Health inspection·January 11, 2024

F 0558 attached to the privacy curtain. Resident #1 revealed that she can't reach it from her bed. Level of Harm - Minimal harm or potential for actual harm Review of Resident #2's face sheet dated 01/11/2024 reflected an [AGE] year-old female admitted to the facility on [DATE] with diagnoses of acute respiratory failure with hypoxia (When the respiratory system cannot adequately provide oxygen to the body); Chronic diastolic (congestive) heart failure (A chronic condition in which the heart doesn't pump blood as well as it should); Unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety(a person is presenting signs and symptoms of a dementia diagnosis, but they lack any symptoms of behavioral disturbances). Residents Affected - Few Review of Resident #2's Comprehensive Care Plan revised 11/02/2023 reflected Resident #2 had a history of falling related to impaired mobility and unsteady gait. She had poor safety awareness and was very impulsive. Review of Resident #2's Quarterly MDS (Minimum Data Set) assessment dated [DATE] reflected the resident was severely cognitively impaired. Resident's BIMS (Brief Interview for Mental Status) Score was: 04/15. Observation on 01/10/2024 at 12:45 PM revealed Resident #2 was in her bed and her call light was in her nightstand drawer beside her bed. Interview with Resident #2 revealed that she was doing fine and did not need anything. Resident was not aware her call cord was in her drawer and out of reach. She tried to reach for it but could not grab it. Resident #2 made no comment related to the call light out of reach. IIn an interview on 01/11/2024 at 1:30 PM with the ADM revealed, he was not aware the call lights were not within reach of the residents. The ADM stated that if the call light was not within reach the resident may try and get up and fall. In an interview on 01/11/2024 at 1:45 PM with CNA A revealed that she did not know the call lights were not within reach for Resident #1 or Resident #2. CNA A revealed that Resident #1 does get up and walk around. CNA A revealed resident could try and get up and fall, may be sick and need assistance, or may just need water. CNA A revealed she would make sure all call lights were within reach. Adm provided policy for Answering Call Light. The purpose of the procedure is to ensure timely response to the resident's request and needs. One specific guideline indicates when the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident. Policy revised March 2021. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675792 If continuation sheet Page 2 of 8 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 675792 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Mansfield 1402 E Broad St Mansfield, TX 76063 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)

F 0700 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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 observations, interviews, and record reviews the facility failed to review the risks and benefits of bed rails and enabler bars with the resident or resident representative and obtain informed consent prior to installation for three (Residents #1, #3, #4) of 3 resident rooms observed and reviewed for bed rails/enabler bars. The facility failed to have consents signed for the quarter bed rails/enabler bars for Residents #1, #3, and #4. This failure could affect residents who used bed rails/enabler bars at risk of the resident/responsible party not being aware of the risk. Findings included: 1. Record review of Resident #1's face sheet, dated 01/11/2024 revealed resident was originally admitted on [DATE] and current admit on 01/09/2024 with diagnoses of chronic respiratory failure with hypercapnia (high levels of carbon dioxide in the blood), Unspecified sequelae of cerebral infarction (unknown complication or condition that results from a pre-existing ischemic stroke; a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it), Type 2 diabetes mellitus without complications (adult onset; condition that happens because of a problem in the way the body regulates and uses sugar as a fuel), Essential (primary) hypertension (abnormally high blood pressure that's not the result of a medical condition), Vitamin D deficiency, unspecified, Atherosclerotic heart disease of native coronary artery with unspecified angina pectoris (thickening or hardening of the coronary artery without recurrent chest pain or discomfort), Gout, unspecified, Anxiety disorder, unspecified, Fever, unspecified, Long term (current) use of anticoagulants (blood clot preventative), Acute myocardial infarction (heart attack; decreased coronary blood flow, leading to insufficient oxygen supply to the