JUBILEE CARE ASSISTED LIVING, LLC

<p>Based on documentation review, record review, and interview, the manager failed to ensure a caregiver provided current documentation of first aid and cardiopulmonary resuscitation (CPR) training, before providing assisted living services, for one of four personnel sampled. The deficient practice posed a risk if an employee was unable to meet a resident's needs during an emergency.</p><p> </p><p><br></p><p>Findings include: </p><p><br></p><p><br></p><p>1. When the Compliance Officer arrived at the facility, E3 and E4 were the only employees at the facility.</p><p> </p><p><br></p><p>2. A review of the facility's policies and procedures revealed a policy titled "First Aid and CPR Training," the policy stated "5. In the Application for Employment form, the hiring person will note the expiration date stated on the First Aid and CPR card(s) and set up a reminder for the expiration date of the card(s) to ensure timely retraining in First Aid and CPR.6. The time frame of retraining is determined by the expiration date shown on the card or 24 months whichever occurs first. The employee or volunteer will be reminded in a timely manner of an expiring card as a condition of employment.”</p><p> </p><p><br></p><p>3. A review of E3's personnel record revealed E3 worked as a caregiver and manager designee. The personnel record revealed a first aid and CPR card with an expiration date of March 01, 2025. There was no other current documentation of first aid and CPR training in E3's personnel record.</p><p> </p><p><br></p><p>4. In an interview, E3 acknowledged E3 did not have current documentation of first aid and CPR training and was not in compliance with the facility's policy on the <span style="color: rgb(68, 68, 68); background-color: rgb(255, 255, 255);">time frame of retraining. </span></p>

<p>Based on observation and interview, the manager failed to ensure a complete personnel record was available for one of four personnel sampled. The deficient practice posed a risk as required information could not be verified for E4.</p><p> </p><p><br></p><p>Findings include:</p><p> </p><p><br></p><p>1. When the Compliance Officer arrived at the facility, E3 and E4 were the only employees at the facility.</p><p> </p><p><br></p><p>2. In an interview, E3 reported E4 was an "Assistant Caregiver."</p><p> </p><p><br></p><p>3. A review of the personnel records revealed no personnel record for E4.</p><p> </p><p><br></p><p>4. In an interview, E3 reported that E4 was a family member visiting and was helping E3 with the residents and acknowledged a personnel record was not available for E4.</p><p><br></p>

<p>Based on record review and interview, the manager failed to ensure a caregiver or an assistant caregiver documented the services provided to a resident in the resident's medical record, for two of three sampled residents. The deficient practice posed a risk as services could not be verified as provided against a service plan.</p><p> </p><p><br></p><p>Findings include:</p><p><br></p><p> </p><p>1. A review of R1's medical record revealed a service plan dated October 2024. The service plan stated the following services were needed:</p><p>"Ambulation (Bed Bound) - Turn every - to 3 hours"</p><p>"Bathing - shower 2x every week and as needed"</p><p>"Oral Care - 2x daily and as needed"</p><p>"Nail Care - Requires Assistance, daily and as needed"</p><p>"Hair Care/shaving: Requires Assistance, comb daily and as needed"</p><p>"Dressing - Requires Assistance"</p><p>"Toileting/ Daily Skin Check - Incontinence care every 2 hours”</p><p>" Night Check/ Bowel Movements – 2 to 4 hours”</p><p>However, documentation was not available indicating these services were provided from March 17th to the present.</p><p> </p><p><br></p><p>2. A review of R2's medical record revealed a service plan dated March 2025. The service plan stated the following services were needed:</p><p>"Bathing - shower 2x every week and as needed"</p><p>"Oral Care - 2x daily and as needed"</p><p>"Nail Care - Requires Assistance, daily and as needed"</p><p>"Hair Care/shaving: Requires Assistance, comb daily and as needed"</p><p>"Dressing - Requires Assistance"</p><p>"Toileting/ Daily Skin Check - Incontinence care every 2 hours”</p><p>" Night Check/ Bowel Movements – 2 to 4 hours”</p><p>However, documentation was not available indicating these services were provided from March 5th to the present.</p><p> </p><p> </p><p>3. In an interview, E3 reported the aforementioned services were provided to R1 and R2 as outlined service plans, but were not documented.</p><p><br></p>

