**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview conducted during the recertification survey, the facility failed to ensure each resident is free from physical or chemical restraints imposed for purposes of discipline or convenience and that are not required to treat the resident's medical symptoms. The facility failed to provide ongoing re-evaluation for the need of the restraint used and attempts to use the least restrictive alternative for the least amount of time. Specifically, residents were observed with restraints in place without 1) adequate assessment and re-evaluation, 2) physician's orders for the restraint, and 3) release from restraints at least every 2 hours per the physician's orders. Resident #2 was observed in the wheelchair on multiple occasions with seatbelt and pommel cushion in place with legs dangling. There were no swing away leg rests in place as ordered, and during observation the seatbelt was not released every 2 hours for 15 minutes as ordered by the physician. There was also no documented evidence the seat belt was released every 2 hours as ordered. Orders for pommel cushion in wheelchair were initiated 5/7/2020 after resident was observed sliding in the wheelchair. There was also no documented evidence the seatbelt was re-evaluated for effectiveness or that a reduction in restraints was attempted once the pommel cushion was initiated. Resident #2 was observed on 11/22/21 with long tube socks placed over both hands. There was no documented evidence the resident was ordered to have hand mittens or other hand restraints. On 8/28/21 Resident #2 was discovered with their leg between the siderail, which resulted in a skin tear, and on 5/7/20 Resident #2 was observed sliding in their wheelchair while a seat belt was in use. Resident #13 was observed on multiple occasions without release of seatbelt every 2 hours for 15 minutes as ordered. There was no documented evidence the seat belt was released as ordered. Resident #13 was also observed in bed on multiple occasions with bilateral full siderails in place. There were no physician's orders for bilateral full side rails. Resident #122 was observed 11/17/21 transferred to bed with the bed in the high position and bilateral full siderails raised. The admission Physician's order dated 11/16/21 documented orders for bilateral 1/2 siderails in place. RN stated maintenance was supposed to switch the full siderails to 1/2 siderails on 11/17/21. This resulted in Immediate Jeopardy and Substandard Quality of Care with the likelihood for serious harm to all residents with medical orders for restraints in the facility. The findings are: The facility policy titled Siderail (SR) Use Guidelines last reviewed 03/2021, documented residents will be assessed upon admission, re-admission, and as needed for SR. Prior to SR use, attempt alternatives, obtain Medical Doctor's Order (MDO), and both SR is considered a restraint. The facility policy titled Restraint Guidelines dated 5/2015 documented residents have the right to be free of restraints used for discipline, convenience, and are to treat medical symptoms. Alternatives should be attempted and documented before restraints ordered. 1) Resident #2 was admitted [DATE] with diagnosis of Alzheimer's Dementia. A significant change Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #2 had severely impaired cognition, required 2-person assist for transfers and 1-person assist for bed mobility, eating, and toilet use. Bed rails and trunk restraint were used in chair and out of bed. The Mobility Assessment initiated 2/4/20 and completed 2/6/20 documented Resident #2 was being assessed for bed mobility, restraint monitoring, and fall risk assessment. There was no documented evidence the resident attempted to get out of bed. The MDOs dated 2/4/20 documented Resident #2 was to have two 1/2 SRs up while in bed as enabler for bed mobility secondary to dementia. SRs were to be released every 2 hours for 15 minutes. On 2/5/20, MDO documented SB while in w/c to prevent unassisted transfer and ambulation related to dementia. Revision dated 2/6/20 documented SB to be released every 2 hours for 15 minutes for Activities of Daily Living (ADLs). The Physical Restraint assessment dated [DATE] documented SRs and SB were recommended for Resident #2 after attempting observation, alarm device, and low bed. Nursing Note (NN) dated 2/6/20 and 2/7/20 documented Resident #2 attempted to open SB, stand while in w/c, and attempted to get out of bed to go to the bathroom. The Fall Risk assessment dated [DATE], 5/7/20, 8/10/20, 10/27/20, 1/24/21, 4/26/21 documented resident was at a high risk for falls related to level of consciousness/mental status, history of fall, ambulation/elimination status, vision status, gait and balance, systolic blood pressure and vitals, medications, and predisposing diseases. The Comprehensive Care Plan (CCP) related to SR use, initiated 2/7/20, last reviewed 11/8/21, documented Resident #2 had dementia, limited mobility, loss of position sense, poor trunk control, and agitation. Interventions included evaluate for risk of entrapment and monitor for changes in cognition, behavior, and ADLs. On 