**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure six of seven sampled residents (Residents 39, 45, 20, 11, 68 and 27) were free of unnecessary physical restraints (devices that limit a patient's movement) by failing to: 1. Ensure six of seven residents (Residents 39, 45, 20, 11, 68 and 27) were free from physical restraints. 2. Follow the Physical Restraint Elimination Assessment (assessment used by the facility for restrained residents to determine whether they are candidates for restraint reduction, score of 0-20 is a priority candidate, 21-35 good candidate, and 35 and above is a poor candidate) for Residents 39, 45, 20, 11, 68 and 27, monthly to assess for the need of physical restraint continued used. 3. Release physical restraint every two (2) hours for 15 minutes to ensure good blood circulation (the flow of fluid, especially blood) to upper extremities and assess skin integrity (the skin being whole, intact, and undamaged) for Residents 39, 45, 20, 11, 68 and 27. 4. Use least restrictive measures (restraint that allows the most freedom of movement while still protecting the resident) prior to use of physical restraints per facility's policies and procedures (P&P), titled Physical Restraints for Residents 39, 45, 20, 11, 68 and 27. 5. Ensure soft wrist restraints (soft material or fabric fit around the limbs [arm or leg] of an individual to limit movement and to prevent the dislodgment of tubes, lines, and catheters) were applied correctly and secured in proper position to Resident 39 and 20's bed frame per manufacturer guidelines (instructions provided by maker of a product to provide detailed insight into how to equipment should be used). These deficient practices placed Residents' 39, 45, 20, 11, 68 and 27, at risk for impaired blood circulation with possible formation of venous stasis ulcers (medical condition characterized by impaired blood flow in the veins), skin injuries including pressure ulcer (an injury that breaks down the skin and underlying tissue) and psychosocial harm from not being treated with respect and dignity. On 12/12/2023 at 4:57 p.m., the Director of Nursing (DON) and Nurse Manager were notified of an Immediate Jeopardy ([IJ], a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious, injury, harm, impairment, or death to a resident ) was called due to six residents, Residents 39, 11 and 27 on right soft mittens (used to prevent residents from pulling out any essential lines or tubes) and right soft wrist restraints, 20 on left soft mittens and left soft wrist restraints, Resident 45 on bilateral soft mittens and 68 on right soft mitten, failed to follow the Physical Restraint Elimination Assessment for all 6 residents, failed to release physical restraint every two (2) hours for 15 minutes for all six residents, failed to use least restrictive measures prior to use of physical restraints for all six residents and failed to ensure soft wrist restraints were applied correctly for Residents 39 and 20. The facility's DON, and Nurse Manager were notified of the seriousness of the risk of physical restraints. An IJ Removal Plan was requested from the facility's staff. On 12/14/2023 the facility submitted an acceptable IJ Removal Plan. On 12/14/23 at 6:21 p.m., the DON and Core Leader were notified the IJ was removed after on-site validation of the implementation of the IJ Removal Plan via observations, interviews, and record review. The IJ Removal Plan included the following: 1. Facility management rounded on 12/12/2023 on Resident 39, 20,11, and 27 to validate appropriate restraint placement and securement to the bed was in the quick-release manner, per manufacturer's guidelines. 2. Facility management rounded on 12/12/2023 on Resident 45 and 68 to validate appropriate restraint placement. 3. Physician's orders stating needs for physical restraints were reviewed for Resident 39, 45, 20, 11, 68 and 27 on 12/12/23. 4. Nursing assessments on continued need for restraints reviewed for Resident 39, 45, 20, 11, 68 and 27 on 12/12/23. 5. Alternatives for physical restraints were attempted and documented within restraint non-violent flowsheet every shift for Resident 39, 45, 20, 11, 68 and 27 on 12/12/23 and 12/13/23. 6. Peripheral, neurovascular (involving both nerves and blood vessels), and skin assessments performed and documented every two hours for Resident 39, 45, 20, 11, 68 and 27 on 12/12/23 and 12/13/23. 7. Physical restraints released for 15 min every two hours and documented for Resident 39, 45, 20, 11, 68 and 27 on 12/12/23 and 12/13/23. 