Based on staff interview and record review, the facility did not ensure their abuse policy was implemented for 1 of 8 employees reviewed for background checks. The facility allowed a Certified Nursing Assistant (CNA) G to work with residents on 01/14/23 and 01/15/23 before background check was received. Background check was received on 01/20/23. This is evidenced by: The facility policy, entitled Abuse, Neglect, Mistreatment, Exploitation and Misappropriation of Resident Property, dated November 2022, states: 1. Screening components . Abuse Policy Requirements: it is the policy of Dove Healthcare to screen employees and volunteers prior to working with residents. Screening components include verification of references, certification and verification of license and criminal background checks. Surveyor was completing the caregiver compliance check when Surveyor noticed that CNA G's start date was dated 01/14/23, and their reports from the Department of Justice (DOJ) and Integrated Background Information System (IBIS) were dated 01/20/23. The background check date was six days after the date of hire. Record review of the CNA Schedule from 01/14/23 to 01/20/23 shows that CNA G worked on 01/14/23 for eight hours and 01/15/23 for eight hours. The CNA Schedule shows that CNA G was shadowing with CNA H on 01/14/23 and CNA I on 01/15/23. CNA G did not work another day until after 01/20/23. On 10/18/23 at 9:20 AM, Surveyor interviewed Nursing Support (NS) F, who sets up the schedule for new hires. NS F was asked what the first week looks like for a CNA. NS F said that first, they have a few hours of general training, but after that general training on the computer is completed, they are sent to the floor to shadow another CNA. On 10/18/23 at 11:20 AM, Surveyor interviewed Director of Nursing (DON) B regarding staff background checks. When asked what their expectations would be regarding receiving a background check, DON B said they would expect staff to have a verified background check before being allowed to work on the floor.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility did not ensure the resident received care consistent with professional standards of practice for pressure injury care for 1 of 1 residents (R) 14. R14 had a deep tissue injury; weekly wound assessments with description of wound and measurements were not completed. Findings include: The facility policy, entitled Skin Assessment and Pressure Ulcer Prevention, with an effective date of August 2010, states in part With each dressing change or at least weekly, an evaluation of the pressure injury should be documented including location and measurements. R14 was admitted to the facility on [DATE] and has diagnosis that include type 2 diabetes with diabetic neuropathy, acute kidney failure, and early onset Alzheimer's. On 10/18/23 at 7:55 AM, Surveyor requested weekly wound measurements for the past 3 months from Director of Nursing (DON) B for R14's left heel. Surveyor received the documentation at 9:50 AM. Documentation indicates that measurements were completed on 7/29/23, 8/12/23, 8/22/23, 8/26/23, 9/13/23, 9/29/23 and 10/03/23. The pressure injury assessments were not completed weekly. Surveyor interviewed RN C on 10/18/23 at 12:32 PM. Surveyor asked her if she was the one who usually does the wound measurements. RN C indicated that RN C was responsible. Surveyor asked how often measurements and assessments should be done. RN C indicated usually weekly. Surveyor showed RN C the documentation of wound measurements starting at 7/29/23 and showed RN C the next measurement was 8/12/23 and asked if that looked right. RN C indicated yes and could not explain why there was a gap in weekly assessments. On 10/18/23 at 12:40 PM, Surveyor interviewed DON B and asked how often wound measurements should be done. DON B indicated they should be done every 7 days.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Example 5 R17 was admitted to the facility on [DATE], and had diagnoses that include Cerebrovascular accident (CVA) and hemiparesis. R17's Minimum Data Set (MDS) assessment indicated that R17 did not have a Brief Interview for Mental Status (BIMS) which indicated resident is rarely/never understood. On 10/18/23, Surveyor reviewed R17's care plan and restorative documentation, identifying the following individualized restorative program. 