Schuyler County Nursing Home District

Inspectors wroteBased on observation and interview, the facility failed to ensure food service equipment/surfaces were appropriately cleaned under sanitary conditions in accordance with professional standards for food service safety, and failed to ensure trash cans were covered when not in use. The facility census was 41. Observations on 9/7/25 between 11:30 A.M. and 5:53 P.M., and on 9/8/25 between 9:27 A.M. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop policies to monitor the water system and implement the facility policy to monitor for Legionella (a bacterium that can cause a serious type of pneumonia called Legionnaires' Disease (a bacterial disease commonly associated with water-based aerosols) in persons at risk) control that included specific control parameters based on Center for Disease Control and Prevention (CDC) and American Society of Heating, Refrigerating and Air Conditioning Engineers (ASHRAE)) standards. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure staff training needs, as identified in the facility assessment and the annual in-servicing calendar, were met for five nurse assistants (NA)'s/ certified nurse assistants (CNA)'s (NA O , NA J, CNA T, CNA K and CNA/Certified Medication Technician (CMT) S), in a sample of five NA's/CNA's reviewed, who had been employed over a year by the facility. Further review showed no documentation of the required 12 hours of training per year were completed, including dementia management and resident abuse prevention training. The facility census was 41. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to develop and implement a comprehensive person-centered care plan that included measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that were identified in the comprehensive assessment (minimum data set, MDS) for three residents (Resident #5, #7, and #36)), in a review of 17 sampled residents. The facility census was 41. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure physician's orders were followed for five residents (Resident's #5, #11, #28, #34, #40) in a sample of 17 residents. The facility failed to follow physician's orders related to daily weights and administering Lasix (a diuretic) according to parameters set by the physician to ensure the resident did not experience fluid overload for Resident #11. The facility failed to follow physician's orders related to fluid restrictions, administering Lasix according to parameters set by the physician, and to check daily weights, according to the parameters set on the Lasix order, to ensure the resident did not experience fluid overload for Resident #5. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to assess the residents for risk of entrapment from bed rails and failed to complete inspections of bed frames, mattresses and bed rails as part of a regular maintenance program to identify areas of possible entrapment for four residents (Residents #40, #5, #7, and #14), in a review of 17 sampled residents. The facility census was 41. During an interview on 09/09/10:15 A.M., the Director of Nursing (DON) said the facility did not have a policy for bed rails. 1. Review of Resident #40's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument, dated 8/08/25, showed the following:-Diagnoses of dementia and need for assistance with personal care; -Severe cognitive impairment;-Required substantial/maximal assistance for mobility and transfers. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure seven nurse aides (NAs) completed a state-approved training program within four months of hire. The facility census was 41. Review of the facility policy, Nurse Aid Qualifications and Training Requirements, revised August 2022, showed the following:-Nurse aides must undergo a state-approved training program;-The facility will not employ any individual as a nurse aide for more than four months, full-time, temporary, per diem, or otherwise, unless: a. That individual is competent to provide designated nursing care and nursing related services, and; b. That individual has completed a training program and competency evaluation program, or a competency evaluation program approved by the state or that individual has been deemed competent as provided in S483. [...]

Inspectors wroteBased on interview and record review, the facility failed to obtain a 14 day stop date on as needed (PRN) psychotropic medication for two residents (Residents #11 and #28), in a review of 17 sampled residents, and did not provide documentation of a clinical reason to extend the PRN medication beyond 14 days. Resident #11's PRN antipsychotic medication was administered for reasons that were not approved and lacked documentation of why the medication was administered. The facility census was 41. Review of drugs.com showed the following:-Seroquel is an antipsychotic medication that may increase the risk of death in older adults with mental health problems related to dementia.-Seroquel can cause a serious heart problem. [...]

Inspectors wroteBased on interview and record review, the facility failed to complete a significant change in status assessment (SCSA) Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by facility staff, for two residents ( Residents #4 and #6), in a review of 17 sampled residents, within 14 days after the facility determined, or should have determined, there had been a significant change in the resident's physical or mental condition which had an impact on more than one area of the resident's health status and required interdisciplinary review and/or revision of the care plan. The facility census was 41. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide adequate supervision and oversight to prevent falls for one resident (Resident #20), in a review of 17 sampled residents. The resident experienced multiple falls and was high risk for falls. The facility failed to plan and reevaluate interventions to address the resident's falls. The facility did not have a consistent system to identify residents at risk for falls. The facility census was 41. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to identify and reevaluate indications for use of indwelling urinary catheter (a thin, flexible tube inserted into the bladder to drain urine) to prevent complications including urinary tract infections (UTI) for two residents (Resident #4 and #6), of 17 sampled residents. The facility failed to ensure that catheters were secured to the resident's leg with a device to reduce friction and movement at the site (also decreasing the chance of accidental removal and infection). The facility census was 41. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to obtain a physician's order for colostomy (a surgical opening in the large intestine also called a stoma) care and failed to develop a plan of care to address the care and monitoring of the colostomy for one resident (Resident #40), in a review of 17 sampled residents. The facility census was 41. Review of the facility policy, Medication Orders, last revised November 2014, showed the following:-Current list of orders must be maintained in the clinical record for each resident;-Treatment orders must specify the treatment, frequency and duration of the treatment. 1. Review of Resident #40's Care Plan, dated 7/15/25, showed the following: -The resident had a colostomy; [...]

