**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, four problems were identified regarding the facility's fall prevention program: 1. The facility did not regularly conduct a thorough investigation regarding the primary causes of falls for Resident 1. 2. The facility did not conduct a fall risk assessment for two of Resident 1's falls. 3. The facility continued using a tab alarm (an alarm that clips onto a resident's clothing) to alert staff for unassisted transfers for Resident 1 who has a history of unclipping the tab alarm from her clothing. The facility did not evaluate if a tab alarm was appropriate for Resident1 in decreasing her fall risks. 4. Staff did not consistently implement interventions within Resident 1 's care plans to minimize fall risks for Resident 1 (application of tab alarm or activation of bed alarm). These failures resulted in four falls for Resident 1, one of two sample residents within four months (April to August 2024). On 08/05/2024, Resident 1 fell and fractured all five of her right toes. Findings: Review of Resident 1's medical records titled MINIMUM DATA SET (MDS, a standardized resident assessment tool), dated 02/11/2025, indicated Resident 1: 1. Had memory problems and was moderately impaired in decision making and problem solving. 2. Needed substantial/maximal assistance with toileting and chair/bed to chair transfers. 3. Had no voluntary control over bowel and bladder functions. Review of Resident 1's medical records titled Event Report, dated 08/08/2024, indicated Resident 1 had multiple diagnoses including: dementia (a progressive decline in mental abilities, impacting memory, thinking, and behavior); Parkinson's disease (a progressive brain and spinal cord disorder affecting movement, causing tremors, stiffness, and slow movement, as well as non-movement symptoms like sleep problems and mood changes); depression (a mental health condition with display of persistent low mood, loss of interest, and low energy) ; anxiety (feelings of uneasiness, worry, or dread, often accompanied by increased heart rate, sweating, and tension); osteoarthritis (progressive break down of joint tissues over time); extrapyramidal and movement disorder (a drug-induced movement disorders causing involuntary movements, muscle contractions, and other motor problems). Review of Resident 1's medical record titled Morse Fall Scale (a fall risk assessment tool), dated 04/26/2024, indicated she was assessed as at high risk for falls. Review of Resident 1's medical record titled Care Plan History, dated 03/01/2024, indicated .Resident has bed alarm when on bed/ tab alarm when up on wheelchair; at risk for fall . Review of Resident 1's medical record titled Event Report, dated 04/05/2024, indicated .(Resident 1) SLIDE FROM HER WHEELCHAIR DOWN TO THE FLOOR. FALL IS UNWITNESSED. WHILE ON BED, BED .(ALARM) IS ON AND TAB ALARM IS ATTACHED-SO . WILL NOT FORGET TO PUT ON WHILE ON .(wheelchair). During an observation of Resident 1 on 04/28/2025 at 12:17 PM with the Assistant Director of Nursing (ADON), Resident 1 was seated in her wheelchair out in the hallway. Resident 1 was able to unclip her tab alarm unassisted. During a concurrent interview and record review on 04/28/2025 at 12:36 PM, the Director of Nursing (DON) stated after a fall, she expected staff to conduct a huddle (meeting) to discuss the fall, identify potential causes of the fall, and formulate interventions. The DON stated these huddles were documented in their IDT (interdisciplinary= a group of health care professionals with various areas of expertise who work together in providing resident care) notes. The DON reviewed the IDT note for the 04/05/2024 fall. After reviewing the IDT note, the DON stated the IDT charting was unclear regarding if: 1. A tab alarm was applied by staff while Resident 1 was in her wheelchair. 2. The tab alarm was removed by Resident 1. The DON stated Resident 1 has a history of removing her tab alarms. 3. The tab alarm malfunctioned. The DON stated the tab alarm may not have been applied prior to the fall on 04/05/2024 as one of the interventions(s) documented was attachment of the tab alarm while in bed so staff will not forget to put tab alarm on while on wheelchair. The DON was asked: 1. For documented evidence staff were reminded to apply Resident 1's tab alarm when she was in her wheelchair. The DON was unable to provide the requested document. 2. If staff knew Resident 1 had the ability to unclip her tab alarm, should staff have considered using a different device to manage her fall risk? The DON stated yes. 3. What other interventions staff could have implemented? The DON stated it would have been more appropriate to use a tamper proof alarm such as a seat belt alarm that alarms when unbuckled. Review of Resident 1's medical record titled Resident Progress Notes, IDT, dated 04/21/2024, indicated at 4:10 AM .while writer making rounds, found resident sitting on the floor with her wet beddings all around her and wet pads and diapers all around her. Asked resident why she's on the floor, resident unable to directly relate why she's on the floor . Writer . presumed, resident walk to the bathroom .and upon returning to bed, trying to look for a pad and ended on the floor. Writer and other staff hadn't heard . (Resident 1 fall). During a concurrent interview and record review on 04/28/2025 at 12:36 PM, after reviewing the IDT note for the 04/21/2024 fall, the DON stated it was not clearly documented if Resident 1's bed alarm was activated and/or malfunctioned. The DON was unable to provide evidence if staff investigated after the fall to see if the bed alarm was activated prior to the fall or if the bed alarm was functioning. Review of Resident 1's medical record titled Resident Progress Notes, IDT, dated 07/04/2024, indicated At around 11 am . heard .(Resident 1) shouting and found .(Resident 1) on the floor in her bathroom.