**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Amended 12/22/2021 Based on record review, interview, interview statements, and policy review, the facility failed to ensure seven residents (Resident (R) 22, R37, R14, R73, R65, R61, and R26) were free from resident-to-resident abuse of 25 sampled residents. The facility failed to provide sufficient monitoring, supervision, and interventions to prevent resident-to-resident abuse from occurring. Specifically, the facility failed to protect Resident (R) 22, R37, R14, and R73 from abuse by R63. R63 had a history of physically aggressive behaviors towards residents and staff since admission [DATE], and the facility did not identify the abuse and initiate care plan interventions to prevent future abuse. Additionally, the facility failed to protect R65 and R61 from abuse by R17 and an altercation between R26 and R14; the facility failed to identify that abuse occurred and initiate care plan interventions to prevent future abuse. On 11/19/21 at 11:10 AM, the Administrator and the Director of Nursing (DON) were notified that the failure to ensure residents were free from resident-to-resident abuse from R63, who was known to have aggressive behavior toward staff and residents with no revisions to the behavior care plan, constituted an immediate jeopardy at F600-K: Abuse: Resident-to Resident Abuse. The immediate jeopardy began on 02/08/21 when R63 struck R14. The facility provided an acceptable plan for removal of the immediate jeopardy on 11/20/21 at 12:00 AM. The survey team validated the removal plan through observations, interviews, and review of policy and in-service documentation. The immediate jeopardy was removed on 11/20/21 at 12:00 AM. The deficient practice remained at a E scope and severity following the removal of the immediate jeopardy. Findings include: Review of the facility's policy titled Abuse, Neglect, Exploitation revised on 11/29/18 defined 'Abuse' as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish . Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain, or mental anguish . This includes resident to resident abuse of any kind. Review of R63's face sheet under the Face Sheet tab in the electronic medical record (EMR) revealed R63 was admitted to the facility on [DATE] for long term care. Review of R63's annual Minimum Data Set (MDS) with an assessment reference date (ARD) of 04/25/21 revealed that R63 was nonverbal and had a Brief Interview for Mental Status (BIMS) score of 99 which indicated the resident was unable to complete the interview and staff assessed R63 with moderate cognitive impairment. Review of R63's Care Plan tab of the EMR documented a care plan for behaviors related to dementia and schizophrenia, dated 05/19/20, and documented R63 was nonverbal and becomes agitated when he cannot make his needs known, paranoid when meal ticket is taken off the meal tray, and may strike out and resist care with a goal to decrease episodes of striking out at others, and for his behaviors to not cause harm to himself or others. Care plan interventions included direction to remove R63 from situations that increase agitation or combativeness, psychiatric consult as ordered, provide as much control to R63 as possible in daily routines and activities, try and constructively channel to physical and social activities when the R63 resident becomes agitated, aggressive, and combative. The facility's DON who was also the facility's Abuse Coordinator, provided the following documentation on resident-to-resident altercations for R63 from the past year: 1. Review of the facility's Final Investigatory Report dated 02/12/21 for a witnessed event on 02/08/21 revealed R63 punched R14 (BIMS score of 11 out of 15 (BIMS 11), moderate cognitive impairment), in face without provocation. The facility's conclusion did not identify abuse and changes were made to R63's Care Plan to redirect him from other resident's exhibiting delusional distress or outbursts. 2. Review of the facility's Final Investigatory Report dated 09/25/21 for an event on 09/22/21 revealed R63 and R37 (BIMS 07, severe cognitive impairment), who were roommates were punching each other. LPN1 separated the residents and R37 sustained a superficial bruise over his right eye. The facility's conclusion did not identify abuse and R37 was moved to a different room. R63's care plan was not updated following the incident. 