8. Trial off physical restraints conducted on 12/14/23 from 8:15 am to 8:25 am to evaluate the continued necessity for restraints for Resident 39. Right hand mitten and right soft wrist restraint were removed for Resident 39. Resident 39 failed trial on 12/14/23. 9. Trial off physical restraints conducted on 12/13/23 from 2:00 pm to 2:30 pm to evaluate the continued necessity for restraints for Resident 45. Bilateral soft mittens were removed. Resident 45 tolerated trial off restraints. Trial continues per facility's policy and procedures. 10. Trial off physical restraints conducted on 12/13/23 from 10:30 pm to 10:35 pm to evaluate the continued necessity for restraints for Resident 20. Right hand mitten and right soft wrist restraints were removed for Resident 20. Resident 20 failed trial on 12/13/23. 11. Trial off physical restraints conducted on 12/13/23 from 8:05 pm to 8:15 pm to evaluate the continued necessity for restraints for Resident 11. Right hand mitten and right soft wrist restraints were removed for Resident 11. Resident 11 failed trial on 12/13/23. 12. Trial off physical restraints conducted on 12/13/23 from 8:55 pm to 9:09 pm to evaluate the continued necessity for restraints for Resident 68. Right hand mitten was removed for Resident 68. Resident 68 failed trial on 12/13/23. 13. Trial off physical restraints conducted on 12/13/23 from 7:45 pm to 7:49 pm to evaluate the continued necessity for restraints for Resident 27. Right hand mitten and right soft wrist restraints were removed for Resident 27. Resident 27 failed trial on 12/13/23. 14. Least restrictive restraint attempted on 12/14/23 at 12:15 pm, right soft wrist restraint removed. Resident 39 tolerating will continue to monitor. 15. Least restrictive restraint attempted for Resident 20 on 12/14/23 at 12:45 pm, right soft wrist restraint removed. Resident 20 failed. 16. Least restrictive restraint attempted for Resident 27 on 12/14/23 at 12:15 pm, right soft wrist restraint removed. Resident 27 failed. 17. Reviewed side rails assessment form for Resident 39, 45,20,27,11 and 68 on 12/14/2023, which included recommendations to use bilateral padded upper and lower side rails. 18. Assess resident for risk for entrapment and document by 12/15/23. Findings: 1.During an observation on 12/11/2023 at 11:55 a.m. at Resident 39's bedside, Resident 39 was observed non-verbal with a soft wrist restraint on the right wrist, a soft mitten restraint on the right hand and all four siderails up on the bed. During a review of Resident 39's admission Record (Face Sheet) the Face Sheet indicated Resident 39 was admitted on [DATE] with diagnoses including respiratory failure (a condition in which your blood doesn't have enough oxygen), tracheostomy (a procedure to help air and oxygen reach the lungs by creating an opening into the trachea [windpipe] from outside the neck) and cerebral vascular accident (CVA[ an interruption in the flow of blood to cells in the brain]) with left arm weakness. During a review of Resident 39's Minimum Assessment Set (MDS - a standardized assessment and care screening tool) dated 11/10/2023, the MDS indicated Resident 39 had severe cognitive (ability to learn, remember, understand, and make decisions) and memory impairment for daily decision making. Resident 39 had impairment (weakness) on both arms and was dependent for all activities of daily living (ADL- consist of eating, dressing/grooming, bathing/personal hygiene, mobility (ambulation and transfer), elimination [toileting]). The MDS indicated Resident 39 used one limb (right arm) physical restraints on the right upper extremity. During an observation on 12/11/2023 at 10:24 a.m. at Resident 45's bedside, Resident 45 was observed with bilateral (both) mitten restraints to the hands. During a review of Resident 45's admission Record (Face Sheet) the Face Sheet indicated Resident 45 was admitted on [DATE] with diagnoses including respiratory failure, dementia (a condition characterized by progress loss of intellectual functioning with memory impairment), and status post fall. During a review of Resident 45's MDS dated [DATE], the MDS indicated Resident 45 had severe cognitive impairment for daily decision making. Resident 45 had impairment on both arms and was dependent for all ADL. The MDS indicated Resident 45 had bilateral (both) hand restraints. During a review of Resident 20's admission Record (Face Sheet ), the Face Sheet indicated Resident 20 was admitted on [DATE] and readmitted on [DATE] with