an observation and interview on 9/19/24 at 11:01 a.m., Resident #11 was observed in bed awake and alert. Resident #11 stated she needed the anxiety medication sometimes. On 9/19/24 at 12:02 p.m., during an interview, LVN A disclosed that she had previously given Alprazolam to Resident #11 to help with anxiety. LVN A explained that psychotropic medications like Alprazolam should be used for a limited time, usually up to 14 days. After 14 days, the nurse is required to contact the physician to reassess the resident's need for the medication. LVN A was unsure why the order for Alprazolam for Resident #11 was written for an indefinite period, and she expressed concern that the resident was at risk of falls by taking the medication for more than 14 days. During an interview and record review on 9/20/24 at 11:19 a.m., the Director of Nursing (DON) revealed that Resident #11 required the use of Alprazolam as recommended by the physician due to the resident's diagnosis. The DON stated that if the medication was taken all the time, it could result in Resident #11 being overmedicated. After reviewing Resident #11's order summary, the DON confirmed that there was no stop date on the order for prn Alprazolam. The DON revealed that the order for Alprazolam was possibly overlooked, as Resident #11 had transferred from assisted living to skilled nursing on 8/12/24, and a different set of regulations apply in skilled nursing. The DON stated that she was currently responsible for overseeing that psychotropic drugs are limited to 14 days, and her Assistant Director of Nursing (ADON) was to start monitoring this monthly moving forward to prevent this from occurring again. Record review of the facility policy and procedure titled, Policy and Procedure for Psychotropic medication use, dated 2001, updated July 2022, revealed in part, PRN orders for psychotropic medication are limited to 14 days.

Based on observation, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 2 kitchens. The facility failed to ensure staff (the cook) covered their facial hair with a hair restraint in the main kitchen. These failures could place residents who received meals and/or snacks from the kitchen at risk for food borne illness. The findings included: Observation on 09/18/2024 at 9:57 a.m. revealed the [NAME] in the main kitchen at the serving line placing uncovered sauces on the serving table while not wearing a beard restraint properly. The [NAME] was observed to have his facial hair restraint down around his neck. The [NAME] upon noticing the state surveyor placed his facial hair restraint over his mustache and beard. During an interview on 09/18/2024 at 10:04 a.m. with the [NAME] he stated staff were to use beard guards (facial hair restraints) so hair did not go into the food. The [NAME] further stated it prevents cross contamination. The [NAME] stated the beard guard (facial hair restraint) was to be worn when handling food or doing prep. During an interview on 09/19/2024 at 11:00 a.m. the Culinary Director stated the [NAME] was currently on a disciplinary action plan from August related to the [NAME] not wearing a facial hair restraint. The Culinary Director further stated due to the [NAME] not wearing his beard restraint properly on 09/18/2024 and having been written up regarding the issue previously a final disciplinary notice was issued. The Culinary Director stated the staff were to wear beard restraints (facial hair restraints) anytime they were handling and prepping food. During an interview on 09/20/2024 at 10:08 a.m. with the Culinary Director he stated hair restraints and facial hair restraints were to be worn to prevent hair from falling in the food or any other sort of contaminate that might be on the beard. The Culinary Director further stated hair falling into the food could cause food poisoning and many other issues. During an interview on 09/20/2024 at 10:16 a.m. the Dietician stated anytime staff were dealing with food items hair restraints should be used. The Dietician further stated hair and facial hair restraints were important in keeping hair out of the food during prep and service. Review of facility's policy Orientation and Education, Subject: Uniform Dress Code, revised date 01/2024, read Procedures: Associates Working with Food: Wear approved hair restraints when on duty regardless of length or presence of hair. The only exception is to remove hair restraints when delivering trays to patients/residents . Restrain all facial hair with a beard net/restraint. Review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022, U.S. Department of H&HS, revealed, 2-402 Hair Restraints, 2-402.11, Effectiveness., (A) Except as provided in paragraph (B) of this section, FOOD EMPLOYEES shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed FOOD; clean EQUIPMENT, UTENSILS, and LINENS; and unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLES.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 2 kitchens reviewed for proper food storage. The facility failed to ensure in the main kitchen pantry 2 partially used open boxes of corn starch, a partially used box of muffin mix, a box of California seedless raisins and a package of organic quinoa were properly sealed and dated with open date. The facility failed to ensure in the main kitchen pantry a partially used container of baking cocoa, and gelatin were dated with an open date. These failures could place residents who received meals and/or snacks from the kitchen at risk for food borne illness. The findings were: Observation on 07/27/2023 at 9:55 a.m. revealed in the main kitchen pantry 2 partially used opened boxes of corn starch, a partially used box of muffin mix, a box of seedless raisins, an opened to air package of quinoa not properly sealed or dated with an opened date. Observation further revealed a container of baking cocoa and gelatin without an opened date. Interview 07/27/2023 at 9:57 a.m. with the Chef revealed the kitchen had a lot of new employees and the items in the pantry should have been wrapped/closed with an opened date. Chef further stated the kitchen staff do go through an orientation and are trained to seal and date opened items before placing back in the pantry. Interview on 07/27/2023 at 2:24 p.m. the FSD stated by not ensuring the boxes and packages were properly sealed it could leave them open to air and attract anything. The FSD further stated the items should not have been brought back in the storage. Record review of the facility's policy titled Food Storage & Handling, revised March 19, 2014, revealed under Policy, revealed It is the policy of the Dining Services Department to cover, label, date, and store all foods in a safe, appropriate manner. Review of the Food Code, U.S. Public Health Service, U.S. FDA, 2017, U.S. Department of H&HS, revealed, 3-305.1, Food Storage, (A) Food shall be protected from contamination by storing the food: (1) in a clean, dry location; (2) Where it is not exposited to splash, dust, or other contamination.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, interview and record review, the facility failed to ensure assessments accurately reflected the resident's status for 1 of 12 residents (Resident #9) reviewed for accuracy of assessments. The facility failed to ensure Resident #9's Quarterly MDS assessment accurately reflected the resident received oxygen. This failure could place residents at risk of inadequate care. The findings were: Record review of Resident #9's face sheet, dated 5/20/22, revealed she was admitted to the facility on [DATE] with diagnoses which included congestive heart failure (condition when the heart cannot supply the cells with enough blood which results in fatigue and shortness of breath). Record review of Resident #9's electronic consolidated physician orders revealed an order with a start date of 12/3/21 for oxygen via nasal cannula (device used to deliver supplemental oxygen through a lightweight tube with one end splits into two prongs that are placed in the nostrils and the other end of the tube is connected to an oxygen generator) at 2 LPM at bedtime for apnea (difficulty breathing) and as needed for apnea. Record review of Resident #9's February 2022 TARs revealed it was checked the resident received oxygen daily from 2/1/22 to 2/28/22. Record review of Resident #9's MDS, a Quarterly assessment dated [DATE], revealed under Section O it was not checked the resident received oxygen. Record review of Resident #9's Care Plans, revised on 3/3/22, revealed there was no care plan for oxygen. Observation on 5/18/22 at 9:47 a.m. revealed Resident #9 received oxygen at 2 LPM via nasal cannula connected to an oxygen concentrator. In an interview on 5/18/22 at 10:15 a.m., Resident #9's Family Member E stated Resident #9 required oxygen at night and as needed because her o2 sats would drop (levels of blood oxygen would drop below normal values) and he could not remember when she started to receive oxygen). In an interview on 5/19/22 at 11:46 a.m., after the MDS Nurse looked at Resident #9's oxygen order, stated the resident had received oxygen since December 2021. The MDS Nurse reviewed Resident #9's Quarterly MDS, dated [DATE] and said the MDS was not checked to indicate the resident received oxygen. The MDS Nurse stated he would look through the resident's clinical record to determine if the resident received oxygen and stated frankly, I missed that one. In an interview on 5/19/22 at 12:01 p.m., the DON stated to ensure accuracy of the MDS she would review residents' MDS and did not indicate how often they were reviewed. The DON stated if the MDS was not accurate, she did not see any direct risk to the resident other than it could affect the reimbursement rate from Medicare. In an interview on 5/19/22 at 4:00 p.m., the Administrator stated she relied on the MDS Nurse and DON to ensure the residents' MDS were completed accurately and did not see any risk to the resident if the MDS was inaccurate. Record review of CMS's RAI Version 3.0 Manual, October 2019, Chapter 3 Section O, Page O-1 to O-3, revealed Steps for Assessment 1. Review the resident's medical record to determine whether or not the resident received or performed any of the treatments, procedures, or programs within the last 14 days. Under Coding Instructions for Column 2 was Check all treatments, procedures, and programs received or performed by the resident after admission/entry or reentry to the facility and within the 14-day look-back period. Under Oxygen therapy was Code [check] continuous or intermittent oxygen administered via mask, cannula, etc., delivered to a resident to relieve hypoxia [low blood oxygen level] in this item. Record review of the undated policy Certifying the Accuracy of the Resident Assessment revealed All personnel who complete any portion of the MDS assessment .must sign a hard copy of such assessment certifying the accuracy of that portion of that assessment. .