10/16/2023 Transfer: Standing to tolerance in paralell bars or grab bar in room, x 3 attempts as able 7x / wk. Sunday Monday Tuesday Wednesday Thursday Friday Saturday cAM [NAME] cOM cPMin T First date: 3/31/23 Goals: maintain strength for transfers On 10/18/23, Surveyor reviewed R3's care plan and restorative documentation from 9/28/23 through 10/17/23, which identified the restorative program indicating the program was not completed. Surveyor noted 48 missed opportunities. On 10/17/23 at 2:05 PM, Surveyor interviewed Certified Nursing Assistant (CNA) D and CNA E, who stated they are responsible for completing some of the individual programs and some are completed by the restorative aide. Both CNA D and CNA E stated that the restorative aide and CNA staff are expected to complete the program and required documentation and if they are unable to complete the program or if resident refuses, they should not leave blank and place a 0. On 10/17/23 at 4:21 PM, Surveyor interviewed Director of Nursing (DON) B regarding the blank documentation on the therapy logs. DON B stated that while reviewing restorative documentation last month blanks were noted. DON B brought information forward at the 9/26/23 QAPI meeting and are going to be starting a performance improvement plan (PIP) and started educating staff on 09/27/23 regarding expectation of charting restorative pans. DON B stated auditing is planned over the next month to ensure it is being done. On 10/18/23 at 11:18 AM, Surveyor interviewed DON B after reviewing documentation of education of staff during a meeting on 9/27/23, with expectations of completing restorative programs Surveyor informed DON B that since the staff meeting there continues to be blanks in the documentation indicating program was not completed. DON B stated that her expectations after receiving the education were there should be documentation supporting the program was completed or documentation to support why it was not completed. DON B stated that a formal PIP had not been developed but planned to start it today. Based on observations, interviews and record reviews, the facility did not ensure residents received appropriate treatment and services to maintain or prevent further reduction in range of motion (ROM) and mobility for 5 of 5 residents (R) (R11, R13, R16, R3, R17). The facility did not consistently provide services or treatment for residents (R11, R13, R16, R3, R17) identified with having a restorative program. This is evidenced by: Example 1 R11 was admitted on [DATE] and has diagnoses that includes a stroke, Alzheimer's disease, and hemiplegia. R11's most recent annual Minimum Data Set (MDS), dated [DATE], indicates is severely impaired - never/rarely makes decision and has an activated Power of Attorney (POA) 5/16/23. R11 is totally dependent on staff for all Activities of Daily Living (ADL). On 10/17/23, Surveyor reviewed R11's care plan and restorative documentation from 9/28/23 through 10/17/23, which identifies the following individualized restorative program and missing documentation indicating the program was not completed. • ROM: Lower body exercise: Bilateral lower extremity with moderate assist of passive ROM 10 repetitions of 3 sets supine in bed 7x week on AM and PM shifts: Noted 16 missed opportunities out of 40. Example 2 R13 was admitted on [DATE] and has diagnoses that include arthritis, non-traumatic brain dysfunction, and dementia. R13's most recent annual MDS, dated [DATE], indicates a BIMS score of 5 and has an activated POA. R13's MDS also indicates a decline in ADLs from previous MDS dated [DATE]. • Bed mobility went from requiring limited assist to requiring extensive assist. • Transfer ability went from limited assist to requiring extensive assist. • Walk in room went from supervision to requiring limited assist. On 10/17/23, Surveyor reviewed R13's care plan and restorative documentation from 9/28/23 through 10/17/23, which identifies the following individualized restorative program and missing documentation indicating the program was not completed. • Ambulation: 1 assist with walker and wheelchair (WC) in hallway. Complete 2 trials with distance to fatigue 7 x a week on AM shift. Noted 36 missed opportunities out of 40. • Ambulation: 1 assist with walker and wheelchair (WC) in hallway with distance to fatigue 7 x a week on PM shift. Noted 12 missed opportunities out of 