diagnoses including deep venous thrombosis (blood clot formed in the deep vein of the body), history of traumatic brain injury (damage to the brain that disrupts normal functioning caused by an outside force, typically such as a violent blow to the head), functional quadriplegia (complete immobility to move due to physical disability or frailty), gastrostomy (opening into the stomach from the abdomen for the introduction of food), presence of tracheostomy, and history of CVA. During a review of Resident 20's MDS dated [DATE], the MDS indicated Resident 20 had severely impaired cognitive skills and was dependent on staff members with bed mobility, bathing, personal hygiene, dressing and toileting. The MDS indicated Resident 20 was on upper limb restraint. During a review of Resident 20's Physician Order dated 10/19/2023 timed at 11:50 p.m., the Physician Order indicated an order to place left hand soft mitten (used to prevent residents from pulling out any essential lines or tubes) and left soft wrist restraints to prevent from pulling out tubes, release and check for redness, circulation, hydration, nutritional/elimination needs, hygiene, safety every two hours and perform range of motion ([ROM] is the extent of movement of a joint, measured in degrees of a circle) exercises until discontinued. During a review of Resident 11's admission Record (Face Sheet), the Face Sheet indicated Resident 11 was admitted on [DATE] with diagnoses including history of hemorrhagic stroke (blood vessels rupture in or near the brain which can cause permanent damage to the brain), tracheostomy, chronic respiratory failure, ileostomy (opening in the abdomen to evacuate stool from the body), anoxic brain injury( blood flow and oxygen to the brain was interrupted which can cause damage to the brain),and dysphagia ( difficulty of swallowing). During a review of Resident 11's Minimum Data Set ([MDS] standardized assessment and care screening tool) dated 11/15/2023, the MDS indicated Resident 11 had severely impaired cognitive skills and was dependent on staff members with bed mobility, transfer from bed to wheelchair, bathing, toileting hygiene and personal hygiene. The MDS indicated Resident 11 had an indwelling catheter (flexible tube used to empty the bladder and collect urine in a drainage bag) and ostomy (creation of an artificial opening in the abdomen to allow for the elimination of body wastes). During a review of Resident 68's admission Record (Face Sheet), the Face Sheet indicated Resident 68's was admitted on [DATE] with diagnoses including aneurysm (an abnormal bulge or ballooning in the wall of a blood vessel), subarachnoid hemorrhage (bleeding in the space between the brain and the tissue covering the brain), cerebral edema (swelling of the brain), tracheostomy and gastrostomy. During a review of Resident 68's MDS dated [DATE] indicated Resident 68 had severe cognitive impairment and requires total assistance for bed mobility, dressing, toilet use and personal hygiene. The MDS indicated Resident 68 used limb (right arm) restraint daily. During a review of Resident 27's admission Record (Face Sheet), the Face Sheet indicated Resident 27 was admitted on 8/2014, with diagnoses including traumatic brain injury, epilepsy (seizure disorder - sudden, uncontrolled electrical activity in the brain that causes temporary abnormalities in muscle tone or movements, behaviors, sensations, or states of awareness), dysphagia, respiratory failure tracheostomy and gastrostomy. During a review of Resident 27's History and Physical (H/P), dated 1/3/23, the H/P indicated, Resident 27 did not have the ability to communicate. During a review of Resident 27's MDS dated [DATE], the MDS indicated, Resident 27 had persistent vegetative state/no discernible consciousness (when a person is awake but is showing no signs of awareness). Resident 27 required extensive assistance (resident total dependent; full staff assistance) with bed mobility and extensive assistance with transferring, dressing, toilet use, personal hygiene and did not utilize a mobility device. The MDS indicated Resident 27 utilized a limb (right arm) restraint daily. 