(Resident 1) on her left side facing the wall. As per .(Resident 1) she was trying to get up from the toilet seat and fell. Noted that .(Resident 1's) walker is outside the bathroom and .(Resident 1) removed the tab alarm. Review of Resident 1's medical record titled Resident Progress Notes, IDT, dated 07/04/2024, indicated there was IDT meeting after her fall. Staff documented .(non-compliant) regarding the call light even she is reminded to use .(her call light) and .(Resident 1) many times remove the tab alarm . During a concurrent interview and record review on 04/28/2025 at 12:36 PM, after reviewing the IDT note for the 07/04/2024 fall, the DON stated Resident 1 was either forgetful and/or non-compliant with using her call light to ask for assistance with transfers. The DON stated reminders to use call lights or reminding Resident 1 to ask for assistance may not be the most effective way to decrease her fall risks. The DON stated more frequent checks to assess toileting needs and/or more frequent supervision might have been more appropriate. Review of Resident 1's medical record titled Resident Progress Notes, IDT, dated 08/6/2024, indicated .Around .(10:15 PM, on 08/05/2024), Reported by .(staff) - Resident was found sitting on the floor in her room, legs extended. Per resident, ' I thought it was . (Hannukah=a late December religious Jewish holiday) so I was trying to get to dinner and then I fell ' . Resident with confusion Resident's walker was beside her bed. Review of Resident 1's Medical record titled X-ray of the right foot, dated 08/07/2024, indicated Fractures of the distal necks of the 2nd through 5th metatarsals (2nd, 3rd, 4th and 5th toes) and fracture of the medial aspect (middle/center section) of the head of the metatarsal of the great toe appear acute (sudden onset). During a concurrent interview and record review on 04/28/2025 at 12:36 PM, after reviewing the IDT note for the 08/05/2024 fall, the DON stated the IDT notes failed to identify if the bed alarm was activated or was not functioning properly. The DON stated staff at the Quality department may have more information regarding this fall. The DON stated she will ask the department to send over more information. Review of a document titled FRAMEWORK FOR ROOT CAUSE ANALYSIS AND CORRECTIVE ACTIONS, dated 08/05/2024, indicated staff did a root cause analysis of the fall on 08/05/2024 and concluded .Bed alarm was not utilized . During an interview on 04/28/2025 at 3:48 PM, the Clinical Quality Analyst (CQA) stated she only conducted a root cause analysis on Resident 1's fall dated 08/05/2024. The CQA stated she did not conduct a root cause analysis on Resident 1's other falls on 04/05/2024, 04/21/2024, and 07/04/2024. Review of the facility's policy titled Fall Prevention and Management, revised on January 2025, indicated . PURPOSE .Appropriate interventions used to reduce falls and fall-related injuries A fall risk assessment . will be conducted by the registered nurse and documented in the medical record . After a fall . During a concurrent record review and interview on 05/14/2025 at 1:00 PM, the ADON was asked to provide documented evidence fall risk assessments were conducted after Resident 1's falls on 04/05/2024, 04/21/2024, 07/04/2024, and 08/05/2024. The ADON searched Resident 1's medical records and was unable to provide documented evidence a fall risk assessment was conducted after Resident 1 fell on [DATE] and 07/04/2024. During an interview on 05/15/2025 at 1:50 PM, the DON stated her expectation was staff should conduct a fall risk assessment after each fall within 72 hours. The DON also stated falls regardless of injuries are treated as unusual occurrences and should be thoroughly investigated to determine root cause(s) and appropriate intervention(s) implemented to reduce fall risks.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to prevent the development of an avoidable pressure ulcer (PU) for one of 14 sampled residents (Resident 22) when interventions were not implemented to avoid skin breakdown for Resident 22. This deficient practice resulted in the development of Stage 2 PU for Resident 22. Definition/Stages for Pressure Ulcer/Pressure Injury (also called a bed sore, is an injury to skin and underlying tissue resulting from prolonged pressure on the skin. Stage I: Intact skin with a localized area of non-blanchable redness (non-blanchable: redness persists and does not fade or turn white after removal of fingertip pressure). Stage II: Partial-thickness loss of skin with exposed upper skin layer. The wound bed is pink. May also present as an intact or ruptured blister. Fat tissue and deeper tissues (muscle, tendons, bone) are not visible. Findings: Resident 22 was admitted on [DATE] with diagnoses including hemiplegia (complete paralysis on one side of the body) and hemiparesis (partial weakness on one side of the body) and diabetes (abnormally high sugar level in the blood). The facility assessed Resident 22 as high risk for developing pressure ulcers. Review of Resident 22's Minimum Data Set (MDS - an assessment tool) dated 7/6/23 indicated, Resident 22 needed extensive assistance with bed mobility, was always incontinent with bladder and bowel functions, and had impairment on one side of both upper and lower extremities. Resident 22 had no pressure injuries on admission. During an initial tour observation on 01/29/24 at 3:04 PM, Resident 22 was lying in bed with pillow under his head, watching on his laptop. There was no device to offload pressure from his coccyx (tailbone). During a concurrent interview and record review on 2/2/24 at 11:31 AM with RN 2, Resident 22's Wound Management Detail Report (WMDR) dated 8/9/23 was reviewed. The WMDR indicated, Resident 22 was observed on 8/4/23 to have a PU on the coccyx with a measurement of 1 centimeter by 1 centimeter (1 cm x 1 cm). RN 2 said, the Stage 2 PU was discovered on 