**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to use alternatives to bed rails, and assess and monitor for risks including injury and entrapment related to the use of bed rails for 3 of 3 residents (R7, R10 and R6) reviewed for bedrails in the sample of 11. This failure resulted in an Immediate Jeopardy when R7's right arm was caught in the bedrail during care resulting in R7's fractured arm and decline in R7's overall physical condition. In addition, R10 was observed several times with her arm through the right bedrail on her bed. R10's documented history of dementia with behavior disturbances, hallucinations, and psychiatric history put R10's entrapment of her right arm through the bedrail at an increased risk of injury. The Immediate Jeopardy began on 4/21/24 when during care, R7's right arm was caught in the bedrail and R7 sustained a closed distal fracture to R7's right humerus. R7 had a known history of grabbing the siderail with a death grip. R7's Care Plan documents to ensure bed rails are padded to prevent injuries. R7's Assessment did not address any risks related to bed rail use. V1, Administrator, V12, Director of Nursing, V10, Social Service Director, V43, Regional Director of Operations and V44, Regional Clinical Director was notified of the Immediate Jeopardy on 5/21/24 at 11:43AM. The surveyor confirmed by observation, record review, and interview that the Immediate Jeopardy was removed on 5/23/24, but noncompliance remains at Level Two while the facility continues to educate all staff and evaluate the effectiveness of the in-service training. Findings include: 1. R7's undated Face sheet documents R7 was re-admitted on [DATE] with a diagnoses of dementia, primary osteoarthritis right and left knee, age related osteoporosis, dorsalgia, unspecified hearing loss, history of falling, dependence on wheelchair, contracture of muscle, multiple sites, contracture, left and right hip, left and right knee, unspecified fracture of shaft of humerus, right arm, sequela, and dysphagia. R7's Physician Order Report dated 11/19/2018-5/13/2024 does not document an order for bedrails. R7's Progress Notes dated 4/21/24 at 5:21PM documents: staff called writer to res (resident) room stating that while changing and dressing res before dinner, she hooked her arm in the bed rails when turning and there was a pop. Writer went to assess and found res laying in the bed on her left side, there is a large area between the right shoulder and right elbow to be raised about 2 inches. Res is able to move fingers. Does not appear to be in pain; does not appear to be in distress. Ambulance was called and res is being send to ER for eval and tx (treatment). Writer left message for POA as there was not answer. Writer spoke with emergency contact and informed of above. He states he will meet res at ER. Ambulance provider en route to transport. R7's Minimum Data Set, dated [DATE] documents R7 has short- and long-term memory problems, Brief Interview for Mental Status is left blank, and severely impaired decision making. The MDS documents R7 uses wheelchair with no impairment to upper extremities and impairment on both sides of lower extremities and is dependent upon staff for activities of daily living. R7's MDS further documents R7 requires substantial/maximal assistance for rolling left and right. R7's Care Plan dated 4/18/24 documents an approach start date of 10/6/2022 I prefers to have upper bilateral ¼ rails up while I am in bed to reduce anxiety so I can assist myself when I am able with turning and repositing. The Care Plan further documents an approach start date of 10/5/2022 Siderails: ¼ up x2 to enable bed mobility. I lay on the very edge of my bed. I even scoot down past my rails or with my head down towards the foot board. On 7/8/2022 an approach to talk to me while providing care. There are no risk versus benefits documented for the use of R7's. The 4/21/24 Approach documents to ensure bed rails are padded to prevent injuries (Day of injury). R7's Most recent side rail Assessment, dated 1/6/24, documents type of slide rails indicated: both to allow for increased bed mobility, safety risk with use of side rails none. There is no side rail assessment for the quarterly 4/2/24 reporting period. R7's Progress Notes dated 4/21/24 documents R7 went out to hospital per family preference after R7 had hooked her arm in the bed rails when turning and there was a pop and returned on 4/22/24 with a closed displaced fracture on the shaft of the right humerus. R7's