2. During a concurrent interview and record review on 12/12/2023 on 2:15 p.m. with the Nurse Manager (NM) 1, NM 1 stated Resident 39 Physical Restraint Elimination Record assessment score was 26. NM 1 stated a score of 21-35 means Resident 39 was a good candidate to have a trial to see if the restraints can be released. During a review of Resident 20's Physical Restraint Elimination Assessment, the Physical Restraint Elimination assessment indicated Resident 20 was assessed on 10/1/2023, 11/1/2023 and 12/1/2023 with a score of 22 (score of 22 was a good candidate for restraint reduction). During a review of Resident 20's Nurses Progress Notes dated 10/22/2023, at 12:59 p.m., the Nurses Progress Notes indicated the Resident 20 had episodes of pulling essential lines when restraints were released and was not a good candidate for restraints removal. There was no other documentation except for 10/20/2023 and 10/22/2023 regarding weekly assessment of restraint usage for the month of October 2023. During a review of Resident 20's Nursing Progress Notes for the month of November 2023, the Nursing Progress Notes indicated on 11/13/23, 11/19/2023, and 11/28/23 Resident 20 was not a candidate for restraint removal of hand soft mitten and soft wrist restraint due to pulling of essential lines (tracheostomy and gastrostomy tube) when restraints were removed. The Nursing Progress Notes indicated no weekly assessment was done for the week of 10/29/2023 and 11/5/2023. During a review of Resident 20's Nursing Progress Notes for October, November and up to December 11, 2023, the Nursing Progress Notes indicated no trial of restraint removal or least restrictive restraint was attempted and was documented. During a review of Resident 11's Physical Restraint Elimination Assessment, the Physical Restraint Elimination Assessment indicated on 8/1/2023, 9/1/2023, 10/1/2023 and 11/1/2023 Resident 11's score was 24. The Physical Restraint Elimination Assessment indicated a score of 24 was a good candidate for restraint reduction. During a review of Resident 11's Restraints Progress Notes for the month of October 2023, the Restraints Progress Notes indicated weekly assessment for restraint use was performed on 10/1/2023, 10/15/2023, 10/22/2023, and 10/29/2023.The Progress Notes indicated no weekly assessment done for the week of 10/8/2023. During an interview on 12/12/2023, at 2:17 p.m. with Nurse Manager (NM) 1, NM 1 stated Restraints Elimination Assessment was used to determine if a resident (in general) on restraints was a good candidate for reduction or if restraints can be released from restraints. NM 1 stated the low score on the assessment indicates resident (in general) was a good candidate for restraints reduction. NM 1 stated the assessment of restraints were performed weekly by registered nurses' and the licensed nurses must be physically present to release the restraints, check the resident's skin and circulation. NM 1 stated unnecessary restraints could inhibit residents' mobility. 3. During a review of Resident 39's Physician Order dated 3/9/2022, indicated Resident 39 with right hand soft mitten and release every two hours for blood circulation check, redness, and safety, and to apply a right soft wrist restraint and to release every two hours for blood circulation check, redness, and safety. During a review of Resident 39's Restraint Every Two-Hour Monitoring record (documentation log used when residents are in restraints) dated 12/9/2023 timed at 6 a.m. through 12/14/2023 timed at 6:15 p.m., the licensed nurses documented that Resident 39's behavior was calm in response to the restraints. During a review of Resident 39's Restraint Every Two-hour Monitoring record dated 12/9/2023 timed at 6 a.m. through 12/13/2023 timed at 4 a.m., indicated no documentation of Resident 39's right soft mitten and right soft wrist restraints were released every two hours for 15 minutes for blood circulation check. During a review of Resident 39's Restraint Every Two-hour Monitoring record dated 12/11/2023 timed at 6 p.m. through 12/12/2023 timed at 8 a.m., indicated no documentation of Resident 39 was monitored every two (2) hours while on a right soft wrist restraint, and right-hand mitten restraint for blood circulation, and skin integrity. During a review of Resident 45's Restraint Every Two-hour Monitoring record dated 12/9/2023 at 10 a.m. through 12/14/2023 at 6:00 a.m., the licensed nurses documented that Resident 45's behavior was calm in response to the restraints (bilateral soft mittens). During a review of Resident 45's Restraint Every Two-hour Monitoring record dated 12/11/2023 at 12 a.m. through 12/11/2023 at 6 a.m., indicated no documentation that Resident 45's bilateral soft mittens were released every two hours for 15 minutes to check for circulation. During an interview on 12/13/2023 at 8:53 a.m., with Certified Nursing Assistant (CNA) 3, CNA 3 stated, Resident 68 right hand soft mitten should be released every two (2) hours for 15 minutes and during resident care and reapply after resident care was done. CNA 3 stated Resident 68 right hand soft mitten was not released during resident care. During an observation on 12/13/2023 at 9:29 a.m., Resident 68 was observed with a right-hand soft mitten. During an observation on 12/13/2023 at 11:31 a.m., Resident 68 was observed with a right-hand soft mitten. During an observation on 12/14/2023 at 9:03 a.m., Resident 68 was observed with a right-hand soft mitten. During an observation on 12/14/2023 at 11:08 a.m., Resident 68 was observed with a right-hand soft mitten. During a review of Resident 11's Physician Order dated 8/16/2022, timed at 5:17 p.m., the Physician Order indicated to apply right hand mitten and right soft wrist restraint due to poor safety awareness secondary to poor cognition related to history of hemorrhagic stroke until discontinued. The Physician Order indicated to release the right soft restraint and right-hand mitten every two hours for 15 minutes and as needed for activities of daily living, skin, and blood circulation check. During a review of Resident 11's Care Plan titled Restraints dated 8/2/2022, the Care Plan indicated to monitor for episodes of agitation (feeling of uneasiness) or anxiety (feeling of worry or nervousness), assess for less restrictive measures or devices prior to restraint use, check proper placement, release, and check for circulation, hygiene, and impaired skin integrity every two hours as interventions. During a review of Resident 11's Restraint Every Two-hour Monitoring record dated 12/11/2023, indicated Resident 11 was not monitored from 8:26 p.m. to 6:00 a.m. on 12/11/2023. The Restraint Every Two-hour Monitoring record indicated monitoring was resumed on 12/12/2023 at 8:00 a.m. During an interview on 12/14/2023, at 11:52 a.m. with Director of Staff Development (DSD), DSD stated CNA and licensed vocational nurses (LVN) do a visual check of residents on restraints for proper placement every hour, and Hourly Patient Care Rounds log was posted on the door of the resident's room. DSD stated either the LVN or CNA will sign in after hourly checks and the registered nurses check if the LVN had completed the Hourly Patient Care Rounds logs. During a review of Resident 11's Hourly Patient Care Rounds log for residents at risk for removing essential lines from 11/2/2023 to 11/28/2023, the Hourly Patient Care Rounds log indicated hourly rounds were not signed on the following dates and times: 11/2/2023 from 7 a.m. to 10 a.m. and 6:00 p.m. 11/3/2023, at 5p.m. and 6:00 p.m. 11/4/2023 at 5 a.m.,10 p.m. to 12 a.m. 11/5/2023 at 1a.m. to 6 a.m., 9 p.m., 11p.m. 11/6/2023 at 1 a.m. ,3 a.m. and 5 a.m.,9 p.m., and 11p.m. 11/7/2023 at 3 a.m., 5 a.m., 7 p.m., and 9 p.m. 11/8/2023 at 11p.m. 11/9/2023 at 1 a.m., 3 a.m., and 5 a.m. 11/10/2023 at 9 p.m. and 11 p.m. 11/14/2023 at 7 p.m. and 10 p.m. 11/15/2023 at 12 a.m., 4 a.m., 6 a.m. and 7 p.m. 11/16/2023 at 1 a.m. and 5 a.m. 11/18/2023 at 9 a.m., 7 p.m., and 10 p.m. 11/19/2023 at 2 a.m., 6 a.m. 4 a.m., 9 p.m. and 11 p.m. 11/20/2023 at 6 p.m. 11/21/2023 at 4 a.m., 5 a.m., and 6 a.m. 11/26/2023 at 6 p.m. During a review of Resident 27's Physician Order dated 12/1/23, the Physician Order indicated, release restraints every two hours and check for skin redness, blood circulation, hydration, nutritional. During a review of Resident 27's Care Plan titled Absence of Harm or Injury, dated 3/12/23, indicated interventions including check for proper placement of the right-hand soft mitten and right soft wrist restraint; release and check for redness, circulation, hygiene, and impaired skin integrity every two hours and as needed. During a review of Resident 27's Restraint Every Two-hour Monitoring record dated 12/6/23 timed at 10:00 p.m. and 12/8/23 timed at 10 p.m., indicated Resident 27 has no documentation of Resident 27's right soft wrist restraint were released every two hours for 15 minutes for blood circulation check. During an interview on 12/15/2023 at 9:14 a.m., with RN 6, RN 6 stated if right hand soft mitten was not release from Resident 68's hands every two hours for 15 minutes, there was a possibility that will lead to decrease blood circulation. If the Resident 68's restraints were too tight it can lead to skin irritation or even pressure ulcer. During an interview on 12/15/2023 at 11:15 a.m., with CNA 5, CNA 5 stated soft hand mittens should be release