3. Review of the facility's Final Investigatory Report dated 10/18/21 for an event that occurred on 10/14/21 revealed R22 shielded Certified Nursing Assistant (CNA) 1 from R63 who had raised his hand and was about to strike her. R22 was struck by R63 and sustained two skin tears. The facility's conclusion did not identify abuse; however, documented that R63 was sent to the emergency department (ED) for admission to a Behavioral Health Unit but was returned to the facility the next day. No changes were made to R63's plan of care or physician's orders upon return from the facility. 4. Review of the facility's Final Investigatory Report dated 11/16/21 for an occurrence on 11/12/21 revealed R63 struck R73 (BIMS 03, severe cognitive impairment) in the head with a ball point pen. Staff intervened and sent him to the ED for possible admission to the Behavioral Health Unit. R73 did not sustain a significant injury. The facility's conclusion did not identify abuse. Review of a nursing progress note in the notes tab of R63's EMR dated 11/12/21 revealed R63 was admitted to the Behavioral Health Unit. Review of a nursing progress note in the Notes tab in the EMR dated 11/06/21 at 3:46 AM revealed at approximately 2:45 AM R63 chased CNA4 down the hall, snatching a pull-up out of her hand and began punching her. R63 redirected, and later went down same hall attempting to enter a resident room. Registered Nurse (RN) 1 blocked R63's entry to the room. R63 began punching staff, staff were unable to calm him, police were notified, and placed R63 in handcuffs. R63 continued to exhibit aggressive behavior kicking the police. Police restrained R63 until the ambulance arrived. He returned to the facility on [DATE] at 2:47 PM with no new orders. An ED report was not in R63's hard chart or EMR and no changes were made to his plan of care. Review of the facility's Resident-to-Resident Investigations for the past 6 months revealed the following three events provided by the DON: 1. Review of the facility's Final Investigatory Report dated 07/23/21 for an event that occurred on 07/19/21 documented that R65 (BIMS 03, severe cognitive impairment), was pushing a snack cart down the hall and R17 (BIMS 15, cognitively intact) kicked him in the chest. The facility conclusion documented no abuse was substantiated and no resident was injured. No changes were made to the residents' plans of care or physician orders. 2. Review of the facility's Final Investigation Report dated 08/21/21 for an event that occurred on 08/17/21 documented that R17 kicked R61 (BIMS 03) in the stomach when he was wandering in lobby. Review of the facility's conclusion documented No abuse or neglect was substantiated. No new care plan interventions were identified in the investigation report. 3. Review of the facility's Final Investigation Report dated 01/10/21 revealed R26 (BIMS 99) scratched R14's face, and R14 struck R26 with his fist. The facility conclusion documented no abuse was substantiated and no care plan changes were made for either resident. During an interview on 11/18/21 at 12:01 PM, the Director of Nursing (DON) acknowledged she was the facility's Abuse Coordinator, she conducted all the facility's abuse investigations, and that the occurrences of resident-to-resident abuse occurred as documented. The DON stated she did not perceive the residents' actions were willful at the time she investigated the incidents for F63, R17, R14, and R26. In addition, the DON said she was frustrated about the inability to get R63 admitted to the Behavioral Health Unit prior to 11/12/21 event, and the general lack of psychiatric services, despite having a contract, to their rural community, and did not know what else she could do. The DON reported she had contacted psychiatric services for R63 on multiple occasions without response. The DON acknowledged that the ED did not provide a comprehensive psychiatric evaluation and/or provide medication to the resident. The DON acknowledged R63's aggressive behaviors were erratic and not constant; it would just depend on if something triggered him. The DON confirmed there was no increased supervision for R63 following the resident-to-resident altercations.