**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interviews conducted during the Recertification and abbreviated survey (NY# 00291493) from 02/23/2022 through 03/03/2022, the facility did not ensure that each resident remained free from physical restraints not required to treat the resident's medical symptoms. This was evident for 11 of 12 residents sampled for Physical Restraints (Resident #s 199, 260, 113, 191, 126, 110, 55, 295, 63, 503, and 157). Specifically, Resident #260 and Resident #113 had bilateral half SR ordered as enablers. The residents had severely impaired cognition, required extensive assistance with bed mobility and transfers, and the half SR were not identified as a restraint. There was no medical justification, restraint assessment, care plan, or evidence of alternatives attempted before using the bilateral half SR. Resident #s 191, 126, 110, 55, 295, 63, 503, and 157 had impaired cognition and required extensive assistance for bed mobility and transfers. They all had bilateral half siderails as an enabler, but they were unable to release the side rails to independently get in and out of bed. These side rails were not identified as a restraint and had no medical justification, family/resident education regarding the risks and benefits of restraint use, or restraint assessment. Resident #199, diagnosed with Dementia and severely impaired cognition, was found to have a swollen left eye on 01/09/2022. The Certified Nursing Assistant (CNA #13) reported that Resident #199 was observed with their face against the side rails (SR) with their legs on the floor. The facility investigated the incident and failed to identify the side rails as a restraint. The interdisciplinary team (IDT) met and determined the side rails were still appropriate to promote independence for the resident. On 02/19/2022, Resident #199 was found kneeling on the floor mat with head between the side rail and the bed. A facility team meeting note dated 02/21/2022 documented that the side rails were identified as a potential restraint. The team discussed risk and benefits of the rails and decided to remove the rails and replace them with a concave mattress. There was no documented evidence in the medical record that there is a medical justification for the use of the concave mattress, a restraint assessment, care plan, or alternatives prior the use of the Concave Mattress. This resulted in Immediate Jeopardy with the likelihood for serious, injury, serious harm, serious impairment, or death to all residents using side rails other devices that were potential restraints. Immediate Jeopardy (IJ) was identified and declared. IJ began on 2/19/2022 and was called on 02/23/2022 at 7:04PM. The facility submitted an IJ removal plan on 2/23/2022 with a revision on 2/24/2022. IJ was removed on 02/28/2022 at 6:38PM. The findings include but are not limited to: The Policy and Procedure for Restraints dated 09/2021 documented: Residents have the right to be free from physical or mental abuse, corporal punishment, involuntary seclusion and any physical or chemical restraint imposed for purposes of discipline or staff convenience and not required to treat the resident's medical symptoms. The Policy and Procedure for Side Rails dated 09/2019 documented: It is the policy of this facility to ensure residents attain and maintain their highest practicable level of well-being and be free of restraints. Each resident will be assessed for functional status on admission, readmission, and quarterly, for any significant change and as needed. Side rails will only be used by a resident to assist with his or her bed mobility. Side rails will not interfere with the resident's ability to egress from the bed surface. Side rails will be analyzed for safety and prevention of entrapment. The Policy and Procedure for Concave/Perimeter Mattress Use dated 09/2021 documented that the facility may choose to add a concave/perimeter mattress to improve a resident's safety and or comfort while sleeping in bed. 1) The Facility's Investigation dated 02/22/2022 documented on 02/19/2022, Resident #199 was observed kneeling on the floor mat on the right side of the bed. Staff noted that her/his head was between the siderail and the mattress. The nurse was notified, and the resident was removed from the kneeling position and the siderail. Resident #199 was assessed and noted with a reddened area, measuring 1.5 cm (centimeters) by 0.5 cm, to the forehead. Resident #199 did not display any signs or symptoms of pain and denied pain. The CNA demonstrated the position in which the resident was found. The resident's face was in the downward position and the siderail was noted to be against the resident's left temple area. The resident's airway was clear, and the resident was alert with vital signs within normal limits. The resident was unable to dislodge herself/himself, however, the position in which the resident was found did not indicate there was an imminent threat of significant or life-altering injury. The resident was assessed the month prior, and the SR were deemed non-restraint and appropriate to facilitate bed mobility. The facility side rail monitoring for entrapment risk was reviewed, and the resident's SR met state and federal guidelines. The investigation concluded the incident was unpredictable and unavoidable due to the resident's poor safety awareness, and there was no evidence to support that any abuse, neglect, mistreatment, or misappropriation may have occurred. Resident #199 was admitted with diagnoses of Unspecified