**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow its policy and procedure (P&P) titled, Resident Examination and Assessment, which indicated the facility will assess a resident for any abnormalities in health status, such as abdominal distention, pain duration, severity and factors that worsen the pain, for one of three sampled residents (Resident 65), when Resident 65 complained of severe abdominal pain on 8/24/2024 at 11:00 p.m. and on 8/25/2024 at 2:30 p.m. This failure caused Resident 65 to be emotionally distressed (angry, scared, and frustrated), suffer severe pain for an extended period and was transferred to a general acute care hospital (GACH) for evaluation and treatment. Findings: During a review of Resident 65 ' s admission Record, the admission Record indicated Resident 65 was admitted to the facility on [DATE] with diagnoses including urinary tract infection (UTI- a bacterial infection in the organ that removes urine) and hereditary (inborn)and idiopathic (a disease of unknown cause) neuropathy (nerve pain). During a review of Resident 65 ' s physician orders dated 7/29/2024, the physician orders indicated the following: 1. Monitor level of pain every shift (using 0-10 pain scale). 2. Oxycodone-Acetaminophen (a strong pain medicine) 5 milligrams (mg)/ 300 mg one (1) tablet by mouth (PO) every six (6) hours (Q6hrs) as needed (PRN) for moderate to severe pain. 3. Monitor suprapubic catheter (a medical device that helps drain urine from the bladder through a small incision in the abdomen) drainage bag every shift and document signs and symptoms (S/S) of UTI such as bladder distention and burning sensation. 4. Change suprapubic catheter by wound care consultant every 6 months and PRN if blocked (obstructed) or pulled out. During a review of Resident 65 ' s History and Physical (H&P) dated 7/30/2024, the H&P indicated Resident 65 had the capacity to understand and make decisions. The H&P indicated Resident 65 had an intact suprapubic catheter. During a review of Resident 65 ' s Minimum Data Sheet ([MDS] a standardized care screening and assessment tool) dated 8/18/2024, the MDS indicated Resident 65 had an intact cognition (understanding). The MDS indicated Resident 65 had a suprapubic catheter. The MDS indicated Resident 65 required moderate assistance (helper does less than half the effort) with eating, maximal assistance (helper does more than half the effort) with oral hygiene and dependent with toileting hygiene, personal hygiene, showers, and upper and lower body dressing. The MDS indicated Resident 65 was dependent with toilet transfer, sit to stand position and chair/bed-to-chair transfer (the ability to transfer to and from a bed to a chair (or wheelchair). During a review of Resident 65 ' s Medication Administration Record (MAR) dated 8/25/2024, the MAR indicated Resident 65 had a pain level of 10/10 ([numeric pain scale] a pain scale used in a facility with 0 no pain, 1-3 mild pain, 4-6 moderate pain, 7-8 severe pain, 9-10 worst pain possible) during the 11:00 p.m. to 7:00 a.m. shift ([(11 p.m. on 8/24/2024 to 7 a.m. on 8/25/2024] no specific time indicated). The MAR indicated a signature next to Oxycodone on 8/25/2024 (time not specified), indicating the resident was medicated. During a review of Resident 65 ' s Nurses ' Notes dated 8/25/2024, at 1:03 a.m., the Nurses ' Notes indicated Resident 65 complained of abdominal pain. The notes did not indicate Resident 65 was assessed for the pain level and pain characteristics. The notes indicated Resident 65 was offered (unspecified) pain medication, but the resident refused. The Nurses ' Notes at 2:00 a.m. indicated Resident 65 was offered pain medication and he refused. The notes indicated Resident 65 requested to go to hospital, and that Resident 65 ' s doctor was notified on 8/25/2024 at 1:00 a.m. The nurse ' s note at 5:30 a.m. indicated Resident 65 ' s doctor called the facility and ordered Resident 65 be transferred to the GACH on 8/25/2024 at 10:30 a.m. The nurses ' notes at 2:30 p.m. indicated Resident 65 was picked up by the ambulance on 8/25/2024 at 2:30 p.m., with a pain level of 7/10 pain (severe pain). The nurses ' notes did not indicate any pain interventions were provided to Resident 65. During a review of the GACH emergency department (ED) notes dated 8/25/2024 at 7:10 p.m., the ED notes indicated Resident 65 arrived at the GACH on 8/25/2024 at 3:25 p.m. with a chief complaint of abdominal pain radiating (spreading) to the flank (sides of the body between ribs and hips) area that started last night on 8/24/2024. The ED notes indicated Resident 65 had gross pus (large amount of thick yellowish, whitish, or greenish fluid) from the suprapubic catheter and sepsis (a life-threatening complication of an infection). The ED notes indicated Resident 65 ' s suprapubic catheter was changed by the ED staff, and the abdominal pain improved. The ED notes indicated Resident 65 received antibiotics and pain medications, was admitted to the GACH for evaluation, treatment, and care for urinary tract infection, dehydration (body does not have enough water), and acute kidney injury (an abrupt decrease in kidney function). During an interview on 9/17/2024 at 4:23 p.m. with Resident 65, Resident 65 stated on 8/24/2024 at 11:00 p.m., he complained of severe abdominal pain to LVN 9 and Registered Nurse 4 (RN 4). Resident 65 stated LVN 9 and RN 4 did not assess his pain, and he suffered severe abdominal pain from 11:00 p.m., on 8/24/2024 to 8/25/2024, when he received treatment at the GACH. Resident 65 stated on 8/25/2024 at 2:00 a.m., he asked LVN 9 to call 911 (emergency phone number) because he could not handle the pain anymore. Resident 65 stated LVN 9 did not assess his pain or suprapubic catheter and did not call 911 to assess him or take him to a GACH. Resident 65 stated, Isuffered severe abdominal pain and felt angry, scared, and frustrated until I was transferred to the GACH on 8/25/2024 at 2:30 p.m. Resident 65 stated, I would rather be dead than re-experience the pain on 8/25/2024. During a concurrent interview and record review on 9/18/2024 at 3:53 p.m., with RN 4, Resident 65 ' s care plan titled Potential for Pain, dated 7/25/2024, physician orders dated 7/29/2024, August 2024 MAR and nurses ' notes dated 8/24/2024 and 8/25/2024 were reviewed. RN 4 stated the care plan interventions indicated staff will assess Resident 65 ' s pain symptoms, identify the frequency, location, quality, onset, and how Resident 65 expressed pain, provide non-pharmacological interventions such as relaxation techniques, deep breathing exercises, proper positioning, and provide 