8/2/23 and was facility acquired. Review of Resident 22's WMDR dated 8/11/23 indicated, Resident 22 had a Stage 2 injury on his coccyx with a measurement of 2.5 cm x 1 cm, with irregular wound edges and declining wound healing status. The facility was waiting for the delivery of the low air low mattress (LAL - mattress designed to prevent and treat pressure wounds). Review of Resident 22's WMDR dated 9/1/23 indicated, Resident 22 was observed on 8/31/23 to have a Stage 2 injury on his coccyx measuring 3 cm x 1.4 cm x 0.2 cm, irregular wound edges with slight maceration (softening and breaking down of skin resulting from prolonged exposure to moisture) and declining wound healing status. The facility was waiting for the delivery of the LAL mattress. Review of Resident 22's Physician Order Report dated 8/1/23 through 8/31/23 indicated, Resident 22 had an order for LAL mattress related to (r/t) pressure ulcer and to prevent further skin breakdown every shift with a start date of 6/29/23. Review of Resident 22's Treatment Administration Record (TAR) dated 7/1/23 through 7/31/23, 8/1/23 through 8/31/23, and 9/1/23 through 9/12/23 indicated, order for LAL mattress was not administered pending delivery of the mattress. Review of Resident 22's Interdisciplinary Team (IDT) Note dated 8/18/23 indicated, Resident 22 had a Stage 2 PU on coccyx with new measurement of 2 cm x 3 cm and excoriation on bilateral buttocks with redness throughout the area observed. The facility was waiting for LAL mattress to get installed. During a concurrent interview and record review on 2/5/24 at 10:12 AM, with RN 3, Resident 22's Progress Notes (PN) was reviewed. The PN dated 6/29/23 through 7/30/23 did not indicate RN was notified of a change in Resident 22's skin condition. The PN dated 8/2/23 indicated, CNA (Certified Nursing Assistant) reported wound on resident's coccyx area, a Stage 2 PU and an excoriated bilateral buttock. RN 3 said, Stage 1 pressure injury was not identified, and stated, I don't see any report if there's redness, excoriation before it turned to Stage 2. RN 3 added, If it was identified at an early stage, we could have prevented it going to Stage 2. During a concurrent wound care observation and interview on 2/5/24 at 11:18 AM, with the Treatment Nurse (TN), the TN explained that she will do wound treatment on the resident's coccyx. Resident 22 was lying in bed with a pillow under his head, watching on his laptop. There was no device implemented to offload pressure from his coccyx. TN said, Resident 22's coccyx had an open wound with scant amount of pink drainage. During a concurrent observation and interview on 2/13/24 at 11:22 AM, with CNA 2, Resident 22 was in bed, lying on his back with a pillow under his head. There was no device implemented to offload pressure from his coccyx. CNA 2 said Resident 22 has a wound on his back and stated, We usually put a pillow when he's on his side or when on his back. CNA 2 acknowledged that there was no pillow placed under his back. Review of Resident 22's Care Plan (CP) edited on 12/22/23, indicated the following: .Problem: Risk for Skin Breakdown secondary to (s/t) Pressure Injury r/t diagnosis (DX), disease process . Goal: Patient will remain free from skin breakdown or any pressure injury x 90 days .target date: 4/3/24. Approach: Assess the overall condition of the skin every shift. Report to MD if new skin issue; Patient on special mattress (LAL); Remind the CNA to report to Team Leader (TL)/RN if there's any skin issues noted especially during activities of daily living (ADL) care .created 8/4/23 . Review of Resident 22's CP created on 2/2/24, indicated the following: .Problem: Resident's skin has actual impairment: Stage 2 Pressure Ulcer on coccyx .Problem start date: 8/2/23 . Goal: Will have no complications through the review date .target date: 4/2/24. Approach: Monitor for increase in size and any changes in wound appearance; Wound Care follow up; Off-load affected area. Reposition every 2 hours or as needed; Administer treatment as ordered . Review of facility policy titled Skin Care, Pressure Injury, and Wound Management last revised on 1/22 indicated, .II. Skin Inspection .B. Monitoring:1. The CNA checks the patient's/resident's skin during skin and routine care and turning schedules and reports any new skin issues to licensed nurses .III. Interventions .B. Care and Interventions: 1. The care and intervention for skin breakdown/wounds is intended to prevent wound advancement and/or additional skin breakdown .3. Wound Care Nurse .b. Nursing driven treatments may include .use of therapeutic support surfaces, and offloading measures . The Journal of Legal Nurse Consulting, Volume 23 Spring 2012 indicated, Pressure ulcers occur over bony prominences like the heels, sacrum, ischial tuberosities (sitting bones) or the greater trochanters (hip bones). Pressure, coupled with other comorbid states (medical conditions that are simultaneously present in a patient) such as diabetes, can further complicate treatment and increase risk. Pressure can be lessened by implementing an appropriate pressure-redistribution support surface to both the seated and recumbent (lying) surfaces that the patient's body contacts at the first sign of risk.