Dementia, Osteoporosis and Anxiety Disorder. The Quarterly Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #199 had a Brief Interview for Mental Status (BIMS) score of 3 out of 15, indicating severely impaired cognition. The MDS documented Resident #199 required extensive assist of two or more staff for bed mobility and needed to be transferred using a Hoyer lift. Physical restraints and bedrails were not used for the resident. On 2/23/22 at 5:21PM, Resident #199 was observed in bed sleeping with a concave mattress in place. The bed was in the lowest position with bilateral floor mats in place. The Comprehensive Care Plan (CCP) for Risk for falls dated 11/21/2018 documented Resident #199 was at high risk for falls. The CCP for Non-restraint SR dated 12/21/2018, revised 08/04/2021, documented Resident #199 used SR for increased independence and mobility. Interventions included: Educate resident on how to safely move in bed with assist of SR; Offer resident assistance with position change and bed mobility often during the shift; and Orient resident to call light and safety measures. The CCP for Activities of Daily Living (ADLs) dated 05/13/2021 documented Resident #199 required extensive assist of 2 staff for bed mobility, dressing, personal hygiene, toilet use and transfers. The SR assessments dated 03/10/2021, 06/02/2021 and 09/09/2021, documented Resident #199 used the SR as an enabler. The Physician Order Summary report for all orders from 11/13/2019 to present documented an order for non-restraint bilateral half siderails as an enabler for bed mobility and positioning, initiated 09/18/2021. This was the only side rail order entered for the resident. A Physical Therapy (PT) note dated 12/16/2021 at 5:00 PM documented Resident #199 was unable to safely perform sit-to-stand or bed-to-wheelchair transfers without total assistance due to confusion. Resident #199 was unable to follow instructions. The CNA Assignment Tasks dated 01/01/2022 documented Resident #199 was totally dependent (unable to participate in the activity) and required two staff members for bed mobility and transfers with Hoyer lift. Resident #199 could not assist with rolling on/off the lift sheet. There was no documented evidence that other devices were used for enablers prior to the use of half SR. There was no evidence the resident was observed using the half SR as an enabler. The bilateral half SR were not identified as a restraint. A Nurse's note, by Licensed Practical Nurse (LPN) #2, dated 01/09/2022 at 7:47AM documented Resident #199 was observed in bed with swelling to the left eye. As per the Certified Nursing Assistant (CNA #13), Resident #199 was observed with their face against the SR with their legs on the floor. An Incident report dated 01/09/2022, documented by the RN Supervisor (RNS #1), revealed that RNS #1 was called to the 5th floor because Resident #199 had left eye swelling. RNS #1 was told that the left side of Resident #199's upper body was against the siderails, and the resident's legs were on the floor. Resident #199 was trying to slide to the floor. A cold compress was applied. The Facility's investigation, completed by the Director of Nursing (DON), dated 01/09/2022 documented that Resident #199 was noted with discoloration and ecchymosis to the left eye. Upon discovery, Resident #199's left side was leaning on the side rail with the side of the resident's face against the siderail. Resident #199 was trying to slide to the floor. The investigation concluded the injury was not a consequence of having the side rails, rather incidental due to the resident's attempt to place self on the floor. The Interdisciplinary team (IDT) met to determine if Resident #199 still required side rails and decided side rails were still appropriate to promote independence for Resident #199. The half side rails were continued and not identified as a restraint. There was no documented evidence the facility assessed the resident to determine if the resident could demonstrate the ability to release the side rails and use the half side rails as an enabler. A Nurse's note, by LPN #7, dated 02/19/2022 at 3:58AM documented Resident #199 was observed kneeling on the floor mat with their head between the SR and the bed. The Physician's Orders dated 02/21/2022 documented the bilateral half SR were discontinued, and a concave mattress to promote the resident to lie in the middle of the bed was ordered. A Nurse's note, by Director of Nursing (DON) dated 02/21/2022 at 4:25PM documented Resident #199 was status post fall from bed. The resident was provided with a concave mattress. The assist rails were removed for trial basis. Floor mats continued for safety to prevent injury. There was no documented evidence in the medical record that there was a medial justification for the use of the concave mattress, a restraint assessment, care plan, or alternatives attempted prior to the use of the concave mattress. During an interview on 02/28/2022 at 8:37AM, CNA#13 reported that he/she worked on the 5th floor on 02/19/2022 and observed Resident #199 kneeling on the floor mat at approximately 3:30AM. CNA #13 stated the resident's head was stuck facedown between the mattress and side rails. CNA #13 stated that while he/she was waiting for RNS #2, the resident was restless and moving around. CNA #13 assisted the resident back to bed as the resident was not staying still on the floor. CNA #13 stated that he/she never observed the resident using the side rails independently to move around in bed. CNA #13 reported was not aware that half side rails