1 to 1 interaction, monitor effectiveness of non-pharmacologic interventions, and notify the physician of increasing pain. RN 4 stated the nurses ' notes did not indicate Resident 65 was assessed when he complained of severe abdominal pain on 8/24/2024 and on 8/25/2024. RN 4 stated Resident 65 ' s suprapubic catheter should have been assessed for blockage (obstruction) and output because it might have been the cause of pain. RN 4 stated the nurse ' s assessment should have been documented in the progress notes. RN 4 stated, a blockage to the suprapubic catheter could result in pain, fever, and sepsis. RN 4 stated she did not know if Resident 65 had a fever, or his catheter was blocked when the resident complained of severe abdominal pain. RN 4 stated she did not assess Resident 65 ' s suprapubic catheter, or the location, frequency, duration, onset, and pattern of pain, on 8/24/2024 at 11:00 p.m., and 8/25/2024 at 2:30 p.m. RN 4 stated the failure to assess Resident 65 ' s pain for prompt interventions, caused the resident to experience severe pain for a long time (approximately 15 hours). RN 4 stated on 8/25/2024, during the 11:00 p.m. to 7:00 a.m. shift, the MAR indicated Resident 65 had a pain level of 10/10 (location unspecified) with a staff ' s initial next to Oxycodone on 8/25/2024 (time not specified), indicating the resident was medicated. RN 4 stated Resident 65 ' s nurses ' notes and MAR did not indicate Resident 65 ' s pain was assessed on 8/25/2024 prior to the medication administration (Oxycodone) and did not indicate a reassessment after the medicine was administered to evaluate for its effectiveness. RN 4 stated Resident 65 should have been assessed prior to and one hour after Resident 65 ' s Oxycodone administration. RN 4 stated when Resident 65 complained of 7/10 abdominal pain on 8/25/2024 at 2:30 p.m. (prior to ambulance transport to GACH), Resident 65 was not assessed. RN 4 stated Resident 65 ' s licensed nurse should have assessed the resident (Resident 65). RN 4 stated, the nurse ' s notes indicated Resident 65 asked LVN 9 to call the paramedics (medical emergency personnel). RN 4stated the nurses ' notes also indicated on 8/25/2024 at 3:00 a.m., Resident 65 ' s family member (FM 1), called LVN 9 and requested for LVN 9 to call the paramedics. During an interview on 9/18/2024 at 4:45 p.m., with the Director of Nursing (DON), the DON stated Resident 65 ' s unresolved pain should have been reassessed frequently and interventions provided according to the facility ' s policy and resident ' s plan of care. The DON stated Resident 65 ' s physician should have been notified of Resident 65 ' s pain condition. The DON stated pain assessment and reassessment could identify the cause of pain and guide interventions. The DON stated unresolved severe abdominal pain was considered a medical emergency (a serious condition that requires immediate medical attention to prevent a person's worsening health and death) requiring immediate transfer to a GACH. The DON stated the delay in providing interventions and addressing Resident 65 ' s severe pain could result in worsening condition and complications. During a review of the facility ' s undated policy and procedure (P&P) titled, Resident Examination and Assessment, the P&P indicated the facility will examine and assess the resident for any abnormalities in health status, such as abdominal distention and hardness, urine output if they were clear or cloudy, presence of foley catheter (a flexible tube that is inserted into the bladder through the urethra to drain urine), description, location, duration, severity of pain and factors that worsened the pain, current medication and treatments for pain. During a review of the facility ' s undated P&P titled, Pain Management, the P&P indicated the facility will ensure pain management was provided to residents who required such services consistent with professional standards of practice, the comprehensive person-centered care plan and the resident ' s goals and preferences. The P&P indicated pain assessment and evaluation should be done by nurses, practitioners and review resident ' s diagnosis or conditions and any additional factors that may have caused or contributed to pain, identifying the location, frequency, duration, onset, and pattern of pain. The P&P indicated staff will identify the current prescribed pain medications, dosage and frequency, resident ' s goals for pain management and the effectiveness of drugs and other treatments used in the past to treat pain. The P&P indicated, if the resident ' s pain was not controlled with the current treatment regimen, the practitioner should be notified.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2a. A review of Resident 113's admission Record (Face Sheet), indicated Resident 113 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses that included but not limited to muscle wasting and atrophy (decreased muscle size), major depressive disorder (mood disorder), and dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities). A review of Resident 113's MDS, dated [DATE], indicated Resident 113's cognition was moderately impaired. The MDS indicated Resident 113 required substantial assistance sitting to standing, toilet transfers and bed to chair transfers. A review of Resident 113's Physician Orders, dated 3/1/2023, indicated that Resident 113 was to receive RNA for passive range of motion to bilateral upper and lower extremities as tolerated daily, five times a week. 2b. A review of Resident 92's admission Record (Face Sheet) indicated Resident 92 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses that included but not limited to muscle weakness, major depressive disorder, and dementia. A review of Resident 92's MDS, dated [DATE], indicated Resident 92's was severely impaired. The MDS indicated Resident 92 required moderate assistance sitting to standing, toilet transfers and bed to chair transfers. A review of Resident 92's Physician Orders, dated 11/21/2023, indicated that Resident 92 was ordered RNA to ambulate with front wheeled walker daily for five times a week as tolerated. 