<p>Based on documentation review, observation, and interview, the manager failed to ensure a resident's medical record was protected from loss, damage, or unauthorized use. The deficient practice posed a risk of protected and sensitive resident health information being disclosed without the resident's consent or knowledge. </p><p><br></p><p><br></p><p>Findings include:</p><p><br></p><p><br></p><p>1. A.R.S. § 12-2291(6) "Medical records" means all communications related to a patient's physical or mental health or condition that are recorded in any form or medium and that are maintained for purposes of patient diagnosis or treatment, including medical records that are prepared by a health care provider or by other providers.</p><p><br></p><p><br></p><p>2. During the environmental tour with E3, the Compliance Officer observed that medical records for R1, R2, and other residents were stored on a shelf in the dining room area. The Compliance Officer also observed multiple ambulatory residents and visitors walking through the facility. </p><p><br></p><p><br></p><p>3. In an interview, E3 acknowledged that resident medical records were not protected from loss, damage, or unauthorized use.</p>

<p>Based on documentation review, observation, and interview, for a facility authorized to provide directed care services, the manager failed to ensure there was a means of exiting the facility that provided access to an outside area from which a resident could exit to a location at least 30 feet away from the facility and controlled or alerted employees of the egress of a resident from the facility. The deficient practice posed a risk if the facility was unaware of the general or specific whereabouts of a resident.</p><p> </p><p><br></p><p>Findings include:</p><p> </p><p><br></p><p>1. A review of Department records revealed the facility was licensed to provide directed care services.</p><p> </p><p><br></p><p>2. <span style="color: rgb(68, 68, 68); background-color: rgb(255, 255, 255);">During the environmental tour with E3</span>, the Compliance Officer observed the front doors leading to the front yard. The doors leading out to the front yard from the facility did not control or alert employees to the egress of a resident to the outside area.</p><p> </p><p><br></p><p>3. <span style="color: rgb(68, 68, 68); background-color: rgb(255, 255, 255);">During the environmental tour with E3</span>, the Compliance Officer observed the sliding door leading to the backyard. The door leading out to the backyard had a device that was intended to alert employees to the egress of a resident to the outside area. However, the door was not secured and the door chime was turned off.</p><p> </p><p><br></p><p>4. <span style="color: rgb(68, 68, 68);">During the environmental tour with E3</span>, the Compliance Officer observed a door leading to the backyard from R4’s room (Bedroom 1). The door leading out to the backyard from the facility did not control or alert employees to the egress of a resident to the outside area.</p><p> </p><p><br></p><p>5. In an interview, E3 acknowledged a means of exiting the facility to an outside area did not control or alert employees of the egress of a resident from the facility.</p>

<p>Based on record review and interview, the manager failed to ensure a medication administered to a resident was documented in the resident's medical record, for two of three residents sampled. The deficient practice posed a risk as medication could not be verified as administered against a medication order.</p><p> </p><p><br></p><p>Findings include:</p><p> </p><p><br></p><p>1. A review of R1's medical record revealed a current written service plan, which indicated R1 received medication administration. A review of R1's medical record revealed signed medication orders for the following medications; </p><p>- Aspirin EC - 81mg - 2 tab - BID - PO</p><p>- Trazodone - 100mg - 1 tab - QHS - PO</p><p>- Amlodipine - 10mg - 1 tab - QD - PO</p><p>- Escitalopram - 10mg - 1 tab - QD - PO</p><p>- Lorazepam - 2mg - 1 tab - QD – PO</p><p> </p><p><br></p><p>2. A review of R1's medical record revealed a March 2025 medication administration record (MAR). This MAR did not include documentation that the aforementioned medications were provided from March 15th to the present.</p><p> </p><p><br></p><p>3. A review of R2's medical record revealed a current written service plan, which indicated R2 received medication administration. A review of R2's medical record revealed signed medication orders for the following medications; </p><p>- Atorvastatin – 10 mg, 1 tablet, QHS, PO</p><p>- Metoprolol Succinate ER – 50 mg, 1 tablet, QHS, PO; hold if SBP < 100 or HR < 60</p><p>- Acetaminophen – 325 mg, 2 tablets, PO, every 4 hours PRN</p><p>- Lorazepam Concentrate – 2 mg/mL, 0.25 mL, PO, every 4 hours PRN</p><p>- Morphine Sulfate – 20 mg/mL, 0.25 mL, PO, every 2 hours PRN</p><p><br></p><p><br></p><p>4. In an interview, E3 reported R2 was on Hospice and that the PRN medications were administered. </p><p><br></p><p><br></p><p>5. A review of R2's medical record revealed a March 2025 MAR. This MAR did not include documentation that the aforementioned medications were provided from March 15th to the present.</p><p> </p><p><br></p><p>6. In an interview, E3 reported the medications were administered per the medication orders and acknowledged R1's and R2's MARs did not include documentation the medications were administered.</p><p><br></p><p><br></p><p>7. This is a repeat deficiency from the inspection conducted on April 10, 2023.</p>