can be a potential restraint. CNA#13's re-enactment of how Resident #199 was found, revealed the resident's knees were on the floor and his/her head was face down, stuck between the siderail and mattress. During an interview on 02/26/2022 at 10:10AM, LPN #7 reported that he/she worked on the 11-7 shift on 02/19/2022. LPN #7 stated that CNA #13 made rounds at 3:30AM and observed Resident #199 kneeling on the floor. LPN #7 stated that he/she observed the resident's knees on the floor mat and the resident's face between the mattress and side rail. LPN #7 stated that he/she and CNA #13 repositioned the resident on the floor mat and called the Registered Nurse Supervisor (RNS #2). LPN #7 stated the resident used the SR to move up and down in the bed, but LPN #7 never observed Resident #199 using the SR to move or turn and position self in bed. LPN #7 stated the resident could not release the SR or move the SR up and down. On 02/26/2022 at 10:10 AM, LPN #7 re-enacted the position they found Resident #199 in prior to RNS #2's arrival, demonstrating the knees were on the floor mat with the head stuck face down between the side rails and the mattress. During an interview on 02/24/2022 at 9:40AM, LPN #3 stated Resident #199 could hold onto the SR during care when prompted by staff. LPN #3 stated Resident #199 kept sliding out of the bed, and the half SR were put in place to prevent the resident from falling out of bed. During an interview on 02/24/2022 at 10:24AM, RNS #2 stated LPN #7 called him/her to the unit on 2/19/2022. When he/she entered Resident #199's room, Resident #199 was in bed. RNS #2 stated LPN #7 and CNA #13 reported that the resident's head was between the side rail and mattress, and the knees were on the floor mat. RNS #2 stated that LPN #7 reported that LPN #7 put the resident back in bed for safety reasons. RNS #2 stated the resident was assessed and observed with a discoloration to the right side of the forehead. RNS #2 reported he/she was aware that the siderails can be used a restraint, but the SR were considered enablers. During an interview on 02/24/2022 at 10:35AM, the Medical Director (MD #4) stated that he/she was aware that Resident #199's cognition was impaired. MD #4 stated that Resident #199 was assessed by the Physical Therapist (PT #1) and the Occupational Therapist (OT #1) upon admission, and Physical Therapy (PT) and Occupational Therapy (OT) demonstrated how to use the side rails with Resident #199. MD #4 stated that some residents with impaired cognition, who ambulate without assistance from staff, used the SR as an enabler for bed mobility to assist in pulling themselves up in bed and for turning and position. MD #4 stated that Resident #199 used the SR as an enabler. MD #4 reported he/she never saw Resident #199 used the siderails to pull themselves up or turn and position. MD #4 reported he/she did not consider the half side rails a potential restraint. During an interview on 03/03/2022 at 9:40AM, the MDS Coordinator (MDSC # 9) stated a restraint is any object that restricts the resident's movement. The MDS manual dated October 2019 documents if a resident is immobile and cannot voluntarily get out because of physical limitation or because proper assistive devices were not present, the bedrail does not meet the definition of physical restraint. The MDSC stated there was an order for half SR for bed mobility, so the SR were not coded as a restraint. The MDSC stated that he/she never saw the resident use the side rails to turn and position in bed. MDSC did not consider the siderails as a potential restraint until they were in-service on the topic after the IJ was called. During an interview on 03/03/2022 at 10:00AM, the Physical Therapist (PT #1) stated that the resident was assessed for bed mobility and would benefit from using the siderails to turn and position self in bed. PT #1 stated Resident #199 could hold onto the siderails independently. PT #1 stated that he/she did not assess the resident's ability to release the side rails or move the SR up and down because the resident was not able to follow commands and staff provided total care for bed mobility. PT #1 stated that they did not consider the siderails as a potential restraint until they were in-service on it after the IJ was called. During an interview on 02/28/2022 at 4:23PM, the Director of Nursing (DON) stated upon admission all residents are assessed by physical therapy for bed mobility. The DON stated if residents can benefit from side rails to aid in their bed mobility, then PT will recommend side rails as an enabler. The DON stated that the Interdisciplinary team (IDT) meets after every fall to discuss appropriate interventions and involve the resident and resident representative. The DON stated the IDT considers the resident's mental status, ADL status, and the risk and benefits prior to the initiation of any type of restraint. The DON stated after the IDT meeting and discussion with the Nurse Practitioner (NP), it was decided that Resident #199 would benefit from side rails to assist with bed mobility. The DON stated Resident #199 requires 2-person assist with bed mobility. The SR were used for Resident #199 to hold onto during care and for safety and security. The DON stated Resident #199 is totally dependent and cannot rise on their own without staff assist. The DON stated that the facility did not view the side rails as a restraint because it did not restrict Resident #199's freedom of movement. Resident #199 was able to grab onto the siderail to assist in turning and positioning. The DON stated after the incident with the side rails on 02/19/2022 the IDT met and decided they would place Resident #199 on a concave mattress on a trial basis for safety and security after Resident #199 had several falls within a three-month period. 