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident 70 was admitted on [DATE] with diagnoses including dementia, delusional disorders and anxiety disorder. Review of Resident 70's Physician Order Report dated from 2/1/24 through 2/29/24 indicated, .Start Date 11/30/23 .Citalopram 10 mg (milligram) 1 tab (tablet) oral once a day . Review of Resident 70's Medication Administration Record for December 2023 indicated, .Citalopram 10 mg 1 tab oral once a day . was administered on 12/1/23 through 12/31/23 at 8 AM. Review of Resident 70's Medication Administration Record for January 2024 indicated, .Citalopram 10 mg 1 tab oral once a day . was administered on 12/1/23 through 12/31/23 at 8 AM. Review of Resident 70's Medication Administration Record for January 2024 indicated, .Citalopram 10 mg 1 tab oral once a day . was administered on 1/1/24 through 1/31/24 at 8 AM. Review of Resident 70's admission MDS dated 7/18/23 and quarterly MDS dated 1/11/24 indicated, Resident 70 was admitted with diagnoses including dementia and anxiety disorder. Diagnosis of depression was not coded on the MDS. During a concurrent interview and record review on 2/7/24 at 2:16 PM with Registered Nurse (RN)3, Resident 70's History and Physical was reviewed. RN3 stated, I cannot find any diagnosis of depression. Review of Resident 70's Physician Order Report dated from 2/1/24 through 2/29/24 indicated, .Start date: 7/13/23 .End date: open-ended .lorazepam 0.5 mg every 4 hours PRN . During an interview on 2/5/24 at 3:14 PM with Pharmacist 1, Pharmacist 1 said, MRR is done monthly, and all medications are reviewed. Identified irregularities are communicated to the RN and the physician. For psychotropic medications, Pharmacist 1 said, PRN medications are recommended for 14 days and should be renewed after. 3. Resident 86 was admitted on [DATE] with diagnoses including mood disorder (described by marked disruptions in emotions), major depressive disorder (medical illness that negatively affects how you feel, the way you think and how you act). Review of Resident 86's Physician Order Report dated 12/1/23 through 12/31/23 indicated, .Start date 11/27/23 Risperdal (Risperidone) 1 mg 1 tab oral at bedtime .for mood disorder . Review of Resident 86's Pharmacy Services: MRR dated 11/26/23 and 12/13/23 indicated, .D (diagnosis): Mood Disorder (need to be more specific): Risperidone 0.5 mg .Irregularities: Mood Disorder is not an appropriate diagnosis for antipsychotic use .it may be viewed as a chemical restraint especially when used in the post-acute care (long term care, skilled nursing facilities) . Review of Resident 86's admission MDS dated 11/27/23 indicated, Resident 86 was admitted with diagnoses including stroke and depression. Diagnosis of psychotic disorder was not coded on the MDS. During an interview on 2/5/24 at 11:16 AM with RN3, RN3 stated, I don't see any diagnosis of psychosis, only depression and mood disorder. Review of Resident 86's Physician Order Report dated 2/1/24 through 2/29/24 indicated, .Start date: 12/13/23 .End date: open ended .lorazepam 0.5 mg BID (twice a day) PRN . Review of Resident 86's Pharmacy Services: MRR dated 12/13/23 indicated, .D: Anxiety: Lorazepam 0.5 mg ordered as PRN and without frequency .Need to have specific frequency and duration of therapy . During an interview on 2/5/24 at 3:14 PM with Pharmacist 1, Pharmacist 1 acknowledged that identified irregularities for the use of Lorazepam by Resident 86 were uncorrected by the physician. Based on interview and record review, the facility failed to ensure three of eight sampled residents (Residents 409, 70, and 86) were free from unnecessary psychotropic medications (drugs that affect brain activities associated with mental processes and behavior) when the facility did not ensure: 1.Resident 409 a. was free from side effects due to the use of Haldol. Haldol is an anti-psychotic drug used to treat symptoms of psychosis. Symptoms of psychosis includes hallucinations (perceiving sights, sounds, smells, tastes, or touches that are not real), delusions (false beliefs), and dementia (loss of the ability to think, remember, learn, make decisions, and solve problems). b. Aggressive behaviors were managed via non-medication means such as modifying smoking rules. c. Haldol dosage was not lowered for 96 days when side effects were first identified. 2. Resident 70 a. there was no clinical indication for the use of Citalopram (an antidepressant drug). b. order for Ativan (also known as lorazepam, a medication used to treat anxiety [a condition characterized by extreme fear and worry that interferes with daily activities]) PRN (as needed) did not have a stop date. 3. Resident 86 a. there was no clinical indication for the use of Risperdal (an antipsychotic medication). b. order for Ativan PRN did not have a stop date. These failures led to Resident 409 developing side effects from the use of Haldol and being put on Ingrezza. Ingrezza is a medication to counteract the side effects of Haldol. For Residents 70 and 86 these failures had the potential for them to receive unnecessary psychotropic medications, be exposed to adverse health consequences from the medications, which could negatively impact the residents' mental, physical, and psychosocial well-being (having to do with the mental, emotional, and social aspects of a resident's life). Findings: 1. Review of Resident 409's record titled Minimum Data Set assessment (MDS - a standardized resident assessment tool), dated 01/11/2024, indicated he had multiple admissions and discharges to the facility. The last admission was dated 12/27/2023. He was admitted to the facility with multiple diagnoses including anxiety disorder, vascular dementia with behavioral disturbances (blood vessel related loss of intellectual ability manifested by verbal or physical aggression, agitation and/or wandering). According to his MDS, he scored 6 out of 10 on his Brief Interview for Mental Status assessment (BIMS - assessment tool used to determine mental status and memory). A BIMS score of 6 indicated, Resident 409 had severe problems with reasoning and memory. His MDS indicated he had no physical behavior directed towards others (hitting, kicking, pushing, grabbing), no verbal behavior directed towards others (threatening others, screaming or cursing at others) and no other behaviors not directed toward others. Review of Resident 409's record titled Physician Orders, dated 1/1/2023, indicated, he has been on Haldol 5 mg (milligram) twice a day since 1/1/2023, to treat a major neurocognitive disorder with behavioral disturbances continues screaming; yelling. Major neurocognitive disorder is a decreased mental function due to a medical disease other than a mental illness. Review of Resident 409's record titled Medication Regimen Review (MRR), dated 10/18/2021, indicated, .NUMEROUS REPORTS OF AGRESSION, SCREAMING AND YELLING-TYPICALLY IN SETTING OF WANTING TO SMOKE. Review of Resident 409's record titled Consult Note - Psychiatry, dated 10/30/2021, indicated, .Psychiatry re-consulted after episode of agitation, via telephone today, when .