2c. A review of Resident 93's admission Record (Face Sheet) indicated Resident 93 was admitted to the facility on [DATE] with diagnoses that included but not limited to tachycardia (fast heart rate), and hyperlipidemia (high cholesterol). A review of Resident 93's MDS, dated [DATE], indicated Resident 93's cognition was severely impaired. The MDS indicated Resident 93 required substantial assistance with showering and toileting, was dependent on staff for chair to bed transfers and sitting to standing. A review of Resident 93's Physician Orders, dated 12/20/2023, indicated that Resident 93 was ordered RNA for passive range of motion to bilateral upper and lower extremities as tolerated daily for five times a week and RNA to apply right lower extremities knee splint for four to six hours daily five times a week as tolerated. A review of the Physician Orders List, dated 4/2024, the list indicated that there 19 residents with active RNA orders. During an interview with RNA 2, on 4/19/2024, at 11:55 a.m., RNA 2, stated that there were usually about 20 residents total on RNA therapy and that the facility had asked RNAs to perform CNA work often when they worked their shifts. RNA 2 stated that some of their duties included, performing range of motion exercises, applying, and removing splints, and feeding and weighing residents. RNA 2 stated that some of the residents did not get their RNA sessions on a consistent basis. During a concurrent review and interview, on 4/19/2024, at 11:55 a.m., with RNA 2, Resident 113's Restorative Record, dated 4/2024, was reviewed. The Restorative Record had a slash marked in the box for 4/5/2024. RNA 2 stated that the slash indicated that there was no RNA available to perform the RNA order. During an interview with RNA 3, on 4/19/2024, at 12:39 p.m., RNA 3 stated she was the only RNA for the entire facility (Building A and B) today because the other RNA that was scheduled was pulled to perform CNA duties due to a lack of CNAs on the floor. RNA 3 stated that there needed to be two RNAs working in Building A and two RNAs working in Building B to ensure all the residents on RNA therapy received good, quality RNA sessions and to ensure that all orders would be carried out. RNA 3 stated that the facility normally asked the RNAs to perform CNA duties about once or twice a week and this affected their workload. RNA 3 stated she knew that she would not be able to physically work with all the residents that had RNA orders today (4/19/2024) because she would need the help of another RNA. RNA 3 stated that the lack of RNAs and CNAs negatively affected the quality of care provided to the residents. RNA 3 stated that the quality of the RNA sessions for the residents ordered to have RNA services would be better if there were more RNAs to help perform the work. RNA 3 stated that the residents were at risk for the development of contractures and decreased mobility if the RNA orders were not provided as prescribed by the Physician. During a concurrent review and interview, on 4/19/2024, at 12:39 p.m., with RNA 3, Resident 92's Restorative Record, dated 1/2024, was reviewed. The Restorative Record had a slash marked in the boxes corresponding to following dates 1/2/2024, 1/4/2024, 1/11/2024, 1/22/2024, 1/24/2024, 1/25/2024, and 1/31/2024. RNA 2 stated that the slash indicated that there was no RNA available to perform the RNA order due to either a lack of CNAs on the floor and that the RNAs did not work overtime and weekends. During a concurrent review and interview, on 4/22/2024, at 1:35 p.m., with RNA 1, Resident 93's Restorative Record, dated 4/2024, was reviewed. The Restorative Record had a slash marked in the boxes corresponding to two of Resident 93's RNA orders on 4/5/2024. RNA 1 stated that she worked 7 a.m. to 3 p.m. on 4/5/2023 and RNA 4 were both reassigned to work as CNAs that day because of a lack of CNA staff. RNA 1 stated that all the residents that were ordered to have RNA therapy five times a week missed their session that day, including Resident 93. RNA 1 stated that the lack of consistent provision of RNA therapy could have led to a gradual decline in range of motion or ability to perform activities daily living. During an interview, on 4/22/2024, at 2:05 p.m. with the Director of Staff Development (DSD), the DSD stated that the best practice was staff four RNAs total to meet the needs of the facility. The DSD stated that RNAs must be reassigned to take on CNA roles instead of performing the RNA orders about two to three times a week. The DSD stated the if the RNAs were not able to consistently carry out the RNA orders, due to staffing issues, then the residents would decline and that the needs of the facility would not be met. A review of the facility's undated P&P titled, Restorative Nursing Programs, indicated the facility was to provide maintenance and restorative services designed to maintain or improve a resident's abilities to the highest practicable level. Based on observation, interview, and record review, the facility failed to provide services to maintain mobility (ability to move) for four of six sampled residents (Resident 91, Resident 92, Resident 93, and Resident 113) with limited range of motion ([ROM] full movement potential of a joint (where two bones meet) and mobility by failing to: 1. Monitor Resident 91's ROM in both arms and legs quarterly (every three months) in accordance with Resident 91's care plan between 4/21/2021 and 3/27/2024 (approximately 3 years). 2. Provide Resident 91 with Restorative Nursing Aide ([RNA] certified nursing aide program that helps residents to maintain their function and joint mobility) services for ambulation (the act of walking) using a front-wheeled walker ([FWW] an assistive device with two front wheels used for stability when walking) in accordance with the physician orders, dated 5/5/2020, for the months of 3/2022, 4/2022, 5/2022, 7/2022, and 8/2022. 3. Provide Resident 91 with intervention to prevent a decline in ROM of both legs and a decline in the ability to walk prior to changing Resident 91's RNA program from walking using a FWW to sit to stand transfers (ability to come to a standing position from sitting) on 9/15/2022. 4. Provide Resident 91 with intervention to prevent a decline in ROM of both arms and a decline in the ability to use both hands prior to applying hand rolls (soft fabric and positioned in the palm of the hand to protect from skin irritation) on 9/28/2022. 5. Provide Resident 91 with RNA services for sit to stand transfers and application of both hand rolls in accordance with the physician orders, dated 9/15/2022 and 9/28/2022, for the months of 12/2022, 2/2023, 3/2023, 9/2023, and 1/2024. 6. Provide Resident 91 with interventions to prevent further ROM loss in both arms and both legs when a decline was identified on Resident 91's Joint Mobility Assessment ([JMA] brief assessment of a resident's range of motion in both arms and both legs), dated 3/27/2024, in accordance with the facility's policy. 