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, interview, and record review the facility failed to ensure residents received adequate supervision and assistance devices were put into place prevent accidents for 1 of 2 residents (Resident #34) reviewed for falls. The facility failed ensure Resident #34's fall mat was on the floor, next to her bed to prevent potential fall injury for 3 of 4 days. This failure could place the resident who require supervision assistance due at risk for falls with injuries, hospitalization, and a decreased quality of life. The findings were: Record review of Resident #34's face sheet dated 5/20/22 revealed she was admitted to the facility on [DATE] with diagnoses which included dementia (progressive or persistent loss of intellectual functioning) and psychotic disorder (a mental health problem that causes people to perceive or interpret things differently from those around them) with hallucinations (an experience involving the apparent perception of something not present). Record review of Resident #34's Fall Risk Evaluation, dated 2/2/22, revealed the resident was at risk for falls. Record review of Resident #34's Fall Risk Evaluation, dated 3/18/22, revealed the resident was at risk for falls. Record review of Resident #34's nurse's note written by RN H, dated 3/18/22, revealed Resident #34 was found on the floor with a small skin tear to her left elbow. The nurse cleansed the wound and completed an assessment. Record review of Resident #34's care plan for the focus area of The resident is high risk for falls, initiated 1/21/22 and revised on 4/26/22 revealed under Interventions was Due to fall on 3/18 [2022] resident will have a floor [fall] matt [sic] when in bed with an initiation date of 3/18/22. Record review of Resident #34's MDS, a Quarterly assessment dated [DATE], revealed her cognitive skills for daily decision making were severely impaired, required total dependence of 1 staff member to physically assist with bed mobility, and had 1 fall with minor injury since the last assessment. Record review of the facility's Occurrence Report (Incident/Accident Log) from 11/18/21 to 5/17/22 revealed Resident #34's last fall occurred on 3/18/22. Observation on 5/17/22 at 10:03 a.m. revealed Resident #34 was lying in bed with the bed in the lowest position and there was no fall mat on the floor next to the bed. Further observation of Resident #34's room revealed there was no fall mat in the room or in the resident's bathroom. Observation on 5/17/22 at 2:56 p.m. revealed Resident #34 was lying in bed with the bed in the lowest position and there was no fall mat on the floor next to the bed. Further observation of Resident #34's room revealed there was no fall mat in the room or in the resident's bathroom. Observation on 5/18/22 at 10:57 revealed Resident #34 was lying in bed with the bed in the lowest position and there was no fall mat on the floor next to the bed. Further observation of Resident #34's room revealed there was no fall mat in the room or in the resident's bathroom. Observation on 5/19/22 at 9:54 a.m. revealed Resident #34 was lying in bed with the bed in the lowest position and there was no fall mat on the floor next to the bed. Further observation of Resident #34's room revealed there was no fall mat in the room or in the resident's bathroom. In an interview on 5/19/22 at 9:55 a.m., CNA F stated Resident #34 did not need a fall mat on the floor when she was in bed. CNA F stated Resident #34 required total assistance with her care and did not state if the resident needed assistance with repositioning. In an interview on 5/19/22 at 9:58 a.m., LVN G stated when Resident #34 was in bed the bed would be in the lowest position and thought there should be a fall mat on the floor in case the resident fell out of bed, but she was not sure. LVN G looked at Resident #34's care plan and stated the care plan indicated a floor (fall) mat should be on the floor when the resident was in bed. Observation on 5/19/22 at 10:05 a.m. with LVN G in Resident #34's room, LVN G stated there was no fall mat on the floor and verified there was no fall mat in the room. In an interview on 5/19/22 at 10:12 a.m., LVN G stated the risk of not having a fall mat on the floor when Resident #34 was in bed could result in skin tears and increase the resident's risk for injuries. In an interview on 5/19/22 from 12:01 p.m. to 12:35 p.m., the DON stated Resident #34 had 1 fall from her bed. The DON reviewed Resident #34's care plan and stated after the 3/18/22 fall, the facility implemented a mat on the floor when the resident was in bed to decrease her risk of injury. The DON stated Resident #34 was no longer at risk for falling out of bed as the resident did not move much in bed and relied on staff to reposition her. In an interview on 5/19/22 at 4:00 p.m., the Administrator stated Resident #34 could get injured if she fell out of bed and there was no fall mat on the floor next to the bed. The Administrator stated the fall mat was to decrease the resident's risk for injury. Record review of the facility's undated policy Care Planning revealed An individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing and psychological needs is developed for each resident. Further review of the policy revealed 2. The comprehensive care plan is based on a thorough assessment that includes, but is not limited to, the MDS .5. Care plan interventions are designed after careful consideration of the relationship between the resident's problem areas and their causes .6. Identifying problem area and their causes and developing interventions that are targeted and meaningful to the resident are interdisciplinary processes that require careful data gathering, proper sequencing of events and complex clinical decision making 8. Assessment of residents are ongoing and care plans are revised as information about the resident and the resident's condition change. .

. Based on observations, interviews, and record reviews the facility failed to store all drugs and biologicals in locked compartments under proper temperature controls for 1 of 1 medication refrigerators in 1 of 2 medication storage rooms for the facility, in that: The facility failed to ensure Refrigerator #1 [Medication Fridge North] maintained a safe storage temperature. This deficient practice could lead to residents being exposed to medications that do not produce the expected therapeutic effects or produce negative reactions. The findings were: In a record review on 05/19/22 at 3:58 PM of Refrigerator Temperature logs for the north hallway were completed up to the current date; no missing entries, and no entries were outside of safe temperature ranges [36-41 degrees Fahrenheit]. This log included the Medication, Specimen and Snack refrigerators on the north hallway. In a record review of Storage of Medications policy, undated, revealed in step #2 nursing staff shall be responsible for maintain medication storage .in a clean, safe and sanitary manner. Further, in step #11, Medications requiring refrigeration .3. Monitored for temperature at least one time per day; and 4. Temperatures above 41 degrees F[ahrenheit] should be reported to the DON. In observations and interview with LVN A on 5/19/2022 at 3:03 PM the medication refrigerator on the north hallway displayed a temperature of 43 degrees Fahrenheit. Interior ambient air in the refrigerator and items in the refrigerator felt cool at this time. LVN A stated she did not know how long the temperature had been above 41, and the last time anyone would have been in the Medication Refrigerator North Hallway would have been before lunch [noon] trays were delivered when a resident received his scheduled liquid pain medication. This surveyor stayed in the area and did not observe anyone unlock the medication room door, go in or unlock to open the refrigerator. At 3:20 PM the medication refrigerator on the north hallway displayed a temperature of 44 degrees Fahrenheit. LVN A stated she would notify her boss for further instructions as she wasn't sure what to do about an elevated temperature. LVN A stated it was the responsibility of the overnight nurse to check the temperatures of the refrigerators and document the findings. In an interview on 05/19/22 at 03:51 PM the DON stated the ADON was responsible for reviewing temperature logs daily. The DON stated if the temperature readings are beyond the parameters for safety, the expectation was for the ADON to notify management, and remove items from that refrigerator, place an out of order sign on the refrigerator, and notify maintenance. The DON stated if medications were used that had been outside the parameters for safe temperatures, the resident could have adverse drug reactions or subtherapeutic effects of medications. The DON stated all items in the Medication Fridge North were disposed of and reordered when it was discovered they were out of parameters for safety. In an interview on 05/19/22 at 3:55 PM the ADON stated the temperature logs are reviewed every morning by her. She stated, if necessary, she will recheck temperatures if the log shows temperatures close to being out of range. On weekends or scheduled days off, this task was assigned to the weekend nurse. She stated the equipment would be placed out of order, items removed, and maintenance notified to service the refrigerator. .