heart), unspecified, Changes in skin texture, Scabies (infestation of the skin by the human itch mite), Local infection of the skin and subcutaneous tissue, unspecified, Other conduct disorders, Major depressive disorder, recurrent, moderate, Generalized anxiety disorder, Rash and other nonspecific skin eruption, Hereditary and idiopathic neuropathy (unknown cause of nerve damage), unspecified, Contact with and (suspected) exposure to COVID-19, Shortness of breath, Other lack of coordination, Failure to thrive in newborn, Adult failure to thrive, Dysphagia (difficulty swallowing), unspecified, Cognitive communication deficit (difficulty with thinking and how someone uses language), Other sexual disorders, Pneumonia due to other specified infectious organisms, Urinary tract infection, site not specified, Xerosis cutis (dry skin that's more severe than typical), Hypokalemia (lower than normal potassium in the bloodstream), Edema (swelling caused by too much fluid), unspecified, Nutritional deficiency, unspecified, Other sites of candidiasis (fungal infection caused by a yeast), Dementia in other diseases classified elsewhere, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, Other idiopathic peripheral autonomic neuropathy(disorders affecting the peripheral nerves that automatically (without conscious effort) regulate body processes), Cough, Idiopathic gout, unspecified site, Deficiency of other vitamins, Hyperlipidemia (elevated level of lipids - like cholesterol and triglycerides - in your blood), unspecified, Tinea pedis (Athlete's foot), Sebaceous cyst (harmless, slow-growing bumps under the skin), Intermittent explosive disorder, Other (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675792 If continuation sheet Page 3 of 8 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 675792 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Mansfield 1402 E Broad St Mansfield, TX 76063 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)

F 0700 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some insomnia, Muscle weakness (generalized), Dysphasia following cerebral infarction (difficulty swallowing after a stroke), Gastro-esophageal reflux disease without esophagitis, Other constipation, and Pain, unspecified. Per the face sheet, Resident #1's responsible party was a family member. Review of Resident #1's MDS assessment (discharge with return anticipated), dated 01/02/2024, and signed by DON as RN assessment coordinator verifying assessment completion, revealed the resident had issues with short term memory, cognitive skills were severely impaired with resident rarely having daily decision making. Resident was indicated with needed assistance with oral hygiene, set up, and clean up assistance with meals. Resident needed substantial assistance with rolling right and left in bed. Resident was indicated to not have bed rails used. Resident used a wheelchair for mobility. Record review of Resident #1's Care Plan, dated 10/30/2023, revealed no indication of bed rail or enabler bar discussion of risks and benefits with Resident or responsible party. Resident #1's Care Plan has no reference to an assessment that was completed for bed rails or enabler bars. Review of Medical record of Resident #1 revealed no written Physician Order for quarter bed rails/enabler bars for mobility and positioning. No assessment for use of enabler bars or bed rails was located in the medical record for Resident #1. Review of Medical Record of Resident #1 revealed no Physical Device Acknowledgement form (bed rail/enabler bar consent) for the quarter bed rails/enabler bars signed by the resident's responsible party. Observation on 01/11/2024 at 2:07 PM revealed Resident #1's room had the resident's bed with quarter bed rails/enabler bars raised on both sides of bed with call light in resident's hand in lap. 2. Record review of Resident #3's face sheet dated 01/11/2024 revealed resident's current admit date of 05/10/2023, initial admit date of 10/15/2018, with diagnosis of mild cognitive impairment of uncertain or unknown etiology, Wheezing, Disorder of gingiva and edentulous alveolar ridge (gums and bony ridge that holds the sockets of the teeth but lacking teeth), unspecified, Vitamin deficiency, unspecified, Scabies (infestation of the skin by the human itch mite), Intestinal helminthiasis (infestation with one or more intestinal parasitic roundworms), unspecified, Local infection of the skin and subcutaneous tissue, unspecified, Tinea pedis (Athlete's foot), Follicular disorder (Diseases of the skin and subcutaneous tissue), unspecified, Major depressive disorder, recurrent, mild, Generalized anxiety disorder, Other chronic pain, Restless legs syndrome, Atopic