7/1/21 the intervention of full SRs due to behavior, anxiety, restlessness, and dementia and psychosis was added. The CCP related to restraint/alarms, initiated 2/7/20 and last reviewed 11/11/21, documented SB, bed alarm, and full SRs were needed to address Resident #2 attempting to self-transfer, high risk for falls, anxiety, right hemiplegia, and psychosis. Interventions included application of the restraints per MDO and monitor for continued need and negative outcomes. The CCP related to falls/accidents/incidents, initiated 2/7/20, documented interventions for bed mobility assessment and padding to both SR due to a history of falls, fragile skin, poor balance, restlessness, and risk of bruising. The SR Use assessment dated [DATE] recommended the use of bilateral 1/2 SR to assist with bed mobility. The Physical Restraint assessment dated [DATE] documented Resident #2 had poor sitting/standing balance, and Resident #2 was observed and provided a low bed prior to the placement of a bed alarm. The MDO dated 2/15/20 documented a bed alarm was ordered. NN dated 5/7/20 documented Resident #2 was evaluated by the Occupational Therapist due to sliding in the w/c, and a new cushion was recommended. The MDO dated 5/7/20 documented Resident #2 was to use a standard w/c with swing-away adjustable, elevating, removable leg rests and pommel cushion (a seat cushion with a protrusion in the front that rises between the legs to prevent sliding). NN dated 6/11/20, 6/27/20, and 7/5/20 documented Resident #2 attempted to get out of bed by climbing over the SRs. NN dated 7/30/20 documented Resident #2 pulled half of the left SR off the bed and their left upper body was stuck between the left SR and bed. NN dated 9/16/20, 11/11/20, 1/25/21, and 1/31/21 documented Resident #2 had skin discolorations on bilateral lower extremities, removed SR padding, and kicked their legs on the SR. The Physical Restraint Assessments dated 1/25/21 and 4/27/21, documented the resident's SB was a restraint and did not document a pommel cushion was in place. The NN dated 6/1/21 documented Resident #2 was agitated, restless, removed SR padding, and was observed with a decline in functional ability, bed mobility and ADLs. The MDO dated 6/22/21 documented 2- 1/2 SRs discontinued. Resident #2 was ordered bilateral full SR released every 2 hours for 15 minutes for behavior, anxiety, restlessness, depression, dementia, and psychosis. There was no documented evidence a SR Safety Assessment was completed for Resident #2 prior to the application of half and full SRs. The CCP related to anticoagulant use initiated 6/27/21 documented Resident #2 had a left-hand discoloration and SR padding was added to minimize skin friction. The NN dated 7/1/21 documented Resident #2 threw both feet over the SR and removed the SR padding. The Physical Restraint Assessments dated 7/8/21 and 7/27/21 documented SR, SB and bed alarm were restraints used with Resident #2. Pommel cushion was not documented. NN dated 8/27/21 documented Resident #2 kept putting their left leg in between the SR rails, and a NN dated 9/26/21 documented Resident #2 removed the SR padding. The Fall Risk assessment dated [DATE] documented resident had no falls in the past 3 months and was not a high risk for falls. The Physical Restraint assessment dated [DATE] documented that Resident #2 had a SB and bed alarm restraint in place. Pommel cushion and SRs were not documented. The Physician's Monthly Notes from 3/3/20 to 11/6/21 documented physical restraints/SR were not being used with Resident #2. There was no documented evidence restraints were released per MDO. In addition, the was no documented evidence in the medical record that the facility attempted restraint reduction or evaluated the effectiveness of the restraints used and/or attempt alternatives when Resident #2 had issues with the restraint used. During multiple observations (11/16/21 from 3:09 PM to 3:48 PM, 11/18/21 from 8:54 AM to 11:38 AM, and 11/19/21 from 8:38 AM to 3:40 PM), Resident #2 was calm, quiet, and in bed with bilateral padded full SR in the raised position. During multiple observations on (11/16/21 at 11:38 AM, 11/18/21 from 12:15 PM to 3:10 PM, and 11/19/21 at 12:59 PM), Resident #2 calm and quiet, seated in a wheelchair (w/c) with SB fastened and pommel cushion (a seat cushion with a protrusion between the legs to keep the resident in position) in place between the legs. Leg rests were not observed, and resident's feet were dangling above the floor. On 11/18/21 at 12:15 PM, a staff member sat beside Resident #2 and began feeding them lunch without releasing the SB or pommel cushion. During an interview on 11/19/21 at 06:34 PM, CNA #15 stated Resident #2 would intermittently scream, curse, move in bed, grab, and shake the SRs, throw items from the bed to the floor, and express desire to go home. SB and pommel cushion were ordered due to agitation. SR padding was placed for safety, i.e., resident could hit their head when shaking the SRs. CNA #15 stated, Resident #2 has not been agitated or attempted to get out of bed or w/c for a long time. Due to recent activities of daily living (ADL) decline, Resident #2 required 2 