(resident) was refusing to respond to limits set and escalated, refusing .(to) allow lighter to be taken away and refusing to listen to RN (Registered Nurse). During an interview on 2/14/2024 at 7:48 AM, RN 3 stated Resident 409's aggressive behaviors seem to be centered around smoking. During an interview on 2/14/2024 at 8:01 AM, Certified Nursing Assistant (CNA) 3 stated Resident 409 can be .anxious when you are like not on time with what he wants. He doesn't really want to wait. to be change or for his medications. when he pushes the call light, he wants it immediately. CNA 3 was asked if Resident 409's aggressive behaviors were centered around not getting his cigarettes on time, running out of cigarettes, and an inability to keep his own lighter, CNA 3 stated, Yes. During an interview on 2/14/2024 at 9:50 AM, the Director of Infection Prevention (DIP) stated, We were cited previously for not having a structured smoking program in place to make sure residents were safe. So, we put one in place and this is the consequence of that. Some residents can get agitated, when there's a change. The above record reviews and staff interviews were shared with the DIP. The DIP agreed that issues around smoking appear to be a trigger for Resident 409's aggressive behaviors. The DIP was asked if the facility was medicating Resident 409 for a facility imposed smoking restrictions such as: scheduled smoking times, restrictions to cigarettes, and giving up his lighter, the DIP did not verbally answer and just shrugged his shoulders. Review of Resident 409's record titled PHARMACY SERVICES MRR CHART REVIEW, dated 03/23/2023, indicated, Resident 409 had side effects associated with Haldol. Staff charted Resident 409 was on .(Haldol) 5MG . (twice a day).RESIDENT OBSERVED WITH JAW GRINDING AND CLENCHING, SIALORRHEA. (excessive saliva production and drooling) HALDOL IS KNOWN TO CAUSE SIALORRHEA, DYSPHAGIA, AND SWALLOWING ISSUES. Review of Resident 409's record titled Prescription Order, dated 6/27/2023, indicated he was not started on Ingrezza, a medication to treat Haldol's side effects, until 6/27/2023. During an interview on 2/14/2024 at 9:49 AM, Pharmacist 1 stated that there was a delay in starting Ingrezza as this was a specialty medication that required a third party approval. Pharmacist 1 was asked if decreasing Haldol dosage while waiting for the Ingrezza to be approved was a viable clinical option, Pharmacist 1 said Yes, the team would recommend that. Review of Resident 409's records titled History and Physical, dated 1/23/2023, and Initial Medication Regimen Review, dated 1/11/2024, indicated Resident 409's Haldol has not been lowered. Resident 409 has been on Haldol 5 mg twice a day for this entire time.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure resident comfort is achieved in accordance with comprehensive person-centered care plan when physician's order of No turning on Right Side was not implemented for one of 33 sampled residents (Resident 33). The deficient practice resulted in Resident 33 having a headache and discomfort, and had the potential to cause further brain tissue injury and increase intracranial pressure (pressure inside the skull). Findings: Review of Resident 33's History and Physical Report dated 12/13/21, indicated, Resident 33 was admitted to the facility on [DATE] with the following diagnoses: i. Right-sided hemorrhagic stroke (a condition in which a blood vessel breaks and bleeds into the brain), ii. Right hemicraniectomy on 6/26/19 (a surgical procedure where a large flap of the skull is removed to give space for the swollen brain to bulge and reduces the intracranial pressure), iii. Seizure (a sudden, uncontrolled electrical disturbance in the brain) and iv. Constantly recurring left-sided pain. The Minimum Data Set (MDS, a resident assessment tool) comprehensive assessment dated [DATE], indicated Resident 33 was cognitively intact. Under Section J 400, the pain assessment indicated, Resident 33 was frequently in pain and was receiving routine and as needed pain medications for pain management. During an observation on 2/10/22, at 10:33 AM, a sign posted on the wall by the left side of the bed indicated, NURSING ALERT (PLEASE READ BEFORE GIVING CARE). Another sheet was attached after the nursing alert sign, it indicated, DO NOT TURN PATIENT TO THE RIGHT SIDE. During a concurrent interview, Resident 33 stated she reminded Certified Nursing Assistant (CNA) 4 not to turn her on the right side but continued to do so. Resident 33 stated, It happened during diaper change. I was pushed to the left side and right side. My left side does not work (referring to weakness on left side of the body) and it (left side of the body) hurts all the time. I have something on my head (pointing at the bulging area on the right side of her head). The History and Physical Report dated 12/13/21, indicated, .Her craniotomy on the right side is without the scalp plate and she is wearing a protective helmet at the movement . At present, the patient's main issue is her chronic pain on the left side of her body, for which she was referred to Pain Clinic. She was also referred to Neurosurgery Specialty Clinic in (Name of facility) and (Name of facility) Neurosurgery Department to cover for her right craniotomy with a scalp plate . Head: Bulging of the right side of the head. Soft, nontender, no