<p>Based on documentation review and interview, the manager failed to ensure the disaster plan required in subsection (A)(1) was reviewed at least once every 12 months. The deficient practice posed a risk if employees were unable to implement the disaster plan in an emergency.</p><p><br></p><p><br></p><p>Findings include:</p><p><br></p><p><br></p><p>1. A review of facility documentation revealed no documented review of the facility's disaster plan conducted at least once every 12 months. </p><p><br></p><p><br></p><p>2. In an interview, E3 acknowledged there was no documentation available for review at the time of the inspection to indicate the disaster plan required in subsection (A)(1) was reviewed at least once every 12 months. </p>

<p>Based on documentation review, observation, and interview, the manager failed to ensure the premises at the assisted living facility were free from a condition or situation that may cause a resident or other individual to suffer physical injury. The deficient practice posed potential dangers to residents.</p><p> </p><p><br></p><p>Findings include:</p><p> </p><p><br></p><p>1. A review of Department records revealed the facility was licensed to provide directed care services.</p><p><br></p><p> </p><p>2. The Compliance Officer observed one ambulatory resident.</p><p><br></p><p><br></p><p>3. During the environmental tour with E3, the Compliance Officer observed an unlocked door leading to the backyard. In the backyard, an unsecured garden hose was found on the path, creating a tripping hazard.</p><p> </p><p><br></p><p>4. In an interview, E3 acknowledged that it could be a situation that may cause a resident or other individual to suffer physical injury.</p><p><br></p><p><br></p><p>5. This is a repeat deficiency from the inspection conducted on April 10, 2023.</p>

<p>Based on documentation review, record review, and interview, for two of three residents sampled, the facility failed to maintain a standardized form for each resident that included the information prescribed in A.R.S. 36-420.04. The deficient practice posed a risk as required patient information was not prepared in case of an emergency.</p><p><br></p><p>Findings include:</p><p><br></p><p>1. A.R.S. 36-420.04.A states, "A. An assisted living center or assisted living home that contacts an emergency responder on behalf of a resident shall provide to the emergency responder a written document that includes all of the following:</p><p>1. The reason or reasons the emergency responder was requested on behalf of the resident. 2. Whether the resident receives medication services and, if the resident has provided this information to the assisted living center or assisted living home, a list of all the resident's prescription and over-the-counter medications, their dosages and how frequently they are administered. 3. The name, address and telephone number of the resident's current pharmacy. 4. A list of any known allergies to any medications, additives, preservatives or materials like latex or adhesive. 5. The name and contact information for the resident's primary care physician and power of attorney or authorized representative. 6. Basic information about the resident's physical and mental conditions and basic medical history, such as having diabetes or a pacemaker or experiencing frequent falls or cardiovascular and cerebrovascular events, as well as dates of recent episodes, if known. 7. The point-of-contact information for the assisted living center or assisted living home, including the telephone number, if available, cell phone number and email address. A point of contact must be available to respond to questions regarding the information provided twenty-four hours a day, seven days a week. 8. A copy of the resident's health insurance portability and accountability act (HIPAA) release authorizing a receiving hospital to communicate with the assisted living center or assisted living home to plan for the resident's discharge. This paragraph does not preclude a resident from revoking the resident's health insurance portability and accountability act release authorization. 9. A copy of the resident's advance directives, if any, on file at the assisted living center or assisted living home. This paragraph does not preclude a resident from revoking or modifying the resident's advance directives."</p><p><br></p><p><br></p><p>2. A review of R1's and R2's medical records revealed no documentation of the completed emergency responder patient information documentation required in Arizona Revised Statute (A.R.S.) § 36-420.04(A)(1) through (9).</p><p> </p><p><br></p><p>3. In an interview, E3 acknowledged the information required in A.R.S. § 36-420.04 was not prepared in a standardized emergency responder patient information form as required.</p><p><br></p>

Based on observation, documentation review, record review, and interview, the manager failed to implement policies and procedures to protect the health and safety of a resident covering termination of residency. The deficient practice posed a risk as the facility's standards were not followed and the bedrails posed a risk as R3's legs would get stuck between the rails.