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the environment remained free of accident hazards for nine residents of 16 residents (Resident (R)7, R20, R21, R26, R27, R44, R54, R73, and R74) reviewed for accidents and hazards. Specifically, four residents (R21, R26, R44, and R74) who had bed (side) rails installed had falls (with injuries for three residents (R21, R26 and R44)) while the bed rails were present and up in position. Following the falls the facility failed to complete root cause analysis/investigations of falls or reassess the use of bed rails. Additionally, three residents (R54, R7, and R73) assessed as not requiring bed rails were observed to have bed rails in use; and two residents (R20 and R27) had bed rail assessments but bed rails in use did not align with the assessment. Furthermore, the facility failed to assess for the use of the least restrictive devices or no devices; and implement care plans to ensure the safety of residents. The failure to put interventions in place to respond to this issue has resulted in a potential for increased risks of falls, entrapments, and death related to the facility's continued use of bed rails for these residents and other vulnerable residents. On 11/18/21 at 6:00 PM, the Administrator was notified an Immediate Jeopardy (IJ) was identified at F689 related to the facility's failure to ensure residents were provided an environment safe from accidents and hazards, specifically related to the use of bed rails. F689 was determined to be at a scope and severity of K, pattern with serious likelihood of serious injury, harm, impairment, or death. The facility provided an acceptable plan for removal of the IJ on 11/19/21 at 10:08 PM. The survey team validated the IJ was removed on 11/19/21 at 10:20 PM following the facility's implementation of the plan for removal of the Immediate Jeopardy. The removal was validated by observations, chart reviews, and interviews of steps taken by the facility to protect residents from accidents related to bed rails. These measures included: All residents were assessed for the need of the side rails. This was confirmed per interview and record review. Observations conducted of the beds that have removable side rails and the residents had been assessed as not requiring these side rails, the side rails were observed as removed. Residents that reside in beds that the side rails are non-removable and did not require side rails or did not require all four side rails per assessment, these side rails were secured in a down position with zip-ties. Residents requiring side rails were confirmed as having side rails per the physician orders. The risk and benefits were reviewed with the resident and/or resident representatives, and consents obtained. Policies for side rail use, risk and benefits, and fall risks and prevention were reviewed and revised per facility and are deemed acceptable. Training was based on the risk and benefits of the use of side rails, prevention, reporting, and investigating falls. Reviewed facility staff sign in sheets for training. A sample of residents updated care plans and evaluations were reviewed and were complete. Interviews were conducted with facility staff to verify training The facility was notified that the IJ was removed on 11/19/21 at 10:20 PM. After the immediacy removal, the noncompliance remained at a lower scope and severity of E (no actual harm with the potential for more than minimal harm that was not immediate jeopardy). Findings Include: 1. Review of R21's undated face sheet located in R21's electronic medical record (EMR), under the Face Sheet tab, indicated R21 was admitted to the facility on [DATE]. R21's diagnoses included muscle weakness, history of falling, abnormalities of gait and mobility, unsteadiness on feet, dementia without behavioral disturbance. Review R21's quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of 09/05/21, revealed R21's Brief Interview for Mental Status (BIMS) score was seven out of 15, indicating R21 had severe cognitive impairment. R21 was assessed as independent with bed mobility with a one person assist. Review of R21's care plan located in R21's EMR under the Care Plan tab, revealed the resident's bed rails had not been care planned for monitoring, interventions, and risks. Observation conducted on 11/16/21 at 9:00 AM revealed R21 was in bed with four quarter bed rails up. R21's head was resting against the left upper bed rail and her left arm was between the upper and lower left sided bed rail, hanging to the floor. R21 was not interviewable. Observation on 11/16/21 at 9:49 AM revealed R21 was observed in the same position, the Assistant Director of Nursing (ADN) stated, this is the resident's norm. The ADN did not attempt to reposition resident. Observation on 11/16/21 at 10:13 AM revealed Certified Nursing Assistant (CNA) 2 and CNA 3 repositioned R21 in bed, stating, the resident favors her left side. Observation conducted on 11/16/21 at 4:26 PM revealed R21 was still in bed with all four bed rails in place. Throughout 11/16/21 from 10:27 AM to 7:30 PM, and 11/17/21 from 9:00 AM to 7:00 PM, R21's