**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews and review of the facility's policy, the facility failed to provide adequate supervision and protect 1 of 1 residents from entrapment in the quarter side rails of the resident's bed, resulting in death. Specifically, Resident (R)1 was found by staff on [DATE] at 2:30 AM unresponsive. R1's head was trapped on the inside on the side rail and her body was off the bed against the wall. On [DATE] at 5:30 PM the Administrator was notified that the failure to protect a resident from entrapment in a bed rail, that resulted in death, constituted immediate jeopardy at F689. On [DATE] at 5:30 PM the survey team provided the Administrator with a copy of the CMS Immediate Jeopardy (IJ) Template and informed the facility IJ existed as of [DATE]. The IJ was related to 42 CFR 483.25 Quality of Care. On [DATE] at 10:15 AM, the facility provided an acceptable IJ Removal Plan. The survey team, validated the facility's corrective actions and verified the facility did their due diligence to address the non-compliance. The IJ is considered at Past Non-compliance as of [DATE]. An Extended Survey was conducted in conjunction with the Complaint Survey for non-compliance at F689, constituting substandard quality of care. Findings include: Review of the facility's policy titled, Side Rails dated [DATE], revealed, To utilize a person-centered approach when determining the use of grab bars/side rails/bed rails and enhance resident's mobility and functional independence. Item 1 stated, Side rail/Bed Rail screen, (to be completed in the electronic medical record (EMR), to be completed upon admission and quarterly thereafter, which will address alternatives attempted and how these alternatives failed to meet the resident's assessed needs. Review of R1's Face Sheet revealed R1 was admitted to the facility on [DATE] with diagnoses including but not limited to; depression, hypertension, diabetes type 2, chronic kidney disease stage 3, and unspecified dementia. Review of R1's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of of [DATE] revealed R1 had a Brief Interview for Mental Status (BIMS) score of 3 out of 15, indicating R1 was severely cognitively impaired. Further review of the MDS revealed R1 required extensive assistance with activities of daily living. Review of R1's Progress Note dated [DATE] at 7:00 AM, revealed at approximately 4:30 AM during routine rounds, Certified Nursing Assistant (CNA)1 stated she entered room [ROOM NUMBER] and observed R1 entangled in quarter length side rail on the right side of the bed (if standing at foot of bed). CNA1 notified this nurse of this situation and I went immediately to the room. I observed R1 being unresponsive and entangled inside the side rail. I called Emergency Medical Services (EMS) immediately. EMS arrived at the facility at approximately 5:00 AM and was unable to revive R1. EMS manager and coroner notified by EMS staff. EMS manager arrived at facility at approximately 5:15 AM and assistant corner arrived at approximately 5:30 AM. During an interview on [DATE] at 9:50 AM, the Administrator (with the Director of Nursing present), revealed that the facility conducted an internal investigation and concluded that the facility would no longer use the quarter side rails and they have since removed them. The Administrator stated the facility did a bed measurement on all beds with the Bionix device on [DATE] and on [DATE] removed all the devices from each bed in the facility. The Administrator further stated the facility used the quarter rails on each resident bed since the opening of the facility in 2018 and this was the first death in relation to the use of the rails. The Administrator concluded, [R1] was a DNR (do not resuscitate) and when EMS arrived at the facility, they place the leads on her and the leads read asystole (represents the cessation of electrical and mechanical activity of the heart). During an interview on [DATE] at 11:20 AM, R1's daughter revealed that her brother got a call from the facility on [DATE] at 6:30 AM notifying that EMS came to the facility due to an accident where R1 was found unresponsive. R1's daughter stated that she got to the facility and saw the coroner leaving and was told by the coroner that R1 fell out of the bed, her head got stuck on the bed rail and she was paralyzed and she broke her left leg. R1's daughter stated that she had an autopsy performed and the autopsy did not mention anything about R1 