**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to: 1. Consistently complete bed rail assessments to determine resident initial need and continued use for bed rails. 2. Assess all residents with bed rails for risk of entrapment and ensure the absence of bed entrapment zones through consistent and scheduled measurement by facility staff, 3. Ensure compatibility between facility bed frames and bed rails, 4. Follow the manufacturer's recommendations for installation and maintenance of bed rails, 5. Ensure the presence of, and compliance with physician orders for bed rails, and/or 6. Ensure informed consent was obtained prior to installation of bed rails for seven Residents (#1, #19, #22, #31, #33, #34, and #46) of seven residents reviewed for bed rails, resulting in immediate jeopardy (IJ). These deficient practices resulted in the likelihood of entrapment, serious injury or harm, and/or death, for any facility resident using bed rails without assessment of appropriateness for medical condition and safety. Findings include: Resident #46 Review of Resident #46's MDS assessment, dated 08/30/22, revealed Resident #46 was admitted to the facility on [DATE], with diagnoses including Alzheimer's disease, dementia, kidney disease, and sepsis (a severe systemic infection). Resident #46 required limited one-person assistance with bed mobility, transfers, walking, dressing, and toileting. The BIMS assessment revealed a score of 9 out of 15, which indicated Resident #46 had moderate cognitive impairment. An observation on 09/21/22 at 9:02 a.m. revealed Resident #46 seated sitting upright on the edge of her bed eating breakfast. Her bed had a T-bar bedrail attached to the bedframe on both sides in the middle of her bed. There was no manufacture's labeling or identification observed on the bedrail. The bedrail was older and worn in appearance, with the top horizontal handle square-shaped, sticking out at least 6 on each side beyond the vertical anchor pole at each end. This style appeared would be a hazard if the occupant fell onto the bedrail due to the large prongs sticking out from each side of the bedrail handle. Review of Resident #46's Electronic Medical Record (EMR) revealed no resident-centered bedrail assessment to justify safe use of the bedrail, no informed consent by the resident representative, no physician orders, and no zones of entrapment measurements. During an interview on 09/21/22, Resident #46's Unit Manager, Registered Nurse, RN Y, was asked about the missing documents. RN Y confirmed they were not completed and had earlier made the Nursing Home Administrator (NHA) aware the facility policy/process was not being followed respective to expectations for bedrail standards of practice. During an interview on 09/22/22 at 5:11 p.m., the NHA was asked about the type of bedrail, and safety of this type of bedrail, given the concerns observed. The NHA confirmed they did not have manufacturer's directions for the bedrail, and could not verify when it was installed, or if it was safe for Resident #46. Further review of the EMR showed Resident #46 had three recent falls in her room. The accident and incident report dated 08/21/22 showed Resident #46 was found sitting upright on the floor at her bedside, with her back resting on the bed. Resident #46 reported at that time she was trying to stand up from her bed and slipped onto her bottom. She denied injury and no injury was found by staff. A nursing progress note dated 09/25/22, revealed Resident #46 fell while ambulating to her bed from her bathroom, and was found seated on her buttocks at her bedside, without injury. Two of the three falls staff found Resident #46 by her bed. Review of a document titled, Enabler Bar Documentation, provided by the Environmental Services Director, Staff E, on 09/26/22, dated 06/22/22, revealed the type of device, T-Bar, and four locations on bed/measurement, labeled 1 - 4. Items 1. and 2. were checked. Both showed, Gap in bar between bar and mattress ½ (handwritten in). No other zones of entrapment were measured, per standards of practice related to bedrails. There was no additional documentation to show measurements taken for four additional days, per standards of practice and facility policy. During an interview on 09/26/22 at approximately 4:45 p.m., the Environmental Services Director, Staff E, confirmed they would accompany Surveyors to take measurements of the T-bar bedrails, and the measurements of any bedrail gaps, per regulatory and standards of practice guidelines. During an interview on 09/27/22 at 2:57 p.m., the Director of Rehabilitation Services, Physical Therapist (PTA) CC, was asked about Resident #46's safety with the use of the T-bar bedrail, which had since been removed by the facility on 09/26/22. PTA CC reported while Resident #46 had used the T-bar bedrail for bed mobility and transfers, he acknowledged the grab bar style appeared outdated and was a safety concern, given one bar sticking out the bed occupant could possibly catch their neck or arm on the bar. PTA CC reported the enabler bars with the curved edges would be much safer for