four bed rails remained up at all times, whether the resident was in or out of bed. Review of R21's Evaluation for Use of Side Rails dated 06/01/08, located in R21's EMR, under the Assess tab, documented the reason for the side rails was for safety and security. Further review of the evaluation form revealed the alternatives were discussed with the resident representative, there was no indication the precautions were discussed with the resident and/or resident representative. Review of R21's Resident Incident Report dated 06/30/21, provided by the facility documented alerted by CNA to [R21's] room, resident lying on floor and complaining of head pain to back of head. Fall was not witnessed, but resident was heard hitting the floor by CNA passing by. Bed rails was checked as ordered and up. Further review of R21's EMR and paper chart revealed the facility did not review the use of the bed rails following the fall and did not determine a root cause analysis for the fall. The investigation listed Medical risk factors possibly related to incident: Fall history; Inability to understand directions, confusion/disorientation, and incontinency. Review of R21's Resident Incident Report, dated 08/10/21, provided by the facility, documented resident was noted on floor by bed, scooting to the bathroom. No injury. Bed rails was checked as ordered and up. The facility did not review the use of bed rails following the fall and did not determine a root cause analysis for the fall. The report listed Medical risk factors possibly related to incident: Fall history, arthritis/osteoporosis, confusion/disorientation, B&B (bowel/bladder) urgency, tremors/Parkinson's. During an interview on 11/18/21 at 10:54 AM, Licensed Practical Nurse (LPN) 2 stated R21 used bed rails to reposition herself. LPN 2 was questioned based on the observation made on 11/16/21, if the bed rails could be an entrapment risk? LPN 2 stated, No, I don't see any entrapment issues. 2. Review of R26's undated face sheet located in R26's EMR under the Face Sheet tab, indicated R26 was admitted to the facility on [DATE]. R26's diagnoses included moderate intellectual disabilities, anxiety disorder, and fractured right clavicle. Review of R26's admission MDS with an ARD of 08/08/21, BIMS score was 11 out of 15 indicating R26 had moderate cognitive impairment. R26's bed mobility was assessed as limited assistance of one staff member. Review of R26's care plan located in R26's EMR under the Care Plan tab, revealed the resident's bed rails had not been care planned for monitoring, interventions, and risks. On 11/16/21 at 9:35 AM, R26 was observed in the hallway sitting in her wheelchair. R26 was observed with blood on her face and forehead where there was a laceration. R26 was not interviewable. During an interview conducted on 11/16/21 at 10:00AM at the R26's bedside, LPN 2 stated, she [R26] got that [laceration] from falling. Review of R26's Resident Incident Report dated 08/01/21, provided by the facility, documented resident attempting to transfer self out of bed. Holding on to side rails and sat on floor. No injury. Bed rails was checked as present. The facility did not reassess the bed rail use following the fall and did not conduct a root cause analysis of the fall. The report listed Medical Risk factors possibly related to incident: Fall history, seizure history, confusion/disorientation, incontinency. Review of R26's Resident Incident Report dated 10/20/21, provided by the facility, documented staff responded to resident crying in her room and resident had got out of bed without assistance and was on the floor. Laceration above right eyebrow was reopened. Bed rails were checked as ordered, present, and up. The facility did not reassess the bed rails following the fall and did not complete a root cause analysis for the fall. The report listed Medical risk factors possibly related to incident: Fall history, seizure history, confusion/disorientation, incontinency, B&B urgency. Review of R26's Resident Incident Report dated 11/02/21, provided by the facility, documented Resident heard crying, upon entering room, resident was observed lying on the impact mat between her and her roommate's bed with her head on the tile floor. Small amount of blood noted from nares, and shallow/superficial laceration to the middle of her forehead. Bed rails was checked as ordered, present, and up. The facility did not re-assess the bed rails following the fall and did not complete a root cause analysis following the fall. The report documented Medical risk factors possibly related to