dermatitis (eczema) is a condition that causes dry, itchy and inflamed skin), unspecified, Ventral hernia without obstruction or gangrene, Unspecified abdominal hernia without obstruction or gangrene, Nausea, Migraine with aura, not intractable, with status migrainosus (a headache that doesn't respond to usual treatment or lasts longer than 72 hours), Headache, unspecified, Unspecified traumatic cataract, right eye, Adult failure to thrive, Unspecified fall, initial encounter, Type 2 diabetes mellitus (adult onset; condition that happens because of a problem in the way the body regulates and uses sugar as a fuel) with diabetic cataract, Other disorders of the left eye following cataract surgery, Other specified hypothyroidism (when the thyroid gland doesn't make enough thyroid hormones to meet your body's needs), Other irritable bowel syndrome, Nutritional deficiency, unspecified, Gastro-esophageal reflux disease without esophagitis, Acute upper respiratory infection, unspecified, Bacterial infection, unspecified, Unspecified open-angle glaucoma, stage unspecified, Urinary tract infection, site not specified, Other insomnia, Hypokalemia ((lower than normal potassium in the bloodstream), Edema (swelling caused by too much fluid), unspecified, Angina pectoris (chest pain or discomfort that keeps coming back), unspecified, Constipation, unspecified, Primary insomnia, Cough, Bipolar disorder, unspecified, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675792 If continuation sheet Page 4 of 8 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 675792 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Mansfield 1402 E Broad St Mansfield, TX 76063 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)

F 0700 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Unspecified intellectual disabilities, Other psychotic disorder not due to a substance or known physiological condition, Pruritus (itching), unspecified, Other seasonal allergic rhinitis, Chronic obstructive pulmonary disease, unspecified, Other peripheral vertigo (a problem in the part of the inner ear that controls balance), unspecified ear, essential (primary) hypertension (abnormally high blood pressure that's not the result of a medical condition), Hyperlipidemia (elevated level of lipids - like cholesterol and triglycerides - in your blood), unspecified, Type 2 diabetes mellitus without complications, Other muscle spasm, Family history of osteoporosis, and Pain, unspecified. Per face sheet, the responsible party was a family member. Brief interview with Resident #3 revealed that the resident was not aware of the bedrails/grab bars as she has been here over six years. Resident #3 was only able to hold a brief conversation before confusion set in when asked questions related to past events or circumstances. Record review of Resident #3's Care Plan, dated 10/23/2023, revealed resident was a fall risk and had a history of falls, had impaired vision due to cataracts, and utilized a walker for ambulation assistance. Record review of Resident #3's Physician Orders revealed twice daily psychotropic medication for anxiety and twice daily narcotic pain medication. Record review of Resident #3's Care Plan, dated 10/23/2023, revealed no indication of bed rail or enabler bar assessment or discussion of risks and benefits with Resident or responsible party. Review of Medical record of Resident #3 revealed no written Physician Order for quarter bed rails (enabler bars) for mobility and positioning. Review of Medical record of Resident #3 revealed no Physical Device Acknowledgement form (bed rail/enabler bar consent) for the quarter bed rails signed by the resident's responsible party. Observation on 01/11/2024 at 09:35 AM revealed Resident #3 sitting in a recliner at bedside eating lunch. Resident #3's bed was equipped with quarter bed rails/enabler bars that were raised. Resident's call light was wrapped around the enabler bar and laying on the bed in reach. 3. Record review of Resident #4's face sheet dated 01/11/2024 revealed resident was admitted on [DATE], with a current admit date of 11/17/2023, with diagnosis of Sepsis due to Methicillin resistant Staphylococcus aureus(Primary) (condition in which the body responds improperly to an infection caused by a type of staph bacteria that's become resistant to many of the antibiotics), Respiratory failure, unspecified, unspecified whether with hypoxia (oxygen is not available in sufficient amounts at the tissue level to maintain adequate homeostasis) or hypercapnia (high levels of carbon dioxide in your blood) (Admission), Cellulitis (common bacterial skin infection that causes redness, swelling, and pain in the infected area of the skin) of right