erythema, no discharge . During an interview on 2/10/22, at 10:42 AM, Charge Nurse (CN) 2 stated Resident 33 had a right hemicraniectomy and should not be turned on her right side. CN 2 explained that a Nursing Alert sign of do not turn patient on right side was posted on the wall as a reminder for the staff providing care for Resident 33. CN 2 confirmed during the evening shift on 5/19/21, Resident 33 complained of a headache after CNA 4 turned her on the right side. CN 2 stated, She's not supposed to be turned on her right side. There's no bone in there (referring to the bulging area on the right side of her head). During an interview on 2/10/22, at 2:35 PM, Resident 33 was asked how she felt after she was turned on her right side on 5/19/21, Resident 33 stated, I was in pain. There's a sign do not turn on right side but she kept going. My right side hurt. My head hurt. During an interview on 2/14/22, at 4:38 PM, CNA 4 stated she was told by Resident 33 not to turn on her right side during care on 5/19/21. CNA 4 acknowledged she did not know Resident 33 cannot be turned on her right side. CNA 4 stated, I did not see the note posted on the wall. I was told by other CNAs not to turn on her right side after she complained of pain on the head. I was not aware of the care plan. I have not read her care plan. Review of the Patient Care Notes, dated 5/20/21, indicated, .CNA (referring to CNA 4) pushed her on her R (right) side even when she's telling the CNA (referring to CNA 4) to stop & don't turn on the right side . Pt. c/o (patient complained of) slight pain on her R side, the head & shoulder. Review of the 5-DAY INVESTIGATION SUMMARY, dated 5/24/21, indicated, .On 5/20/2021 at approximately 0830, (Resident 33) reported to the charge nurse . the CNA (Certified Nursing Assistant) from the night before (5/19/2021), pushed her hard to the right side lying position even if she had just told her that she did not want to be turned . (Resident 33) mentioned to CNA that there are instructions posted that she cannot be turned to the right . after CNA pushed her, she felt pain on the right shoulder and right side of neck . Review of Resident 33's Physician's Orders, dated May 2021, indicated, No turning on Right Side Q (every) SHIFT ordered on 12/5/19. Review of Resident 33's care plan indicated the following: a. The Activities of Daily Living (ADL) care plan, started on 12/5/19 and revised on 6/2/21, indicated, .13. No turning on right side as ordered. b. The Pain care plan, started on 12/8/19 and revised on 6/2/21, indicated, Potential for pain and discomfort r/t (related to) Right hemorrhagic stroke . right hemi craniotomy with left side hemiplegia (paralysis of one side of the body), chronic left side pain . 1. Check pain level Q (every) shift and medicated per pain scale . Check patient 30-60 minutes after medication if relieved or not. 2. Repositioning/turning for comfort to relieve pressure . Review of the facility's policy and procedure titled, Plan of Care, dated 9/2019, indicated, . (Name of the facility) must develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meets professional standards of quality care . 1. The comprehensive plan of care shall include: a. The frequency at which care, services, treatments, and interventions will occur b. The IDT member(s) responsible for providing the care, treatment, interventions . d. Current needs, problems, goals, care, treatment and services . 3. The evaluation of the resident's progress is made based upon the care plan goals and the resident's plan of care, treatment and services.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide preventative treatment, equipment, and services to maintain, improve, and prevent further decline in range of motion (ROM) and/or mobility when: 1. The physician's order for hand splint and rolled bath blanket at lumbar spine were not implemented for Resident 33. The deficient practice resulted in pain, further increase in contractures, and decline in ROM for Resident 33. A contracture is a condition of shortening and hardening of muscles, tendon or other tissue, often leading to deformity and rigidity of joints which limit and interfere with daily functioning. 2. The Physical Therapist (PT) recommendation to ambulate with staff supervision was not implemented for Resident 46. The deficient practice could potentially contributed to Resident 46's decline in range of motion, mobility and pressure injuries on left and right foot. 3. The physician's order for hand splint was not implemented for Resident 44. The deficient practice could potentially worsen the stiffness of Residdent's 44 hands and further decline in ROM. 4. Residents 65 and 127 missing splints were not promptly replaced. The deficient practice could potentially worsen the contractures and decline in ROM for Resident 65 and Resident 127. 5. The physician's order for range of motion exercise was not implemented for Resident 76. The deficient practice could potentially resulted in pain, further increase in contractures, and decline in ROM for Resident 76. 6. There was no evidence Resident 111's private caregivers was given education and training in performing ROM excersice and the use of Active Passive Trainer (APT, a unique exercise rehabilitation trainer for the upper or lower limbs) machine to aid in improving the ROM. In addition, there is no evidence a physician's order was obtained, an assessment and care plan were completed prior to the use of APT machine. The deficient practice could potentially contribute in further pain and increase in contractures of Resident 111. 7. The physician's order for hand roll was not implemented for Resident 66. This deficient practice had the potential for Residents 66's contractures to worsen and cause further decline in ROM. A hand roll is a rubber device or rolled washcloth used to maintain joint positioning and further prevent joint deformity. 