being paralyzed or having a broken leg but listed the cause of death as asphyxiation. During an interview on [DATE] at 11:45 AM, CNA1 stated she and CNA2 went to check on R1 on [DATE] at 2:30 AM and CNA2 went inside the room first. CNA2 came out and said R1 is not breathing. R1's neck was caught between the rail and the wall. CNA2 had to unlock the bed to get to R1, as R1 was still warm to touch. CNA2 attempted to get as close as possible to dislodge her neck from the rails and the wall and she said, I was not able to get [R1's] neck out of the rail and the wall so we called for the nurse to come help. [Registered Nurse (RN)1] came and she could not get close enough to get [R1's] neck from the bed so she called 911. CNA1 stated, EMS came and I cannot remember what else occurred because I was so upset. CNA1 further stated she has been working for the facility for 16 years and this was the first death as a result of the quarter rails. CNA1 confirmed that the quarter rails were at the head of the bed. CNA1 concluded that she did not receive in-service training for side rails prior to or after the incident. During an interview on [DATE] at 12:16 PM, RN1 stated that on [DATE] CNA1 went to R1's room at 4:30 AM and reported to her that R1 was not responsive. R1's head was inside on the rail and her body was up against the wall and she had gotten stuck between the wall and the bed. R1 was warm to touch but she was not responsive and R1 did not have a pulse. RN1 stated, I tried to move the bed to keep her neck from further moving so I made a decision to call 911. RN1 further stated when the paramedics arrived, they told her to unplug the bed and they put the leads on her and it registered asystole and we started calling everyone. During an interview on [DATE] at 12:50 PM, the Director of Therapy stated, [R1] initially was on the rehabilitation unit and transitioned to Medicare unit. [R1] was a full body lift, a 2-person assistance and a Hoyer stand and lift patient. The Director of Therapy concluded, regarding R1's deficits in upper body strength, she could feed herself, but staff would have to provide assistance to get out of bed. During an interview on [DATE] at 2:31 PM, Licensed Practical Nurse (LPN)1 stated, the facility conducted an assessment for [R1's] side rails at admission and quarterly and all residents have a quarter side rail prior to the removal of all on [DATE]. LPN1 stated that all patients and family are told the benefits and negatives of having the quarter rails. LPN1 stated that R1 had quarter side rails for position in bed mobility and for staff assistance. LPN1 said to her knowledge, the quarter rails and the handrails were not considered a restraint and she was not sure why no physician orders were in place for the use of the rails. LPN1 further stated on [DATE] she conducted an assessment for continued use of the quarter side rails. R1 was not very mobile at admission, she was able to scoot out of chair and over time she was more mobile, to include being able to feed self, assist staff with turn and reposition in bed, and could hold on to rails for staff to assist her. During an interview on [DATE] at 2:48 PM, LPN2 revealed she conducted an assessment on [DATE] for the use of the quarter side rails. LPN1 stated that R1 had quarter rails for turning, mobility and to aid with her moving from side to side. LPN2 concluded, At admission [R1] had an aid device, but she was not able to recall which one. Multiple attempts were made to interview CNA2 with no success. On [DATE] the facility provided a removal plan, which included the following: 1. Immediate action(s) taken for the resident(s) found to have been affected include: Resident CR1, expired [DATE]. 2. Identification of other residents having the potential to be affected was accomplished by: Residents with quarter length (1/4) side rails have the potential to be affected. 3. Actions taken/systems put into place to reduce the risk off uture occurrence include: 100% audit of bed measurement to mattress with Bionix device on 11 beds, empty and occupied by maintenance on [DATE]. Resident CR1's Bed Inspected by Maintenance [DATE]. Attachment A 100% side rail screens completed on [DATE] by the therapy department. Any noted side rails for removal removed [DATE] by maintenance. 