Inspectors wroteBased on interview and record review, the facility failed to consistently monitor residents' weights as ordered, failed to identify weight loss and notify the resident's physician and the dietician of the weight loss, failed to ensure staff evaluated current interventions and/or implemented new interventions to prevent further weight loss for two residents (Residents #2 and #39), in a review of 17 sampled residents. The facility census was 41. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the Dietary Director had the appropriate competencies and skills set to carry out the function of the food and nutrition services. The facility census was 41. Review of the facility's current employee list, dated 9/7/25, showed the Dietary Director began employment with the facility on 5/9/22. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide a written notice of transfer/discharge with required information to the resident and/or resident representative for three residents (Residents #5, #6, and #39), in a review of 17 sampled residents, when the facility initiated a transfer to the hospital. The facility also failed to provide a copy of the bed hold notice on transfer/discharge. The facility census was 41. Review of the facility policy, Facility-Initiated Transfer or Discharge, revised October 2022, showed the following:-Facility-initiated transfers and discharges, when necessary, must meet specific criteria and require resident/representative notification and orientation, and documentation as specified in this policy;-The resident and representative are notified in writing of the following information: a. The specific reason for the transfer or discharge; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to accurately assess the resident and correctly code the minimum data set (MDS) assessment for five residents (Residents #11, #14, #36, #6, and #7), in a review of 17 sampled residents, and one additional resident (Resident #47). The facility failed to accurately code a wound that was present on admission for Resident #7, failed to accurately code a Wanderguard alarm for Residents #11 and #14, failed to accurately code hospice for Residents #36 and #47, and failed to code active diagnoses for Resident #6. The facility census was 41. During an interview on 09/10/25 at 7:30 P.M., the Director of Nursing (DON) said the facility followed the Resident Assessment Instrument (RAI) manual for completion of the MDS. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide the resident or resident representative a copy of the resident's baseline care plan for three residents Resident (#5, #7, and #14). The facility census was 41. Review of the facility policy, Care Plans - Baseline, revised 2022, showed the following:-A baseline plan of care to meet the resident's immediate health and safety needs is developed for each resident within 48 hours of admission;-The resident and/or representative are provided a written summary of the baseline care plan (in a language that the resident/representative can understand) that includes, but is not limited to the following: -The stated goals and objectives of the resident; -A summary of the resident's medications and dietary instructions; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure sanitary practices in the kitchen. Staff did not perform proper handwashing technique during meal preparation, did not store food items and maintain and clean equipment under sanitary conditions, and did not maintain a clean and sanitary environment in the kitchen. The facility census was 37. Review of the facility policy, Preventing Foodborne Illness - Employee Hygiene and Sanitary Practices, revised December 2008, showed the following: -Employees must wash their hands: -After handling raw meat, poultry or fish and when switching between working with raw food and working with ready-to-eat food; -After handling soiled equipment or utensils; -During food preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure nursing staff washed their hands and changed soiled gloves after each direct resident contact and when indicated by professional standards of practice during care for two residents (Resident #9 and Resident #12), in a review of 14 sampled residents. The facility failed to ensure proper infection control was utilized for respiratory care supplies for five residents (Resident #4, #7, #18, #30 and #289). [...]

Inspectors wroteBased on observation and interview, the facility failed to have an adequate audible system for the residents to signal the nursing staff when they were in need of staff assistance. The facility also failed to ensure one resident (Resident #21)'s call light functioned properly when the light did not illuminate above the resident's door. The facility census was 37. The facility did not provide a policy regarding the resident call light system. Review of the DHSS exception log showed the facility did not have an approved exception for a wireless call light system. 1. Review of Resident #21's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 10/26/23 showed the following: -Short and long term memory problems; [...]