8. PT and Occupational Therapy (OT) initial and/or quarterly evaluation assessment was not completed for Resident 100, 11, and 133. The deficient practice could result residents not receiving the proper services or treatment to address their needs. 9. Resident-centered and individualized ROM exercises was not provided in accordance to facility policy. The deficient practice prevents the residents from attaining their maximum functional potential and from achieving or maintaining their highest practicable physical, mental, and psychosocial well-being. Findings: 1A. Resident 33 was admitted on [DATE] with diagnoses including stroke, hemiplegia (paralysis of one side of the body) and chronic pain (persistent pain that lasts weeks to years). Review of Resident 33's history and physical (H&P) report dated 12/13/21 indicated, . The patient's physical condition has been stable for the last 2 years. The patient was able to participate in her physical therapy and occupational therapy program. She continues to require assistance . Has complaints of chronic left-sided continues pain . EXTREMITIES: Weak left upper extremity and left lower extremity secondary to CVA (cerebrovascular accident, also known as stroke). Good range of motion on the right upper extremity and right lower extremity . Review of Resident 33's physician's order for May 2022 indicated the following orders: i. 5/29/21 - Continue OOB (out of bed) daily. PROM LUE/LLE daily if patient allows. ii. 9/16/21 - OT order: Place rolled bath blanket at lumbar spine when up in wheelchair. iii. 10/18/21 - OT order: Left hand splint wearing schedule ON during the day when up in wheelchair and PRN (as needed) per pt (patient) preference to decrease loss of ROM. iv. 4/30/22 - Clarification PT order cont. (continue) 1x1 month for 1 month include there-ex (therapeutic exercise), there-act (therapeutic activity), neuromuscular ex due to generalized weakness. During an observation on 5/2/22, at 10:06 AM, in the activity room, Resident 33 was sitting in a wheelchair with the left arm resting on the armrest. Resident 33's left hand and fingers were bent and curled inward. Resident 33 did not have a splint on the left hand and did not have a rolled bath blanket to support the lumbar spine During concurrent interview, Resident 33 stated she's been having pain on the left side of her body. Resident 33 was observed tearing up while verbalizing, The pain never goes away. Resident 33 acknowledged she's been given pain medications and stated, It's not helping my pain. During an interview with Licensed Vocational Nurse (LVN) 6 on 5/2/22 at 2:15 PM, LVN 6 stated Resident 33 has pain on her left side of the body and is on pain management which includes, repositioning and ROM. LVN 6 also stated Resident 33 has a splint on the right leg and left hand PRN (as needed). During an interview with the Rehab Staff (RS) on 5/3/22, at 11:05 AM, RS stated, Certified Nursing Assistant (CNA) supposed to apply the splint to the resident when she's up on a wheelchair but there are times when Resident 33 does not want to wear the splint. RS also explained that ROM should be done during ADLs (activities of daily living) and stated Usually it's not done. During an observation on 5/4/22 at 11:10 AM, in the activity room, Resident 33 was sitting in a wheelchair with the left arm/hand resting on the arm rest. Resident 33's left hand and fingers were bent and curled up. During observation, there was no hand splint on Resident 33's left hand and no rolled bath blanket on her lower back. During an interview with Certified Nursing Assistant (CNA) 5 on 5/4/22 at 11:50 AM, CNA 5 stated, She (Resident 33) has no splint. I'm not sure if she has a splint. CNA 5 also stated he provides 5 to 8 minutes of ROM exercises for both the upper and lower extremities for Resident 33 during ADL care such as dressing. CNA 5 added that the ROM exercises were not fully performed due to Resident 33's constant complaints of pain on the left side arm and hand. Review of Resident 33's care plan for ADL Functional/Rehabilitation Potential last revised on 2/23/22 did not include the use of hand splint and range of motion exercise. During an interview on 5/4/22, at 11:56 AM, LVN 6 acknowledged the care plan for ADL Functional/Rehabilitation Potential did not include the use of hand splint and range of motion exercises. During an interview with Resident 33's Responsible Party (RP) on 5/4/22, at 2:31 PM, the RP stated, She's (Resident 33) not getting enough therapy. She's only doing standing in parallel bars once a week and her toes started to curl up. She needed more assistance than before. She's deteriorating and her quality of life is not improving at all. During an interview with CNA 13 on 5/4/22, at 2:50 PM, CNA 13 stated, She's (Resident 33) total care. She declined a little. She complained of pain when putting on the splint. Review of Resident 33's progress notes from the pain clinic dated 3/2/22 indicated, .Patient reports she gets PT 1x/week and states standing up is the only time she feels ok. She mentions she has worsening spasticity throughout the left side . She reports she doesn't sleep well, either, as a result of pain . Assessments . May have chronic intractable pain on left side of her body due to spasticity vs. central pain . Treatment . 1d. Consider increasing tizanidine (used to treat muscle spasm) to 4 mg po BID (milligrams by mouth twice a day) as patient reports worsening spasms . 2. Mobilize with PT as much as possible and HEP (home exercise program) . Review of Resident 33's Minimum Data Set (MDS, an assessment tool) dated 11/30/21 indicated, Resident 33 required extensive assistance (resident involved in activity, staff provide weight-bearing support) with dressing. The MDS assessment dated [DATE] indicated, total dependence (full staff performance) with dressing, upper extremity (UE) impairment on one side, and lower extremities (LE) impairment on both sides. 