lower limb, Bacterial infection, unspecified, Acquired absence of right leg below knee, Urinary tract infection, site not specified, Erythematous condition (exhibiting abnormal redness of the skin or mucous membranes due to the accumulation of blood in dilated capillaries (as in inflammation)), unspecified, Local infection of the skin and subcutaneous tissue, unspecified, Scabies (infestation of the skin by the human itch mite), Bacterial infection, unspecified, Insomnia, unspecified, Functional urinary incontinence, Neuralgia (pain in the nerve pathway) and neuritis (inflammation of a nerve or nerves secondary to injury or infection of viral or bacterial origins), unspecified, Post-traumatic stress disorder, unspecified, Other muscle spasm, Unspecified abnormal findings in urine, Anxiety disorder, unspecified, Unspecified disorder of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675792 If continuation sheet Page 5 of 8 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 675792 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Mansfield 1402 E Broad St Mansfield, TX 76063 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)

F 0700 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some adult personality and behavior, Type 2 diabetes mellitus (adult onset; condition that happens because of a problem in the way the body regulates and uses sugar as a fuel) with unspecified complications, Cellulitis, unspecified, Major depressive disorder, recurrent, moderate, Hyperglycemia (high blood glucose (blood sugar)), unspecified, Vitamin D deficiency, unspecified, Chronic pain due to trauma, Other chronic pain, Essential (primary) hypertension, Gastro-esophageal reflux disease without esophagitis, Constipation, unspecified, Neuralgia and neuritis, unspecified, Pressure ulcer of right ankle, unspecified stage, Muscle weakness (generalized), Tremor, unspecified, Other lack of coordination, Morbid (severe) obesity due to excess calories, Anxiety disorder due to known physiological condition, Major depressive disorder, recurrent, mild, Type 2 diabetes mellitus without complications, Generalized anxiety disorder, Restless legs syndrome, Obstructive sleep apnea (adult) (pediatric), Encounter for other orthopedic aftercare, Long term (current) use of anticoagulants (blood clot preventative), Dislocation of right ankle joint, subsequent encounter, Pain, unspecified, Pure hypercholesterolemia (high cholesterol), unspecified, and Depression, unspecified. Per the face sheet, the responsible party was the resident. Interview with Resident #4 revealed she was alert to person and place. Resident #4 was easily distracted and changed/embellished recollections of prior events when asked for what she remembered. Resident #4 did not answer all asked questions instead giving information on events and circumstances that she wanted to speak about. Review of Resident #4 Care Plan dated 11/10/2023 revealed resident was assessed as a fall risk and had impaired vision. Review of Medical Record of Resident #4's Care Plan, dated 11/10/2023, revealed there was no care plan addressing the use of bilateral quarter bedrails or enabler bars on resident's bed. Review of Resident #4's Nursing Home Medicare Part A Prospective Payment System Discharge (for change in payor source without a discharge from the facility) revealed no assessment or mention of bedrails or enabler bars. Review of Medical record of Resident #4 revealed no written Physician Order for half bed rails (pivot assist bars) for mobility and positioning. Review of Medical record for Resident #4 revealed Physician orders for narcotic pain reliever as needed, opioid pain reliever every 6 hours as needed, and psychotropic drug. Review of Medical record of Resident #4 reveals no Physical Device Acknowledgement form (bed rail/enabler bars consent) for the enabler bars signed by the resident. Observation on 01/11/2024 at 1:41 PM revealed Resident #4 sitting in a manual wheelchair at bedside. Resident bed had both quarter bedrails/enabler bars raised. Call light was wrapped on the bed rail/enabler bar and within reach. In an interview with the ADM on 01/11/2024 at 4:17 PM, it was expressed that the facility has used the halo enabler bars on beds in the facility. He stated he was unsure how residents were determined appropriate for the enabler bars, he did not know how the residents were evaluated for the use of the enabler bars, or how often the residents were evaluated for the ability to use the enabler bars safely. The ADM stated during the interview that he did know that the bed rails and halo bars need to be care planned for each resident they were used for. The ADM stated he was not familiar with the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675792 If continuation sheet Page 6 of 8 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 675792 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Mansfield 1402 E Broad St Mansfield, TX 76063 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)