Findings include:

1. The Compliance Officer observed R3's bed to have one bedrail measuring approximately the length of the bed, on the resident's right side of the bed. The bedrail contained removable padding. The left side of the bed was pushed against the wall.

2. A review of facility documentation revealed a policy and procedure titled "Resident Acceptance, Rights and Termination" (dated August 31, 2022). The policy and procedure stated "...Resident Termination:...With a 14-day written notice of termination of residency ...or if any of the following:...The individual requires restraints, including the use of bedrails."

3. A review of R3's (accepted in 2022) medical record revealed a service plan for directed care services dated in January 2023. The service plan revealed R3 was bedbound and was a high risk for falling.

4. In an interview, E2 reported R3 was on home health and R3's home health agency provided the facility with a bedrail for R3's bed.

5. In an interview, E2 reported the bedrail attached to R3's bed was used to prevent R3 from falling out of bed. E2 reported R3 moved around a lot in bed and would often slide down and out of the bed. E2 reported R3 was bedbound and was not able to lower the bedrail or maneuver around the bedrail. E2 reported R3 was able to remove the padding attached to the bedrail and R3's legs would get stuck between the rails.

Based on record review, documentation review, and interview, the manager failed to ensure documentation required by Article 8 was provided to the Department within two hours after a Department request. The deficient practice posed a risk as the Department was unable to determine substantial compliance.

Findings include:

1. A review of E3's personnel record revealed current in-service education required by the facility's policy and procedure was not available for review.

2. A review of R2's medical record revealed a document titled, "Determination of Continuous Residency." However, the document was not dated and signed by a physician, registered nurse practitioner, registered nurse, or physician assistant.

3. A review of R1's medical record revealed a service plan dated in August 2022 for personal care services. However, documentation to demonstrate R1's service plan was reviewed and updated at least once every six months was not available for review.

4. A review of R2's medical record revealed a service plan dated in January 2023 for directed care services. However, the service plan was not signed and dated by the resident's representative or the manager.

5. A review of R3's medical record revealed a service plan dated in January 2023 for directed care services. However, the service plan was not signed and dated by the resident's representative or the manager.

6. A review of R1's and R3's medical records revealed documentation of freedom from infectious tuberculosis was not available for review.

7. A review of R1's medical record revealed a service plan dated in August 2022 for personal care services. The service plan stated R1 was to receive assistance in activities of daily living. However, documentation of assisted living services for March 12, 2023 through March 31, 2023 and April 1, 2023 through April 9, 2023 were not available for review.

8. A review of R2's medical record revealed a service plan dated in January 2023 for directed care services. The service plan stated R2 was to receive assistance in activities of daily living. However, documentation of assisted living services for March 1, 2023 through March 31, 2023 and April 1, 2023 through April 9, 2023 were not available for review.

9. A review of R3's medical record revealed a service plan dated in January 2023 for directed care services. The service plan stated R3 was to receive assistance in activities of daily living. However, documentation of assisted living services for March 1, 2023 through March 31, 2023 and April 1, 2023 through April 9, 2023 were not available for review.

10. A review of R1's medical record revealed a medication administration record (MAR) for April 2023. The MAR revealed R1 received medication administration of Metoprolol 25 mg on April 1-9, 2023 at 8AM. However, medication administration of Metoprolol 25 mg was not documented as administered on R1's MAR on April 1-9, 2023 at 5PM

11. A review of facility documentation revealed disaster drills were completed on the following dates and times:
-December 10, 2022 at 10AM; and
-March 10, 2023 at 10AM.
However, additional documentation of disaster drills for employees conducted on each shift at least once every three months was not available for review.

12. In an interview, E2 acknowledged documentation required by Article 8 was not provided to the Department within two hours after a Department request.

Based on documentation review, record review, and interview, the manager failed to ensure a personnel record for an employee included documentation of the individual's in-service education required by policies and procedures, for one of three personnel members sampled. The deficient practice posed a risk the Department was unable to determine substantial compliance as the documentation was not in the personnel records during the inspection, and the documentation was not provided within two hours after a Department request.

