Based on observation, record review and interview, the facility failed to ensure one Resident (#46) was free from restraints out of a total sample of 21 residents. Specifically, for Resident #46 the facility failed to assess the use of pillows under the fitted sheet on both sides of the bed as a potential restraint. Findings include: Review of the facility policy titled Restraints and dated as revised 2/7/22, indicated that all patients have the right to be free from restraints. The least restrictive method of restraint that meets the patient's assessed need is used. Further review indicated that the documentation of the management of medical conditions along with documentation of alternate approaches used to manage a patient's behavior should be entered in the medical record. Further review indicated that if the provider wishes to utilize restraints, a provider order shall be obtained by the nurse responsible for the care of the patient for each use of a restraint. The nurse shall document an assessment at least every 2 hours. The nurse will include the use of restraints in the patient's care plan. Resident #46 was admitted to the facility in May 2023 with diagnoses including Parkinson's disease, hip dislocation and depression. On 6/6/23 at 7:59 A.M., the surveyor observed Resident #46 lying in bed with pillows tucked under the fitted sheet on each side of the bed potentially preventing him/her from getting out of bed, the bed was in the low position and a floor matt was on the floor. During an interview on 6/6/23 at 7:59 A.M., Certified Nurse's Aide (CNA) #1 said that Resident #46 has had falls and tries to get out of bed and that is why the pillows are under the fitted sheet on each side of the bed. On 6/6/23 at 9:46 A.M., the surveyor observed Resident #46 lying in bed with pillows under the fitted sheet on both sides of the bed potentially preventing him/her from getting out of bed. On 6/7/23 at 7:13 A.M., the surveyor observed Resident #46 lying in bed with pillows under the fitted sheet on both sides of the bed potentially preventing him/her from getting out of bed. Review of the care plan failed to indicate a plan of care for the use of a restraint or the use of pillows under the fitted sheet on both sides of the bed. Review of the physician's orders, dated June 2023, failed to indicate an order for the use of a restraint. On 6/7/23 at 7:45 A.M., the surveyor, the Director of Nursing (DON) and CNA # 1 observed Resident #46 lying in bed with pillows under the fitted sheet on both sides of the bed potentially preventing him/her from getting out of bed. CNA #1 said that the nurse's put the pillows under the fitted sheet but that she put another one at the bottom because Resident #46 kept swinging her/his legs over the side of the bed trying to get out. The DON said that the pillows beneath the fitted sheet would be considered a restraint. The DON then said that the pillows should not be there and instructed CNA #1 to remove them. During an interview on 6/7/23 at 10:11 A.M., the Quality Regulatory Nurse said that the medical record did not include a pre-restraining assessment or a restraint assessment for the use of pillows beneath the fitted sheet on both sides of the bed.