incident: Fall history, seizure history, confusion/disorientation, incontinency, B&B urgency. During an interview conducted on 11/18/21 at 10:56 AM, LPN 2 was questioned why R26 no longer has bed rails? LPN 2 stated the resident now has a low bed because she (R26) would throw herself out of the bed. 3. Review of R44's undated face sheet, located in R44's EMR under the Face Sheet tab, indicated R44 was admitted to the facility on [DATE]. R44's diagnoses included difficulty in walking, unsteadiness on feet, and dementia. Review of R44's quarterly MDS with an ARD of 09/26/21, revealed R44's BIMS score was six out of 15 indicating R44 had severely impaired cognition. The resident's bed mobility was assessed as independent. Review of R44's care plan located in R44's EMR under the Care Plan tab, revealed the resident's bed rails had not been care planned for monitoring, interventions, and risks. Observation conducted on 11/16/21 at 11:34 AM, revealed R44 was in bed with bilateral quarter bed rails in the up position, located at the head of the bed. The bed rails were observed throughout the rest of 11/16/21 from 11:34 AM to 7:30 PM and 11/17/21 from 9:00 AM to 7:00 PM. Review of R44's Resident Incident Report dated 12/06/20, provided by the facility, documented R44 was observed on impact mat beside bed sustained a skin tear to left wrist and elbow, and discoloration to left forearm. Bed rails was checked as ordered, present, and up. The facility did not reassess the bed rails following the fall and did not complete a root cause analysis following the fall. The report documented Medical risk factors possibly related to incident: Fall history, hard of hearing, confusion/disorientation, B&B urgency. Review of R44's Resident Incident Report dated 12/10/20, documented R44 was noted sitting on her safety mat next to the bed at about 3AM [3:00 AM] by the CNA. She was incontinent of urine and upset, but not hurt. She said she had been attempting to go to the toilet independently. Bed rails was checked off on incident report as up. The facility did not reassess the bed rails following the fall and did not complete a root cause analysis following the fall. The report documented Medical Med risk factors possibly related to incident: Fall history, fatigue, arthritis/osteoporosis, confusion/disorientation, incontinency, B&B urgency. Review of R44's Resident Incident Report dated 08/08/21, provided by the facility, documented resident told this writer that she fell when she was transferring to the bed, hit her head on the floor, and then put herself back in the chair. Sustained contusion with discoloration noted to left occipital area. Bed rails was checked off on incident report as up. The facility did not re-assess the bed rails following the fall and did not complete a root cause analysis following the fall. The report documented Medical risk factors possibly related to incident: arthritis/osteoporosis, incontinency. During an interview on 11/18/21 at 10:53 AM, LPN 2 stated R44 used her bed rails to reposition herself. LPN 2 stated R44 needed supervision of one person for bed mobility. 4. Review of R74's undated face sheet located in R74's EMR under the Face Sheet tab, indicated R74 was admitted to the facility on [DATE]. R74's diagnoses included Alzheimer's disease, muscle weakness, need for assistance with personal care, and dysphagia. Review of R74's quarterly MDS with an ARD of 10/24/21, BIMS revealed R74's score was assessed as 99 indicating the resident was unable to complete the assessment questions. The resident's bed mobility was assessed as bed fast, self-position. An observation was conducted on 11/16/21 at 10:27 AM of R74 in bed with four quarter bed rails up, resident was moving from side to side independently. At 11:52 AM, R74 was observed in bed with all four bed rails up. The four bed rails were observed on bed and up throughout 11/16/21 from 10:27 AM to 7:30 PM and 11/17/21 from 9:00 AM to 7:00 PM. Review of R74's care plan located in R74's EMR under the Care Plan tab, revealed the R74's bed rails had not been care planned for monitoring, interventions, and risks. Review of R74's Resident Incident Report dated 02/18/21, provided by the facility documented resident was found beside bed by CNA. Roommate stated she [R74] climbed out of bed to floor. No injuries noted. Bed rails was checked as ordered, present, and up. The facility did not reassess the bed rails following the fall and did not complete a root cause analysis following the fall. The report documented Medical risk factors possibly related to incident: fall history, inability to understand directions, confusion/disorientation, incontinency. During an interview conducted on 11/18/21 at 10:36 AM at R74's bedside, CNA6 was questioned why R74 has four bed rails up and two wedges in her bed? CNA6 stated, the bed rails are to keep the wedges from falling off the bed. Not sure why she has wedges. When asked if the resident has ever attempted to climb over the bed rails? CNA6 stated, I don't know if she has ever climbed out of bed. During an interview on 11/18/21 at 10:40 AM, LPN3 stated, the bedrails are for safety and assisting for repositioning and the wedges are to help keep her in position. LPN3 stated the resident is dependent on the staff [for bed mobility] but does have non- purposeful movement. LPN3 was questioned if the resident has ever fallen or climbed out of bed? LPN3 stated, not that I am aware of. LPN3 stated she had worked for the facility for nine years and her primary assignment was the day shift for R74's hall. 5. Review of R20's face sheet in the Face Sheet tab of the EMR revealed the resident was admitted on [DATE] for long term care. Review of R20's quarterly MDS with an ARD of 08/03/21 revealed R20 had a BIMS score of 11 out of 15 which indicated the resident had moderate cognitive impairment. Review of R20's care plan under the Care Plan tab in the EMR revealed on 08/28/21 two upper side rails were added to at the head of the bed for bed mobility. Review of the CNA Care Sheet, on 11/17/21, located in the resident's closet in the room revealed it did not address the inclusion of side rails in the R20's care. Review of a Side Rail Assessment in the Assessments tab in the EMR dated 08/23/21 revealed a recommendation for R20 to have had two quarter upper rails for turning and positioning. Observation on 11/16/21 at 12:00 PM revealed R20 was in bed with all four quarter side rails up; however, R20's Side Rail Assessment only indicated two quarter side rails were needed. Observation on 11/17/21 at 12:53 PM revealed R20 was in bed with all four quarter side rails up. During an interview with CNA 1 at 1:30 PM, she stated that she gets the residents' side rails recommendations in report. CNA 1 acknowledged that each resident had a CNA Care Sheet in the room; however, they [CNA staff] rarely look at it and rely on a verbal report. 6. Review of R54's face sheet in the Face Sheet tab of the EMR revealed the resident was admitted on [DATE] for long term care. Review of R54's annual ''MDS'' with an ARD of 10/03/21 revealed R54 had a BIMS score of five out of 15 which indicated the resident had severe cognitive impairment. Review of R54's care plan in the Care Plan tab in the EMR revealed the use of two upper side rails as an undated intervention for fall prevention. Review of R54's CNA Care Sheet located in the resident's closet in the room revealed it did not include use of side rails in the resident's care. Review of R54's most recent Side Rail Assessment in the Assessments tab in R54's EMR dated 06/28/21 revealed side rails were not recommended for use for R54. Observation on 11/16/21 at 11:30 AM revealed R54 was in bed with two upper quarter side rails in use. An additional observation on 11/17/21 at 11:31 AM revealed R54 had two upper quarter side rails while the resident was lying in bed. During an interview with CNA1 at 1:30 PM, she stated that she gets the residents' side rails recommendations in report. CNA1 acknowledged that each resident had a CNA Care Sheet in the room; however, they [CNA staff] rarely look at it and rely on a verbal report. 7. Review of R27's face sheet in the Face Sheet tab of the EMR revealed the resident was admitted on [DATE] for long term care. Review of R27's admission MDS with an ARD of 09/27/21 revealed R27 had a BIMS score of seven out of 15 which indicated the resident had severe cognitive impairment. Review of the care plan in the Care Plan tab in R27's EMR revealed there was not a care plan for the use of side rails for the resident's care. No CNA Care Sheet, usually located in the resident's closet in the room was available in R27's room nor was one provided by the Director of Nursing (DON) upon request on 11/16/21 at 1:00 PM. Review of a Side Rail Assessment in the Assessments tab in R27's EMR, dated 09/11/21, revealed the use of two upper quarter rails was discussed with the responsible party; however, the assessment did not document a reason for use; if the responsible party consented to the use of side rails; or a determination for the use of side rails. Observation on 11/16/21 at 11:42 AM revealed R27 was in bed with all four quarter side rails up. An additional observation on 11/17/21 at 11:31 AM revealed R27 was in bed with all four side rails up. During an interview with CNA1 at 1:30 PM, she stated that she gets the residents' side rails recommendations in report. CNA1 acknowledged that each resident had a CNA Care Sheet in the room; however, they [CNA staff] rarely look at it and rely on a verbal report. 