Findings include:

R9-10-101.116. "In-service education" means organized instruction or information that is related to physical health services or behavioral health services and that is provided to a medical staff member, personnel member, employee, or volunteer.

1. A review of facility documentation revealed a policy and procedure titled "Orientation and In-Service Training" (dated August 31, 2022). The policy and procedure stated " ...In-service Fall Prevention and Recovery Training will be provided upon hire and at least every 12 months thereafter..."

2. A review of E3's (hired in 2023) personnel record revealed current in-service education required by the facility's policy and procedure was not available for review.

3. In an interview, E2 acknowledged E3's in-service training required by the facility's policy and procedure was not provided for review.

Based on record review and interview, the manager failed to ensure before or at the time of acceptance of an individual, the individual submitted documentation dated within 90 calendar days before the individual was accepted by the assisted living facility and was dated and signed by a physician, registered nurse practitioner, registered nurse, or physician assistant, for one of three residents sampled. The deficient practice posed a risk the Department was unable to determine substantial compliance as the documentation was not available in the medical record during the inspection, and the documentation was not provided within two hours after a Department request.

Findings include:

1. A review of R2's (accepted in 2022) medical record revealed a document titled, "Determination of Continuous Residency." However, the document was not dated and signed by a physician, registered nurse practitioner, registered nurse, or physician assistant.

2. In an interview, E2 acknowledged R2's aforementioned document was not dated and signed by a physician, registered nurse practitioner, registered nurse, or physician assistant.

Based on record review and interview, the manager failed to ensure a written service plan was reviewed and updated at least once every six months for a resident receiving personal care services, for one of one resident sampled who received personal care services. The deficient practice posed a risk as the Department was unable to determine substantial compliance as the documentation was not in the medical record during the inspection, and the documentation was not provided within two hours after a Department request.

Findings include:

1. A review of R1's (accepted in 2021) medical record revealed a service plan dated in August 2022 for personal care services. However, documentation to demonstrate R1's service plan was reviewed and updated at least once every six months was not available for review.

2. In an interview, E2 reported R1's updated service plan was completed, however, E2 was unable to locate the requested documentation.

Based on record review and interview, the manager failed to ensure a resident had a written service plan signed and dated by the resident or resident's representative and the manager, when updated, for two of three residents sampled. The deficient practice posed a risk as the Department was unable to determine substantial compliance as the documentation was not in the medical records during the inspection, and the documentation was not provided within two hours after a Department request.

Findings include:

1. A review of R2's medical record revealed a service plan dated in January 2023 for directed care services. However, the service plan was not signed and dated by the resident's representative or the manager.

2. A review of R3's medical record revealed a service plan dated in January 2023 for directed care services. However, the service plan was not signed and dated by the resident's representative or the manager.

3. In an interview, E2 acknowledged the service plans provided for R2 and R3 had not been signed and dated by R2's and R3's representatives or the manager.

Based on observation, record review and interview, the manager failed to ensure a resident was not subjected to restraint, for one of three residents sampled. The deficient practice posed a risk to the resident's rights and the bedrails posed a risk as R3's legs would get stuck between the rails.

Findings include:

1. The Compliance Officer observed R3's bed to have one bedrail measuring approximately the length of the bed, on the resident's right side of the bed. The bedrail contained removable padding. The left side of the bed was pushed against the wall.

2. A review of R3's medical record revealed a service plan for directed care services dated in January 2023. The service plan revealed R3 was bedbound and was a high risk for falling.

3. In an interview, E2 reported the bedrail attached to R3's bed was used to prevent R3 from falling out of bed. E2 reported R3 moved around a lot in bed and would often slide down and out of the bed. E2 reported R3 was bedbound and was not able to lower the bedrail or maneuver around the bedrail. E2 reported R3 was able to remove the padding attached to the bedrail and R3's legs would get stuck between the rails.

4. In an interview, E2 reported R3 was on home health and R3's home health agency provided the facility with a bedrail for R3's bed.

5. In an interview, E2 acknowledged R3's bed had a bedrail and the bedrail was used to as a restraint.

Based on record review and interview, the manager failed to ensure a resident's medical record contained documentation of freedom from infectious tuberculosis (TB), for two of three residents sampled. The deficient practice posed a TB exposure risk to residents, the Department was unable to determine substantial compliance as the documentation was not in the medical records during the inspection, and the documentation was not provided within two hours after a Department request.