Inspectors wroteBased on interview and record review, the facility failed to update interventions in the resident's care plan to reflect current care needs for three residents (Resident #10, #12 and #25), in a review of 14 sampled residents. The facility census was 37. Review of the facility's policy, Care Plans-Comprehensive, revised 2010, showed the following: -An individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident; -The facility's care planning/Interdisciplinary team, in coordination with the resident, his/her family or representative, develops and maintains a comprehensive care plan for each resident that identifies the highest level of functioning the resident may be expected to attain; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure three nurse aides (NA C, NA D and NA E) completed a nurse aide training program within four months of their employment in the facility. The facility census was 37. 1. Review of the undated list of NA's employed by the facility showed the following: -NA C's date of hire was 2/27/23; -NA D's date of hire was 5/15/23; -NA E's date of hire was 2/27/23. 2. Review of NA C's employee file showed no documentation he/she completed a nurse aide training program within four months of his/her hire date. 3. Review of NA D's employee file showed no documentation he/she completed a nurse aide training program within four months of his/her hire date. 4. Review of NA E's employee file showed no documentation he/she completed a nurse aide training program within four months of his/her hire date. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to adequately document appropriate diagnoses of residents or resident behaviors to justify the implementation or continued used of antipsychotic medications (a type of psychiatric medication used to treat certain types of mental health problems, such as schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly) and bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs), for three residents (Residents #10, #21 and #25) in a review of 14 sampled residents. The facility also failed to complete a 14 day review for the as-needed (PRN) use of a benzodiazepine (a drug that produces sedation and hypnosis) for one resident (Resident #21) and one additional resident (Resident #34). The facility census was 37. [...]

Inspectors wroteBased on observation and interview, the facility failed to keep the medication cart containing drugs and biologicals locked when not in use. The cart remained unlocked for the entire morning medication pass. The facility census was 37. Review of the facility's undated storage of medication policy showed the following: -The facility shall store all drugs and biologicals in a safe, secure, and orderly manner; -Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing drugs and biologicals shall be locked when not in use, and trays or carts used to transport such items shall not be left unattended if open or otherwise potentially available to others. Observation on 12/12/23 at 5:30 A.M. showed Certified Medication Technician (CMT) P entered room [ROOM NUMBER]-1 to administer medications to the resident. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow menus for three sampled residents (Residents #12, #18 and#25) and five additional residents (Residents #4, #6, #13, #22 and #23) on therapeutic diets to ensure staff served the proper food items and portion sizes as directed. The facility census was 37. Review of the facility policy, Menus, revised December 2008, showed menus shall meet the nutritional needs of residents, be prepared in advance, and be followed. 1. Review of the Diet Orders, provided by the facility, showed four residents (Residents #4, #6, #12 and #25) had physician's orders for a diabetic (consistent carbohydrate) diet. Review of the spreadsheet menu for the lunch meal on 12/11/23 showed staff was to serve residents on a consistent carbohydrate (CCHO) diet a 3-ounce portion of macaroni and tomatoes. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow standards of practice and ensure proper administration of physician ordered insulin (medication used to treat diabetes) via an insulin pen for one resident (Resident #6), in a review of 14 sampled residents. Staff failed to hold the insulin pen in place for the appropriate amount of time during administration per policy and per the manufacturer's instructions. Failure to follow this procedure for administration results in residents not receiving the ordered dose of insulin. The facility census was 37. Review of the facility's policy, Insulin Administration, dated 6/14/23, showed to depress the plunger and remove the needle after approximately five seconds. Review of the Novolog (fast acting insulin) Flex Pen manufacturer instructions, last revised February 2023, showed the following: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff safely transferred one resident (Resident #12), who had left side weakness and required two staff assistance for transfers, in a review of 14 sampled residents. The facility failed to ensure staff transported two residents (Resident #14 and #18) safely in wheelchairs with foot rests/pedals. During staff transport of Resident #18, his/her feet touched the floor and he/she fell forward, out of the wheelchair, striking his/her forehead on the floor. During staff transport of Resident #14, his/her feet drug the ground and caused the resident to jolt forward in his/her wheelchair. The facility census was 37. Review of the facility's undated policy, Wheelchair Pedals, showed the following: -All residents who require staff to propel them in a wheelchair are to have bilateral pedals on; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide appropriate care and services to an urinary catheter (a sterile tube inserted through the urethra into the bladder to drain urine) consistent with acceptable standards of practice, for two residents with a urinary catheter (Residents #4 and #18), in a review of 14 sampled residents. The facility census was 37. Review of the Nurse Assistant in a Long Term Care Facility, 2001 revision, showed the following: -The bladder is considered sterile, the catheter, drainage tubing and bag are a sterile system; -Drainage tubing/bags must not touch the floor. Review of the facility policy, Catheter Care and Emptying Drainage Bag, dated 4/5/23, showed the following: -The purpose of this procedure is to prevent catheter associated urinary tract infections; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to administer the correct dosage of levothyroxine (a medication to treat hypothyroidism, a condition in which the thyroid doesn't produce enough thyroid hormone) from the order date of 10/4/23 through 12/12/23 for one resident (Resident #33), in a review of 14 sampled residents. The facility census was 37. Review of the facility's undated policy, Medication Error, showed the following: -A medication error is the failure to administer medications as prescribed and/or the administration of medication not prescribed by a licensed physician/nurse practitioner/physician's assistant, e.g. incorrect dosage, time of administration and/or route, and omission of dosages; -Medication errors include the medication was given in the wrong dosage. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to post required nurse staffing information, which included the facility name and total actual hours worked by both licensed and unlicensed nursing staff directly responsible for resident care, per shift, on a daily basis. The facility census was 37. The facility did not provide a policy for posted nurse staffing information. 1. Observation on 12/10/23 at 2:10 P.M. of the Daily Staff/Census sheet showed the following: -Date 12/10/23; -Census; -Director of Nursing (DON) scheduled hours; -Assistant Director of Nursing (ADON) scheduled hours; -Registered Nurse (RN) scheduled hours; -Licensed Practical Nurse (LPN) scheduled hours; -Certified Medication Technician (CMT) scheduled hours; -Certified Nurse Aide (CNA) scheduled hours; -Nurse Aide (NA) scheduled hours; [...]