. Based on observations, interviews and record reviews, the facility failed to store food in accordance with professional standards for food safety in 1 of 1 refrigerator reviewed for food service safety. The facility failed to ensure Refrigerator #1 [Resident Snack Fridge North] maintained a safe storage temperature. This failure could place residents at risk for food-born illness and food contamination. The findings include: In a record review on 05/19/22 at 3:58 PM of Refrigerator Temperature logs for the north hallway were completed up to the current date; no missing entries, and no entries were outside of safe temperature ranges (36-41 degrees Fahrenheit). This log included the Medication, Specimen and Snack refrigerators on the north hallway. In a record review of food receiving and storage policy, undated, revealed in step #8, refrigerated foods must be stored below 41 degrees F[ahrenheit]. Further in step #11, monitored at designated intervals .and documented. Step #13, Food items and snacks kept on the nursing unit must be maintained as indicated below: 1. All food items to be kept below 41 degrees F[ahrenheit]; 3. Refrigerators must have working thermometers and be monitored for temperatures. In an observatio n on 5/19/2022 at 3:08 PM Refrigerator #1 [Resident Snack Fridge North] on the north hallway displayed a temperature of 50.2 degrees Fahrenheit. At 3:16 PM the resident snack refrigerator on the north hallway displayed a temperature of 52.0 degrees Fahrenheit. This refrigerator had individual serving packages of pudding, gelatin, juice, and milk containers in it. The interior ambient air was only slightly cooler than room temperature to the touch and the items did not feel refrigerated to the touch; items were not cold. In an interview and observation on 05/19/22 at 3:11 PM LVN A confirmed the temperature reading of 50.2 degrees Fahrenheit; LVN A adjusted the dial in the fridge to colder; LVN A stated she did not know if anyone had recently been in this refrigerator recently. This survey stayed in the area and did not observe any one open the refrigerator until at 3:22 PM when LVN A confirmed temperature reading at 52.0 degrees Fahrenheit. LVN A stated she would notify her boss for further instructions as she wasn't sure what to do about an elevated refrigerator temperature. LVN A stated it is the responsibility of the overnight nurse to check the temperatures of the refrigerators and document the findings. In an interview on 05/19/22 at 03:51 PM the DON stated the ADON was responsible for reviewing temperature logs daily. The DON stated if the temperature readings are beyond the parameters for safety, the expectation was for the ADON to notify management, and remove items from that refrigerator, place an out of order sign on the refrigerator, and notify maintenance. The DON stated if food items were consumed that had been outside the parameters for safe temperatures, the resident would be at risk for a food borne illness. The DON stated all items in the resident snack refrigerator were disposed of and reordered when it was discovered they were out of parameters for safety. In an interview on 05/19/22 at 3:55 PM the ADON stated the temperature logs are reviewed every morning by her. She stated, if necessary, she will recheck temperatures. On weekends or scheduled days off, this task was assigned to the weekend nurse. She stated the equipment would be placed out of order, items removed, and maintenance notified to service the refrigerator. .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on interview and record review, the facility failed to obtain the hospice election form and physician certification of terminal illness, most recent hopsice plan of care, hospice medication information for for 1 of 1 resident (Resident #34) reviewed for hospice services, in that: The facility failed to obtain Resident #34's most recent hospice Plan of care, hospice election form, physician certification of the terminal illness, hospice medication information and interdisciplinary documentation of the hospice staff that provided services. This failure could place residents who receive hospice services at-risk of receiving inadequate end-of-life care due to a lack of documentation, coordination of care and communication of resident needs. The findings were: Record review of Resident #34's face sheet dated 5/20/22 revealed she was admitted to the facility on [DATE] with diagnoses which included dementia (progressive or persistent loss of intellectual functioning) and psychotic disorder a mental health problem that causes people to perceive or interpret things differently from those around them) with hallucinations (an experience involving the apparent perception of something not present). Record review of Resident #34's electronic consolidated physician orders revealed an order dated 1/20/22 for hospice care from Hospice Company I. Record review of Resident #34's MDS, a Quarterly assessment dated [DATE], revealed her cognitive skills for daily decision making were severely impaired and received hospice care. Record review of Resident #34's care plan initiated 1/24/22 revealed she received hospice services. Record review of Resident #34's electronic clinical record revealed there was no recent hospice plan of care, hospice election form, physician certification of the terminal illness, hospice medication information, or any other interdisciplinary documentation of the hospice staff that provided services from Hospice Company I. In an interview on 5/20/22 at 9:11 a.m., LVN A stated she thought Resident #34's hospice documents were scanned and put into the electronic clinical record. LVN A reviewed Resident #34's electronic clinical record and stated she could not find any documents from Hospice Company I. LVN A then looked around the nurse's station for a binder from Hospice Company I for Resident #34 and could not find one. LVN A stated Hospice Company I would visit Resident #34 three times a week and she did not know what documentation they would leave with the facility. In an interview on 5/20/22 at 12:43 p.m. the Administrator stated she had uploaded Resident #34's hospice records into the resident's electronic chart under the document section today (5/20/22) after the surveyor had requested the documents. The Administrator stated Resident #34's hospice records were in the hospice company's electronic chart system that a few people in the facility had access to and did not state who those people were beside the administrator when the surveyor inquired. When asked how nurses could view Resident #34's electronic clinical record that had not been uploaded in the document section before 5/20/22, the Administrator stated the hospice staff would communicate with the facility nurse when hospice was in the facility. In an interview on 5/20/22 at 3:36 p.m. the Administrator stated the Social Worker would coordinate care between the facility and hospice and was responsible for ensuring the hospice documents were in place. In an interview on 5/20/22 at 3:44 p.m. the Social Worker stated she would contact the hospice company chosen by the resident's family so the hospice company could assess the resident, but she was not responsible for ensuring the hospice documentation was in the facility. The social worker stated historically, the hospice documents would be kept in a binder at the nurse's stations. Record review of Hospice Company I's Hospice Service Agreement (contract) with the facility, dated 5/1/14, revealed under Section III. Services to be Furnished by the LTCF [Long-Term Care Facility] was B. LTCF Services .17. Ensure proper documentation of all services provided to Hospice Company I patients. Hold in strict confidence all patient records and Protected Health Information in accordance with applicable Federal and State laws and regulations and disclose Protected Health Information only to persons or entities authorized by law or written consent of the patient or the patient's representatives. Records shall be maintained for a period of five years from date of discharge or such other time period as required by applicable Law. LTCF shall take reasonable precautions to safeguard records against loss, destruction and unauthorized disclosure. Further review of the contract revealed under Section VIII. Compliance was Hospice Company I and LTCF hereby acknowledge that it is the full intent of both parties to comply with all Federal and State laws and regulations that apply to the provision of hospice care in long term care facilities. Record review of the facility's undated policy Hospice Services revealed the objective was To provide end of life care for residents. Under Responsibility: the Licensed Nursing Home Administrator, Nursing services and Social Services were listed. Under Guideline was 7. Hospice will be requested to provide documentation in the resident's clinical record. Record review of the facility's undated policy Clinical Records revealed the objective was To make certain that clinical records on each resident are maintained with accepted professional standards. Under Responsibility: the Licensed Nursing Home Administrator and Designee were listed. Under Guideline was 1. Clinical records will be: a. Complete; b Accurately documented; c. Readily accessible for resident care; and d. Systematically organized. 2. The Clinical record will contain an accurate and functional representation of the actual experience of the resident. 3. The Clinical record will contain enough information to show that The Health Center knows the status of the individual, has adequate plans of care, and provides sufficient evidence of the effects of the care provided. 4. Documentation will provide a picture of the resident's progress, including response to treatment, change in condition and changes in treatmen .11. The clinical record will contain: Signed and dated clinical documentation from all health care practitioners involved in the resident's care .

. Based on observation, interview, and record review, the facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition for 1 of 1 facility, in that: 1. One of two clothes dryers was inoperable. This deficient practice could result in residents not having access to hygienically clean laundry and the prevention of transmissions of disease or infection could be inhibited. The findings were: In a record review of documents provided by facility revealed a credit card receipt dated 5/11/2022 with service technicians' business card. In a record review of documents provided by facility revealed email dated 5/19/2022 that service technician would be at the facility on Saturday [5/21/2022] at 8AM to check on dryer #1. In an observation on 5/20/2022 at 10:35 AM in the laundry area one of two clothes dryers was not running. In an interview on 5/20/2022 at 10:40 AM with Housekeeper J, she stated Dryer 1 has not worked for about 3 weeks now. She stated it could affect residents receiving laundry on time. Housekeeper J stated it has not affected residents because she and other [unnamed] staff work longer hours now to complete all the laundry using only one dryer. In an interview on 5/20/2022 at 11:20 AM with the Executive Director, he stated Dryer 1 was not functioning, service technician was on site 5/11/22 to service both dryer 1 and dryer 2, but dryer 1 needed a part to complete servicing. He stated the part has been ordered, and the technician is scheduled to return to the facility tomorrow morning [5/21/2022] at 8:00 AM. The Executive Director stated that it is important to the residents' dignity and for infection control to have hygienically clean laundry. He stated having only one operable dryer has not affected the residents, instead the facility has extended the hours of the laundry operations. The Executive Director stated that if Dryer 2 breaks down before Dryer 1 is repaired, the facility can utilize the residential dryers on the Assisted and Independent Living side of the facility to ensure residents have access to hygienically clean laundry. Policy and procedure for functional equipment was not received prior to survey exit. Facility did not provide a work order for when the Dryer 1 stopped working. .