20. • Dressing/grooming: set up at sink in WC with upper body and lower body clothing, allow patient to compete with cues and supervision 6x week. Noted 11 missed opportunities out of 18. • ROM: Hand bike level 3 5x week to maintain tolerance for daily cares on AM shift. Noted 8 missed opportunities out of 14. Example 3 R16 was admitted to facility on 01/19/19, and has diagnoses that include non-traumatic brain dysfunction, cerebrovascular accident (CVA), and Alzheimer's disease. R16's most recent quarterly MDS, dated [DATE], indicates R16 requires limited assist with one-person physical assist with transfers and walk in corridor. Requires extensive assist with one person assist for dressing. On 10/17/23, Surveyor reviewed R16's care plan and restorative documentation from 9/28/23 through 10/17/23, which identifies the following individualized restorative program and missing documentation indicating the program was not completed. • Ambulation: 50-100' with 1 assist and walker and WC to follow 5x week 2x on AM shift. Noted 21 missed opportunities out of 28. • Ambulation in hallway to fatigue, walker, and WC to follow a7x week on PM shifts. Noted 11 missed opportunities out of 20. • Transfer: static standing in parallel bar 3x to fatigue 2x a week. Noted 6 opportunities out of 9. • Dressing/grooming: upper body dressing with set up while edge of bed or in chair - restorative to complete AM cares 7x week on AM and PM shifts. Noted 21 missed opportunities out of 40. • ROM: NU Step Level 5 x 15 minutes 3x week on Am Shift. Noted 4 missed opportunities out of 8. • ROM: Upper body exercise: Bilateral Upper Extremity Hand Bike Level 3 x 15 minutes 2x week on AM Shift. Noted 4 missed opportunities out of 6. Example 4 R3 was admitted to the facility on [DATE], and had diagnoses that include paranoid schizophrenia, anxiety disorder, major depressive disorder, dementia, hypertensive heart disease, and type 2 diabetes. R3's Minimum Data Set (MDS) assessment indicated that R3 had a Brief Interview for Mental Status (BIMS) of 05 which indicated R3 has severe impairment. On 10/17/23, Surveyor reviewed R3's care plan and restorative documentation, which identifies the following individualized restorative program. ROM Group exercises 5 times a week with a goal is strength for cares done Monday, Tuesday, Wednesday, Thursday, and Friday. On 10/17/23, Surveyor reviewed R3's care plan and restorative documentation from 9/28/23 through 10/17/23, which identifies the restorative program missing documentation indicating the program was not completed. Noted 9 missed opportunities out of 14. ROM Upper body exercise hand bike 5 times a week Monday, Tuesday, Wednesday, Thursday, and Friday to maintain tolerance for cares. Surveyor reviewed R3's care plan and restorative documentation from 9/28/23 through 10/17/23, which identifies the restorative program missing documentation indicating the program was not completed. Surveyor noted 11 missed opportunities out of 14.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility did not ensure prior to the installation or use of bed rails, attempted to use alternative devices, assess the resident for risk of entrapment from bed rails, obtain consent with the resident or resident representative for review of risks and benefits of bed rails for 8 of 8 residents (R) R12, R13, R16, R27, R3, R4, R14, R22) observed with side rails/enabler bars during the survey process. The facility failed to attempt alternatives prior to installation of grab bars and failed to obtain informed signed consent of risk and benefit for grab bars with the resident or resident representative for R12, R13, R16, R27, R3, R4, R14, and R22. This is evidenced by: On 10/18/23 at 10:06 AM, Surveyor received and reviewed side rail policy entitled: Restraint-free environment which includes .8. The resident may request assist and/or grab bars to allow for proper mobility, rise from the bed and/or maintain items within reach. An assessment of the grab bar must be performed to ensure resident safety and proper use. Assessment must also indicate that this is not a restraint. If assessment determines that the grab bar is a restraint, the restraint policy and procedure must be followed. Example 1 On 10/18/23 at 11:07 AM, Surveyor observed right grab bar on R12's bed. R12 was admitted to facility on 05/24/23 and has diagnoses that include