7. Ensure Resident 92, Resident 93, and Resident 113 were provided RNA services as ordered. These deficient practices caused Resident 91 to develop moderate joint mobility limitations (50 to 75 percent [50-75%] available ROM; 25-50% ROM loss) in both elbows, both wrists, and the right hand and minimal joint mobility limitations (75-100% available ROM; 0-25% ROM loss) in both hips, both knees, and both ankles, which limited Resident 91's ability to participate in activities of daily living ([ADLs] tasks related to personal care including bathing, dressing, hygiene, eating, transfers, and walking) and prevented Resident 91 from being able to stand upright. This deficient practice also had the potential to cause joint mobility limitations for Resident 92, 93, and 113. Cross reference F580, F641, and F657. Findings: 1. A review of Resident 91's Resident Status History List (record of hospitalizations and room changes) indicated the facility originally admitted Resident 91 on 11/14/2014, re-admitted Resident 91 on 4/21/2020, and discharged Resident 91 on 1/1/2023. A review of Resident 91's Face Sheet (admission record) indicated the facility admitted Resident 91 on 1/1/2023 with diagnoses including chronic obstructive pulmonary disease ([COPD] lung disease that causes constriction of the airways making it difficult or uncomfortable to breathe), intracranial injury (brain injury), and epilepsy (abnormal electrical activity in the brain marked by sudden, recurrent episodes of loss of consciousness or uncontrolled body shaking). A review of Resident 91's physician orders, dated 5/5/2020, included RNA for ambulation with front-wheeled walker ([FWW] an assistive device with two front wheels used for stability when walking) five times per week as tolerated. A review of Resident 91's JMA, dated 4/21/2021, indicated both of Resident 91's shoulders, elbows, wrists, hips, knees, and ankles were within functional limits ([WFL] sufficient movement without significant limitation). The JMA indicated Resident 91 had minimal to moderate joint mobility limitations to the left hand and had minimal joint mobility limitations in the right hand. A review of Resident 91's Minimum Data Set ([MDS] a comprehensive assessment and care planning tool), dated 2/15/2022, indicated Resident 91 had intact cognition (ability to think, understand, learn, and remember). The MDS indicated Resident 91 had a ROM limitation in one arm and no ROM limitations in both legs. The MDS indicated Resident 91 used a walker and wheelchair for mobility and required extensive assistance (resident involved in activity while staff provide weight-bearing support) for transfers between surfaces, walking in room, walking in the corridor, and eating. A review of Resident 91's Restorative Record ([RNA Record] record of RNA treatment sessions) for 2/2022 indicated the RNA Record included a weekly summary, dated 2/17/2022, which indicated Resident 91 required moderate assistance (requires 25-50% physical assistance) to maximum assistance (requires 50-75% physical assistance to perform the task) to stand up from the wheelchair and walked 30 to 40 (30-40) steps with rest breaks. A review of Resident 91's RNA Record for 3/2022 indicated the RNA Record had a slash (/) and did not have RNA initials to indicate a treatment was provided to Resident 91 for ambulation with a FWW on 3/1/2022, 3/4/2022, 3/14/2022, 3/16/2022, 3/25/2022, and 3/28/2022. A review of Resident 91's RNA Record for 4/2022 indicated the RNA Record had a slash (/) and did not have RNA initials to indicate treatment was provided to Resident 91 for ambulation with a FWW on 4/1/2022, 4/11/2022, 4/19/2022, and 4/25/2022. A review of Resident 91's RNA Record for 5/2022 indicated the RNA Record had a slash (/) and did not have RNA initials to indicate treatment was provided to Resident 91 for ambulation with a FWW on 5/2/2022, 5/4/2022, 5/5/2022, 5/10/2022, 5/11/2022, 5/12/2022, and 5/30/2022. A review of Resident 91's RNA Record for 7/2022 indicated the RNA Record had a slash (/) and did not have RNA initials to indicate treatment was provided to Resident 91 for ambulation with a FWW on 7/1/2022, 7/4/2022, 7/5/2022, 7/6/2022, 7/7/2022, 7/8/2022, 7/28/2022, and 7/29/2022. A review of Resident 91's RNA Record for 8/2022 indicated the RNA Record had a slash (/) and did not have RNA initials to indicate treatment was provided to Resident 91 for ambulation with a FWW on 8/1/2022, 8/11/2022, 8/25/2022, 8/26/2022, and 8/29/2022. A review of Resident 91's RNA Record for 9/2022 indicated the RNA Record included a weekly summary, dated 9/12/2022, indicating Resident 91 required maximum assistance to stand with two RNAs (unknown) and moderate to maximum assistance to maintain balance while walking with the FWW. The weekly summary also indicated Resident 91 dragged both feet while walking 10-20 short, slow steps with rest breaks. A review of Resident 91's Nurses Notes, dated 9/15/2022 timed at 9:30 a.m., indicated to discontinue the current RNA program and begin RNA to assist with a sit to stand program, every day, five times per week as tolerated. A review of Resident 91's physician orders, dated 9/15/2022 (untimed), indicated to discontinue current RNA program and begin RNA to assist with a sit to stand program, every day, five times per week as tolerated. A review of Resident 91's Nurses Notes, dated 9/28/2022 timed at 12:00 p.m., indicated the Occupational Therapist [[OT] profession aimed to increase or maintain a person's capability of participating in everyday life activities (occupations)] evaluated Resident 91 who had contractures (condition of shortening and hardening of muscles, tendons, or other tissue, often leading to joint stiffness) in both hands. The Nurses Notes indicated for RNA to apply hand rolls, every day, five times per week for four to six (4-6) hours or as tolerated. A review of Resident 91's physician orders, dated 9/28/2022 timed at 12:00 p.m., indicated for the RNA to apply both hand rolls, every day for 4-6 hours, five times per week or as tolerated. A review of Resident 91's RNA Record for 10/2022 included a weekly summary, dated 10/24/2022, indicating the RNA (unspecified) assisted Resident 91 to place hands on the hallway handrail and required moderate to maximum assistance to perform 5-10 repetitions of sit to stand exercises. The RNA weekly summary also indicated Resident 91 tolerated both hand rolls for 4-6 hours with checks every 2 hours as Resident 91 removed the hand rolls. A review of Resident 91's care plan for RNA, dated 11/15/2022, indicated Resident 91 required the RNA program to maintain and/or improve joint mobility. The goal for Resident 91 was to maintain maximum joint capacity (greatest possible amount) for the next