**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, facility documentation review, medical record review and interview the facility failed to ensure 1 (Resident #43) of 13 residents reviewed on the secured unit was free from physical restraints when a staff member placed chairs around Resident #43's bed which resulted in Immediate Jeopardy (IJ) (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause serious injury, harm, impairment, or death to a resident). The Administrator was informed of the Immediate Jeopardy (IJ) on 9/24/19 at 3:05 PM in his office. F604 was cited at a scope and severity of J. The facility was cited F604-J which is Substandard Quality of Care. An extended survey was conducted from 9/24/19 to 9/25/19. The Immediate Jeopardy was effective from 9/18/19 through 9/24/19. An acceptable Allegation of Compliance (AOC), which removed the immediacy of the jeopardy was received on 9/25/19 at 2:10 PM and corrective actions were validated onsite by the surveyors on 9/25/19. The findings include: Facility policy review, Abuse, revised 11/28/17, revealed .Verbal, sexual, physical and mental abuse, corporal punishment, involuntary seclusion, and neglect of the resident as well as mistreatment, injuries of unknown source, exploitation, and misappropriation of resident property are strictly prohibited .This includes, but is not limited to, corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms . Facility policy review, Use of Restraints, revised 2007, revealed .Restraints shall only be used for the safety and well-being of the resident(s) and only after other alternatives have been tried unsuccessfully .Restraints shall only be used to treat the resident's medical symptom(s) and never for discipline or staff convenience or for the prevention of falls . Medical record review revealed Resident #43 was admitted to the facility on [DATE] with diagnoses which included Alzheimer's Disease, Dementia with Behavioral Disturbance, Anxiety Disorder, Major Depressive Disorder and Difficulty in Walking. Review of Resident #43's admission Minimum Data Set (MDS) dated [DATE] revealed the resident had severe cognitive impairment. Continued review revealed the resident exhibited physical, verbal, and other behavioral symptoms. Further review revealed the resident rejected care. Continued review revealed the resident required extensive assist of 1 person with walking in room and corridor. Further review revealed the resident required no restraints. Continued review revealed the resident received Occupational Therapy Services and Physical Therapy Services. Review of the facility investigation dated 9/18/19 revealed an allegation of Resident #43 being restrained by 4 chairs surrounding her bed on 9/18/19. Continue review revealed the facility substantiated the allegation. Review of Resident #43's nursing Progress Notes dated 7/25/19 revealed .ambulates very short distances with walker . Review of Resident #43's Nurse Practitioner Progress Note dated 9/17/19 revealed .She walked some with family and staff assistance to the restroom . Review of Resident #43's Progress Note dated 9/18/19 at 8:30 AM by the Social Worker revealed .Resident was found with 2 chairs up against each side of her bed this morning by tech [Certified Nursing Assistant] . Review of Resident #43's Progress Note dated 9/18/19 at 9:45 AM by the Director of Nursing (DON) revealed .A CNA [Certified Nursing Assistant] notified the ADON [Assistant Director of Nursing] that upon entering the residents room she saw three regular chairs and a wheelchair setting around the residents bed enabling resident to get out of bed . Interview with the DON on 9/26/19 at 12:45 PM in the conference room when asked to clarify the progress note for Resident #43 dated 9/18/19 revealed, I documented enabling the resident to get out of bed but I meant to document preventing the resident from getting out of bed. Interview with CNA #2 on 9/23/19 at 2:42 PM in the Harmony Unit dining room when asked concerning the allegation of restraints for Resident #43 revealed, When I went into [named Resident #43] room she had chairs all around her bed; 2 chairs on each side of the bed, one being her wheelchair. She was trying to sit up in the bed. I immediately removed the chairs and got her out of bed into her wheelchair and reported the chairs being around her bed to the nurse. Interview with the Social Worker on 9/23/19 at 2:56 PM in the Harmony Unit dining room confirmed the incident involving a restraint for Resident #43 was reported to the ADON and the Administrator. Telephone interview with CNA #1 on 9/23/19 at 4:04 PM when asked about the incident with Resident #43 revealed, After [named Resident #43] was in bed she was trying to get up so I offered to get her up and she said no and if I tried to get her out of bed she would knock my head off; we had another resident running a high fever and I gave that resident a shower and after I got finished, [named Resident #43] was still trying to get out of bed so I put the chairs around her bed. Continued interview confirmed, I know it was barricading her, but I was afraid she would fall and get hurt; I knew it was a restraint but I was trying to keep her safe. Continued interview revealed, I had forgotten about the chairs; I was notified later that day the day shift staff found the chairs around her bed. Telephone Interview with Resident #43's daughter on 9/25/19 at 3:22 PM revealed when the resident was at home she would get out of bed and walk to the bathroom, living room and the kitchen. Interview with the DON and the Administrator on 9/23/19 at 3:10 PM in the DON's office confirmed the incident in which Resident #43 was restrained in her bed was substantiated. The facility's failure to ensure Resident #43 was free of physical restraints resulted in Immediate Jeopardy. The surveyors verified the AOC by: 1. The chairs were removed from around Resident #43's bed on 9/18/19. The surveyors interviewed staff and confirmed the chairs were removed. 