the bed occupant. PTA CC confirmed Resident #46 was at risk for falls due to an overall medical decline, falls since facility admission, and poor compliance with safety recommendations to ambulate and transfer with assistance. Resident #19 During an observation and interview on 09/21/22 at 10:45 a.m., Resident #19 was found in bed during peri care, with bilateral mobility bed rails (enabler/assist bed rails). Resident #19 verbalized the hallucination of cats being hung by their ears on the telephone line visible outside the room window. No trapeze was present on Resident #19's bed. Review of Resident #19's Minimum Data Set (MDS) assessment, dated 7/5/22, revealed the Resident was admitted to the facility on [DATE], with the most recent re-admission on [DATE]. Active diagnoses included: stroke, hemiplegia (paralysis of left dominant side of Resident #19's body) and muscle weakness. Resident #19 scored 12 of 15 on the Brief Interview for Mental Status (BIMS) reflective of moderate cognitive impairment. Resident #19 required extensive two-person assistance with bed mobility, with a resident transfer not performed during the assessment period. The MDS assessment documented A. Bedrail . Used Daily . in Section P0100. Physical Restraints. Review of Resident #19's Enabler Bar Documentation, dated 6/22/22, by maintenance staff, revealed the following bed rail documentation: Enabler bars need to be measured for gaps in bar and between the bar and the mattress every time a device is applied, or if the resident changes beds or mattresses or type of enabler bar used. Documentation will be kept in the Bedrail Book in Maintenance Department. Type of Device: T-Bar (checked) . Location on bed/Measurement: 1. Top right, Gap in bar between bar and mattress, 0 (zero) in (inches). 2. Top left, Gap . 0 inches. Review of Resident #19's Care Plans revealed the following, in part: I have Bilateral T-Bars on my bed to assist me with bed mobility. Date Initiated: 02/15/2022 Created by: [Registered Nurse (RN) X] Review of Resident #19's Resident Bed Rail/Assist Bar/TBar Consent Form, dated and signed 3/10/22, revealed the following, in part: 1. Please initial one of the following statements of your choice for assistive devices. _____The option of bedrails/assist bars has been offered to me and I choose not to have them at this time. _____I choose to use the following device to assist with bed mobility and security when I am in bed. Device Requested ___Right Side ___Left Side ___ TBar ___Assist Bar ___Half Bed Rail . No initials, checks, or notations showed selection of any of the choices presented on Resident #19's Bed Rail Consent form. The bed rail consent form included the following general information: I am responsible for treatment decisions of the above-named resident. I have been advised that I may request that bed rails/assist/tbars be installed on the resident's bed. The risk and alternatives to using bed rails/assist bars/tbars, as they apply to this resident's particular condition and circumstances, have been clearly explained to me. I understand that, in addition to this signed consent form authorizing the use of bed rails for this resident, a written order from the physician, specifying the medical rationale and circumstances for use, must be obtained prior to the installation of this medical treatment device. It is also my understanding that the Facility will periodically review and re-evaluate the resident's need for bed rails/assist bars/tbars and that the resident, responsible party, and attending physician will be consulted in this matter. With all the above information in mind, I consent to the installation and utilization of bed rails for the care of the above-named resident, consistent with the written orders of the attending physician . Review of Resident #19's Physician Orders related to bed rails, read as follows: Order Date: 3/10/22 14:50 (2:50 p.m.), Resident may use bilateral TBar/assist bars on her bed along with her trapeze to aide with bed mobility and repositioning. Diagnosis: weakness, pain, obesity. Review of Resident #19's Bed Rails Clinical Guidance form, dated 4/27/22, revealed the following, in part: Implementation Plan: 1. Have you anticipated and planned for the Resident getting out of bed at night for such things as hunger, thirst, restroom, restlessness/pain, and/or need for skin care/hygiene? NO . 6. Have you considered the use of floor mats for residents that are prone to rolling out of bed? NO . 9. Evaluate and document the effect of these interventions: Resident . has a trapeze on her bed and has requested T-bar/assist bars to help mover (sic) herself about in bed. [Resident #19] is obese has difficulty even with T-bars moving about in bed. Uses Hoyer lift to transfer. Education provided included: 1. Resident issues that often result in bed rail use include memory disorders, impaired mobility, risk for injury, nocturia/incontinence, and sleep disturbances. 4. Strangling, suffocating, other bodily injury, and death can occur when a resident is caught between bed rails or between bed rails and mattress . Implementation: . 