. Based on interview and record review, the facility failed to conduct regular inspection of all bed frames and bed rails as part of a regular maintenance program to identify areas of possible entrapment. The facility failed to have a maintenance progra to conduct regular inspections of the beds and bedrails to identify risks and problems. This failure could place residents with bed rails at risk of entrapment, injury, or death. The findings were: Observation on 5/18/22 at 8:50 a.m. revealed Resident #10's ¼ bed rail (assist/grab bar) on one side of the bed stuck away from the mattress about 4 inches, the other bed rail was flush with the mattress. Interview on 5/19/22 at 10:12 a.m. with LVN G revealed Resident #10's bed rail that was about 4 inches from the mattress, she stated the Supply Manager would service the bed rails (assist/grab bars). In an interview and observation on 5/19/22 at 10:13 a.m., the Supply Manager, stated he would inspect the bed rails on the residents' bed when informed by staff, did not have a set routine to inspect the bed rails and stated he would walk by the residents' room and look at the bed rails from the hallway. In a further interview on 5/19/22 at 1:33 p.m. the Supply Manager stated he did not have the manufacturer's manual for the residents' beds or for the bed rail (assists/grab bars) on the beds. In an interview on 5/19/22 at 4:00 p.m., the Administrator stated the beds in the facility came with the enabler bars (assist/grab bars/bed rails) on the beds so the residents could use them for repositioning and to hang the bed remote control on. The Administrator stated if the enabler bars were ¼ bars then they would be considered bed rails, but they were enabler bars. The Administrator stated the enabler bars (assist/grab bars/bed rails) should be pushed in so would be flushed with the mattress; if the enabler bar was more than 4 ¾ inches from the mattress then there was the potential the resident could get trapped between the mattress and the enabler bar. The Administrator did not state how the facility monitors the enabler bars (assist/grab bars/bed rails) to ensure they are correctly installed on the bed. Record review of an undated bed brochure provided by the facility from the bed manufacturer revealed the bed came with an assist device (assist bar/bed rail) and did not indicate how far away from the mattress it should be from the assist device. Record review of U.S. Department of Health and Human Services Food and Drug Administration (FDA) Center for Devices and Radiological Health's Guidance for Industry and FDA Staff Hospital Bed System Dimensional and assessment Guidance to Reduce Entrapment issued 3/10/2006, pages 13-17, revealed the space between the bed rail and mattress was a potential zone of entrapment. The FDA is recommending a dimensional limit of less than 120 mm (4 ¾ inches) for the area between the inside surface of the rail and the compressed mattress. Record review of the facility's undated policy Bed Safety revealed Our facility shall strive to provide a safe sleeping environment for the resident. Under Policy Interpretation and Implementation was 1. The resident's sleeping environment shall be assessed by the interdisciplinary team, considering the resident's safety, medical conditions, comfort, and freedom of movement, as well as input from the resident and family regarding previous sleeping habits and bed environment. 2. To try to prevent deaths/injuries from the beds and related equipment (including the frame, mattress, side rails, headboard, footboard, and bed accessories), the facility shall promote the following approaches: a. Inspection by maintenance staff of all beds and related equipment as part of our regular bed safety program to identify risks and problems including potential entrapment risks; b. review the gaps withing the bed system are within the dimensions established by the FDA d. Ensure that bed side rails are properly installed using the manufacturer's instructions and other pertinent safety guidance to ensure proper fit (e.g., avoid bowing, ensure proper distance from the headboard and footboard, etc.). .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and time frames to meet a resident's medical, nursing, and mental and psychosocial needs, for 7 of 12 residents (#7, #8, #9, #10, #15, #19, and #34) reviewed for care plans, in that: 1a. The facility did not develop a care plan to address Resident #9 received oxygen. 1b. The facility did not develop a care plan to address Resident #9's use of bed rails (enabler bars) to reposition in bed and risk for injury. 2. The facility did not develop a care plan to address Resident #7's use of bed rails (enabler bars) to reposition in bed and risk for injury. 3. The facility did not develop a care plan to address Resident #8's use of bed rails (enabler bars) to reposition in bed and risk for injury. 4. The facility did not develop a care plan to address Resident #10's use of bed rails (enabler bars) to reposition in bed and risk for injury. 5. The facility did not develop a care plan to address Resident #15's use of bed rails (enabler bars) to reposition in bed and risk for injury. 6. The facility did not develop a care plan to address Resident #19's use of bed rails (enabler bars) to reposition in bed and risk for injury. 7a. The facility did not develop a care plan to address Resident #34's use of bed rails (enabler bars) to reposition in bed and risk for injury. 7b. The facility did not implement the care plan intervention of placement of a mat on the floor when Resident #34 was in bed to decrease the risk of injury if the resident fell out of bed. This deficient practice could place residents at risk for not receiving necessary care and services needed to maintain optimal health. The findings were: 1. Resident #9: 1a. Record review of Resident #9's face sheet, dated 5/20/22, revealed she was admitted to the facility on [DATE] with diagnoses which included congestive heart failure (condition when the heart cannot supply the cells with enough blood which results in fatigue and shortness of breath). Record review of Resident #9's electronic consolidated physician orders revealed an order with a start date of 12/3/21 for oxygen via nasal cannula (device used to deliver supplemental oxygen through a lightweight tube with one end splits into two prongs that are placed in the nostrils and the other end of the tube is connected to an oxygen generator) at 2 LPM at bedtime for apnea (difficulty breathing) and as needed for apnea. Record review of Resident #9's February 2022 TARs revealed it was checked the resident received oxygen daily from 2/1/22 to 2/28/22. Record review of Resident #9's MDS, a Quarterly assessment dated [DATE], revealed under Section O it was not checked the resident received oxygen. Record review of Resident #9's Care Plans, revised on 3/3/22, revealed there was no care plan for oxygen. Observation on 5/18/22 at 9:47 a.m. revealed Resident #9 received oxygen at 2 LPM via nasal cannula connected to an oxygen concentrator. In an interview on 5/18/22 at 10:15 a.m., Resident #9's Family Member E stated Resident #9 required oxygen at night and as needed because her o2 sats would drop (levels of blood oxygen would drop below normal values) and he could not remember when she started to receive oxygen. In an interview on 5/19/22 at 11:46 a.m., after the MDS Nurse looked at Resident #9's oxygen order, stated the resident had received oxygen since December 2021. The MDS Nurse reviewed Resident #9's Quarterly MDS, dated [DATE] and said the MDS was not checked to indicate the resident received oxygen. The MDS Nurse stated he would look through the resident's clinical record to determine if the resident received oxygen and stated frankly, I missed that one. The MDS Nurse reviewed Resident #9's care plans and stated he did not see a care plan for the oxygen. 1b. Record review of Resident #9's Side Rail/Bed Evaluation assessment, dated 11/19/21 revealed the resident would use the left and right assist/grab bars (bed rails) for mobility and was initiated on admission. Under the Informed Consent for Use of Bed Rails section it was blank and did not indicate consent had been obtained. Record review of Resident #9's electronic clinical record revealed there was no consent for the assist/grab bars (bed rails). Record review of Resident #9's MDS, a Quarterly assessment dated [DATE], revealed her BIMS score was 8 out of 15, indication of her cognitive skills for daily decision making were moderately impaired, and Section P indicated bed rails were not used as a restraint. Record review of Resident #9's care plan, revised 4/19/22, revealed there was no care plan for the assist/grab bars (bed rails). Observation on 5/18/22 at 10:19 a.m. revealed Resident #9 was lying in bed and grabbed hold of the ¼ bed rails (assist/grab bars) that were on both sides of the bed near the head of the bed as CNA B and CNA C provided incontinent care to the resident. In an interview on 5/19/22 from 12:00 p.m. to 12:35 p.m., the DON reviewed Resident #9's electronic clinical record and stated the resident had an assessment for the bed rails but did not have a consent and did not have a care plan for the bed rails. 