emergency room Radiology report dated 4/21/24 documents: History: Patient rolled in bed and arm caught in rail. Obvious deformity. Findings: There is an overriding apex laterally angulated midshaft fracture of the humerus. The proximal humerus is not visualized in entirety given the patients limitation with positioning. Distal humerus on a single view is grossly unremarkable. Impression: Suboptimal position given patients body habitus however there is a overriding angulated midshaft humeral fracture. R7's emergency room record documents R7 was treated for a closed displaced transverse fracture of the shaft of the right humerus and received 2mg (milligrams) Morphine IVP (intravenous push), 50mcg (micrograms) Fentanyl IVP and Zofran 4mg IVPR. R7 was sent back to the facility with hydrocodone/acetaminophen liquid 10mg/325mg/15ml, take ten (10) ml orally every 6 hours for 3 days. R7's Facility Reported Incident Report dated 4/22/24 documents, the caregiver stated that they were providing incontinent care and depressing the resident to go to the dining room for dinner. The resident's arm had slipped between the siderail and her mattress. The CNA (Certified Nurse's Assistant) stated they heard a pop from residents' arm. Upon immediate assessment by the RN, a 2 cm raised area was noted between the resident's right shoulder and R7's elbow. R7 displayed no signs of pain or discomfort during assessment. MD was notified of incident and orders were received to send to ER for further assessment of resident injury. R7's Power of Attorney was notified and stated would meet resident at the ER. The ambulance was then called for transport. R7 returned to the facility at approximately 9:00PM with diagnosis of a closed, displaced fracture of the shaft of her RT (right) humerus. R7 had a splint in place an new orders for pain medication. R7 received pain medication while she was in the hospital. R7 has a follow up appointment with Ortho MD in 1 week. R7's Witness documentation, undated include an undated statement from V25, CNA documents I (V25) checked and changed her (R7) by myself. (V34, CNA) was walking by when I asked for help for the transfer. We started transfer with (V34) on residents left and I was on her rights. I had her cradled with her arm around me when we went to lift up and we heard a snap. V34 went and got nurse. R7's Witness documentation dated 4/21/24 written by V34 documents I was asked by (V25) to help transfer a resident to her wheelchair. We had her on the side of the bed about t transfer when the arm she had around V25 (her right) grabbed for the siderail, but her arms was stuck, and we heard a pop. We immediately laid her down while V25 supported her arm, and I went and got a nurse. R7's Witness documentation, undated, statement from V41, CNA documents I walked in with the nurses saw residents' arm. I said I would assist with getting her (R7) in a gown because the nurses were on the way to send her out to hospital. R7's Progress Notes dated 4/27/24 documents pain medicine given with morning med administrations, as pain was evident upon repositioning. R7 did eat some breakfast and drank some med pass with meds. R7's Progress Notes dated 4/28/24 documents pain medicine given with morning med administration, as pain continues to be evident upon repositioning. R7's Progress Notes dated 4/30/24 documents .splint intact to RUE. Noted edema to right arm. R7's Progress Notes dated 4/30/24 documents .medicated for pain this am, splint in place. arm swollen and discolored . R7's Progress Notes dated 5/2/24 and 5/4/24 documents R7 arm remains edematous and discolored. R7's Progress Notes dated 5/5/24 documents: Tylenol given for slight temp tonight. R7's Progress Notes dated 5/6/24 documents R7 not responding as normal. BP (blood pressure) 117/62, P (pulse) 104. Daughter notified of change in condition. R7's Progress Notes dated 5/7/24 documents at 1:20PM, R7 still not responding well. Holding food and drink in her mouth. Decision made to keep resident here and just keep R7 comfortable. At 7:39PM, Progress Notes continue R7 condition appears to be declining. No response to verbal or tactile stimuli. Vitals stable. No s/s of discomfort noted. Daughter leaving at this time. To call if any changes. R7's Progress Notes dated 5/8/24 documents R7 continues to be unresponsive. Family members here this morning. R7 is unable to accept anything by mouth. Family was asking for pain medication, so writer went into room and discussed in detail why Hospice is worth consideration