Parkinson's and osteoporosis. R12's most recent quarterly Minimum Data Set (MDS), dated [DATE], indicates R12 has modified independence - some difficulty in new situation making decisions regarding tasks of daily life and requires extensive assistance with two-person physical assist for bed mobility and transfers. This would put R12 at risk for entrapment with the use of grab bars. On 10/17/23, Surveyor reviewed R12's current care plan which indicates R12 is a fall risk due to impaired mobility and history of falls. On 10/18/23, Surveyor received R12's quarterly grab bar assessments which indicated on 07/06/23 risk for injury/entrapment: Impaired cognition/confusion. The assessment had no documentation of attempting alternatives prior to installation of grab bars, or evidence of informed signed consent of risk and benefit for grab bars with the resident or resident representative. Example 2 On 10/18/23 at 11:07 AM, Surveyor observed bilateral grab bar on R13's bed. R13 was admitted on [DATE] and has diagnoses that include non-traumatic brain dysfunction and dementia. R13's most recent annual MDS, dated [DATE], indicates R13 has a BIMS score of 5 and requires extensive assist with one-person physical assist with bed mobility NS transfers. This would put R13 at risk for entrapment with the use of grab bars. On 10/17/23, Surveyor reviewed R13's current care plan which indicates R13 is a fall risk due to impaired mobility, cognition, and history of falls. On 10/18/23, Surveyor received R13's quarterly grab bar assessments which indicated on 08/04/23 risk for injury/entrapment: Impaired cognition/confusion. The assessment had no documentation of attempting alternatives prior to installation of grab bars, or evidence of informed signed consent of risk and benefit for grab bars with the resident or resident representative. Example 3 On 10/18/23 at 11:07 AM, Surveyor observed bilateral grab bars on R16's bed. R16 was admitted to facility on 01/19/19, and has diagnoses that include non-traumatic brain dysfunction, cerebrovascular accident (CVA), and Alzheimer's disease. R16's most recent quarterly MDS, dated [DATE], indicates R16 requires extensive assist with one-person physical assist with bed mobility and limited assistance with one-person physical assist with transfers. This would put R16 at risk for entrapment with the use of grab bars. On 10/17/23, Surveyor reviewed R16's current care plan which indicates R16 is a fall risk due to history of falls and history of self-transferring. On 10/18/23, Surveyor received R16's quarterly grab bar assessments. Last assessment dated [DATE], had no documentation of attempting alternatives prior to installation of grab bars, or evidence of informed signed consent of risk and benefit for grab bars with the resident or resident representative. Example 4 On 10/18/23 at 11:07 AM, Surveyor observed left grab bar on R27's bed. R27 was admitted to facility on 10/28/22 and has diagnoses of a CVA and is enrolled in hospice. R27's most recent quarterly MDS, dated [DATE], indicates R27 has both short term and long-term memory problems, is severely impaired-never/rarely makes decisions and requires extensive assist with two-person physical assist with bed mobility and transfers. This would put R27 at risk for entrapment with the use of grab bars. On 10/17/23, Surveyor reviewed R27's current care plan which indicates R27 is a fall risk due to history of falls and history of self-transferring. Example 5 R3 was admitted to the facility on [DATE], and has diagnoses that include paranoid schizophrenia, anxiety disorder, major depressive disorder, dementia, hypertensive heart disease, and type 2 diabetes. R3's Minimum Data Set (MDS) assessment indicated that R3 had a Brief Interview for Mental Status (BIMS) of 05 which indicated R3 has severe impairment. On 10/18/23, Surveyor received R3's quarterly grab bar assessment dated [DATE]. The assessment had no documentation of attempting alternatives prior to installation of grab bars, and the facility did not obtain informed signed consent of risk and benefit for grab bars with the resident or resident representative. Surveyor observed R3 has grab bars on both sides of their bed during initial tour on 10/16/23 at approximately 9:00 a.m. Example 6 R4 was admitted to the facility on [DATE], and has diagnoses that include atrial fibrillation, acute kidney