three months. The care plan's approach (treatment) plan included to provide RNA program as ordered, position the resident to prevent further contractures with pillow or splint (material used to restrict, protect, or immobilize a part of the body to support function, assist and/or increase range of motion) as needed, and quarterly assessments of joint mobility or as needed. A review of Resident 91's RNA Record for 12/2022 indicated a slash (/) but did not have RNA initials to indicate treatment was provided for sit to stand exercises and application of both hand rolls on 12/1/2022, 12/2/2022, 12/5/2022, 12/26/2022, 12/28/2022, and 12/30/2022. A review of Resident 91's RNA Record for 2/2023 indicated a slash but did not have RNA initials to indicate treatment was provided for sit to stand exercises and application of both hand rolls on 2/1/2023, 2/2/2023, 2/6/2023, 2/8/2023, 2/9/2023, 2/17/2023, 2/20/2023, 2/21/2023, 2/22/2023, 2/23/2023, 2/27/2023, and 2/28/2023. A review of Resident 91's RNA Record for 3/2023 indicated a slash but did not have RNA initials to indicate treatment was provided for sit to stand exercises and application of both hand rolls on 3/1/2023, 3/9/2023, 3/16/2023, 3/17/2023, 3/20/2023, 3/21/2023, 3/22/2023, 3/23/2023, and 3/28/2023. A review of Resident 91's RNA Record for 4/2023 indicated a weekly summary, dated 4/24/2023, indicating Resident 91 required moderate to maximum assistance from two RNAs (unspecified) to perform 4-6 repetitions of sit to stand exercises, take breaks during exercises due to tiring easily, and required RNA encouragement to maintain an upright posture. The weekly summary also indicated Resident 91 tolerated both hand rolls for 4-6 hours with checks every 2 hours. A review of Resident 91's RNA Record for 9/2023 indicated a slash but did not have RNA initials to indicate treatment was provided for sit to stand exercises and application of hand rolls on 9/14/2023, 9/18/2023, 9/19/2023, 9/20/2023, 9/21/2023, 9/22/2023, and 9/27/2023. A review of Resident 91's RNA Record for 1/2024 indicated a slash but did not have RNA initials to indicate treatment was provided for sit to stand exercises and application of both hand rolls on 1/1/2024, 1/2/2024, 1/4/2024, 1/11/2024, 1/22/2024, 1/24/2024, 1/25/2024, 1/29/2024, and 1/31/2024. A review of Resident 91's MDS, dated [DATE] indicated Resident 91 had clear speech, expressed ideas and wants, had clear understanding of verbal content, and had moderately impaired cognition. The MDS indicated Resident 91 used a wheelchair for mobility, required substantial/maximal assistance (helper does more than half the effort) for sit to stand and chair/bed-to-chair transfers (ability to transfer to and from a bed to a chair or wheelchair), and walking 10 feet was not attempted due to medical condition or safety concerns. A review of Resident 91's Joint Mobility Assessment ([JMA] brief assessment of a resident's range of motion in both arms and both legs), dated 3/27/2024, indicated Resident 91 had moderate joint mobility limitations in both elbows, both wrists, both hands and minimal joint mobility limitations in both hips, both knees, and both ankles. The JMA indicated Resident 91 maintained assessed mobility and to continue the RNA program. A review of Resident 91's RNA Record for 4/2024 indicated a weekly summary, dated 4/15/2024, indicating Resident 91 required maximum assistance from two RNAs (unspecified) to perform 2-3 repetitions of sit to stand exercises with both knees bent and required encouragement to straighten posture. The weekly summary also indicated Resident 91 tolerated both hand rolls for 4-6 hours. During an interview on 4/15/2024 at 11:36 a.m., with the Director of Rehabilitation (DOR), the DOR stated the OT or Physical Therapist (PT, profession aimed in the restoration, maintenance, and promotion of optimal physical function) performed the JMA for each resident (in general) upon admission, annually (every year), and during a change of condition to monitor for ROM and mobility. The DOR also stated the JMA form also included a quarterly screening (on the back of the JMA form) of each resident for ROM and mobility. During a concurrent observation and interview on 4/16/2024 at 8:31 a.m., with Restorative Nursing Aide 2 (RNA 2) and RNA 3, in Resident 91's room, Resident 91's hands were in a closed fist position and Resident 91 was unable to open either hand. RNA 2 and RNA 3 applied hand rolls into Resident 91's palms. Resident 91 stated, This is the first time I remember these hand rolls. Resident 91 stated the RNAs usually applied terry cloth rags in his hands. RNA 2 and RNA 3 stated towel rolls were applied to Resident 91's hands when the hand rolls were washed. During observation on 4/16/2024 at 8:40 a.m., RNA 2 and RNA 3 wheeled Resident 91 into the hallway facing the hallway handrails. RNA 2 placed a cloth gait belt (assistive device placed around a person's waist to assist with safe transferring between surfaces or while walking) around Resident 91's waist and removed both hand rolls. RNA 2 was positioned on Resident 91's left side, and RNA 3 was positioned on Resident 91's right side. Each RNA placed Resident 91's hand onto the handrail and assisted the resident to stand from the wheelchair. Both of Resident 91's knees remained bent. Both of Resident 91's ankles were bent downward, causing Resident 91 to stand on the toes of both feet. Resident 91 performed two repetitions of sit to stand exercises. RNA 2 removed the cloth gait belt, and RNA 3 wheeled Resident 91 back to the room. During an interview on 4/16/2024 at 9:22 a.m., with RNA 2 and RNA 3, RNA 2 and RNA 3 stated Resident 91 used to walk years ago (unknown length of time). RNA 2 and RNA 3 stated Resident 91 required two people to perform sit to stand transfers because Resident 91 cannot stand without assistance and cannot stand all the way upright. During an interview on 4/16/2024 at 9:50 a.m., with Certified Nursing Assistant 4 (CNA 4), CNA 4 stated Resident 91 required assistance with feeding because she cannot hold a spoon. CNA 4 stated Resident 91 used to stand and transfer to a wheelchair and shower chair approximately 8 months ago. CNA 4 stated Resident 91 currently required a mechanical lift (device used to assist with transfers and movement of residents who require support for mobility) for transfers because Resident 91 had contractures (condition of shortening and hardening of muscles, tendons, or other tissue, often leading to joint stiffness) in both legs and cannot fully extend both legs. During a concurrent interview and record review on 4/16/2024 at 12:14 p.m., with