in this scenario. Family said they would reach out if they wished to discuss further. R7's Progress Notes dated 5/8/24 at 12:21PM, documents writer went and spoke with family about Hospice. They would like to go ahead and move forward with hospice. They would like to keep her comfortable as much as possible. Writer is working on faxing information and getting and order from the Dr. for hospice. R7's Physician Order Sheet documents on 5/8/24: hospice to eval and treat. R7's Progress Notes dated 5/8/24 at 6:58PM, R7 admitted to hospice. R7's Visit Note Report dated 5/8/24 documents: Hospice start of care. R7's Visit note further documents: indicate clinical evidence of advancing illness: change in level of consciousness, decline in systolic blood pressure relative to baseline, decreasing oral intake, recent decline in functional status, worsening vital signs. Indicate existing equipment/supplies present in the home (mark all that apply): bedrails, hospital bed, Hoyer lift, overbed table oxygen concentrator. Narrative: R7 is a [AGE] year-old female patient residing at facility coming on to service with the primary diagnosis of Alzheimer's disease secondary diagnosis of dementia co morbidity to include right humorous fracture. R7 was diagnosed with dementia and Alzheimer's approximately 5 years ago, however 2 weeks ago, patient had a fracture of her right humorous that could not be fixed surgically. R7 was returned to the nursing home. R7 has had a steady decline since patient has been NPO (nothing by mouth) for the past 2 days. Minimally responsive upon admission, R7 is now comatose, R7 lungs clear with rapid shallow respiratory rate of 40. Absent bowel sounds, heart sounds are unable to be heard. Blood pressure, unable to be taken. R7 has bilateral lower extremity mottling up to her knees from her toes. R7 had a BM (bowel movement) time 2 today, severe temporal wasting noted, patient place on 3 liters of oxygen per nasal cannula . R7's Progress notes dated 5/8/24 at 10:06pm documents R7 transitioned at 1916 with family by her side. Hospice nurse was called who then called the coroner. Granddaughter was on the way to facility so writer told hospice nurse she would call when family was ready. Funeral home was then called at 2120 and picked up at 2149. On 5/14/24 at 2:40 PM, V25 CNA, was questioned how the injury to R7's right arm occurred. V25 stated that R7 was extremely contacted with her knees bent up and her spine was like a C shape. V25 stated that he had provided incontinent care for R7. V34 CNA came in and was going to assist me with transferring her to her wheelchair. I was holding onto R7's knees because she was extremely contracted, and she was on her back. R7 had her right arm above her head, and she was holding onto the side rail. While V34 had her back turned putting on gloves. R7 then reached and pulled herself with the left arm onto the opposite side rail very quickly and then we heard a pop. V25 was asked again to explain how this happened. V25 stated that it happened very quickly. He stated that he was not sure and his explanation of what happened changed multiple times. V25 was questioned about his written statement and why his written statement did not match his explanation of events. V25 became very nervous, began sweating, stating he was beginning to have a panic attack, because the event was just so horrible, he is having PTSD (post-traumatic stress disorder) flash backs. V25 then stated that he was told to lie on his written statement of events because everyone knew that he transferred her using a dead man lift (a lift where 2 people are used, each put an arm under R7's arm and the knee.) to transfer her. V25 stated that he felt it was much safer for her because with movement she would grab onto anything she could get her hands onto. V25 stated she would grab the mechanical lift straps, one time she got one strap unhooked, she would flip around and almost throw herself out of it. V25 stated that the facility did not want to get him in trouble that is why he was told to lie. V25 stated that she was not hurt during transfer because they had not started the transfer yet because he was waiting for V34. During this conversation, V25 continued to be upset, exhibit shallow breathing, sweating and turning red. The interview was stopped to get V25 assistance for his panic attack. After the interview, it still remained unclear as to exactly what happened to R7 because R25's recollection of events kept changing. On 5/14/24 at 6:00 PM, V34 CNA