Based on interview, observation and record review, the facility failed to keep one resident (Resident #1) safe when the resident got his/her head stuck between the transfer bar attached to the bed frame and the mattress out of three sampled residents. The facility census was 61. The administrator was notified on 06/14/23 at 2:45 P.M., of an Immediate Jeopardy (IJ) which began on 06/14/2023. The IJ was removed on 06/14/23, as confirmed by surveyor onsite verification. The facility did not provide a policy regarding use of mobility rails. 1. Review of Resident #1's medical record showed: - An admission date of 10/20/2022, with diagnoses of Alzheimer's disease (a progressive disease beginning with mild memory loss and possibly leading to loss of the ability to carry on a conversation and respond to the environment) with late onset, dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), chronic obstructive pulmonary disease (a group of diseases that cause airflow blockage and breathing-related problems), asthma (a disease that affects your lungs), obstructive sleep apnea (characterized by episodes of complete collapse of the airway or partial collapse with an associated decrease in oxygen saturation or arousal from sleep), and depression (a common and serious medical illness that negatively affects how you feel, the way you think and how you act). Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by the facility staff, dated 04/23/2023, showed: - Cognition intact; - Extensive assist of one staff for bed mobility, dressing, eating, and personal hygiene and bathing; - Extensive assist of two or more staff for physical assist with transfers and use of the toilet; - Incontinent of bladder and occasionally incontinent of bowel; - Two or more falls since admission. Review of the resident's Side Rail Assessment, dated 04/11/2023, showed: - Assessed for full half and quarter rails, not for positioning rails such as transfer, pivot or assist rails; - Rails indicated to assist with bed mobility. Review of the resident's June 2023 Physician Order Sheet (POS) showed: - An order the resident may use the transfer bar applied to the bed as a self-positioning device and to increase independence, dated 10/20/22 and discontinued on 06/01/2023. Review of the resident's Interdisciplinary notes showed: - On 06/01/2023, Certified Nurse Aide (CNA) C yelled for help down to the nursing station. Upon arrival to the resident's room, the resident lay on the floor at the side of the bed on his/her abdomen and right side; - CNA C said the resident's head was wedged between the mattress and the transfer bar with his/her body off the bed when he/she arrived to answer the resident call light. The resident's lips were blue when he/she arrived to the room. CNA C assisted the resident off the bed and lay him/her on the floor; - The nurse instructed other staff to call 911 for emergency medical services; - The nurse log rolled the resident onto his/her back while supporting his/her head, neck and shoulder. The resident was alert, conscious, breathing, able to answer questions appropriately, and denied any pain; - The resident explained to the nurse he/she rolled over and went too far; - The resident was transferred to the emergency room for evaluation. Records were not available for review. Review of the notes from the facility's Occupational Therapist, dated 06/05/2023, showed: - Resident #1 presented to the emergency room with near strangulation with examination for possible cervical spinal injury (the upper portion of the spine including the neck and just below the neck) and trachea (large membranous tube reinforced by rings of cartilage, extending from the larynx to the bronchial tubes and conveying air to and from the lungs) soft tissue injury; - The resident was cleared for no acute cervical injuries via x-ray and Magnetic Resonance Imaging (MRI) (a procedure that uses radio waves, a powerful magnet, and a computer to make a series of detailed pictures of areas inside the body); - History of falls when trying to transfer him/herself; - History of left shoulder dislocations multiple times; - Decreased active range of motion to the left shoulder, avoid pulling on the shoulder with poor endurance. During an interview on 06/14/2023 at 1:05 P.M., Registered Nurse (RN) A said he/she did not actually see Resident #1 until after CNA C removed the resident from the railing. When he/she arrived, the resident was responsive, talking, and did not complain of pain but was scared of what had just happened. During an interview on 06/14/2023 at 1:20 P.M., Resident #1 said he/she did not use the rail on the bed for getting up or positioning him/herself in the bed. He/she was in bed and rolled over one too many times and got the right side of his/her head stuck between the rail and the mattress. He/she was unable to get his/her head out due to rolling over on the left side and his/her left shoulder was too weak to move his/herself from the rail. His/Her body fell on the floor, leaving his/her head stuck, he/she was in pain in that position, was very scared and was having difficulty breathing, so just tried yelling until someone finally came by. He/She did not use the rail on the bed for getting up or positioning. During an interview on 6/14/2023 at 2:00 P.M., CNA D and CNA E both said the resident unable to support him/herself and was not able to use the mobility bar independently and would hold onto it only if directed to do so. During an interview on 06/14/2023 at 2:45 P.M., CNA C said he/she walked down the hall and saw Resident #1's call light on and heard him/her yelling. When he/she entered the room, he/she saw Resident #1 with his/her stomach on the floor, his/her back bent, and with his/her head and neck stuck between the rail and the mattress on the bed. His/her lips were blue, his/her eyes were set, and at that time, he/she was not responding. CNA C immediately, without thinking, grabbed Resident #1 by the shoulders and pulled him/her up and lay on his/her side. Resident #1 said, Thank God you're here, I had been so afraid. He/she immediately called out for help and additional staff came to assist. During an interview on 06/14/2023 at 3:00 P.M., the Director of Nursing and the Director of Clinic Operations said neither were aware that the Side Rail Assessment form did not clearly state what type of rails were being assessed. The form was incorrect and should not have been used to evaluate Resident #1. During an interview on 06/14/2023 at 3:10 P.M., Resident #1's Primary Care Physician (PCP) said he would expect the facility to evaluate each resident thoroughly before using any assistive devices. Based upon the information provided, the facility should have removed the transfer bars when the resident was no longer capable of using them. NOTE: At the time of the abbreviated survey, the violation was determined to be at the immediate jeopardy level J. Based on observation, interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to remove the IJ violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the D level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action be taken to address Class I violation(s). Complaint # MO219588