2. CNA #1 was suspended immediately. Skin assessments were completed on 100% of the residents residing in the secure unit. The surveyors reviewed the skin assessments provided on the residents residing in the secure unit. The surveyors observed residents in the secure unit with no restraints noted. On 9/25/19 the facility's Staff Development Coordinator, Assistant Director of Nursing and the Minimum Data Set Coordinator interviewed staff regarding the use of non-standard (not approved) fall interventions on or near a resident. The surveyors reviewed staff interviews. 3. All facility personnel were in-serviced on Abuse and Resident Rights by the facility Staff Development Coordinator beginning on 9/18/19 and completed on 9/20/19. The Surveyors reviewed in-service sign in sheets and interviewed staff on each shift. The surveyors also reviewed CNA #1's personnel file which revealed CNA #1 received training on abuse/neglect and resident rights on 2/13/19. Continued review revealed a complete and thorough investigation was finished on 9/18/19 resulting in termination of Certified Nursing Assistant #1. The noncompliance of F604 continues at a scope of D level for the monitoring of the effectiveness of the corrective actions. The facility is required to submit a Plan of Correction.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, facility documentation review, medical record review, observation and interview the facility failed to ensure 1 (Resident #43) of 13 residents reviewed on the secured unit was free from accident hazards related to chairs being placed around the resident's bed and placed the resident in Immediate Jeopardy (IJ) (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause serious injury, harm, impairment, or death to a resident). The Administrator was informed of the Immediate Jeopardy (IJ) on 9/24/19 at 3:05 PM in his office. F689 was cited at a scope and severity of J. The facility was cited F689-J which is Substandard Quality of Care. An extended survey was conducted from 9/24/19 to 9/25/19. The Immediate Jeopardy was effective from 9/18/19 through 9/24/19. An acceptable Allegation of Compliance (AOC), which removed the immediacy of the jeopardy was received on 9/25/19 at 2:10 PM and corrective actions were validated onsite by the surveyors on 9/25/19. The findings include: Facility policy review, Hazardous Areas, Devices and Equipment, revised July 2017, revealed .All hazardous areas, devices and equipment in the facility will be identified and addressed appropriately to ensure resident safety and mitigate accident hazards to the extent possible . Medical record review revealed Resident #43 was admitted to the facility on [DATE] with diagnoses which included Alzheimer's Disease, Dementia with Behavioral Disturbance, Anxiety Disorder, Major Depressive Disorder and Difficulty in Walking. Review of Resident #43's admission Minimum Data Set (MDS) dated [DATE] revealed the resident had severe cognitive impairment. Continued review revealed the resident exhibited physical, verbal, and other behavioral symptoms. Further review revealed the resident rejected care. Continued review revealed the resident required extensive assist of 1 person with walking in room and corridor. Further review revealed the resident required no restraints. Continued review revealed the resident received Occupational Therapy Services and Physical Therapy Services. Review of Resident #43's Comprehensive Care Plan dated 7/25/19 revealed .at risk for falls r/t [related to] gait/balance problems . Review of the facility investigation dated 9/18/19 revealed a facility substantiated allegation of Resident #43 being restrained when Certified Nursing Assistant (CNA) #1 placed 4 chairs around her bed on 9/18/19. Review of Resident #43's nursing Progress Notes dated 7/25/19 revealed .ambulates very short distances with walker . Review of Resident #43's nursing Progress Notes dated 8/6/19 revealed .Uses reclining chair when up out of bed due to safety/fall risk . Review of Resident #43's nursing Progress Notes dated 8/15/19 revealed .Resident was agitated and anxious pulling picc [peripherally inserted central catheter] line, trying to slide out of bed and between rails . Medical record review of Resident #43 Physical Therapy Discharge summary dated [DATE] revealed .Progress varies day to day depending on cognitive level .When patient is alert can ambulate with rollator walker up to 50 [feet] with CGA [contact guard assist] [Therapist has one or two hands on the residents body to help with balance but provides no other assistance to perform the functional task] . Review of Resident #43's nursing Progress Notes dated 8/20/19 revealed .Several attempts to stand up out of geri chair [reclining chair]. Unable to redirect resident due to her confusion . Review of Resident #43's nursing Progress Notes dated 8/27/19 revealed .several attempts to lay down in bed have been detained