stated, Before supper I was helping (V25) get R7 ready for supper. She always grabs the side rail. She was on her back. She puts her arm through the side rail but we were getting ready to sit her up so we could transfer her. V25 had (R7) up to about a 30-to-40-degree angle. She wasn't all the way up yet. I was at the foot of the bed. I looked down for a second. I was fixing my pants or my shoe. I then heard a pop. I guess she threw her arm in there and moved and then it popped. I did not have my back turned. I was not putting on gloves. (R7) always uses the dead man carry lift to transfer. She is just unsafe for the full mechanical lift. She moved around so much, and she would grab onto anything. I was told that Physical Therapy made her a dead man lift. On 5/14/24 at 2:50 PM, V14, Director of Nurses, stated, (V25 and V34) told me they were changing (R7), and she got a hold of the side rail and then she rolled, and the arm popped. (R7) was a (full mechanical lift) with 2 people. I never heard they were dead man lifting her. I would not be ok with that. On 5/17/24 at 9:59AM V14, Director of Nursing stated she wasn't here when R7's fractured arm occurred. V14 stated she was told that R7 was in bed and two staff members were changing R7 and when they went to turn R7, they heard a pop. V14 stated R7 was known to grab rails even when she was sleeping and had a death grip on the side rails. V14 stated she guessed there was risk of R7 having side rails with her grabbing them and not letting go was injury or entrapment. V14 stated she was unaware that V25, CNA was told to lie on the incident report. V14 stated she expects the risk versus benefits to be assessed and documented. On 5/21/24 at 9:20AM, V1, Administrator stated she did not interview anyone else for R7's investigation and she probably should have. V1 stated she just believed what staff said. On 5/13/24 at 10:25 AM, V14, Director of Nurses, stated R7 was [AGE] years old, total care and had been that way for a while. V14 was questioned if she knew R7's admitting diagnosis for hospice since she was recently admitted to hospice and past on 5/8/24, V14 stated, I don't know but since the break she just went downhill. On 5/13/24 at 3:00 PM, V18, Registered Nurse (RN), stated, (R7) was total care and dependent on staff. I was here when her arm was broken. The CNA came running to me stating We need you. We think her arm is broken. She was lying on her left side. It was evident that her arm was broken. They told me that it happened while getting her up. She had a habit of wrapping her arms around the side rail. I think it was for security. I think her arm was caught in the side rail. I called her family and 911 immediately to get her to the hospital. I honestly can't say if her fracture exacerbated her death. On 5/14/24 at 9:10 AM, V2, RN, stated, I have never known (R7) to wrap her arms around the side rails. She would grab onto them. I think the CNAs might have gotten too forceful in removing her hand or it happened while turning her in bed. Ever since I have worked there, (R7) has always been picked up by 2 staff on each side of her. She was very light and contracted. A (mechanical lift) has never been used on her. I think a lift would have been more dangerous because the way she grabbed, flipped, and her contractures. R7 had been stable for the past 6 months. She came back from the hospital with pain. It was very painful for her. She did have Norco for the pain which helped. She very quickly declined, went on hospice, and passed away. I was afraid we would not get her on hospice fast enough to even help her. On 5/15/24 at 5:15 PM, V2 stated that R7 had 1/4 side rails when the fracture happened, and the side rails remained on her bed after her return. V2 stated that when R7 returned from the hospital she was in a lot of pain. On 5/16/24 11:25AM V39, Certified Nurse Assistant (CNA) stated she cared for R7 and knew her well. V39 stated R7 has always had side rails on her bed and is not aware of any alternative to the side rails that have been tried. V39 stated she put mesh padding on side rails once by herself because R7 always had a death grip on side rails, but R7 was still able to get through to grab the side rails so it didn't last long. V39 stated R7 always found her way to grab the side rails. V39 stated because R7 had a death grip on the side rails you needed to verbally cue her multiple times, take your time with her. V39 stated she felt R7 was scared with rolling and that's why she always was hanging on side