failure, and congestive heart failure. On 10/18/23, Surveyor received R4's quarterly grab bar assessment dated [DATE]. The assessment had no documentation of attempting alternatives prior to installation of grab bars, and the facility did not obtain informed signed consent of risk and benefit for grab bars with the resident or resident representative. Surveyor observed R4 has a grab bar on the right side of their bed during initial tour on 10/16/23 at approximately 9:00 a.m. Example 7 R14 was admitted to the facility on [DATE] and has diagnoses that include type 2 diabetes with diabetic neuropathy, acute kidney failure, and early onset Alzheimer's. R14's MDS indicated that R14 has a BIMS of 12, which indicates that R14 is moderately impaired. On 10/18/23, Surveyor received R14's quarterly grab bar assessment dated [DATE]. The assessment had no documentation of attempting alternatives prior to installation of grab bars, and the facility did not obtain informed signed consent of risk and benefit for grab bars with the resident or resident representative. Surveyor observed R14 has a grab rail on the right side of their bed, during initial tour throughout the day on 10/16/23. Example 8 R22 was admitted to the facility on [DATE] and has diagnoses that include hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, dysphasia, hypertension, and major depressive disorder. R22's MDS indicated that R22 has a BIMS of 12, which indicates that R22 is moderately impaired. On 10/18/23, Surveyor received R22's quarterly grab bar assessment dated [DATE]. The assessment had no documentation of attempting alternatives prior to installation of grab bars, and the facility did not obtain informed signed consent of risk and benefit for grab bars with the resident or resident representative. Surveyor observed R22 has grab bars on both sides of their bed during initial tour throughout the day on 10/16/23. On 10/18/23 at 11:07 AM, Surveyor interviewed Nursing Home Administrator (NHA) A regarding side rail assessments. NHA A stated that they do not consider grab bars as siderails but as an assistive device. They conduct a quarterly assessment which does not require assessment that grab bar is not a restraint. NHA stated they do not conduct siderail assessments for individual safety for risk for entrapment and have not done risk vs benefit education or obtain signed consents from resident or resident representative.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility did not inspect for compatibility of bed frames, mattresses, and bed rails for 8 of 8 residents (R) R12, R13, R16, R27, R3, R4, R14, R22. The facility failed to conduct as part of their regular maintenance program, inspection of all bed frames, mattresses, and bed rails for potential risk of entrapment on 8 of 8 residents (R) R12, R13, R16, R27, R3, R4, R14, R22 observed with side rails/enabler bars up during the survey process. This is evidenced by: Based on the Food and Drug Administration (FDA) documents entitled Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment dated March 10, 2006, Practice Hospital Bed Safety dated February 2013, and Guide to Bed Safety Rails in Hospitals, Nursing Homes and Home Health Care: The Facts as to the proper dimensions and distances apart of various parts of the bed such as distance between bed frames and mattresses, bed rails and mattress etc. to prevent entrapment by users of the bed. Example 1 On 10/18/23 at 11:07 AM, Surveyor observed right grab bar on R12's bed. R12 was admitted to facility on 05/24/23 and has diagnoses that include Parkinson's and osteoporosis. On 10/18/23, Surveyor reviewed R12's quarterly grab bar assessments which did not include inspection of bed frame, mattress, and potential risk of entrapment. R12's most recent quarterly Minimum Data Set (MDS), dated [DATE], indicates R12 has modified independence - some difficulty in new situation making decisions regarding tasks of daily life and requires extensive assistance with two-person physical assist for bed mobility and transfers. This would put R12 at risk for entrapment with the use of grab bars. On 10/17/23, Surveyor reviewed R12's current care plan which indicates R12 is a fall risk due to impaired mobility and history of falls. Example 2 On 10/18/23 at 11:07 AM, Surveyor observed bilateral grab bar on R13's bed. On 10/18/23, Surveyor reviewed R13's quarterly