the Director of Medical Records (DMR), Resident 91's Resident Status History List (record of hospitalizations and room changes) was reviewed. The DMR stated the facility re-admitted Resident 91 on 4/21/2020 and has remained at the facility since 4/21/2020. During a concurrent interview and record review on 4/16/2024 at 1:35 p.m., with the DMR, the DMR reviewed all of Resident 91's current clinical records binder and paper records for JMA records between 4/21/2021 and 3/27/2024. The DMR stated Resident 91's clinical record included 4/21/2021 and 3/27/2024 and was unable to locate any JMA for Resident 91 in 2022 and 2023. During a concurrent observation and interview on 4/16/2024 at 1:47 p.m., in Resident 91's room, Resident 91 was observed sitting on a wheelchair. Resident 91 stated she was unable to use both hands and required staff assistance for eating. Resident 91 stated she stopped walking when both of her knees started to change (unknown time). Resident 91 stated she had difficulty standing because both of her legs were weak and could not fully extend the legs. Resident 91 was observed extending both knees from a bent position while seated in the wheelchair but unable to completely extend knees. During a concurrent interview and record review on 4/16/2024 at 2:34 p.m., with the Director of Rehabilitation (DOR), the DOR stated Resident 91 had never received PT or OT services. The DOR searched the electronic documentation system for any PT and OT records on Resident 91 and was unable to locate any documentation. During an interview on 4/19/2024 at 10:55 a.m., with CNA 8, CNA 8 stated Resident 91 used to walk with a FWW and stood for transfers. CNA 8 stated Resident 91 started to slowly decline and not walk as much. CNA 8 stated Resident 91 currently required two people for transfers. During an interview on 4/19/2024 at 11:26 a.m., with RNA 2, RNA 2 stated Resident 91 could not hold onto a utensil and required assistance for eating. RNA 2 stated Resident 91 previously had a hand roll for the right hand (unknown time) but currently had hand rolls for both hands to prevent contractures. RNA 2 stated she did not know when Resident 91 started needing both hands rolls. RNA 2 stated Resident 91 used to help staff with dressing by standing in the shower room after showers and used to walk outside of the facility using the FWW. RNA 2 stated Resident 91 stopped walking about 2-3 years ago due to difficulty placing weight on both legs and started walking with both knees bent and on the tips of both feet. RNA 2 stated Resident 91 currently needs to be dressed in the bed after showers and required maximum assistance of two people to perform sit to stand exercises. RNA 2 stated Resident 91's decline in walking was reported to the charge nurse about 2-3 years ago. RNA 2 was unsure if the PT or the charge nurse changed the RNA order from walking using the FWW to sit to stand exercises. During an interview on 4/19/2024 at 11:55 a.m., with RNA 2, RNA 2 stated the slashes (/) in the RNA Record (in general) indicated there was no RNA available to provide the treatment so the resident did not receive RNA. During an observation on 4/19/2024 at 11:57 a.m. in the Recreation Room, Resident 91 slept while sitting up in the wheelchair. Both of Resident 91's hands were positioned in a closed fist and did not have any hand rolls applied to either hand. Both knees were bent and both ankles were bent with the toes pointing downward. Resident 91's wheelchair did not have any footrests (footplate attached to the wheelchair to allow the feet to rest and assist with positioning). During a telephone interview on 4/19/2024 at 2:04 p.m., with the DOR, the DOR stated the therapists completed a Joint Mobility Assessment [JMA] upon the resident's admission, checked in with the resident and nursing quarterly to determine if there was a decline in ROM or mobility, and then do another JMA annually. The DOR stated the JMA was completed to ensure a resident (in general) did not experience a decline or change in ROM or mobility. The DOR stated the therapist would report to nursing if there was a change or decline in the resident's JMA, provide therapy services to improve and maintain ROM, and provide RNA as necessary. The DOR stated the PT and OT services were important to attempt to restore and achieve a resident's highest practicable (capable of being done) independence with ADLs and prevent decline as much as possible. During a concurrent interview and record review on 4/19/2024 at 3:18 p.m., with MDS Coordinator (MDS 2) and the DMR, Resident 91's JMA, dated 4/21/2021, was reviewed. The DMR stated Resident 91's JMA was one-sided and did not include quarterly assessments, which were supposed to be located on the back of the double-sided JMA form, after 4/21/2021. MDS 2 stated Resident 91's JMA, dated 4/21/2021, indicated both of Resident 91's arms and legs were WFL for ROM except the right hand had minimal joint mobility limitations and the left hand had minimal to moderate joint mobility limitations. MDS 2 reviewed Resident 91's care plan for RNA, which included interventions to perform quarterly assessments of joint mobility. MDS 2 stated the therapy staff was responsible to perform the JMA quarterly. MDS 2 stated the facility did not follow Resident 91's care plan if Resident 91's clinical record did not include a JMA for 2022 and 2023. MDS 2 reviewed Resident 91's JMA, dated 3/27/2024, and stated Resident 91 had a decline in ROM in both elbows, both wrists, and the right hand from WFL to moderate impairments and a decline in ROM in both hips, knees, and ankles from WFL to minimal impairments. During a concurrent interview and record review on 4/19/2024 at 4:19 p.m., with MDS 2 and the Director of Nursing 2 (DON 2), Resident 91's RNA Records from 3/2022 to 9/2022 were reviewed. MDS 2 stated Resident 91 did not receive RNA for ambulation using a FWW, five times a week, in accordance with the physician orders for multiple dates during the months of 3/2022, 4/2022, 5/2022, 7/2022, and 8/2022. Resident 91's physician order, dated 9/15/2022, for RNA to assist with sit to stand program, five times per week as tolerated, and physician order, dated 9/28/2022, for RNA to apply both hand rolls, 4-6 hours, five times per week as tolerated were reviewed. DON 2 stated the therapists should have done an assessment to determine the RNA program and if hand splints (material used to restrict, protect, or immobilize a part of the body to support function, assist and/or increase range of motion), including the hand rolls, were appropriate. The DON 2 stated the facility did not maintain or