Findings include:

1. A review of R1's medical record revealed documentation of freedom from infectious TB was not available for review.

2. A review of R3's medical record revealed documentation of freedom from infectious TB was not available for review.

3. In an interview, E2 reported R1 and R3 had documentation of freedom form infectious TB, however, E2 was unable to locate the requested documentation.

Based on record review and interview, the manager failed to ensure a resident's medical record contained documentation of assisted living services provided to the resident, for three of three residents sampled. The deficient practice posed a risk as the Department was unable to determine substantial compliance as the documentation was not in the medical records during the inspection, and the documentation was not provided within two hours after a Department request.

Findings include:

1. A review of R1's medical record revealed a service plan dated in August 2022 for personal care services. The service plan stated R1 was to receive assistance in activities of daily living. However, documentation of assisted living services for March 13, 2023 through March 31, 2023 and April 1, 2023 through April 9, 2023 were not available for review.

2. A review of R2's medical record revealed a service plan dated in January 2023 for directed care services. The service plan stated R2 was to receive assistance in activities of daily living. However, documentation of assisted living services for March 1, 2023 through March 31, 2023 and April 1, 2023 through April 9, 2023 were not available for review.

3. A review of R3's medical record revealed a service plan dated in January 2023 for directed care services. The service plan stated R3 was to receive assistance in activities of daily living. However, documentation of assisted living services for March 1, 2023 through March 31, 2023 and April 1, 2023 through April 9, 2023 were not available for review.

4. In an interview, E2 reported assisted living services were provided to R1, R2, and R3. However, E2 reported E2 was unable to locate the requested documentation.

Based on record review and interview, the manager failed to ensure a medication administered to a resident was documented in the resident's medical record, for one of three residents sampled. The deficient practice posed a risk as the Department was unable to determine substantial compliance as the documentation was not in the medical record during the inspection, and the documentation was not provided within two hours after a Department request.

Findings include:

1. A review of R1's medical record revealed a current service plan for personal care services. R1's service plan revealed R1 received medication administration.

2. A review of R1's medical record revealed a medication order dated June 2, 2022 for Metoprolol 25 mg, take half a tablet by mouth two times a day.

3. A review of R1's medical record revealed a medication administration record (MAR) for April 2023. The MAR revealed R1 received medication administration of Metoprolol 25 mg on April 1-9, 2023 at 8AM. However, medication administration of Metoprolol 25 mg was not documented as administered on R1's MAR on April 1-9, 2023 at 5PM

4. In an interview, E2 reported R1 received medication administration of the aforementioned medication. However, E2 reported E2 forgot to document the 5PM administration.

Based on documentation review and interview, the manager failed to ensure a disaster drill for employees was conducted on each shift at least once every three months. The deficient practice posed a risk if employees were unable to implement a disaster plan, the Department was unable to determine substantial compliance as the documentation was not available during the inspection, and the documentation was not provided within two hours after a Department request.

Findings include:

1. A review of Department documentation revealed the facility's perpetual license was effective on October 19, 2020.

2. A review of facility documentation revealed a staffing schedule, dated March/April 2023. The schedule revealed the facility maintained two shifts, 7 AM-7 PM and 7 PM-7 AM.

3. A review of facility documentation revealed disaster drills were completed on the following dates and times:
-December 10, 2022 at 10AM; and
-March 10, 2023 at 10AM.
However, additional documentation of disaster drills for employees conducted on each shift at least once every three months was not available for review.

4. In an interview, E2 acknowledged the facility had not conducted disaster drills on each shift at least once every three months.

Based on observation and interview, the manager failed to ensure equipment used at the assisted living facility was free from a condition or situation that may cause a resident or other individual to suffer physical injury. The deficient practice posed as R3's legs would get stuck between the rails.

Findings include:

1. The Compliance Officer observed R3's bed to have one bedrail measuring approximately the length of the bed, on the resident's right side of the bed. The bedrail contained removable padding. The left side of the bed was pushed against the wall.

2. In an interview, E2 reported R3 was able to remove the padding attached to the bedrail and R3's legs would get stuck between the rails.

3. In an interview, E2 acknowledged the bedrail attached to R3's bed could cause R3 to suffer physical injury.