2. Resident #7: Record review of Resident #7's face sheet, dated 5/20/22, revealed she was admitted to the facility on [DATE] with diagnoses which included hemiplegia (paralysis of one side of the body) and hemiparesis (partial weakness on one side of the body), bipolar disorder (mental health condition that causes extreme mood swings), major depressive disorder (depression), anxiety disorder (type of mental health condition) and cognitive deficit following cerebral infarctions (decline in mental status as result of a stroke). Record review of Resident #7's electronic clinical record revealed there was no assessment for the assist/grab bars (bed rails) and there was no consent. Record review of Resident #7's MDS, a Quarterly assessment dated [DATE], revealed her BIMS score was 7 out of 15, indication her cognitive skills for daily decision making were severely impaired, and Section P indicated bed rails were not used as a restraint. Record review of Resident #7's care plan, revised 4/29/22, revealed there was no care plan for the assist/grab bars (bed rails). Observation on 5/17/22 at 10:51 a.m. revealed Resident #7 was lying in bed with ¼ bed rails (assist/grab bars) on both sides of the bed, towards the head of the bed. Observation on 5/18/22 at 5:06 p.m. revealed Resident #7 was lying in bed with ¼ bed rails (assist/grab bars) on both sides of the bed, towards the head of the bed. In an interview on 5/19/22 from 12:00 p.m. to 12:35 p.m., the DON reviewed Resident #7's electronic clinical record and stated the resident did not have an assessment for the bed rails and did not have a consent or a care plan. 3. Resident #8: Record review of Resident #8's face sheet dated 5/20/22 revealed he was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included aphasia following cerebral infarction (difficulty speaking after a stroke), dementia (progressive or persistent loss of intellectual functioning) and hypertension (high blood pressure). Record review of Resident #8's Side Rail/Bed Evaluation assessment, dated 3/25/21 revealed No bed rails(s)/Bar(s) were used. Record review of Resident #8's electronic clinical record revealed there was no assessment for the assist/grab bars (bed rails) and there was no consent. Record review of Resident #8's MDS, a Quarterly assessment dated [DATE], revealed his BIMS score was 13 out of 15, indication of his cognitive skills for daily decision making were intact, and Section P indicated bed rails were not used as a restraint. Record review of Resident #8's care plan, revised 4/19/22, revealed there was no care plan for the assist/grab bars (bed rails). Observation on 5/17/22 at 10:42 a.m. revealed Resident #8 was lying in bed with ¼ bed rails (assist/grab bars) on both sides of the bed, towards the head of the bed. In an interview on 5/17/22 at 4:00 p.m., Resident #8 stated he used the ¼ bed rails (assist/grab bars) for repositioning. In an interview on 5/19/22 from 12:00 p.m. to 12:35 p.m., the DON reviewed Resident #8's electronic clinical record and stated the resident had a bed rail assessment but it did not indicate bed rails would be used, did not have a consent for the bed rails or a completed bed rail assessment and did not have a care plan for the bed rails. 4. Resident #10: Record review of Resident #10's face sheet, dated 5/20/22, revealed the resident was admitted to the facility on [DATE] with diagnoses which included dementia (progressive or persistent loss of intellectual functioning), osteoporosis (disease that weakens bones) and hypertension (high blood pressure). Record review of Resident #10's Side Rail/Bed Evaluation assessment, dated 11/22/21 revealed the resident would use the left and right assist/grab bar (bed rails) for mobility which were initiated on admission. Under the Informed Consent for Use of Bed Rails section it was blank and did not indicate consent had been obtained. Record review of Resident #10's electronic clinical record revealed there was no consent for the assist/grab bars (bed rails). Record review of Resident #10's MDS, a Quarterly assessment dated [DATE], revealed her BIMS score was 4 out of 15, indication of her cognitive skills for daily decision making were severely impaired, and Section P indicated bed rails were not used as a restraint. Record review of Resident #10's care plan, revised 4/19/22, revealed there was no care plan for the assist/grab bars (bed rails). Observation on 5/17/22 at 10:19 a.m. revealed Resident #10 was lying in bed with ¼ bed rails (assist/grab bars) on both sides of the bed, towards the head of the bed. In an interview on 5/19/22 from 12:00 p.m. to 12:35 p.m., the DON reviewed Resident #10's electronic clinical record and stated the resident had an assessment for the bed rails and did not have a consent or a care plan for the bed rails. 5. Resident #15: Record review of Resident #15's face sheet, dated 5/20/22, revealed she was admitted to the facility on [DATE] with diagnoses which included anemia (low levels of iron in the blood), unsteadiness on her feet, dementia (progressive or persistent loss of intellectual functioning) and osteoporosis (disease that weakens bones). Record review of Resident #15's Side Rail/Bed Evaluation assessment, dated 3/11/22 revealed the resident would use the left and right assist/grab bar (bed rails), the assist/grab bars were initiated on admission for mobility. Under the Informed Consent for Use of Bed Rails section it was blank and did not indicate consent had been obtained. Record review of Resident #15's electronic clinical record revealed there was no consent for the assist/grab bars (bed rails). Record review of Resident #15's MDS, an admission assessment dated [DATE], revealed her BIMS score was 9 out of 15, indication of her cognitive skills for daily decision making were moderately impaired, and Section P indicated bed rails were not used as a restraint. Record review of Resident #15's care plan, revised 5/18/22, revealed there was no care plan for the assist/grab bars (bed rails). Observation on 5/17/22 at 10:05 a.m. revealed Resident #15 was lying in bed with ¼ bed rails (assist/grab bars) on both sides of the bed, towards the head of the bed. Observation and interview on 5/17/22 at 3:18 p.m., revealed Resident #15 was lying in bed with ¼ bed rails (assist/grab bars) on both sides of the bed, towards the head of the bed. Resident #15 stated she used the ¼ bed rails to steady herself when she gets in and out of bed. In an interview on 5/19/22 from 12:00 p.m. to 12:35 p.m., the DON reviewed Resident #15's electronic clinical record and stated the resident did have an assessment for the bed rails and did not have a signed consent or a care plan for the bed rails. 6. Resident #19: Record review of Resident #19's face sheet, dated 5/20/22, revealed she was admitted to the facility on [DATE] with diagnoses which included hemiplegia (paralysis of one side of the body) and hemiparesis (partial weakness on one side of the body), hypertension (high blood pressure) and unsteadiness on her feet. Record review of Resident #19's electronic clinical record revealed there was no assessment for the assist/grab bars (bed rails) and there was no consent. Record review of Resident #19's MDS, a Quarterly assessment dated [DATE], revealed her BIMS score was 13 out of 15, indication of her cognitive skills for daily decision making were intact, and Section P indicated bed rails were not used as a restraint. Record review of Resident #19's care plan, revised 3/16/22, revealed there was no care plan for the assist/grab bars (bed rails). In an interview and observation on 5/18/22 at 10:53 a.m., Resident #19 stated the ¼ bed rails (assist/grab bars) that were on both sides of her bed, had always been on her bed. Resident #19 stated she thought the bed rails came with them [the bed] and she used them to reposition herself in bed. Resident #19 stated she thought a family member had signed a consent for the bed rails when she was admitted to the facility. In an interview on 5/19/22 from 12:00 p.m. to 12:35 p.m., the DON reviewed Resident #19's electronic clinical record and stated the resident did not have an assessment for the bed rails and did not have a consent or a care plan for the bed rails. 7. Resident #34: 7a. Record review of Resident #34's face sheet dated 5/20/22 revealed she was admitted to the facility on [DATE] with diagnoses which included dementia (progressive or persistent loss of intellectual functioning) and psychotic disorder a mental health problem that causes people to perceive or interpret things differently from those around them) with hallucinations (an experience involving the apparent perception of something not present). Record review of Resident #34's Side Rail/Bed Evaluation assessment, dated 1/25/22 revealed No bed rails(s)/Bar(s) were used. Record review of Resident #34's electronic clinical record revealed there was no assessment for the assist/grab bars (bed rails) and there was no consent. Record review of Resident #34's MDS, a Quarterly assessment dated [DATE], revealed her cognitive skills for daily decision making were severely impaired and Section P indicated bed rails were not used as a restraint. Record review of Resident #34's care plan initiated 1/24/22 and revised 4/15/22 revealed there was no care plan for the assist/grab bars (bed rails). Observation on 5/17/22 at 2:56 p.m., revealed Resident #34 was on her right side in bed with her head against one of the ¼ bed rails (assist/grab bars) that were on both sides of the bed, towards the head of the bed. Observation on 5/18/22 at 10:57 a.m. revealed Resident #34 was lying in bed with ¼ bed rails (assist/grab bars) on both sides of the bed, towards the head of the bed. In an interview on 5/19/22 from 12:00 p.m. to 12:35 p.m., the DON reviewed Resident #34's electronic clinical record and stated the resident had a bed rail assessment but it did not indicate bed rails would be used, did not have a consent for the bed rails or a completed bed rail assessment or a care plan for the bed rails. 7b. Record review of Resident #34's Fall Risk Evaluation, dated 2/2/22, revealed the resident was at risk for falls. Record review of Resident #34's Fall Risk Evaluation, dated 3/18/22, revealed the resident was at risk for falls. Record review of Resident #34's nurse's note written by RN H, dated 3/18/22, revealed Resident #34 was found on the floor with a small skin tear to her left elbow. The nurse cleansed the wound and completed an assessment. Record review of Resident #34's care plan for the focus area of The resident is high risk for falls, initiated 1/21/22 and revised on 4/26/22 revealed under Interventions, Due to fall on 3/18 [2022] resident will have a floor [fall] matt [sic] when in bed with an initiation date of 3/18/22. Record review of Resident #34's MDS, a Quarterly assessment dated [DATE], revealed her cognitive skills for daily decision making were severely impaired, required total dependence of 1 staff member to physically assist with bed mobility, and had 1 fall with minor injury since the last assessment. Record review of the facility's Occurrence Report (Incident/Accident Log) from 11/18/21 to 5/17/22 revealed Resident #34's last fall occurred on 3/18/22. Observation on 5/17/22 at 10:03 a.m. revealed Resident #34 was lying in bed with the bed in the lowest position and there was no fall mat on the floor next to the bed. Further observation of Resident #34's room revealed there was no fall mat in the room or in the resident's bathroom. Observation on 5/17/22 at 2:56 p.m. revealed Resident #34 was lying in bed with the bed in the lowest position and there was no fall mat on the floor next to the bed. Further observation of Resident #34's room revealed there was no fall mat in the room or in the resident's bathroom. Observation on 5/18/22 at 10:57 a.m. revealed Resident #34 was lying in bed with the bed in the lowest position and there was no fall mat on the floor next to the bed. Further observation of Resident #34's room revealed there was no fall mat in the room or in the resident's bathroom. Observation on 5/19/22 at 9:54 a.m. revealed Resident #34 was lying in bed with the bed in the lowest position and there was no fall mat on the floor next to the bed. Further observation of Resident #34's room revealed there was no fall mat in the room or in the resident's bathroom. In an interview on 5/19/22 at 9:55 a.m., CNA F stated Resident #34 did not need a fall mat on