5. What steps have you taken to move to lesser restrictive devices? BLANK - no information provided. Signed Date: 4/27/22. Review of the User-Service Manual, copyright 2020, for Resident #19's bed, a [Name Brand, Model Bed], revealed the following, in part: To avoid injury, read user's manual before using . Warning: Possible Injury or Death. If a resident/patient's mental or physical condition could lead to resident/patient entrapment, the mattress support platform should be left in the flat position when unattended. Failure to do so could result in injury or death . Warning: An optimal bed system assessment should be conducted on each resident by a qualified clinician or medical provider to ensure maximum safety of the resident. The assessment should be conducted within the context of, and in compliance with, the state and federal guidelines related to the use of bed system entrapment guidance, including the Clinical Guidance for the Assessment and implementation of Side Rails, published by the Hospital Bed Safety Workgroup of the U.S. Food and Drug Administration . Warning: Possible Injury or Death. Do not use any replacement parts not manufactured, marketed, or provided by [Name Brand] Healthcare on any [Name Brand] bed. Use of unapproved replacement parts may result in injury or death .If using accessories not manufactured, marketed, or provided by [Name Brand] Healthcare . consult with the manufacturer for compatibility and limitations prior to use. Failure to do so may result in injury or death . Entrapment zones involve the relationship of components often directly assembled by the healthcare facility rather than the manufacturer. Therefore, compliance is the responsibility of the facility . While the guidelines apply to all healthcare settings, (hospitals, nursing homes and at home), long-term care facilities have particular exposure since serious entrapment events typically involve frail, elderly, or dementia patients . Resident #33 Review of Resident #33's MDS assessment, dated 7/27/22, revealed Resident #33 was admitted to the facility on [DATE], with diagnoses that included the following, in part: cerebrovascular accident (CVA/Stroke), hemiplegia, disorientation, and dizziness and giddiness. Resident #33 scored 11 out of 15 on the BIMS, reflective of moderate cognitive impairment, and was independent in bed mobility and transfers. The Resident had functional limitations in range of motion on one side of the lower extremities and used a wheelchair for mobility. The use of bed rails was not documented on the MDS assessment. During an observation on 9/26/22 at approximately 12:15 p.m., Resident #33's bed was found with bilateral T-bars installed on the left and right sides of the bed. The T-bars in use appeared old, without manufacturer's labeling or information, and were observed as a single chrome finished bar extending upward from the bed frame, with a single chrome finished, square handle (the area where the user holds the bar), approximately 2 inches x 2 inches in width and approximately 12 inches in length, attached perpendicularly to the top of the mounted bar. The square handle had distinct edges on all sides and ends, and allowed potential for injury, with square metal prongs (not rounded) sticking out at each end. The T-bar appeared as the image of a T. No T-bar identification of any similar bed rail was found in multiple internet searches for a similar appearing bed rail. Review of Resident #33's progress notes revealed the following, in part: 8/4/22 12:05 (p.m.), Family Care Conference, Meeting Note: .When resident (#33) has to use the bathroom at night she tries to raise the back of her bed so she can get up. Resident (#33) ends up raising her whole bed in the air. Resident/Family are afraid of a fall. Family tried to cover the buttons that raise the bed up and down . 8/4/22 12:21 (p.m.), Social Service Progress Note . talked with maintenance. They can take the motor out of the controller that moves the bed up and down. The bed will be kept in the lowest position to prevent a fall . 8/5/22 14:26 (2:46 p.m.), Social Services Progress Note . Maintenance was not able to disconnect the controller on the bed resident had. Resident was given a different bed that allowed the up and down controller to be disconnected. Resident is not happy about the new bed - resident does not like the T-bars compared to the other bed (assist bars) . On 9/26/22 at 12:38 p.m., Review of Enabler Bar Documentation completed 6/22/22 by maintenance staff, revealed Resident #33's bed had bilateral Enabler Bars (assist bed rails) on the top right, and top left of the bed, with a Gap in bar between bar and mattress of ¾ (3/4 inch) on each side. Only one measurement was performed, and other bed entrapment zones were not measured. No resident assessment for bed rails was found in the Electronic Medical Record (EMR), either at the time of admission or at the time she received a different bed with T-bars instead of assist bed rails. No physician order for bed rails was present in the Physician Order Summary for September 2022, retrieved 9/26/22 at 12:26 