Inspectors wroteBased on interview and record review, the facility failed to employ a qualified director of food and nutrition services. The facility did not have a dietary manager (DM) with a background and/or training in food preparation, food service and/or food storage. The facility also did not utilize the services of their qualified, consultant Registered Dietitian (RD) to assist the DM. This practice effected all residents in a facility with a census of 40. Record review of the facility's Dietitian policy, from MED-PASS 2001, revised October 2017 showed under policy interpretation and implementation #1. A qualified dietitian or other clinically qualified nutrition professional will help oversee food and nutrition services provided to the residents; #2 A food and nutrition services manager will oversee the productions, storage, and delivery of food. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide a written notice of transfer with required information (reason for transfer/discharge, date of transfer/discharge, location to which the resident is transferred or discharged , appeal rights and contact information, ombudsman contact information) to the resident and/or resident representative for three residents (Resident #17, 18, and #39) in a review of 12 sampled residents, and one closed record (Resident #140) when the facility initiated transfer to the hospital. The facility census was 40. During an interview on 12/29/20, at 1:33 P.M., the administrator said the facility does not have a policy on discharge notices for facility initiated discharges. 1. Review of Resident #17's medical record showed the following: -Original admission date of 7/27/18; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to complete a significant change in status assessment (SCSA) Minimum Data Set (MDS; a federally mandated assessment instrument required to be completed by facility staff) for three residents (Residents #17, #18, and #29) in a review of 12 sampled residents, within 14 days after the facility determined, or should have determined, there had been a significant change in the resident's physical or mental condition which had an impact on more than one area of the resident's health status and required interdisciplinary review and/or revision of the care plan. The census was 40. Review of the Resident Assessment Instrument (RAI) Manual, dated 10/1/17, directs staff as follows: [...]

Inspectors wroteBased on interview and record review, the facility failed to review the baseline care plan with the resident/responsible party within 48 hours of admission, or provide a copy of the baseline care plan to the resident/responsible party for four residents (Resident #25, #29, #32 and #241) in a review of 12 sampled residents. The facility census was 40. 1. During an interview on 12/30/20, at 3:30 P.M., the assistant administrator said the facility did not have a policy for baseline care plans. 2. Review of Resident #25's face sheet showed the resident was admitted to the facility on [DATE]. Review of the resident's admission Assessment, dated 8/25/20, showed the resident admitted at 11:55 A.M., and transferred with one person assist with a cane or walker. Review of the resident's Bed Rail Consent, dated 8/25/20, showed the resident was to use soft care assist rail on bilateral upper bed. [...]

Inspectors wroteBased on interview and record review, the facility failed to update interventions in the resident's care plan to reflect current care needs for six residents (Resident #7, #9, #17, 19, #22, and #39) in a sample of 12 residents. The facility census was 40. Review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, Version 1.17.1, Chapter 4, dated October 2019, showed the following: -The care plan is driven not only by identified resident issues and/or conditions but also by a resident's unique characteristics, strengths, and needs; -A care plan that is based on a thorough assessment, effective clinical decision making, and is compatible with current standards of clinical practice can provide a strong basis for optimal approaches to quality of care and quality of life needs of individual residents; -A well developed and executed assessment and care plan: [...]

