Inspection·August 6, 2025

F 0700 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to assess residents for risk of entrapment from bed rails prior to installation and/or review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation of 1 of 4 (Resident # 3) reviewed for the use of bed rails. The facility failed to ensure that a bed rail assessment and bed rail consent was completed for Resident # 3 or Resident # 3's family representative. This failure could have placed residents at increased risks for entrapment in bed rails and for lack of informed consent regarding the risks associated with use of bed rails. The findings included:Record review of Resident #3's face sheet dated 8/6/2025 revealed Resident #3 was an [AGE] year-old female admitted on [DATE] with a readmission on [DATE] with the following diagnoses fracture of right femur, high blood pressure, heart disease and weakness.Record review of Resident #3's admission MDS dated [DATE] revealed: Section C- Cognitive Patterns revealed Resident # 3 had a BIMS score of 13 (cognitively intact).Record review of physician orders dated 08/06/2025 revealed: start date 07/14/2025 1/4 side rails up x2 while in bed for mobility every shift.Record review of Resident #3's care plan dated 07/08/2025 revealed interventions of side rails: quarter rails up as per doctor order for safety during care provision, to assist with bed mobility. Observe for injury or entrapment related to side rail use. Reposition PRN to avoid injury. Date Initiated: 07/14/2025Record review of Resident #3's electronic medical chart on 08/05/2025 revealed no evidence of a completed bed rail assessment or bed rails consent. Observation and interview on 08/05/2025 at 1:35 PM Resident #3 was sitting in his wheel chair in the doorway of his room. Resident #3's bed had 1/4 bed rails on both of sides. Resident #3 stated he used the bed rails to move around in his bed. Observation on 08/06/2025 at 11:20 AM Resident #3 was lying in his bed in his room sleeping, bed rails were on both sides of his bed. During an interview on 08/06/2025 at 11:35 AM Resident #3's Representative stated she did not remember signing a consent for Resident #3 to have bed rails on his bed. Resident #3's Representative stated there was no problem with Resident #3 having bed rails on his bed. During an interview on 08/06/2025 at 3:30 PM the ADON stated she had only been at the facility as the ADON for a week. The ADON stated consents for bed rails and bed rail assessments should have been completed before bed rails were placed on bed. The ADON stated the consents and assessments should have been completed and in the resident's electronic medical chart. During an interview on at 08/06/2025 at 4:00 PM the ADMN stated her expectation was for there to have been a bed rail consent and a bed rail assessment prior to bed rails being placed on a bed. The ADMN stated the charge nurse would have been responsible to complete the assessment and the consent, but the ultimately the DON would be responsible to ensure they were done. The DON was responsible to monitor the completion of bed rail consent and bed rail assessments were completed. The ADMN (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 675008 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675008 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/06/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cherokee Rose Nursing and Rehabilitation 203 Gibbs Blvd Glen Rose, TX 76043 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)