8. Review of R7's face sheet in the Face Sheet tab of the EMR revealed the resident was re-admitted on [DATE] for long term care. Review of R7's quarterly ''MDS'' with an ARD of 08/15/21 revealed R7 had severe cognitive impairment per staff assessment. Review of the care plan in the Care Plan tab in R7's EMR revealed an undated approach for side rails up at the head of the bed to assist with bed mobility as inclusion for an activities of daily living (ADL) self-care deficit problem identified on 12/21/19. Review of the CNA Care Sheet located in R7's closet in the room revealed directions for the use of two half rails for the resident's care. Review of a Side Rail Assessment in the Assessments tab in R7's EMR dated 11/01/21 revealed side rails were not recommended for use for R7. Observation on 11/16/21 at 12:00 PM revealed R7 was in bed with four quarter side rails in use. An additional observation on 11/17/21 at 11:31 AM revealed R7 was in bed with four side rails up. 9. Review of R73's face sheet in the Face Sheet tab of the EMR revealed R73 was admitted to the facility on [DATE] for long term care. Review of R73's quarterly ''MDS'' with an ARD of 10/24/21 revealed R73 had a BIMS score of three out of 15 which indicated the resident had severe cognitive impairment. Review of the CNA Care Sheet located in R73's closet in the room revealed side rails were not included in the resident's care. Review of a Side Rail Assessment in the Assessments tab in R73's EMR dated 02/03/21 revealed side rails were not recommended for use for R73. Observation on 11/16/21 at 12:00 PM revealed R73 was in bed with two upper quarter rails and one lower quarter rail up. An additional observation on 11/17/21 at 11:31 AM revealed R73 was in bed with four quarter side rails up. During an interview with CNA1 at 1:30 PM, she stated that she gets the residents' side rails recommendations in report. CNA1 acknowledged that each resident has a CNA Care Sheet in the room; however, they [CNA staff] rarely look at it and rely on a verbal report. During an interview conducted on 11/18/21 at 11:00 AM, the DON stated, the nurses monitor the use of bed rails every shift; resident evaluations are in the resident charts and residents are reevaluated at least annually. The Care Plan team which consists of therapy, social services, activities, MDS coordinator, floor nurse and CNA, evaluates the effectiveness in discontinuing the use of bed rails. Training for bedrails is conducted in orientation and at least, annually, to include the risks and benefits. The Care Plan team assesses residents for bed mobility. The admission Coordinator and Care Plan team initiate the evaluation for bed rails. Depending on the resident's clinical picture the bed rails may need to initiate during the admission process, and they obtain the consent at the same time. The DON confirmed bed rail use should have been re-evaluated following falls where bed rails were in use. The DON acknowledged the falls did not have a root cause analysis. During an interview on 11/18/21 at 2:25 PM, the DON stated that usually the MDS nurse formulates the Care Plans; however, the facility has had three 3 different MDS nurses in the past year and she has had to fill in. The DON acknowledged that the CNA Care Sheets are probably not up to date and the CNA's get their direction for resident care from the CNA Care Sheets and verbal report. Review of the facility's policy titled, Proper Use of Side Rails dated 11/27/17, revealed it is the policy of this facility to utilize a person-centered approach when determining the use of side rails, also known as bed rails. Alternatives are attempted prior to installing a side or bed rail .the facility will provide ongoing monitoring and supervision of side rail/bed rail use for effectiveness, assessment of need, and determination when the side rail/bed rail will be discontinued .Direct care staff will be responsible for care and treatment in accordance with the plan of care .the interdisciplinary team will make decisions regarding when the side/bed rail will be used or discontinued, or when to revise the care plan to address any residual effects of the rail.