due to the resident trying to climb over chair/bed . Review of Resident #43's Nurse Practitioner Progress Note dated 9/17/19 revealed .She walked some with family and staff assistance to the restroom . Review of Resident #43's Progress Note dated 9/18/19 at 8:30 AM by the Social Worker revealed .Resident was found with 2 chairs up against each side of her bed this morning by tech [Certified Nursing Assistant] . Observation of Resident #43 on 9/23/19 at 9:06 AM and 10:46 AM revealed the resident lying in bed with 2 half side rails in the up position and 4 regular chairs and a wheelchair were in the room but not near the bed; 1 regular chair at the resident's left bedside, 2 regular chairs at the end of the bed by the closet, and 1 regular chair at Resident #43's roommate's right bedside and the resident's wheelchair and rollator walker at the end of Resident #43's bed. Interview with Certified Nursing Assistant (CNA) #2 on 9/23/19 at 2:42 PM in the Harmony Unit dining room when asked concerning the allegation of restraints for Resident #43 revealed, When I went into [named Resident #43] room she had chairs all around her bed; 2 chairs on each side of the bed, one being her wheelchair; She was trying to sit up in the bed. Continued interview revealed, I immediately removed the chairs and got her up out of bed into her wheelchair. Interview with Registered Nurse (RN) #1 on 9/23/19 at 2:51 PM in the Harmony Unit dining room when asked concerning the incident on 9/18/19 with Resident #43 revealed, [named CNA #2 and #3] reported [named Resident #43] had 4 chairs around her bed, her wheelchair and 3 other chairs. Interview with the Assistant Director of Nursing (ADON) on 9/23/19 at 3:04 PM in the Harmony Unit dining room when asked about the incident involving Resident #43 revealed, I came over to check on the nurse during morning rounds; It was reported to me by [CNA #2] [named Resident #43] was in the bed with chairs around her bed, keeping her in the bed. Telephone interview with CNA #1 on 9/24/19 at 5:49 PM revealed, That night when I walked into [named Resident #43] room she was laying cross ways of the bed, her head on one side of the bed and her feet hanging off the other side of the bed. She was climbing out of bed. Continued interview revealed, I assisted her back to bed at that time (10:30 PM - 11:00 PM); She kept trying to get out of the bed, approximately 10 times, before I placed the chairs around her bed (around 2:00 AM). Interview with Licensed Practical Nurse (LPN) #1 on 9/24/19 at 6:26 PM in the Harmony unit shower room revealed, [named Resident #43] has a history of climbing out of bed. Continued interview revealed, She was moved to a room closer to the nurses station related to past attempts of climbing out of bed. Continued interview revealed, We normally put a chair outside of her door and chart so we can keep an eye on her because she hangs her legs over the side of the bed. Continued interview revealed She even hangs her legs on the rails likes she's climbing. Continued interview revealed, She [named Resident #43] pulls the rails to position her body so she can dangle her legs over the side of the bed. Continued interview LPN #1 demonstrated to the surveyors Resident #43's frantic flailing and climbing motions. Interview with the Physical Therapy Assistant (PTA) on 9/25/19 at 11:19 AM in the therapy room revealed, She has the ability to move her legs when she wants to; Her therapy depends on her cognition. Telephone Interview with Resident #43's daughter on 9/25/19 at 3:22 PM revealed the resident was able to get out of the bed and ambulate independently from room to room at home. Interview with the Director of Nursing (DON) and the Administrator on 9/23/19 at 3:10 PM in the DON's office confirmed the incident in which Resident # 43 was restrained in her bed was substantiated. The facility's failure to ensure Resident #43 was free from accident hazards placed the resident in Immediate Jeopardy. The surveyors verified the AOC by: 1. The chairs were removed from around Resident #43's bed on 9/18/19. The surveyors interviewed staff and confirmed the chairs were removed. 2. CNA #1 was suspended immediately. Skin assessments were completed on 100% of the residents residing in the secure unit. The surveyors reviewed the skin assessments provided on the residents residing in the secure unit. The surveyors observed residents in the secure unit with no restraints noted. On 9/25/19 the facility's Staff Development Coordinator, Assistant Director of Nursing and the Minimum Data Set Coordinator interviewed staff regarding the use of non-standard (not approved) fall interventions on or near a resident. The surveyors reviewed staff interviews. 3. All facility personnel were in-serviced on Abuse and Resident Rights by the facility Staff Development Coordinator beginning on 9/18/19 and completed on 9/20/19. The Surveyors reviewed in-service sign in sheets and interviewed staff on each shift. The surveyors also reviewed Certified Nursing Assistant (CNA) #1's personnel file which revealed CNA #1 received training on abuse/neglect and resident rights on 2/13/19. Continued review revealed a complete and thorough investigation was finished on 9/18/19 resulting in termination of Certified Nursing Assistant #1. The noncompliance of F689 continues at a scope of D level for the monitoring of the effectiveness of the corrective actions. The facility is required to submit a Plan of Correction.