rails. V39 stated everyone in the building except one resident has side rails. V39 stated there has been no other interventions put in place prior to side rail use. On 5/16/24 at 11:40AM, V18, Registered Nurse stated she cared for R7 routinely and the side rails have been on her bed as long as I can remember, and she has worked here for years. V18 stated there have been no alternative to side rail that was attempted that she is aware of. V18 stated R7 rolled around on her. V18 stated R7 was always hanging on the bedrail all the time. When asked if R7 was at risk for entrapment in the side rail, V18 stated she guessed it could happen to anybody- then stating, I'm sure that could happen. On 5/16/24 at 1:37PM, V28, CNA stated R7 had side rails up the whole time she was here and had a firm grip. V28 stated R7 was a 2 person Hoyer lift. V28 stated there were no alternatives to help turn and reposition R7 but that covers were put on and didn't help, R7 found her way around them to grab side rails. On 5/17/24 at 10:19AM, V1, Administrator stated R7 was being provided care from V25, CNA and when they rolled R7, V25 was cradling R7 and R7's arm was over V25's head and they heard a pop and R7 's arms had been caught in the side rails while positioning her. V1 stated R7 used the side rail and held on for dear life and that staff would sometimes have to pry R7's hands off the siderail. V1 stated knowing R7's history, staff should put a pillow or something to prevent R7 from grabbing side rails during care, or in a perfect world, put the side rail down while providing care. V1 stated she was not aware that V25 told the survey team that he was instructed to lie about his written statement and what happened with R7 and that they should know better than that.V1 stated there are known risk associated with side rails use such as entrapment and the facility is only approved for quarter rails and V1 expects assessments for side rails to be accurately and completely filled out. V1 further stated she expects staff to intervene when a resident arms or legs are in a siderail. On 5/15/24 at 10:38 AM, V1, Administrator, stated that R7 does not have a Side Rail Assessment and has never had a Side Rail Assessment completed. V1 further stated that a resident should have a Side Rail Assessment upon admission and then quarterly. 2. R10's undated Face sheet documents R10 was admitted on [DATE] with a diagnoses dementia with other behavioral disturbances- with hallucinations polyosteoarthritis, age related physical debility, history of fall, mixed receptive-expressive language disorder. R10's Physician Order Report dated 4/21/2024-5/13/2024 does not document an order for side rails. R10's Progress Notes dated 3/1/24 at 1:50PM documents R10's medical doctor notified of increased agitation/hallucinations during the evening ad night. R10 noted to scream that someone is in her room trying to kill her and take her things. Noted to throw things in her room. Comes out to hall yelling for help to get them out of her room. R10's Minimum Data Set, dated [DATE] documents R10 has short- and long-term memory problems, Brief Interview for Mental Status was unable to be completed, moderately impaired decision making, and the ability to understand others is coded a 2: sometimes understands. The MDS documents R10 has behavior symptoms directed towards others and that R10's current behavior status as a two (2): worse. The MDS further documents R10 uses a walker and wheelchair with no impairment to upper extremities and impairment on both sides of lower extremities and is independent with rolling left and right in bed. R10's Care Plan dated 3/28/24 documents to keep environment free of clutter and obstacles to reduce risk of injury with a start date of 4/30/24. R10's Care Plan further documents behaviors symptoms: resident exhibiting problems as seen by making disruptive sounds, hallucinations and delusion, pressure ulcer/injury: ensure proper body alignment when in bed or chair to reduce pressure, activity of daily living function status: start date 10/12/22 siderails: 1/4 rails up as per doctors' orders for safety during care provision to assist with bed mobility. Observe for injury or entrapment related to side rail use. I need to have 1/4 siderails x2 up to assist me with getting around my bed. R10's Most recent Side Rail assessment dated [DATE] documents type of side rails indicated: both to allow for increased bed mobility, safety risk with use of side rails none. There is no side rail assessment for