people to assist with transfers and has not had any falls from the w/c or bed. CNAs inform the nurse if residents attempt to get up unassisted, Rehab Department provides safety devices, and CNAs inform the nurse if devices are ineffective. CNA #15 stated, they were not aware that Resident #2 should be released from restraints every 2 hours for 15 minutes. On 11/22/21 at 05:59 AM, Resident #2 was observed in bed sleeping with long gray tube socks covering bilateral hands pulled up to the middle of the forearms. The tube socks prevented Resident #2 from moving their hands and fingers freely. During an interview on 11/22/21 at 06:54 AM, CNA #13 from the 11PM - 7AM shift, stated Resident #2 was confused and had history of cursing, calling out for no reason, throwing items from the bed to floor, swinging their legs over the SRs, and sliding off the foot of the bed. CNA #13 stated, Resident #2 was no longer able to physically do that. CNAs informed the nurse if residents required SR padding for safety and CNAs were given verbal report from the nurse manager re: which residents had restraints. CNA #13 stated, they did not place socks on Resident #2's hands and that the previous shift must have done that to prevent Resident #2 from digging in their depends. CNA #13 stated, they did not remove the socks because it was an intervention the previous shift deemed necessary. An interview was conducted on 11/22/21 at 07:21 AM with the 11PM - 7AM Registered Nurse Supervisor (RNS #4) who stated RN #4 conducts visual rounds on all residents before going on break. If a resident is agitated and at risk for falls, RNS #4 writes a nursing note with a recommendation for half or full SRs. The RNS stated that the day shift RN Supervisor was responsible for filling out the SR Assessment and obtaining consent from families. In an immediate interview, RNS #4 observed Resident #2 with long gray socks over bilateral hands while Resident #2 was being fed breakfast in bed by a day shift CNA. RNS #4 removed the socks, revealing deep impressions from the elastic on Resident #2's forearms. RN #4 stated Resident #2 does not have a MDO for hand coverings, and the socks restricted Resident #2 from moving their hands. RN #2 stated CNA #13, the 11-7 assigned CNA, should have removed the socks immediately after seeing them. On 11/24/21 at 1:29 PM, CNA #12 was interviewed and stated Resident #2 possibly had SRs and SB in place due to attempts to get out of bed or w/c. CNA #12 stated, Resident #2 was not being released from restraints according to MDO and that CNAs do not document a restraint release schedule for any resident with restraints. On 11/24/21 at 2:58 PM, a telephone interview was conducted with Attending Physician (AP) #1 who stated they had not personally observed inappropriate behavior; however, nursing staff reported Resident #2 had history of behaving wild and had been mellow the past 2 weeks. AP #1 stated, monthly evaluations of Resident #2 included a review of restraints and reports from different disciplines. Facility approach would be to pay closer attention to restraint use. 2) Resident #13 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's Disease, dementia with behavioral disturbance, and Altered mental status. The MDS dated [DATE] documented Resident #13 had moderately impaired cognition and displayed behavior with risk for injury, that put self at significant risk for injury. The resident required limited assistance of 1 person for bed mobility, transfers, and walking, had 2 falls within 6 months, used bed/chair alarm, and did not use restraints. The Mobility assessment dated [DATE] documented Resident # 13 was quiet, and two 1/2 SRs were used as enablers due to diagnosis of Congestive Heart Failure (CHF). The MDO dated 8/13/2021 documented orders for resident to have two 1/2 SRs. The CCP related to Restraints/Alarms initiated 8/19/2021 documented Resident #13 was at high risk of falls/injuries, and restraints to be applied and released per MDO. The CCP related to SR Use initiated 8/19/2021 documented two 1/2 SRs to be evaluated regularly to reduce risk of entrapment. NN dated 09/01/2021 documented Resident Representative consented for SB due to Resident #13 attempts to get up from w/c. MDO initiated 9/1/2021 documented SB to prevent fall with release every 2 hours for 15 minutes for ADLs. On 11/16/21 at 11:37 AM, Resident #13 was observed in bed with all four 1/2 SRs (2 SRs on each side) raised. Resident representative was at the resident's bedside and stated they consented for Resident #13 to have a SB in w/c but was unaware of MDO for four SRs. The Resident representative stated that the SRs were already raised when they entered the room to visit. On 11/17/21 from 01:30 PM to 04:22 PM and 11/18/21 from 09:50 AM to 12:53 PM, Resident #13 was observed sitting in a w/c with SB fastened behind their back. There were no observations or documented evidence that the SB restraint was released. On 11/19/21 at 08:26 AM, Resident #13 was observed in bed with four 1/2 SRs raised. Physical Restraint assessment dated [DATE] documented Resident # 13 had SB as restraint due to poor sitting/standing balance, not calling for