p.m. Resident #34 Review of Resident #34's MDS assessment, dated 7/30/22, revealed the Resident was admitted to the facility on [DATE], with diagnoses that included the following: non-Alzheimer's dementia, muscle weakness, and polyosteoarthritis. Resident #34 scored 5 of 15 on the BIMS reflective of severe cognitive impairment. Resident #34 required extensive two-person assistance with bed mobility. Bed rail usage was not documented in Section P: Restraints and Alarms on the MDS assessment. During an observation and interview on 9/26/22 at approximately 10:45 a.m., Resident #34's bed was observed with a T-bar bed rail on the right side of the bed. A gap (not measured) was observed and identified between the T-bar and the bed mattress in the presence of Staff E. Review of Enabler Bar Documentation completed 6/22/22 by maintenance staff, revealed Resident #34's bed had one T-bar on the top right of the bed, with a Gap in bar between bar and mattress of 0 (zero inches). Only one measurement was performed, and other bed entrapment zones were not measured. Review of Resident #34's Physician Order Summary for September 2022, revealed the following order, beginning on 3/14/22: Resident may use a TBar/assist bar on the right side of his bed to aide with bed mobility and repositioning due to s/s (signs and symptoms) polyosteoarthritis. Review of Resident #34's Bed Rails Clinical Guidance assessment, dated 4/27/22, and noted as In Progress when retrieved on 9/26/22, revealed the following: 1. Multiple questions were blank, and not completed. 2. The Implementation Plan had questions that were unanswered or answered with NO, including: a. Have you anticipated and planned for the Resident getting out of bed at night for such things as hunger, thirst, restroom, restlessness/pain, and/or need for skin care/hygiene? (unanswered) b. Have you attempted transfer and mobility aides such as a trapeze? (NO) c. Have you considered the use of floor mats for residents that are prone to rolling out of bed? (NO) d. Have you considered a referral to therapy or restorative for exercises/interventions to enhance the resident's ability to stand, transfer, to reposition self safely? (NO) If the answer is no to any of the above items go back and implement. Education documented as provided to the Resident/Legal Representative did NOT include the following items included on the bed rail form: - Residents who are frail, or elderly are at risk for entrapment. - A resident with agitation, delirium, confusion, pain, uncontrolled body movement, hypoxia, and elimination issues are at risk for entrapment and/or suffering serious injury from a fall. - A resident may try to climb through, under, or over bed rails or footboard which will greatly increase risk for injury. - Ill-fitted mattresses and rails increase the risk for injury to a resident. Review of the EMR list of all Bed Rails Clinical Guidance forms completed by the facility only showed the 4/27/22 In Progress assessment. No other bed rail assessments had been documented. Review of Resident #34's Care Plans revealed the following ADL (activities of daily living) intervention: SIDE RAILS: I have a T bar on the right side of my bed to assist me with bed mobility. Observed for injury or entrapment related to side rail use. Reposition PRN to avoid injury. Date Initiated: 10/20/21 (Date of Admission) . Residents (#1, #22, #31, #33, #34, and #46) all had old [Name Brand] beds with unidentified old T-bars mounted on the beds. The model was the same for all residents. During an interview on 9/26/22 at 10:13 a.m., Environmental Services Manager (Staff E) was asked for documentation of bed measurements related to the use of bed rails and assessment of entrapment zone risks of resident beds. Staff E stated, (There are) no side rails in the building, so T-rail checks (are performed) on an initial install (of the bed rails) . We (Environmental Services staff) just do them (gap measurements) for the initial install, and do not do them for multiple days or times. During a follow up interview that same day at 10:48 a.m., Staff E provided a pink Bedrail Book binder that he said documented Bed Rail Use and Measurements. Staff E stated, I was never aware or informed that T-bars or assist rails were considered bed rails. Staff E said because they were not considered bed rails, the small assist rails on the beds were not measured for multiple days and therefore measurements of the seven bed entrapment zones were not documented on the bed rail assessment form. The T-bars and assist bed rails were measured only one time and he said there were no measurements done for the T-bars because there was no risk of entrapment from those bed rails. Staff E acknowledged the lack of manufacturer's instructions for the T-bars and confirmed he did not know if the T-bar bed rails, and bed frames were compatible or incompatible as mobility support as currently used by facility residents. Staff E said the T-bars had been present in the building for many years. Staff E stated, I don't have any information on the T-bars. Staff E stated, You will see by the dates