the quarterly 4/2/24 reporting period. On 5/16/24 at 1:45PM, R10's door was shut. Upon entry with V28, CNA, and V39, CNA, R10 was observed to be laying in her bed and her right arm was through the right-side rail. R10's body was adjacent to the side rail and the side rail was all the way up to R10's shoulder. R10 began moving and extending her right arm to point at an object in her room though the side rail. V28 stated they keep R10's door shut all the time because she hallucinates and yells out. R10 stated she didn't have lunch and that people were trying to kill her. V28 went and got R10 ice cream and redirected R10 multiple times to move her (R10's) arm through the side rail to hold the ice cream. On 5/17/24 at 7:53AM, R10 was in her bed with her right arm through the side rail up to her shoulder eating breakfast with her right hand. R10 requested staff assistance and this surveyor went to get V2, Registered Nurse. V2 checked on R10 and R10 was confused about where her stuff was. When asked if R10 was normally positioned with her right hand through the side rail, V2 stated that he had seen R10 like that before. V2 stated the side rails would be a risk for R10 due to her cognition and psychiatry/behavior history and that any object is a risk to her, stating R10 has pulled all the baseboards off, and it wouldn't surprise me if she had a drawer pulled apart even. During this time, it was noted R10's baseboards were gone. On 5/16/24 at 3:10PM R10's side rails were measured at 17 3/4 inches wide and 3 1/2 inch tall, and the bottom portion as 22 3/4 inch wide and the top 3 1/2 inch wide. On 5/17/2024 9:46AM V40, Assistant Director of Nursing stated she just took this position and started 5/13/24. V40 stated every occupied bed in facility has siderails and thinks they are ¾ rails. V40 stated risk of having side rails could be getting stuck in between, ones that can't or are not independent, and that limbs and head can get stuck. V40 stated she is not aware of alternatives to the side rails due to just starting. On 5/17/24 at 9:59AM V14, Director of Nursing she expects the risk versus benefits to be assessed and documented. V14 stated she came from the hospital, so she didn't realize you needed an assessment for side rails. V14 stated R10 has a lot of psych issues and is schizophrenic and she expects staff to move R10's or any residents arm out of the side rail if they saw that. V14 further stated R10 can get agitated but she expected staff to redirect R10 and assist R10 to scoot over in bed away from side rail. On 5/17/24 at 10:19AM, V1 Administrator stated there are known risk associated with side rails use such as entrapment and the facility is only approved for quarter rails and V1 expects assessments for side rails to be accurately and completely filled out. V1 further stated she expects staff to intervene when a resident arms or legs are in a siderail. V1 stated R10 does whatever she wants and sometimes it is hard to redirect her, but she still expects staff to ensure she is safe. V1 state the side rails are a risk to R10. On 5/21/24 at 3:45PM, V1 stated the facility reassessed R10 for side rails use and according to their assessment R10 should have never had side rails on to begin with. On 5/16/24 at 9:30 AM, V1, stated that she is unable to locate a side rail policy. V1 stated, I have had 4 people working on it since yesterday afternoon and they still cannot locate one. On 5/17/2024 9:35AM V1 was asked again if the facility had a side rail policy and V1 stated they do not have a policy on siderails. The facility provided an abatement plan on 5/21/2024 at 1:20pm to remove the immediacy. The survey team reviewed the abatement plan and was unable to accept the plan to remove the immediacy. The abatement plan was returned to the facility for revisions. The facility presented a revised abatement plan on 5/21/2024 at 1:40pm and the survey team accepted the abatement plan on 5/21/2024 at 3:35pm when the facility took the following actions to remove the immediacy: 1. V24, Maintenance Director completed bed gap measurement and assessment for entrapment zones per FDA guidance for all residents' beds with side rails. All bed rails were in compliance on 5/21/2024. 2. V24, Maintenance Director completed side rail audit to ensure they are compatible with bed on 5/21/2024. 3. V14, Director of Nursing and V10, Social Service Director audit of side rails used as a restraint or enabler with completed pre restraint assessment form, side rail assessment form, side rail usage assessment and side rail consent on all residents to ensure least restrictive alternatives on 5/21/2024. 