grab bar assessments which did not include inspection of bed frame, mattress, and potential risk of entrapment. R13 was admitted on [DATE] and has diagnoses that include non-traumatic brain dysfunction and dementia. R13's most recent annual MDS, dated [DATE], indicates R13 has a BIMS score of 5 and requires extensive assist with one-person physical assist with bed mobility and transfers. This would put R13 at risk for entrapment with the use of grab bars. On 10/17/23, Surveyor reviewed R13's current care plan which indicates R13 is a fall risk due to impaired mobility, cognition, and history of falls. Example 3 On 10/18/23 at 11:07 AM, Surveyor observed bilateral grab bars on R16's bed. On 10/18/23, Surveyor reviewed R16's quarterly grab bar assessments which did not include inspection of bed frame, mattress, and potential risk of entrapment. R16 was admitted to facility on 01/19/19, and has diagnoses that include non-traumatic brain dysfunction, cerebrovascular accident, and Alzheimer's disease. R16's most recent quarterly MDS, dated [DATE], indicates R16 requires extensive assist with one-person physical assist with bed mobility and limited assistance with one-person physical assist with transfers. This would put R16 at risk for entrapment with the use of grab bars. On 10/17/23, Surveyor reviewed R16's current care plan which indicates R16 is a fall risk due to history of falls and history of self-transferring. Example 4 On 10/18/23 at 11:07 AM, Surveyor observed left grab bar on R27's bed. On 10/18/23, Surveyor reviewed R27's quarterly grab bar assessments which did not include assessment of bed frame, mattress, and potential risk of entrapment. R27 was admitted to facility on 10/28/22 and has diagnoses of a CVA and is enrolled in hospice. R27's most recent quarterly MDS, dated [DATE], indicates R27 has both short term and long-term memory problems, is severely impaired-never/rarely makes decisions and requires extensive assist with two-person physical assist with bed mobility and transfers. This would put R27 at risk for entrapment with the use of grab bars. On 10/17/23, Surveyor reviewed R27's current care plan which indicates R27 is a fall risk due to history of falls and history of self-transferring. Example 5 R3 was admitted to the facility on [DATE], and has diagnoses that include paranoid schizophrenia, anxiety disorder, major depressive disorder, dementia, hypertensive heart disease, and type 2 diabetes. R3's Minimum Data Set (MDS) assessment indicated that R3 had a Brief Interview for Mental Status (BIMS) of 05 which indicated R3 has severe impairment. Surveyor reviewed R3's quarterly grab bar assessments which did not include inspection of bed frame, mattress, and potential risk of entrapment. Example 6 R4 was admitted to the facility on [DATE], and has diagnoses that include atrial fibrillation, acute kidney failure, and congestive heart failure. Surveyor observed grab bars on R4's bed during the initial tour on 10/16/23 at approximately 9:00 a.m. Surveyor reviewed R4's quarterly grab bar assessments which did not include inspection of bed frame, mattress, and potential risk of entrapment. Example 7 R14 was admitted to the facility on [DATE] and has diagnoses that include type 2 diabetes with diabetic neuropathy, acute kidney failure, and early onset Alzheimer's. R14's MDS indicated that R14 has a BIMS of 12, which indicates that R14 is moderately impaired. Surveyor reviewed R14's quarterly grab bar assessments which did not include inspection of bed frame, mattress, and potential risk of entrapment. Example 8 R22 was admitted to the facility on [DATE] and has diagnoses that include hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, dysphasia, hypertension, and major depressive disorder. R22's MDS indicated that R22 has a BIMS of 12, which indicates that R22 is moderately impaired. Surveyor reviewed R22's quarterly grab bar assessments which did not include inspection of bed frame and mattress for compatibility, which increases potential risk of entrapment. On 10/18/23 at 11:07 AM, Surveyor interviewed Nursing Home Administrator (NHA) A regarding side rail inspections using the hospital bed system standard. NHA A stated that they do not consider grab bars as siderails but as an assistive device. NHA stated they do not conduct siderail inspections for individual safety for risk for entrapment.