every two hours for 15 minutes to prevent wrist pressure that can lead to pressure ulcer. During an interview on 12/15/23 11:16 a.m. with Registered Nurse (RN) 5, RN 5 stated the Restraint Every Two-hour Monitoring record were used for restraint assessment for residents (in general) to check for circulation because if the resident (in general) has poor circulation it can cause poor tissue perfusion (oxygen-rich blood delivered to the tissues in the body) and extremity (part of a limb of the body) could become necrotic. RN 5 stated, residents (in general) could feel frustrated, helpless, and hopeless from wearing physical restraints. During an interview on 12/15/2023 at 12 p.m. with RN 5, RN 5 stated, restrains should be released every two hours to assess for blood circulation and assess if restraint was applied too tight. RN 5 stated if a restraint was applied too tight it can cause harm including impeding blood circulation to the extremity, decrease tissue perfusion and the part of the body restrained can become necrotic and die. RN 5 stated, the risk for using all three restraints (soft mittens, soft wrist restraints and four siderails up) will impede a resident's movement. RN 5 stated, resident (in general) could become frustrated being tied up with a wrist restraint, soft mitten and all four siderails in an up position. During an interview on 12/15/2023 at 12:19 p.m. with NM 1, NM 1 stated resident (in general) with soft mittens, soft wrist restraints could result in impaired blood circulation, loss of movement, stasis ulcer if the resident was not assessed every two hours for 15 minutes. NM 1 stated, a pressure ulcer could occur, or an existing pressure ulcer could worsen, if the restraints are not being released every two hours for 15 minutes or being assessed every two hours. NM 1 stated, if bilateral soft mittens are not removed or assessed every two hours for 15 minutes, it could result in a pressure ulcer or wound for a resident. 4. During a review of Resident 39's Care Plan titled Restraint Care dated 3/8/2018, indicated intervention included assess Resident 39 for least restrictive measures/devices prior to restraint use and to check for proper placement of restraints. The Care Plan indicated the goal was to discontinue the use of restraints on 6/8/2018. During a review of Resident 39's Nursing Progress Note dated 10/1/2023 at 10:22 a.m., indicated no documentation of least restrictive measures were used and unsuccessful prior to the continuation of the use of restraints (right hand soft mittens and right soft wrist restraint). During a review of Resident 39's Nursing Progress Note dated 10/15/2023 at 10:22 a.m., indicated no documentation of least restrictive measures were used and unsuccessful prior to the continuation of the use of restraints (right hand soft mittens and right soft wrist restraint). During a review of Resident 39's Nursing Progress Noted dated 11/5/2023 at 6:08 p.m., indicated no documentation of least restrictive measures were used and unsuccessful prior to the continuation of the use of restraints (right hand soft mitten and right soft wrist restraint). During a review of Resident 39's Interdisciplinary ([IDT] a group of healthcare professional who assess, coordinate, and mange each resident's comprehensive health care, including his or her medical, psychological, social, and functional needs) Team Conference dated 9/21/2023, 10/19/2023 and 11/14/2023, indicated no documentation of the least restrictive measures were used and unsuccessful for Resident 39 prior to the placement of restraints (right soft mitten and right soft wrist restraints). During an interview on 12/15/2023 at 9:41 a.m. with NM 2, NM 2 stated least restrictive measures should be used prior to the initiation of restraints. NM 2 stated the residents (in general) might feel frustrated or angry while being in restraints. During a review of Resident 45's Care Plan titled At risk for social isolation and physical impairment dated 7/31/2023, indicated Resident 45 had potential for injury related to physical restraint use and had on bilateral soft mittens since 11/7/2023. The care plan interventions indicated Resident 45 should be assessed for the least restrictive measures prior to restraint use. During a review of Resident 45's Restraints weekly progress notes dated 11/19/2023, 11/26/2023, 12/3/2023 and 12/11/2023, indicated no documentation of least restrictive measures were used and unsuccessful with the continued use of bilateral soft mitten restraints. During a review of Resident 68's Care Plan titled Restraint non-behavioral dated 07/11/2023, indicated care plan interventions includes evaluate on-going need of restraint by assessing less restrictive measures/devices prior to restraint use, assess at least monthly for continued use of restraints and possible reductions, assess resident's response to restraints, release and check for redness, blood circulation, hygiene, and impaired skin integrity every two hours and as needed. 