Inspectors wrote7. Review of Resident #25's admission MDS, dated [DATE], showed the following: -Moderate cognitive impairment; -Independent with eating; -Not taking diuretics; -Weighs 280 lbs. Review of the resident's Weight Record showed the resident's weight on 11/11/20 was 280 lbs. Review of the resident's Physician's Orders dated 11/23/20, showed the physician ordered bumetanide (a strong diuretic 'water pill'), 2 milligrams (mg) once a day. Review of the resident's laboratory results, dated 11/24/20, showed the following: -Brain neuropeptic peptides (BNP) (measure of protein produced in the heart when it is enlarged with fluid, normal range is less than 1800 for this resident) was 6948 critically high; -Blood urea nitrogen (BUN) (measure of how well kidneys are working, normal is 8-23) was 39 high. Review of the resident's significant change MDS, dated [DATE], showed the following: [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to assess residents for risk of entrapment, document attempted alternatives prior to installing a bed rail, or provide informed consent on the safety risk associated with bed rail use for five residents (Resident #18, #7, #25, #29, and #32) in a review of 12 sampled residents and one additional sample resident (Resident #23) who had bed rails in place on their beds. The facility census was 40. Review of the facility's Bed Safety Policy, revised December 2007, showed the following: -Our facility shall strive to provide a safe sleeping environment for the resident; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the recommendations made by the licensed pharmacist during the monthly medication regimen reviews were communicated to the physician, and a response recorded from the physician for four residents (Resident #9, #18, #29, and #39), in a review of 12 sampled residents. The facility census was 40. Review of the facility policy on Medication Regimen Reviews (MMR), revised May 2019, showed the following: -The Consultant Pharmacist reviews the medication regimen of each resident at least monthly; -The goal of the MMR is to promote positive outcomes while minimizing adverse consequences and potential risks associated with medication; -The MMR involves a thorough review of the resident's medical record to prevent, identify, report and resolve medication related problems, medication errors and other irregularities; [...]

Inspectors wroteBased on interview and record review, the facility failed to attempt a gradual dose reduction (GDR), or document a clinical reason to justify the need to continue psychotropic medication (a medication capable of affecting the mind, emotions, and behavior) for two residents (Resident #18 and #39) in a review of 12 sampled residents. The facility census was 40. Review of the facility policy Medication Regimen Reviews, revised May 2019, did not address gradual dose reduction of psychotropic medication. 1. Review of Resident #18's face sheet showed the resident was admitted to the facility on [DATE]. Review of the resident's Physician's Orders, dated 11/6/2019, directed the staff to administer Duloxetine (a medication for depression) 30 milligrams (mg) daily. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Moderate cognitive issues; [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure insulin vials were properly labeled for one resident (Resident #241) in a review of 12 sampled residents and one additional resident (Resident #10). In addition the facility failed to properly secure a stock controlled substance, removed expired medication and label an open injectable in the medication room. The facility census was 40. Review of the facility's policy for Insulin Administration from MED-PASS 2001, revised September, 2014 showed if opening a new insulin vial, record expiration date and time on the vial. 1. Observation on 12/29/20 at 6:38 A.M. in the medication cart showed the following: -An open, undated vial of Lantus (long acting) insulin for Resident #10; -An open, undated vial of Lantus insulin for Resident #241. 2. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure nursing staff washed their hands and changed soiled gloves after each direct resident contact and when indicated by professional practices during care for two residents (Resident #17, and 241) in a review of 12 sampled residents, and failed to follow infection control practices while performing catheter care and dressing changes for two residents (Resident #17 and #39). The facility census was 40. Review of the facility policy Standard Precautions dated 2001 and last revised 10/18 showed standard precautions are used in the care of all residents regardless of their diagnoses, or suspected or confirmed infection status. Standard precautions presume that all blood, body fluids, secretions and excretions (except sweat), non-intact skin and mucous membranes may contain transmissible infectious agents. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to complete inspections of bed frames, mattresses, and bed rails as part of a regular maintenance program to identify areas of possible entrapment for five residents (Resident #7, #18, #25, #29 and #32 ) of 12 sampled residents and one additional resident (Resident #23). The facility census was 40. Review of the facility's Bed Safety Policy, revised December 2007, showed the following: -Our facility shall strive to provide a safe sleeping environment for the resident; -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; [...]