the floor when she was in bed. In an interview on 5/19/22 at 9:58 a.m., LVN G stated when Resident #34 was in bed the bed would be in the lowest position and thought there should be a fall mat on the floor in case the resident fell out of bed, but she was not sure. LVN G looked at Resident #34's care plan and stated the care plan indicated a floor (fall) mat should be on the floor when the resident was in bed. Observation on 5/19/22 at 10:05 a.m. with LVN G in Resident #34's room, LVN G stated there was no fall mat on the floor and verified there was no fall mat in the room. In an interview on 5/19/22 at 10:12 a.m., LVN G stated the risk of not having a fall mat on the floor when Resident #34 was in bed could result in skin tears and increase the resident's risk for injuries. In an interview on 5/19/22 from 12:01 p.m. to 12:35 p.m., the DON stated Resident #34 had 1 fall from her bed. The DON reviewed Resident #34's care plan and stated after the 3/18/22 fall, the facility implemented a mat on the floor when the resident was in bed to decrease her risk of injury. The DON stated Resident #34 was no longer at risk for falling out of bed as the resident did not move much in bed and relied on staff to reposition her. In an interview on 5/19/22 at 4:00 p.m., the Administrator stated Resident #34 could get injured if she fell out of bed and there was no fall mat on the floor next to the bed. The Administrator stated the fall mat was to decrease the resident's risk for injury. In an interview on 5/19/22 at 12:01 p.m., the DON stated she would periodically review the resident's care plans to ensure they were accurate. The DON stated if the care plan was not accurate it would not be detrimental to the resident as their daily care would still be the same. The DON stated the ¼ bed rails on the resident's bed were called enabler bars, were for the resident to move side to side in bed, the facility did not have to do an assessment or consent for them as the facility did not consider them to be bed rails and she did not see any risk of harm to the resident with the enabler bars on the bed. The DON stated if the enabler bars were considered a bed rail then yes, she would have that care planned as there are risks involved with that and you would have to have things in place. The DON then stated if the enabler bars were considered a bed rail then there would be a risk of entrapment to the resident. In an interview on 5/19/22 at 4:00 p.m., the Administrator stated she relied on the DON and MDS Nurse to ensure the care plan was accurate and did not state what the risk would be to the residents if the ¼ bed rails (assist/grab bars) were not care planned. Record review of the facility's undated policy Care Planning revealed An individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing and psychological needs is developed for each resident. Further review of the policy revealed 2. The comprehensive care plan is based on a thorough assessment that includes, but is not limited to, the MDS 5. Care plan interventions are designed after careful consideration of the relationship between the resident's problem areas and their causes .6. Identifying problem area and their causes and developing interventions that are targeted and meaningful to the resident are interdisciplinary processes that require careful data gathering, proper sequencing of events and complex clinical decision making .8. Assessment of residents are ongoing and care plans are revised as information about the resident and the resident's condition change .9. The Care Planning/Interdisciplinary Team is responsible for the review and updating of care plans: .d. At least quarterly. Record review of the facility's undated policy Bed Safety revealed Our facility shall strive to provide a safe sleeping environment for the resident. Under Policy Interpretation and Implementation was 1. The resident's sleeping environment shall be assessed by the interdisciplinary team, considering the resident's safety, medical conditions, comfort, and freedom of movement, as well as input from the resident and family regarding previous sleeping habits and bed environment. 2. To try to prevent deaths/injuries from the beds and related equipment (including the frame, mattress, side rails, headboard, footboard, and bed accessories), the facility shall promote the following approaches: a. Inspection by maintenance staff of all beds and related equipment as part of our regular bed safety program to identify risks and problems including potential entrapment risks; b. review the gaps withing the bed system are within the dimensions established by the FDA .d. Ensure that bed side rails are properly installed using the manufacturer's instructions and other pertinent safety guidance to ensure proper fit (e.g., avoid bowing, ensure proper distance from the headboard and footboard, etc.); and e. Identify additional safety measures for residents who have been identified as having a higher than usual risk for injury including entrapment (e.g., altered mental status, restlessness, etc.) .6. The staff shall obtain consent for the use of side rails from the resident or the resident's legal representative prior to their use .9. Before using side rails for any reason, the staff shall inform the resident and family about the benefits and potential hazards associated with side rails. .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observations, interviews and record reviews, the facility failed to ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice and the comprehensive person-centered care plan for 3 (# 35, # 32 and # 9) of 11 residents reviewed for oxygen therapy in that: oxygen concentrator filters had grayish white particulate matter on them. This deficient practice could affect residents who receive oxygen therapy and could result in impaired delivery of effective and safe purified oxygen at the desired concentrations ultimately causing infection or respiratory compromise. The findings were: Record review of an undated Care and Use of Oxygen Concentrators policy revealed in Section E - Care and Maintenance of the Concentrator: Nursing Responsibilities 1. Once a week remove the filter .wash with soap and water, air dry and return to the concentrator. Record review of Manufactures' Service Manual, 2008, indicated on page 7 under Preventative Maintenance Summary instructions to clean air filter on back of unit weekly. On page 6 under Air Filter and Oxygen Outlet a Warning that operation .in extreme environments or without the air filter will prematurely occlude the intake .cause a decrease in the unit performance. Further, on page 9 under Simplified Troubleshooting, occluded filters can cause pressure to rise slowly or have low pressures; Additionally on page 10, Troubleshooting Chart A, indicates occlude filters can cause fluctuating oxygen flow, low oxygen concentration. 1. Record review of admission Record printed 5/20/2022 revealed Resident # 35 was an [AGE] year-old woman with an initial admit date of 1/23/2017; pertinent diagnoses included: history of COVID-19; obstructive sleep apnea [characterized by episodes of complete or partial collapse of the airway with an associated decrease in oxygen saturation or arousal from sleep]; chronic obstructive pulmonary disease [inflammatory lung disease causes breathing difficulty, mucus production and wheezing]. Record review of quarterly MDS date 4/29/2022 for Resident # 35 revealed in Section C - Cognitive Patterns, a BIMS [Brief Interview for Mental Status] summary score of 10 [indicative of moderately impaired cognition]. In Section O - Special Treatments, Resident # 35 received oxygen while a resident of this facility. Record review of Care Plan, with a last reviewed date of 05/02/2022, for Resident # 35 revealed Focus Area for oxygen therapy related to respiratory illness with interventions: 02 via nasal cannula at 2 liters continuous humidified, with a revision date of 4/16/2022. Record review of Physicians' Orders for Resident # 35 revealed orders for oxygen at 2 liters per minute via nasal cannula continuous with a start date of 2/19/2021; May increase up to 5 liters per minute via nasal cannula for respiratory distress with a revision date of 7/17/2021; clean oxygen concentrator air filter weekly and PRN, every night shift Sundays for patency and as needed with a start date of 5/6/2021. Record review of treatment administration record for Resident # 35 revealed positive documentation that the oxygen concentrator filter was cleaned on the following dates: 3/6/2022, 3/13/2022, 3/20/2022, 3/27/2022, 4/3/2022, 4/10/2022, 4/17/2022, 4/24/2022, 5/1/2022, 5/8/2022, and 5/15/2022; with no documentation indicating PRN entries. In an observation on 5/17/2022 at 10:24 AM, Resident # 35 had a red sign attached to her door frame indicating oxygen in use; Resident # 35 was sitting up in her wheelchair dressed appropriately for the weather; oxygen concentrator was powered on; nasal cannula positioned appropriately; external filter on the oxygen concentrator had white particulate matter interspersed across its surface. 2. Record review of admission Record printed 05/23/2022 revealed Resident # 32 was a [AGE] year-old woman with an initial admit date of 7/3/2019; with pertinent diagnoses: chronic obstructive pulmonary disease; pulmonary hypertension [high blood pressure affecting the arteries of the lungs, right side of the heart resulting in chest pain and shortness of breath]. Record review of annual MDS, dated [DATE], for Resident # 32 revealed in Section C - Cognitive Patterns, a BIMS [Brief Interview for Mental Status] summary score of 10 [indicative of moderately impaired cognition]. In Section O - Special Treatments, Resident # 32 received oxygen while a resident of this facility. Record review of Care Plan, with a last reviewed date of 05/04/2022 for Resident # 32 revealed Focus Area for oxygen therapy related to ineffective gas exchange related to COPD; interventions included: administer O2 as ordered, initiated 5/19/2022. Record review of Physicians' Orders for Resident # 32 revealed orders for oxygen at 1-3 liters per minute via nasal cannula continuous with a start date of 3/11/2020; clean oxygen concentrator air filter weekly and PRN, every night shift Saturdays and as needed with a start date of 3/11/2020. Record review of treatment administration record for Resident # 32 revealed positive documentation that the oxygen concentrator filter was cleaned on the following dates: 3/5/2022, 3/12/2022, 3/19/2022, 3/27/2022, 4/2/2022, 4/9/2022, 4/16/2022, 4/23/2022, 4/30/2022, 5/7/2022, and 5/14/2022; with no documentation indicating PRN entries. In an observation on 5/17/2022 at 11:56 AM Resident # 32 was sitting up in her wheelchair dressed appropriately for the weather; oxygen concentrator was powered on; nasal cannula positioned appropriately; external filter on the oxygen concentrator had white particulate matter covering its surface. 