2) Resident #260 was admitted with diagnoses of Dementia, Cerebral Infarction, and bipolar disorder. The Quarterly Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #260 had a Brief Interview for Mental Status (BIMS) score of 5 out of 15, indicating severely impaired cognition. Resident #260 required extensive assist of two or more persons for bed mobility and extensive assist of one person for transfers. The Care Plan for Non-restraint Side rails dated 02/23/2022, revised 02/24/2022, documented Resident #260 used side rails for increased independence and mobility. Interventions included: educate resident on how to safely move in bed with assist of side rails, offer resident assistance with position change and bed mobility often during the shift, orient resident to call light and safety measures, and reevaluate side rail use quarterly and as needed. A Physician's Order initiated on 02/23/2022 documented bilateral half siderails were medically appropriate to assist with bed mobility, turning and positioning. There was no documented evidence Resident #260 was assessed for side rails used as a restraint. There was no documented evidence the resident was educated on how or demonstrated the ability to use the SR for bed mobility or release the SR to get in and out of bed. There was no documented evidence that Resident #260's designated representative was educated about the risks and benefits of side rails used as a potential restraint. 3) Resident #113 was admitted with diagnoses of Cerebrovascular Disease, Anxiety Disorder and Peripheral Vascular Disease. The Quarterly Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented that Resident #113 had a Brief Interview for Mental Status (BIMS) score of 2 out of 15, indicating severely impaired cognition. The resident required extensive assist of one staff for bed mobility and transfers. The Care Plan for Non-restraint Side rails dated 09/18/2021, revised 02/24/2022, documented Resident #113 used side rails for increased independence and mobility. Interventions included: educate resident on how to safely move in bed with assist of side rails, offer resident assistance with position change and bed mobility often during the shift and orient resident to call light and safety measure, reevaluate side rail use quarterly and as needed. A Physician's Order initiated on 02/23/2022 documented bilateral half siderails to aid in bed mobility (non-restraint). There was no documented evidence Resident #113 was assessed for restraints or bedrails prior to 2/23/22. There was no documented evidence the resident was educated on how or demonstrated the ability to use the SR for bed mobility or release the SR to get in and out of bed. There was no documented evidence that Resident #113's designated representative was educated about the risks and benefits of side rails used as a potential restraint. Immediate Jeopardy (IJ) was identified and declared. The facility Administrator and Director of Nursing were notified on 02/23/2022 at 7:04PM. The facility submitted a removal plan that was reviewed and accepted by NYS DOH on 02/23/2022 at 9:43 PM. The removal plan was revised on 02/24/2022 at 5:32PM after the initial plan due to continued issues. On 02/28/2022 at 6:38PM, the survey team declared the IJ was removed based on the following corrective actions taken by the facility: • Observations were conducted on all floors from 02/25/2022 to 02/28/2022. There were no observed concerns related to side rail use or other restraints. • The facility re-evaluated all residents who had side rails in use. The facility completed a side rails assessment, rehab assessment, medical assessment, IDT meeting, and family/resident notification. On 02/23/2022, the day IJ was called, the facility had 51 side rails in place. By 02/28/2022, the facility removed 49 side rails, leaving only 2 residents with side rails in use. • Resident #199 record review and observation completed to confirm immediate corrections. Resident re-assessed and concave mattress discontinued. CCP updated. • Additional sampled residents also reviewed to confirm all assessments, revised orders, updated care plans, IDT, and resident/family notification was completed. • Reviewed revised policies and procedures for Physical Restraint Use and Side Rails. • Reviewed in-service lesson plans and sign-in sheets to confirm the following staff were in-serviced on restraints/side rails: Activities/Recreation 8/8 = 100%; Administration/Finance/Human resource/staffing/Medical Records/Security 16/16= 100%; CNAs 113/125 = 90%; Dietary/dietary 23/24 = 96%; LPN 38/46 = 83%, Housekeeping/maintenance 24/25 =96%, Nurse Practitioner/MD 5/5 = 100%, Nursing Supervisors 16/21 = 76%, Social Worker 4/4 = 100%, Therapy 28/35 = 80%. • Interviews were conducted with the following staff: DON, Administrator, 25 CNAs, 8 LPNs, 4 RNs, 6 Housekeepers, 3 Occupational Therapists, 4 Physical Therapists, 1 Speech Therapist, 1 Nurse Practitioner, 1 Social Worker, 2 dietary Aides, 2 maintenance workers. All staff were in-serviced and knowledgeable on Restraints and Side Rails. Based on observations, interviews and record review conducted on 02/28/2022, the facility fully implemented the revised Immediate Jeopardy Removal Plan, and the Immediate Jeopardy was removed as of 02/28/2022 at 6:38PM. 415.4(a)(2-7)