improve Resident 91's mobility and ROM if Resident 91 did not receive any therapy services. Resident 91's RNA Records, dated 9/2022 to 4/2024, were reviewed. MDS 2 stated Resident 91 did not receive RNA for sit to stand exercises and application of both hand rolls, five times a week, in accordance with the physician orders for multiple dates during the months of 12/2022, 2/2023, 3/2023, 9/2023, and 1/2024. The DON 2 stated ROM exercises and therapy services were important to prevent a decline, including the development of contractures, and to increase ROM and mobility. DON 2 stated there was no documented evidence indicating Resident 91 received a JMA in 2022 and 2023, which was at least eight missed opportunities (every three months starting from 4/2022 to 3/27/2024) to monitor Resident 91's ROM. DON 2 reviewed Resident 91's JMAs, dated 4/21/2021 and 3/27/2024, and stated Resident 91 had a decline in ROM in both elbows, both wrists, the right hand, both hips, both knees, and both ankles. DON 2 stated there was no documented evidence Resident 91 received any ROM exercises to prevent ROM decline or further decline after a decline in ROM was identified on 3/27/2024. DON 2 and MDS 2 stated Resident 91's decline in mobility and ROM was preventable since the facility failed to properly screen Resident 91 quarterly and did not provide therapy services to prevent a decline in mobility and ROM, properly evaluate the use of splints, and determine the RNA exercise program to prevent ROM and mobility loss, including the development of contractures. DON 2 reviewed the facility's undated Policy and Procedures (P&P) titled, Activities of Daily Living (ADLs) and Prevention of Decline in Range of Motion. DON 2 stated the facility did not follow its policies to maintain Resident 91's ADLs, which included mobility, and prevent ROM decline. During an interview on 4/19/2024 at 5:25 p.m., with the DON 2, DON 2 stated the therapists should have performed an annual JMA on 4/2022. During an interview and record review on 4/19/2024 at 5:45 p.m., with the DMR, Resident 91's Face Sheet was reviewed. The DMR stated Resident 91's Face Sheet indicated an admission of 1/1/2023 since the facility merged two buildings into one license (legal authority to provide services). The DMR stated Resident 91 had not physically left the facility since re-admission on [DATE]. A review of the facility's undated P&P titled, Activities of Daily Living (ADLs), indicated the facility will ensure a resident's abilities in ADLs do not deteriorate unless deterioration is unavoidable which included the resident's ability to transfer, ambulate (walk), and eat. The P&P indicated the facility will provide a maintenance and restorative program to assist the resident in achieving and maintaining the highest practicable outcome based on the comprehensive assessment. A review of the facility's undated P&P titled, Prevention of Decline in Range of Motion, indicated a resident who enters the facility without limited range of motion will not experience a reduction in range of motion unless the resident's clinical condition demonstrated that a reduction in range of motion is unavoidable. The P&P also in[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure the resident, who was assessed as high risk for falls, was not left unattended on the bed raised from the floor above a safe height and without a floor mat next to the residents' bed for one of three sampled residents (Resident 1). The facility failed to: 1. Ensure a Certified Nursing Assistant (CNA 1) did not leave Resident 1 unattended on a elevated bed from the floor above safe level after feeding Resident 1 breakfast. 2. Ensure CNA 1 lowered Resident 1's bed after feeding the resident breakfast and before leaving the resident's room. 3. Ensure Resident 1 was provided with a safe environment as indicated in Resident 1's care plan titled Resident is at risk for falls and injuries related to dementia, impaired vision and hearing problems. 4. Ensure CNA 1 followed the facility Policy and Procedure (P&P) titled, Fall Prevention Program to minimize the likelihood of Resident 1 falling by having Resident 1's bed lowered to a level that allows the resident's feet to be flat on the floor when the resident is sitting on the edge of the bed. 5. Ensure CNA 1 placed a floor mat next to Resident 1's bed in accordance with the resident's care plan titled Risk is present Primarily as a Result of Physical Limitation. These deficient practices resulted in Resident 1 falling from the bed to the floor face down and sustaining two bumps on the forehead that required evaluation at an acute care hospital (GACH). According GACH's record, Resident 1 had a left frontal scalp (forehead) soft tissue swelling and hematoma (clotted blood that forms in the body due to broken blood vessels) to the head. Findings: During a review of Residents 1's face Sheet (admission Record), dated 6/16/2023, the face sheet indicated Resident 1 was originally admitted to the facility on [DATE], and readmitted on [DATE] with diagnoses including schizoaffective disorder (a mental illness that can affect a person's thoughts, mood, and behavior), epilepsy (a disorder of the brain characterized by repeated seizures), unspecified abnormality of gait and mobility. During a review of Residents 1's History and Physical (H&P), dated 9/29/2022, the H&P indicated, Resident 1 had a fluctuating capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set ([MDS] a standardized assessment and care screening tool), dated 5/10/2023, the MDS indicated Resident 1 was not able to recall information. The MDS indicated Resident 1 required a one-person physical assistance with bed mobility, transfer (how resident moves between surfaces including from bed, chair and standing position), walking eating, bathing, and locomotion. The MDS indicated Resident 1 required a two-persons physical assistance with dressing, toilet use and personal hygiene. During a review of Resident 1's care plan titled, Risk is Present Primarily as a Result of Physical Limitation dated 6/12/2023, the care plan indicated staff will perform frequent visual checks, ensure the floor was uncluttered, lighting was adequate, use personal or pressure sensor alarms (if ordered) when the resident was in a chair or bed, and floor mats when in bed. During a review of Resident 1's care plan titled, Resident is at risk for falls and injuries related to dementia, impaired vision and hearing problems dated 6/5/23, the care plan indicated staff will assess Resident 1 for propensity for falls, evaluate current fall prevention interventions, provide resident