3. Record review of Resident #9's face sheet, dated 5/20/22, revealed she was admitted to the facility on [DATE] with diagnoses which included congestive heart failure (a condition when the heart can't supply the cells with enough blood which results in fatigue and shortness of breath). Record review of quarterly MDS, dated [DATE] revealed Resident # 9 was a [AGE] year-old woman admitted [DATE]. Under Section C - Cognitive Patterns, a BIMS [Brief Interview for Mental Status] summary score of 8 [indicative of moderately impaired cognition]. Section J - Health Conditions indicates shortness of breath with exertion. Under Section O - Special Treatments, oxygen was not checked. Record review of Resident #9's Care Plans, revised on 3/3/22, revealed there was no care plan for oxygen. Record review of Resident #9's electronic consolidated physician orders revealed an order with a start date of 12/3/21 for oxygen via nasal cannula (device used to deliver supplemental oxygen through a lightweight tube with one end splits into two prongs that are placed in the nostrils and the other end of the tube is connected to an oxygen generator) at 2 LPM at bedtime for apnea (difficulty breathing) and as needed for apnea. Further review of Resident #9's electronic consolidated physician orders revealed an order with a start date of 3/13/22 to Clean Oxygen Concentrator Air Filter on the night shift every Sunday and as needed. Record review of Resident #9's May 2022 TARs revealed it was checked the oxygen filter was cleaned on Sunday 5/15/22. Observation on 5/17/22 at 10:46 a.m. revealed the oxygen concentrator in Resident #9's room had 2 filters which were covered with white lint. The oxygen concentrator was off, and oxygen was not being administered to Resident #9 at the time of the observation. Observation on 5/18/22 at 9:47 a.m. revealed Resident # 9 received oxygen at 2 liters per minute via nasal cannula connected to the oxygen concentrator with the 2 filters covered with white lint. Observation and interview on 5/18/22 at 10:01 a.m. with LVN A in Resident # 9's room as the resident received oxygen via nasal cannula connected to the oxygen concentrator with the filters covered with lint. LVN A removed the filter on Resident #9's oxygen concentrator and picked off some of the lint, stated it was dirty. LVN A replaced the filter covered with lint back on to the oxygen concentrator without cleaning it, stated she did not know whose responsibility it was to clean the concentrator's filters. Resident # 9 continued to receive oxygen via nasal cannula that was connected to the oxygen concentrator with the filters covered with lint. In an interview on 5/18/22 at 10:15 a.m. with Resident # 9's Family Member E in Resident # 9's room as the resident received oxygen via nasal cannula connected to the filters covered with lint, Family Member E stated Resident # 9 required oxygen at night and as needed because her o2 sats would drop (levels of blood oxygen would drop below normal values). In an observation on 5/18/2022 between 10:25 and 10:35 AM with CNA B and CNA C during peri-care, Resident # 9 was receiving supplemental oxygen via nasal cannula that was connected to an oxygen concentrator with a dirty filter. In an interview on 5/18/22 at 10:38 a.m., LVN A stated the nurses who worked the night shift were responsible for cleaning the filters on the oxygen concentrators. In an interview on 5/18/22 at 6:00 p.m. the DON stated the oxygen filters on the oxygen concentrator were cleaned on the night shift once a week and did not know why the filters were dirty when observed by the surveyors. The DON stated the risk to the residents of having a dirty filter on the oxygen concentrator was that the oxygen concentrator could result in overheating. In an interview on 5/20/2022 at 12:17 PM with the ADON she stated it is the responsibility of the night nurse assigned to whichever residents receive oxygen to change the oxygen filters on the designated night. The ADON stated documentation of task completion is done on the Treatment Administration Record. The ADON stated that it is her responsibility as an ADON to check that duties are completed. The ADON stated she did not know what the outcome could be if the filters are dirty but could negatively impact the resident in some way. If oxygen concentrator alarms are sounding, and cannot be cleared, she stated it would be removed from the floor as out of service, and oxygen tanks could be used instead. .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observations, interviews, and record reviews the facility failed to review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation for 8 of 8 residents (Resident #9, #7, #8, #15, #19, #34, #33, and #10) review for bed rails in that: 1. Resident #9 did not have a consent for the quarter bed rails on her bed. 2. Resident #7 did not have a consent and initial assessment for her quarter bed rails on her bed. 3. Resident #8 did not have a consent for his quarter bed rails on his bed and had an initial assessment for bed rails, but the assessment indicated bed rails would not be used. 4. Resident #15 did not have a consent for the quarter bed rails on her bed. 5. Resident #19 did not have a consent and initial assessment for her quarter bed rails on her bed. 6. Resident #34 did not have a consent for her quarter bed rails on her bed and her assessment indicated bed rails would not be used. 7. Resident #33 did not have a consent for the quarter bed rails on her bed. 8. Resident #10 did not have a consent for the quarter bed rails on her bed. These failures could affect residents who utilized some type of bedrail in the facility and could put the residents at risk for potential injuries. The findings were: 1. Resident #9: Record review of Resident #9's face sheet, dated 5/20/22, revealed she was admitted to the facility on [DATE] with diagnoses which included congestive heart failure (condition when the heart cannot supply the cells with enough blood which results in fatigue and shortness of breath). Record review of Resident #9's Side Rail/Bed Evaluation assessment, dated 11/19/21 revealed the resident would use the left and right assist/grab bars (bed rails) for mobility and was initiated on admission. Under the Informed Consent for Use of Bed Rails section it was blank and did not indicate consent had been obtained. Record review of Resident #9's electronic clinical record revealed there was no consent for the assist/grab bars (bed rails). Record review of Resident #9's MDS, a Quarterly assessment dated [DATE], revealed her BIMS score was 8 out of 15, indication of her cognitive skills for daily decision making were moderately impaired, and Section P indicated bed rails were not used as a restraint. Record review of Resident #9's care plan, revised 4/19/22, revealed there was no care plan for the assist/grab bars (bed rails). Observation on 5/18/22 at 10:19 a.m. revealed Resident #9 was lying in bed and grabbed hold of the ¼ bed rails (assist/grab bars) that were on both sides of the bed near the head of the bed as CNA B and CNA C provided incontinent care to the resident. In an interview on 5/19/22 from 12:00 p.m. to 12:35 p.m., the DON reviewed Resident #9's electronic clinical record and stated the resident had an assessment for the bed rails but did not have a consent. 2. Resident #7: Record review of Resident #7's face sheet, dated 5/20/22, revealed she was admitted to the facility on [DATE] with diagnoses which included hemiplegia (paralysis of one side of the body) and hemiparesis (partial weakness on one side of the body), bipolar disorder (mental health condition that causes extreme mood swings), major depressive disorder (depression), anxiety disorder (type of mental health condition) and cognitive deficit following cerebral infarctions (decline in mental status as result of a stroke). Record review of Resident #7's electronic clinical record revealed there was no assessment for the assist/grab bars (bed rails) and there was no consent. Record review of Resident #7's MDS, a Quarterly assessment dated [DATE], revealed her BIMS score was 7 out of 15, indication her cognitive skills for daily decision making were severely impaired, and Section P indicated bed rails were not used as a restraint. Record review of Resident #7's care plan, revised 4/29/22, revealed there was no care plan for the assist/grab bars (bed rails). Observation on 5/17/22 at 10:51 a.m. revealed Resident #7 was lying in bed with ¼ bed rails (assist/grab bars) on both sides of the bed, towards the head of the bed. Observation on 5/18/22 at 5:06 p.m. revealed Resident #7 was lying in bed with ¼ bed rails (assist/grab bars) on both sides of the bed, towards the head of the bed. In an interview on 5/19/22 from 12:00 p.m. to 12:35 p.m., the DON reviewed Resident #7's electronic clinical record and stated the resident did not have an assessment for the bed rails and did not have a consent. 3. Resident #8: Record review of Resident #8's face sheet dated 5/20/22 revealed he was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included aphasia following cerebral infarction (difficulty speaking after a stroke), dementia (progressive or persistent loss of intellectual functioning) and hypertension (high blood pressure). Record review of Resident #8's Side Rail/Bed Evaluation assessment, dated 3/25/21 revealed No bed rails(s)/Bar(s) were used. Record review of Resident #8's electronic clinical record revealed there was no assessment for the assist/grab bars (bed rails) and there was no consent. Record review of Resident #8's MDS, a Quarterly assessment dated [DATE], revealed his BIMS score was 13 out of 15, indication of his cognitive skills for daily decision making were intact, and Section P indicated bed rails were not used as a restraint. Record review of Resident #8's care plan, revised 4/19/22, revealed there was no care plan for the assist/grab bars (bed rails). Observation on 5/17/22 at 10:42 a.m. revealed Resident #8 was lying in bed with ¼ bed rails (assist/grab bars) on both sides of the bed, towards the head of the bed. In an interview on 5/17/22 at 4:00 p.m., Resident #8 stated he used the ¼ bed rails (assist/grab bars) for repositioning. In an interview on 5/19/22 from 12:00 p.m. to 12:35 p.m., the DON reviewed Resident #8's electronic clinical record and stated the resident had a bed rail assessment but it did not indicate bed rails would be used, did not have a consent for the bed rails or a completed bed rail assessment. 