100% side rail re-assessment completed [DATE] by MDS Department with resident/resident representative notification of results or assessment. [DATE] DON and Administrator reviewed Bionix Bed Checks conducted in the past for Resident CR1. [DATE] DON, Administrator, Lead Maint Tech, Facility Services Director went to CR1's room and utilized the Bionix device and measured Zone 1 with a regular mattress with CR1's bed and all areas passed. Bed checked again with Low Air Loss Mattress inflated and deflated, Zone l again passed. [DATE] 100% audit of all beds, by the admission Coordinator, noted 8 beds against the wall as care plan approach for fall prevention. Maintenance notified to remove the side rail against the wall in rooms 204 (left), 208 (right), 209 (right), 210 (left), 211 (left), 214 (left), 301 (right), 318 (right). Side rails removed [DATE]. [DATE] In-Service held by Lead Maintenance Tech, Administrator, and DON on Bionix Safety Technologies Bed System Measuring Device Test Results and Worksheet reviewed with the Maintenance Department. Maintenance Techs provided return demonstration regarding utilization of the Bionix device and measuring of the bed/side rails with pass/fail results. The entire Maintenance Department reiterated that they had and continue to have knowledge of the Bionix process of measuring mattress/bed. [DATE] DON and Administrator re-educated admission Nurse, RN Manager, Health Services Nurse Specialist, MDS Coordinator, and MDS Assistant on completion of the side rail assessment, notifying resident/resident representative. Will utilize therapy screens for appropriateness of side rails in conjunction with nursing services. [DATE] DON and Administrator reviewed electronic call light monitoring system reviewed for activity from CR1's room and there was none with a date range of [DATE]-[DATE]. [DATE] Scheduled QA meeting conducted. Incident from [DATE] discussed including action plan/plan of correction. [DATE] Ad Hoc QA Committee meeting scheduled for 9:00 am [DATE]. [DATE] Ad Hoc QA Committee Meeting. [DATE] After investigation/review by the Ad Hoc QA Committee, to eliminate the possibility of future entrapment, all quarter side rails removed by Maintenance [DATE]. admission Nurse, LPN, RN Manager, Health Services Nurse Specialist, LPN, notified resident/resident representative of removal of quarter side rails. Therapy Department re-screened residents for the need for alternatives to side rails, [DATE]. Care Plans/ [NAME]'s updated by MOS, [DATE]. [DATE] After investigation/review by the Ad Hoc QA Committee, the 8 beds, against the wall, as care plan approach for fall prevention, were moved away from the wall and an additional fall mat was put in to place related to the therapy screen or another appropriate intervention was put in place from the therapy screen by the Therapy Department. Care plans/[NAME] updated by MDS Nurses. [DATE] Current staff were educated regarding the elimination of side rails, alternatives to side rails, fall precautions and location. Staff were re-educated regarding two hour rounding process and newly hired nursing staff will be informed of all of the above including two hour rounding process by Director of Nursing or Designee and/or Health Services Manager/CNA Mentor. All staff were educated before their next scheduled shift. [DATE] Social Worker held a special Resident Council meeting to explain the discontinuation of quarter length side rails in the facility to eliminate the possibility of entrapment. Social Worker discussed alternative options to quarter length side rails. [DATE] In order to ensure alternatives to quarter length side rails were implemented/documented MD orders reviewed and revised as needed, Care Plans reviewed and revised as needed, Point of Care [NAME] reviewed and revised as needed by MDS Coordinator, RN, MDS Assistant, LPN, and Health Services Nurse Specialist, LPN. [DATE] Side Rail Policy, 2100.211 revised by Administrator and communicated to staff. 4. How the corrective action(s) will be monitored to ensure the practice will not reoccur: Newly hired maintenance department employees will receive training on the use of the Bionix measuring system by the lead maintenance technician and Relias (On Line Training) and instructed to remove bed rails from any newly purchased beds. 100% audit daily times one week and then weekly for one month by Maintenance Department to ensure no side rails present. Audits will be given to the VP of operations. POC, Investigation reviewed by Ad Hoc QA Committee on [DATE] and will become part of the QA process for the next three months to ensure continued compliance. Corrective action completion date: [DATE]