with safe and clutter free environment assess, anticipate, and intervene for factors causing prior falls. During a review of Resident 1's Fall Risk Assessment dated 6/12/23, the assessment indicated Resident 1 had a fall risk score of 16 and a score of 10 or greater indicated the resident had a high potential for falls. The fall risk assessment indicated a fall protocol should be initiated immediately and care planned. During a review of Resident 1's Body Assessment Post Incident report dated 6/15/2023, the report indicated Resident 1 had two bumps on the forehead. During a review of Resident 1's Physician order dated 6/15/23, the order indicated transfer to GACH. During a review of Resident 1's, Nurses Notes (NPN) dated 6/15/2023, the NPN indicated, during medication administration (Med Pass) on 6/15/2023, at 8:15 a.m., in Resident 1's room, the Licensed Vocation Nurse (LVN 1), observed Resident 1 lying face down on the floor next to her bed. The NPN indicated Resident 1 had labored breathing and was no longer stable. The NPN indicated upon assessing Resident 1, LVN 1 observed two bumps on Resident 1's forehead. According to the NPN, Resident 1 was assisted back to bed and observed to still have labored breathing and a hard time focusing. The NPN indicated Resident 1's heart rate was 144 beats (reference range is 60-100) per minute (bpm), respiration rate 26 (reference range is 16-20), oxygen saturation (amount of oxygen in blood) 86 (reference range is 90-100) percent ([%] unit of measurement). The NPN indicated Resident 1's was transferred to a GACH for further evaluation. During a review of Resident 1's Fall Investigation Report (FIR) dated 6/15/2023, the FIR indicated at 8:10 a.m., Resident 1 was found on the floor next to her bed. The FIR indicated Resident 1 tried to transfer herself unassisted and fell from the bed to the floor, in her room. The FIR indicated Resident 1 was bare feet, did not use a gait assist or an alarm at the time of the fall. The report also indicated Resident 1 appeared restless. During a review of Resident 1's Interdisciplinary team ([IDT] a group of healthcare providers from different fields who work together or toward the same goal to provide the best care or best outcome for residents) Meeting/Care Conference report dated 6/15/23, the report indicated CNA 1 left Resident 1 unattended on a bed after breakfast. The report indicated Resident 1's bed was left in higher-than-normal position, and the resident fell off the bed. The report indicated Resident 1 had no capacity to transfer herself and required a total assistance from staff. According to https://www.sondercare.com/learn/senior-caregiving/how-high-should-caregiver-raise-height-of-clients-bed/ a hospital bed has an adjustable height range. The height off the floor to the top of the mattress can be as low as 16 inches, with the upper limit going as high as 39 inches. A safe bed height is between 18 inches to 23 inches, roughly the same as the seat of a chair. During an interview on 6/28/2023 at 2:00p.m., LVN 1 stated on 6/15/2023, around 8:15 a.m., during med pass, he (LVN 1) walked into Resident 1's room but did not see Resident 1 in bed. LVN 1 stated he observed Resident 1's bed was in High Fowlers (the head of the bed elevated between 60 to 90 degrees), and the bed was elevated from the floor higher than normal. LVN 1 stated Resident 1's bed should be raised from the floor low enough for the resident's feet to touch the floor when in a sitting position. LVN 1 stated he observed Resident 1 was on the floor, next to her bed, facing down. LVN 1 stated he observed Resident 1 had two bumps on the forehead, was agitated and had trouble breathing. LVN 1 stated Resident 1's oxygen saturation was 70% and the resident was transferred to the GACH via 911. LVN 1 stated to prevent falls and injuries, Resident 1's bed should not have been elevated high from the floor and the resident should not have been left unattended on an elevated bed. During an interview on 6/28/23 at 3:20p.m., the Director of Nursing (DON) stated that on 6/15/2023, after feeding Resident 1 breakfast, CNA 1 took the meal tray out of the resident's room without lowering Resident 1's bed back in a low position and without ensuring the floor mat was in place to prevent Resident 1 from injuries in case she fell from the bed. The DON stated Resident 1 fell out of bed to the bare floor, was in respiratory distress and sustained two bumps on her forehead. The DON stated, when the bed is in high (elevated) position from the floor the resident is at risk for falling, especially when the resident lacking cognitive skills to assess surrounding environment safety properly to evaluate if he/she could fall or not. The DON stated, Resident 1 did not have any understanding of safety and as a resulted she fall out of bed. During a concurrent interview and record review on 6/28/2023 at 4:00p.m. with Human Resource (HR) 1, CNA 1's Counseling Record dated 6/15/2023 was reviewed. HR 1 stated, on 6/15/2023, CNA 1 forgot to put Resident 1's floor mat back after feeding the resident breakfast. HR 1 stated CNA 1 did not lower Resident 1's bed. CNA 1 left Resident 1 unattended after breakfast and forgot to lower the bed. Resident 1 fell from bed. During a review of the GACH emergency room (ER) note, dated 6/15/2023 the note indicated, Resident 1 had a hematoma (clotted blood that forms in the body due to broken blood vessels) to the head. During a review of the GACH computerized tomography ([CT] an imaging test that helps healthcare providers detect diseases and injuries) scan, dated 6/15/2023, the scan indicated Resident 1 had a left frontal scalp soft tissue swelling. During a review of the facility's Policy and Procedure (P&P) titled, Fall Prevention Program dated 2022, the P&P indicated, Each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls. The P&P indicated the resident's bed is locked and lowered to a level that allows the resident's feet to be flat on the floor when the resident is sitting on the edge of the bed. The P&P indicated staff will monitor changes in resident's cognition, gait, ability to rise/sit, and balance and then provide additional interventions as directed by the resident's assessment, including but not limited to a low bed. During a review of the facility's P&P titled, Safety and Supervision of Residents undated, the P&P indicated, Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accident are facility-wide priorities .Employees shall be trained and in-serviced on potential accident hazards and how to identify and report accident hazards and try to prevent avoidable accidents.