assistance, and being unaware of own limitations. The Fall Risk assessment dated [DATE] documented Resident #13 was at high risk for falls. The SR Use assessment dated [DATE] documented to use two 1/2 SRs. The CNA Instructions for November 2021 documented Resident #13 had SB in w/c to be released every 2 hours for 15 minutes, and SRs as positioning device. There was no documented evidence of SR safety assessment was completed prior to the application SR in August 2021. The SR Use assessment dated [DATE] did not address safety or risk for entrapment. There was no documented evidence of an assessment or MDO for four 1/2 SRs. On 11/18/21 at 02:19 PM, an interview was conducted with the CNA #1 who stated Resident #13 had the SB fastened at the back of w/c to prevent the resident from unfastening it and falling. The CNA stated, they observed and reported Resident #13 had four 1/2 SRs raised by the 11PM-7AM shift, but they continued to be raised each morning. CNA #1 stated, they forgot to release the SB for Resident #13 because they were busy. On 11/18/21 at 04:37 PM, an interview was conducted with RN #2 who stated they gave report to the CNAs at start of shift re: residents with restraints. RN #2 stated that Resident #13's SB was fastened at back of the w/c to prevent the resident from unfastening and falling. The RN stated that Resident #13 unfastened their SB when it was fastened in the front a few months ago and fell. RN #2 stated that SB should be released per MDO and that nursing does not document restraint release. RN #2 stated they do spot checks of the residents to ensure MDO implemented. On 11/19/21 at 08:30 AM, RN # 1 observed Resident #13 lying in bed with four 1/2 SRs raised. RN # 1 stated Resident # 13 MDO was two 1/2 SRs and that the 11PM-7AM shift must have raised the four 1/2 SRs. The RN stated that CNAs receive report from RN #1 restraint MDOs and should report discrepancies. RN #1 stated they complete rounds every 2 hours to observe residents. On 11/19/21 at 10:23 AM, an interview was conducted with Director of Nursing (DON). The DON stated that a MDO was necessary for four 1/2 SRs and/or bilateral full SRs because they were restraints that prevented confused residents from getting out of bed and falling. The DON stated that SBs should be released per MDO. On 11/23/21 at 10:21 AM, AP #1 stated they ordered a SB for Resident #13 due to the resident was a high fall risk. AP #1 state there was no MDO for four 1/2 SRs. AP #1 stated the Medical Doctor Monthly Notes dated 9/1/21 through 11/1/21 did not accurately reflect Resident #13 restraint use. #3) Resident #122 was admitted to the facility on [DATE], was cognitively intact, and diagnosed with ataxia and vertigo. On 11/17/21 at 3:27 PM, Resident #122 was observed lying in bed with bilateral full SRs raised. CNA #14 and a 2nd CNA exited the room. RN #1 observed Resident #122 bilateral full SRs raised. MDO dated 11/16/21 documented orders bilateral 1/2 SRs for Resident #122. NN dated 11/16/21 documented Resident #122 to receive bilateral 1/2 SRs and bed in lowest position. SR Use Assessment initiated 11/16/21 documented Resident #122 had a history of falls and used SR for positioning. The Maintenance Logbook documented a request for 1/2 SRs in the resident's room on 11/16/2021. There was no documentation that the request was completed in the logbook. There was no documented evidence Resident #122 was adequately assessed for full SR use. An interview was conducted on 11/17/21 at 03:27 PM and 11/26/21 03:00 PM with RN #1 who stated a request was placed in Maintenance Logbook for Resident #122 to receive 1/2 SRs, but Nursing was short staffed, and RN #1 did not have time to follow up. The staff used the full SRs already attached to Resident #122 bed upon admission until they were switched to 1/2 SRs. On 11/18/21 at 11:43 AM, interview was conducted with Resident #122 who was cognitively intact and stated the CNAs transferred them to bed on 11/17/21 and raised the SRs. The SRs were replaced, and Resident #122 now had bilateral 1/2 SRs. Nursing staff told Resident #122 the longer SRs were on their bed in error. Resident #122 stated they did not consent for full SRs and was unable to release SRs. An interview was conducted on 11/19/21 at 07:00 PM with RN #2 who stated there is no overnight staff to switch SRs. New admissions who arrive to facility late may not have SRs switched per MDO. Resident #122 arrived at 10:30PM and was preassigned to a bed with bilateral full SRs and the staff decided to use the full SRs to ensure safety. On 11/23/21 at 10:21 AM, an interview was conducted with the AP #1 who stated physical restraint use was avoided unless for safety or high risk for fall. There is an attending physician present at the facility daily and residents are assessed prior to restraint use. APs receive reports from Nursing staff and assess restraint use monthly. On 11/22/21 at 03:19 PM, an interview was conducted with Medical Director (Med Dir) who stated SB and all SRs raised are restraints and used for safety and not to address behavior. The Med Dir stated that the APs discussed restraints with nursing staff, and it should be documented. 415.4(a) (2-7)