listed in here (Bedrail Book), that we just started measurements (of the assist and T-bar bed rail's one entrapment zone next to the bed rail) in June of 2022. Staff E acknowledged he was aware of one previous resident death, in another facility, due to entrapment in a bed rail, but because the facility didn't have bed rails (quarter rails, half rails, or full bed rails) Staff E said he was not aware bed entrapment zones had to be measured. During an interview on 9/26/22 at 2:27 p.m., Staff E stated, We don't have any information on the T-bars. We don't have any information at all. Staff E confirmed Environmental Services (Maintenance) (Staff) II and JJ measured all the assist/T-bars (bed rails) on June 22, 2022. Staff E said all the beds currently with T-bars were old [Brand Name] beds, and stated, We don't have information on the beds or the bars (T-bars). Staff E provided a Parts Catalogue for the old [Name Brand] beds, but no instructions for use were available or provided by the facility for either the [Name Brand] bed or the T-bars that were absent manufacturer identification/information. Staff E was asked to provide the bed manufacturer, model, serial number, and type of rail on the bed. Review of the Bed Rails policy, revised 12/20, revealed the following information related to bed rails: Policy: Full and half bed rails will be safely used only as needed to treat a resident's medical symptoms. Policy Explanation and Compliance Guidelines: 1. The IDT (interdisciplinary team) to complete the following items prior to initiating side rail usage. a. Complete the resident bedrails consent form. b. Complete the bedrails clinical guidance assessment. c. Obtain a Physician order that contains statements and determinations regarding medical symptoms and is specific to the circumstances under which bed rails are to be used and time limit for use. d. Initiate a Care Plan. e. Complete the [Facility Name] Side Rail Measurement Monitoring UDA at the time of instillation (sic) and every day for 4 days (to total 5 days of measurement). f. Document corrective action taken if measurements do not meet [State Name] guidelines for gaps. g. Complete the [Facility Name] Side Rail measurement Monitoring UDA every quarter unless resident has any of the following: new/different mattress, new/different side rails, new/different bed frame and/or resident experiences weight loss. 2. Complete the [Facility Name] Bed Rail Clinical guidance assessment quarterly. 3. Prior to the discontinuation of side rails document reasons for the discontinuation in the medical record, to include resident choice and interdisciplinary team recommendations. Review of the Guidance for Industry and FDA Staff, Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment, Document issued on: March 10, 2006, revealed the following, in part: Potential Zones of Entrapment: This guidance describes seven zones in the hospital bed system where there is a potential for patient entrapment. Entrapment may occur in flat or articulated bed positions, with the rails fully raised or in intermediate positions . The seven areas in the bed system where there is a potential for entrapment are .: Zone 1: Within the Rail Zone 2: Under the Rail, Between the Rail Supports or Next to a Single Rail Support Zone 3: Between the Rail and the Mattress Zone 4: Under the Rail, at the Ends of the Rail Zone 5: Between Split Bed Rails Zone 6: Between the End of the Rail and the Side Edge of the Head or Foot Board Zone 7: Between the Head or Foot Board and the Mattress End During a telephone interview on 9/27/22 at 12:46 p.m., Customer Service Representative (CSR) DD, from the old [Name Brand] bed corporation, confirmed the serial numbers of the [Name Brand] model beds in question showed the beds were [AGE] years old. CSR DD said the corporation no longer made the bed model or bed rails for the [Name Brand] bed. CSR DD said hospital beds had bed rails made exactly for the model of bed in use. When asked if a different bed rail could be attached to the bed frame, CSR DD stated, For safety reasons, I would not recommend it. CSR DD was able to provide the [Name Brand] bed Owner's Operator and Maintenance Manual, copyright 2003, via email to this Surveyor. Review of the Owner's Operator and Maintenance Manual, copyright 2003, revealed the following, in part: WARNING: DO NOT OPERATE THIS EQUIPMENT WITHOUT FIRST READING AND UNDERSTANDING THIS MANUAL .The side rails when used with a Manual/Electric bed DO NOT fall within any weight limitations. Side rails can be deformed or broken if excessive side pressure is exerted on them. These side rails are for the purpose of preventing an individual from inadvertently rolling/climbing out of bed .Replacement mattresses and bed side rails with dimensions DIFFERENT that the original equipment supplied or specified by the bed manufacturer may not be interchangeable. Variations in bed side rail design and thickness or density of the mattress could cause entrapment. Use ONLY authorized [Name Brand] replacement parts . Review of the policy, Bed Rails, revised 12/20/22, revealed, The IDT [interdisciplinary team] is to complete, a.the bedrail consent form. b. the bedrails clinical guidance assessment. c. obtain physician order .e. complete the [company name] side rail measurement monitoring at time of installation and every days for 4 days [to total 5 days of measurements] . An Immediate jeopardy was identified on 9/26/22. It began on 6/22/22. The Nursing Home Administrator (NHA) was verbally notified on 9/26/22 at 3:30 p.m. An abatement plan was requested from the facility at this same time. The facility's IJ Abatement Plan included the following: 1. Identification of residents affected or likely to be affected The facility took the following actions to address the citation and prevent any additional residents from suffering an adverse outcome. (Completion Date: 9/26/2022) Beginning on 9/26/22, the facility Unit Managers identified all residents with devices fitting the definition of bed rails. Beginning on 9/26/22, the facility EVS (Environmental Services) is removing any bed rails without accessible manufacturer's instructions for use. Beginning on 9/26/22, the facility Unit Managers assessed the continued need for bed rails and discontinued any bed rails no longer warranted. Resident responsible party will be notified if bed rail removed. On 9/26/22, the Regional Director of Plant Operations educated the facility EVS Director on the proper way to perform bed rail measurements in person via electronic platform. Beginning on 9/26/22, the EVS performed measurements, per policy, on each bed with a device fitting the description of a bed rail. The facility Unit Manager notified the Medical Director via phone of this event and the residents impacted. 2. Actions to Prevent Occurrence/Recurrence: The facility took the following actions to prevent an adverse outcome from reoccurring. (Completion Date: 9/26/2022). Beginning on 9/26/22, all facility policies and procedures regarding bed rails were reviewed/revised. Beginning on 9/26/22, the DON educated all licensed staff, prior to their next scheduled shift, on the proper use of bed rails per facility policy, the process of determining proper use of side rails depending on resident's mental and physical status, and the increased risk of injury and death when bed rails are used improperly. Beginning on 9/26/22, the IDT reviewed and assessed all residents with bed rails to determine the appropriateness of continued bed rail placement and risk of entrapment. Physician orders for the use of bed rails were obtained for residents considered appropriate for the use of bed rails. Beginning on 9/26/22, IDT reviewed and revised the care plans of residents with bed rails to ensure they had resident specific interventions to reflect the identified need for bed rails. Date Facility Asserts Likelihood for Serious Harm No Longer Exists: 9/26/22 An observation on 09/26/22 at 5:01 p.m. revealed Resident #46 was observed in her room, seated on the edge of her bed. Her T-bar bedrails had been removed. During an interview on 09/26/22 at approximately 5:10 p.m., the NHA confirmed all T-bar style bedrails in the building had been removed as they and the facility management were unable to find any manufacture's name or any other information on these style of bedrails to determine if they were safe per regulatory and standards of practice guidelines. Although the immediate jeopardy was removed on 9/26/22, the facility remained out of compliance at a scope and severity of no actual harm with potential for more than minimal harm that has the potential to affect a large portion of the facility's residents due to the inability to verify staff education, all policy updates, system changes, and sustained compliance. Resident 1 Review of the MDS assessment, dated 6/6/22, showed R1 with the following diagnoses: Alzheimer's disease, coronary artery disease, and chronic obstructive pulmonary disease. The Brief Interview for Mental Status (BIMS) score was 4 out of 15 which reflected severely impaired cognition. R1 had impaired vision and required one staff assistance for toilet use and personal hygiene. Balance during transitions and walking were not steady. R1 was occasionally incontinent of bowel and bladder. During an observation on 9/20/22 at 9:44 a.m., R1 was lying in bed with a T-bar in the upright position to only the left side of the bed. The bed pendant was clipped to the top, left side of the headboard with the control options facing the bed and not the wall. The pendant options contained six, white square buttons which read HEAD, BED, FOOT printed with black triangles indicating the movements for up and down. R1 was wearing dark colored socks without anti-slip grippers to the soles of the feet. The left sock was pulled slightly off the foot. During an observation on 9/26/22 at 10:22 a.m., R1 was lying diagonally on his back, in bed with his head positioned to the right upper corner and his leg/feet positioned to the bottom left portion of the mattress. The bed pendant was wrapped around the T-bar and dangling just above the floor. The call light was also wrapped around the T-bar and dangling directly [TRUNCATED]