5. During an observation on 12/11/2023, at 11:52 a.m. in Resident 20's room, Resident 20 was awake, calm, lying in bed with bilateral upper and lower bed rails (a barrier attached to the side of a bed) were up and padded. Observed Resident 20 had a left soft wrist restraint with white plastic buckle and hand mitten on the left wrist. The soft wrist restraint was tied in a knot and not tied in a quick release knot. During a concurrent observation and interview on 12/12/2023, at 12:30 p.m. with CNA 1, observed left soft wrist restraint of Resident 20 became tighter when head of bed was raised placed higher than thirty degrees. CNA 1 stated, CNAs make rounds to ensure the resident was repositioned, changed, restraint was in place and ensuring two fingers will fit under the soft wrist restraint and Resident 20's skin. CNA 1 stated LVN would assess the circulation and skin integrity every two hours. CNA 1 stated Resident 20 soft wrist restraints moved when the head of the bed was raised, and the soft wrist restraints got tighter on Resident 20's wrist. CNA 1 stated the facility was using a buckle to release the restraint instead of the quick release tie knot used in other facilities. During an observation on 12/12/2023, at 12:21 p.m. Resident 20 remained on four bedrails up, left-hand mitten and left soft wrist restraint with buckle was tied in a knot on the adjustable head part of the bed. During a concurrent observation and interview with on 12/12/2023 at 12:18 p.m. with LVN 12, observed Resident 39's restraint was tied in a knot on the bed. LVN 12 stated, the right wrist restraint was tied in the wrong place on a movable bed frame and there was a risk for injury for Resident 39. LVN 12 stated, it was the responsibility of the licensed nurses to assess and check placement of restraints (right soft mittens and right soft wrist restraint) every two hours. During a concurrent interview and record review on 12/14/2023 at 11:51 a.m. with the Director of Staff Development (DSD), the DSD observed the photo of placement of Resident 39's right soft wrist restraint and stated it was tied in the wrong place on the bed. The DSD stated the way Resident 39 restraint was tied; Resident 39 will not be able to use the call light to call for help. During an interview on 12/15/2023, at 12:22 p.m. with LVN 7, LVN 7 stated soft wrist restraint should not be tied on the adjustable head part of the bed because it could hurt the resident's wrist and tighten the restraint on the wrist, which had the potential to cause deep vein thrombosis (blood clot) due to poor circulation. During an observation 12/11/2023, at 11:39 a.m., observed Resident 11 lying in bed, asleep with tracheostomy to oxygen at 5 liters/ minute, right hand soft mitten, right soft wrist restraints with white plastic buckle and padded bilateral upper and lower bedrails were present and applied. Observed the right soft wrist restraint was tied tightly in a loop to the frame of the bed without using the method of a quick release knot. During a concurrent observation and interview on 12/11/2023, at 4:01 p.m. with Family Member (FM) 1, observed Resident 11's right soft wrist restraint and right-hand mitten were not present but padded bilateral lower and upper bedrails were in use. FM 1 stated she would release the right-hand mitten and right soft wrist restraint whenever she would visit because the staff members do not release the restraints most of the time that it would leave a mark on Resident 11's wrist. FM 1 showed a photo she took less than two weeks ago indicating a deep indentation on the right wrist. Observed the photo of Resident 11's right hand had skin discoloration and slight mottling (uneven, discolored patches on the skin due to lack of blood flow). During a review of Resident 11's Nursing Progress notes dated 11/22/2023 at 11:00 a.m., the Nursing Progress Notes indicated the FM expressed concerns about the tightness of right-hand soft mitten. The Nursing Progress Notes indicated the licensed nurse documented the right hand [TRUNCATED]