4. V14, Director of Nursing and V10, Social Service Director audit and update care plans for residents using side rails regardless of used as enabler or restraint and for any other residents with restraints other than side rails. Care plans include medical symptoms justifying use of restraint, type of restraint used, frequency, durations, circumstances for when it is to be used, interventions to address potential or actual complications from restraints use such as increase incontinence, decline in ADLs or ROM, increased confusion agitation or depression completed on 5/21/2024. 5. V14, Director of Nursing and V10, Social Service Director audit completed of physician orders for side rails and correct as needed to include medical symptom being treated, type of restraint, frequency of releasing the restraint completed on 5/21/2024. 6. V43, Regional Director and V44, Regional Director reviewed and updated Bed Rail Maintenance and Installation and Entrapment Prevention, Restraint Reduction Program, Restraint Policy, and Restraint Usage Guide. 7. Education to clinical staff currently in the facility on 5/21/2024 conducted by V1, Administrator, V14, Director of Nursing and V10, Social Services Director on Restraint Policy, Restraint Reduction Program, and Restraint Usage Guide. 8. Education to V24, Maintenance Director completed on 5/21/2024 by V56, Corporate Director of Environmental Services. Education Plan: 1. Education to clinical staff currently in the facility on 5/21/2024 conducted by V1, Administrator, V14, Director of Nursing and V10, Social Services Director on Restraint Policy, Restraint Reduction Program, and Restraint Usage Guide. 2. Education to all clinical staff prior to next working shift conducted by V1, Administrator, V14, Director of Nursing and V10, Social Services Director on Restraint Policy, Restraint Reduction Program, and Restraint Usage Guide. Education to V24, Maintenance Director completed on 5/21/2024 by V56, Corporate Director of Environmental Services. QA component: 1. V24, Maintenance Director will complete bed gap analysis quarterly and whenever new enabling or restraint device applied. 2. V14, Director of Nursing will complete audit of small sample of resident daily x 1 week, 2x a week x 2 weeks and weekly for 3 months to ensure resident safety with enablers or restraints, care plan current, physician orders current and appropriate documentation in place. 3. V1, Administrator will review audits weekly to ensure compliance. The immediate jeopardy was determined to not be removed on 5/22/24 upon review of the implementation of the facility's abatement plan. The surveyor confirmed through observation, interview, and record review that the facility did not implement appropriate measurements of Zone 1 of the siderails. The survey team returned on 5/23/24 and verified that the immediate jeopardy was removed. The surveyor confirmed through observation, interview and record review that the facility appropriately measured zone 1 in the siderails. 3). R6's Resident Face Sheet, undated, documents that R6 was admitted on [DATE] with diagnoses of Dementia with Anxiety and Weakness of the Left Side. R6's Minimum Data Set, dated [DATE], documents that R6 is severely cognitively impaired, is dependent on staff for all mobility, activities of daily living, does not ambulate and does not have a pressure ulcer. On 5/15/24 at 9:00 AM, V4 Certified Nurses Aide (CNA), stated that on 5/1/24 she transferred R6 to bed by herself and did not hit R6's leg on the side rail. On 5/16/24 at 9:30 AM, V1, Administrator, stated that R6 did have 1/4 side rails on before she went to the hospital, R6 did not have a Side Rail Assessment before the side rails were place, R6 does not move in bed, and the family wanted the side rails on the bed. R6's Side Rail Use and Risk Assessment, dated 5/7/24, documents that R6 has bilateral 1/4 length side rails. Reason for Use: Resident or Legal Representative request for side rails. Purpose of side rail(s) being used for a resident who is immobile and can not voluntary get out of bed because of physical limitations. Unmarked. Resident has medical symptom(s) contributing to use of side rail(s) Unmarked. Resident factors impacting side rail use: Requires assist with transfers. Select other methods used besides side rails: None of the bed. Resident / Family/ Resident Representative Information Consent Information:[TRUNCATED]