F 0700 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some facility policy on bed rails and enabler bars as he had only been with this facility and company for 30 days and he has not had a chance to review it. In an interview on 01/11/2024 at 4:23 PM, the DON reviewed facility process for bed rail and grab/enabler bar use. The DON stated the bed rails and grab/enabler bars were used for residents for positioning and comfort. The DON stated that on admission the resident or responsible party were informed about the use and evaluated for the extent of need for bed rails and grab/enabler bars. The residents were also reviewed quarterly by therapy department or a nurse for continued safety and use of the bad rails and enabler bars. The DON stated that consent was obtained verbally from the resident or responsible party for the use of bed rails or enabler bars. The DON stated that electronic health records should be updated with the resident evaluations for safe use of bed rails and grab/enabler bars and that staff should be reviewing and familiar with resident status in their care areas. Interview with LVN C on 1/11/2024 at 12:52 PM was completed about bed rail or grab bar use in the facility. LVN C stated that residents should have been evaluated at admission to facility for use of bed rails or enabler bars and put on bed. LVN C stated he thought that reevaluation for safe use was done by the MDS nurse when they did assessments and annually. LVN C stated that bed rails can be a hazard as a resident could be hurt by having limb caught in the open spaces of the bar resulting in fractures or injury. Interview with RN D on 1/11/2024 at 2:10 PM was completed about bed rail or grab bar/enabler bar use in the facility. RN D stated he thinks if a resident wants them therapy department should evaluate at admission to the facility or when a resident asks for the bars then maintenance will put what therapy says to on the bed. RN D stated that bed rails or grab/enabler bars can be dangerous due to the potential of injury to a resident. RN D stated he was not sure who or how often a resident would be reevaluated as he was PRN. Record review of the facility's provided Proper Use of Side Rails, ©2001 (Revised December 2016), revealed the purpose To ensure the safe use of side rails as resident mobility aids and to prohibit the use of side rails as restraints unless necessary to treat a resident's medical symptoms. General Guideline item #2 states Side rails are only permissible if they are used to treat a resident's medical symptoms or to assist with mobility and transfer of residents. General Guideline #3 states An assessment will be made to determine the resident's symptoms, risk of entrapment, and reason for using side rails. When used for mobility or transfer, an assessment will include a review of the resident's: a. Bed mobility; b. Ability to change positions, transfer to and from bed or chair, and to stand and toilet; c. Risk of entrapment from the use of side rails; and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675792 If continuation sheet Page 7 of 8 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 675792 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Mansfield 1402 E Broad St Mansfield, TX 76063 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)

F 0700 d. Level of Harm - Minimal harm or potential for actual harm That the bed's dimensions are appropriate for the resident's size and weight. Residents Affected - Some General Guideline #4 states The use of side rails as an assistive device will be addressed in the resident care plan. General Guideline #5 states Consent for using restrictive devices will be obtained from resident or legal representative per facility protocol. General Guideline #7 states Documentation will indicate if less restrictive approaches are not successful, prior to considering the use of side rails. General Guideline #11 states The resident will be checked periodically for safety relative to side rail use. General Guideline #15 states Facility staff, in conjunction with the Attending Physician, will assess and document the resident's risk for injury due to neurological disorders or other medical conditions. No General Guideline item indicated need for a physician order before side rails or grab/enabler bars can be used or installed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675792 If continuation sheet Page 8 of 8