4. Resident #15: Record review of Resident #15's face sheet, dated 5/20/22, revealed she was admitted to the facility on [DATE] with diagnoses which included anemia (low levels of iron in the blood), unsteadiness on her feet, dementia (progressive or persistent loss of intellectual functioning) and osteoporosis (disease that weakens bones). Record review of Resident #15's Side Rail/Bed Evaluation assessment, dated 3/11/22 revealed the resident would use the left and right assist/grab bar (bed rails), the assist/grab bars were initiated on admission for mobility. Under the Informed Consent for Use of Bed Rails section it was blank and did not indicate consent had been obtained. Record review of Resident #15's electronic clinical record revealed there was no consent for the assist/grab bars (bed rails). Record review of Resident #15's MDS, an admission assessment dated [DATE], revealed her BIMS score was 9 out of 15, indication of her cognitive skills for daily decision making were moderately impaired, and Section P indicated bed rails were not used as a restraint. Record review of Resident #15's care plan, revised 5/18/22, revealed there was no care plan for the assist/grab bars (bed rails). Observation on 5/17/22 at 10:05 a.m. revealed Resident #15 was lying in bed with ¼ bed rails (assist/grab bars) on both sides of the bed, towards the head of the bed. Observation and interview on 5/17/22 at 3:18 p.m., revealed Resident #15 was lying in bed with ¼ bed rails (assist/grab bars) on both sides of the bed, towards the head of the bed. Resident #15 stated she used the ¼ bed rails to steady herself when she gets in and out of bed. In an interview on 5/19/22 from 12:00 p.m. to 12:35 p.m., the DON reviewed Resident #15's electronic clinical record and stated the resident did have an assessment for the bed rails and but did not have a signed consent. 5. Resident #19: Record review of Resident #19's face sheet, dated 5/20/22, revealed she was admitted to the facility on [DATE] with diagnoses which included hemiplegia (paralysis of one side of the body) and hemiparesis (partial weakness on one side of the body), hypertension (high blood pressure) and unsteadiness on her feet. Record review of Resident #19's electronic clinical record revealed there was no assessment for the assist/grab bars (bed rails) and there was no consent. Record review of Resident #19's MDS, a Quarterly assessment dated [DATE], revealed her BIMS score was 13 out of 15, indication of her cognitive skills for daily decision making were intact, and Section P indicated bed rails were not used as a restraint. Record review of Resident #19's care plan, revised 3/16/22, revealed there was no care plan for the assist/grab bars (bed rails). In an interview and observation on 5/18/22 at 10:53 a.m., Resident #19 stated the ¼ bed rails (assist/grab bars) that were on both sides of her bed, had always been on her bed. Resident #19 stated she thought the bed rails came with them [the bed] and she used them to reposition herself in bed. Resident #19 stated she thought a family member had signed a consent for the bed rails when she was admitted to the facility. In an interview on 5/19/22 from 12:00 p.m. to 12:35 p.m., the DON reviewed Resident #19's electronic clinical record and stated the resident did not have an assessment for the bed rails and did not have a consent. 6. Resident #34: Record review of Resident #34's face sheet dated 5/20/22 revealed she was admitted to the facility on [DATE] with diagnoses which included dementia (progressive or persistent loss of intellectual functioning) and psychotic disorder a mental health problem that causes people to perceive or interpret things differently from those around them) with hallucinations (an experience involving the apparent perception of something not present). Record review of Resident #34's Side Rail/Bed Evaluation assessment, dated 1/25/22 revealed No bed rails(s)/Bar(s) were used. Record review of Resident #34's electronic clinical record revealed there was no assessment for the assist/grab bars (bed rails) and there was no consent. Record review of Resident #34's MDS, a Quarterly assessment dated [DATE], revealed her cognitive skills for daily decision making were severely impaired and Section P indicated bed rails were not used as a restraint. Record review of Resident #34's care plan initiated 1/24/22 and revised 4/15/22 revealed there was no care plan for the assist/grab bars (bed rails). Observation on 5/17/22 at 2:56 p.m., revealed Resident #34 was on her right side in bed with her head against one of the ¼ bed rails (assist/grab bars) that were on both sides of the bed, towards the head of the bed. Observation on 5/18/22 at 10:57 a.m. revealed Resident #34 was lying in bed with ¼ bed rails (assist/grab bars) on both sides of the bed, towards the head of the bed. In an interview on 5/19/22 from 12:00 p.m. to 12:35 p.m., the DON reviewed Resident #34's electronic clinical record and stated the resident had a bed rail assessment but it did not indicate bed rails would be used, did not have a consent for the bed rails or a completed bed rail assessment. 7. Resident #33: Record review of admission Record printed 5/20/2022, revealed Resident #33 had an initial admit date of 1/24/2022 with the following pertinent diagnoses: heart failure; morbid (severe) obesity; muscle weakness (generalized); and lack of coordination. Record review of quarterly MDS [Minimum data set] with a target date of 05/03/2022, revealed in Section C - Cognitive patterns a summary score of 15 [13 to 15 points indicative of intact cognition] for the Brief Interview for Mental Status. Section P - Restraints and alarms revealed bedrail not used as physical restraint. Record review of Side Rail/Bed Evaluation dated 1/24/2022, revealed Resident #33 had left and right Assists/Grab Bars on admission for mobility during transfers to enable mobility. In an observation on 05/17/2022 at 11:04 AM, Resident # 33 was sitting up in her wheelchair at bedside table, dressed appropriately for weather including foot ware, independently feeding self. Quarter bedrails at head of bed. In an interview on 05/18/2022 at 6:25 PM, Resident # 33 stated she use those [bedrails] to move around in bed, or when I am first getting out of bed for balance. 8. Resident #10: Record review of Resident #10's face sheet, dated 5/20/22, revealed the resident was admitted to the facility on [DATE] with diagnoses which included dementia (progressive or persistent loss of intellectual functioning), osteoporosis (disease that weakens bones) and hypertension (high blood pressure). Record review of Resident #10's Side Rail/Bed Evaluation assessment, dated 11/22/21 revealed the resident would use the left and right assist/grab bar (bed rails) for mobility which were initiated on admission. Under the Informed Consent for Use of Bed Rails section it was blank and did not indicate consent had been obtained. Record review of Resident #10's electronic clinical record revealed there was no consent for the assist/grab bars (bed rails). Record review of Resident #10's MDS, a Quarterly assessment dated [DATE], revealed her BIMS score was 4 out of 15, indication of her cognitive skills for daily decision making were severely impaired, and Section P indicated bed rails were not used as a restraint. Record review of Resident #10's care plan, revised 4/19/22, revealed there was no care plan for the assist/grab bars (bed rails). Observation on 5/17/22 at 10:19 a.m. revealed Resident #10 was lying in bed with ¼ bed rails (assist/grab bars) on both sides of the bed, towards the head of the bed. In an interview on 5/19/22 from 12:00 p.m. to 12:35 p.m., the DON reviewed Resident #10's electronic clinical record and stated the resident had an assessment for the bed rails and did not have a consent. In an interview on 5/19/22 from 12:00 p.m. to 12:35 p.m., the DON stated the ¼ bed rails on the resident's bed were called enabler bars and were for the resident to move side to side in bed, the facility did not have to do an assessment or consent for them as the facility did not consider them to be bed rails and she did not see any risk of harm to the resident with the enabler bars on the bed. The DON stated if the enabler bars were considered a bed rail then yes, she would have that care planned as there are risks involved with that and you would have to have things I place. The DON then stated if the enabler bars were considered a bed rail then there would be a risk of entrapment to the resident. In an interview on 5/19/22 at 4:00 p.m., the Administrator stated the beds in the facility came with the enabler bars (assist/grab bars/bed rails) on the beds so the residents could use them for repositioning and to hang the bed remote control on, and the facility did not have to complete any paperwork (bed rail assessment or obtain consent) since they were enabler bars. The Administrator verified the facility did not obtain consents or complete a bed rail assessment for residents who had enabler bars (bed rails) on their beds. The Administrator stated if the enabler bars were ¼ bars then they would be considered bed rails, but they were enabler bars. The Administrator then asked the surveyor if the enabler bars were bed rails. Record review of an undated bed brochure provided by the facility revealed the bed came with an assist device (assist bar/bed rail). Record review of the facility's undated policy Bed Safety revealed Our facility shall strive to provide a safe sleeping environment for the resident. Under Policy Interpretation and Implementation was 1. The resident's sleeping environment shall be assessed by the interdisciplinary team, considering the resident's safety, medical conditions, comfort, and freedom of movement, as well as input from the resident and family regarding previous sleeping habits and bed environment. 2. To try to prevent deaths/injuries from the beds and related equipment (including the frame, mattress, side rails, headboard, footboard, and bed accessories), the facility shall promote the following approaches: a. Inspection by maintenance staff of all beds and related equipment as part of our regular bed safety program to identify risks and problems including potential entrapment risks; b. review the gaps within the bed system are within the dimensions established by the FDA .d. Ensure that bed side rails are properly installed using the manufacturer's instructions and other pertinent safety guidance to ensure proper fit (e.g., avoid bowing, ensure proper distance from the headboard and footboard, etc.); and e. Identify additional safety measures for residents who have been identified as having a higher than usual risk for injury including entrapment (e.g., altered mental status, restlessness, etc.) .6. The staff shall obtain consent for the use of side rails from the resident or the resident's legal representative prior to their use .9. Before using side rails for any reason, the staff shall inform the resident and family about the benefits and potential hazards associated with side rails. .