2. Resident 46 was admitted to facility on 11/26/19 with diagnoses including schizophrenia (a disorder that affects the ability to think, feel, and behave clearly) and Alzheimer's disease (a progressive disease that destroys memory and other important mental functions). Review of Resident 46's physician's order for May 2022 indicated, Recommendation from PT 9/15/21: Ambulate with walker by staff supervision and assistance. During an observation on 5/3/22, at 8:45 AM, Resident 46 was awake in bed wearing foam booties on both feet. During an interview with the Wound Care Nurse (WCN) 1 on 5/3/22, at 9:03 AM, WCN 1 stated Resident 46 used to get up on the wheelchair and wheel around the unit. WCN 1 further stated, Resident 46 experienced a change in condition on 4/23/22. Resident 46 developed four deep tissue injury (DTI, an injury to a patients underlying tissue below the skin's surface that results from prolonged pressure in an area of the body) on the left and right foot. During an observation on 5/4/22, at 3:19 PM, CNA 2 was feeding Resident 46 in bed with the head of bed elevated and foam booties on both feet. During concurrent interview, CNA 2 stated Resident 46 was wearing foam booties to protect the wounds on his feet. CNA 2 stated Resident 46 used to wheel himself around and into other resident's room but recently, Resident 46 had been staying in bed. CNA 2 added, Resident 46 had a decline in ADL function, he used to require limited assistance but now requires total assistance. During an interview with CNA 2 on 5/4/22, at 3:22 PM, CNA 2 stated, He's (Resident 46) not ambulatory. He was evaluated by PT/OT but no recommendation. CNA 2 further stated, he provides ROM exercises (stretching) to Resident 46 during ADL care for a total of two to three minutes on both UE/LE. During a concurrent interview and record review with LVN 2 on 5/5/22, at 11:35 AM, Resident 46's care plan was reviewed. LVN 2 was unable to find a care plan addressing Resident 46's ROM exercises and PT's recommendation for ambulation. LVN 2 stated he was not aware of Resident 46's recommendation for ambulation. LVN 2 added, He's not ambulatory. Review of Resident 46's MDS dated [DATE] indicated, Resident 46 was independent with bed mobility and locomotion (how resident moves in and out of the unit) and required limited assistance with transfer. Under ROM, indicated no impairment of upper extremities (UE) and impairment on both sides of lower extremities (LE). Under Restorative Nursing Program indicated 0 on walking. Review of Resident 46's MDS significant change assessment dated [DATE] indicated, Resident 46 required total assist with bed mobility, transfer, eating, and hygiene while locomotion and walking activity did not occur. Under Section M, Skin Condition indicated Resident 46 has four DTIs. During an interview with MDS Coordinator (MDSC) 1 on 5/5/22, at 3:15 PM, MDSC 1 acknowledged and stated, a significant change assessment was completed for Resident 46 due to a decline in ADL function and development of DTI. MDSC 1 added, Resident 46 now requires more assistance with ADLs. Review of Resident 46's Occupational Therapy Initial Evaluation/Discharge Summary dated 5/5/22 indicated, the prior level of function was I (independent) propel w/c (wheelchair), min (minimum) assist with ADL's. Resident 46's current level of function indicated dependent. The Occupational Therapy Initial Evaluation/Discharge Summary indicated, the upper extremity assessment indicated decreased AROM on the shoulder and increased rigidity in tone. The overall assessment indicated, Impaired ADL ability. Impaired functional mobility/transfers. Impaired ADL endurance. Impaired standing/sitting balance. At risk for deconditioning/contractures/skin breakdown. Seating and positioning needs not met. Review of Resident 46's ADL Function/Rehabilitation Potential care plan dated 5/6/22 indicated, .Pt has increased weakness and requires total assist with ADL's . Review of facility's policy and procedure titled, Change in Resident Condition, revised on 10/2021, indicated, .2b. A significant change reassessment must be done when a decline or improvement occurs in 2 or more of the following areas: c. Decline: 1) Any decline in ADL/physical functioning where a resident is newly coded as 3 (extensive assistance), 4 (total dependency), or 8 (activity did not occur) . 8) Emergence of a condition/disease in which the resident is judged to be unstable. 9) Emergency of a pressure ulcer at Stage II or higher, when no ulcers were present at Stage II or higher. 10) Overall deterioration of a resident's condition or resident receives more support, e.g., in ADLs or decision-making . 3. Resident 44 was admitted on [DATE] with diagnoses including stroke and hemiplegia. Review of Resident 44's physician's order dated 3/10/22 indicated, DON (put on) RIGHT HAND SPLINT with foam under wrist 4 hours every day from 10 AM to 2 AM. Check for redness and skin irritation. During an observation on 5/5/22, at 10:45 AM, Resident 44 was on his wheelchair and did not have a hand splint on the right arm/wrist. The hand splint was observed on top of the bedside drawer. During concurrent interview, Resident 44 stated his hand is very stiff and that he does not wear the splint every day. Resident 44 added, Nobody helps me (referring to splint application). During an interview with CNA 5 on 5/5/22 at 10:52 AM, CNA 5 stated, I'm not sure when the resident wears the splint. I will ask the OT. During a follow up interview with CNA 5 on 5/5/22 at 11:14 AM, CNA 5 stated Resident 44 should wear the splint 4 hours a day from 10 AM to 2 PM according to the OT instruction. During concurrent interview and record review with LVN 2 on 5/5/22 at 2:45 PM, Resident 44's OT's progress notes for March 2022 indicated there was no assessment and documentation regarding the hand splint that was ordered on 3/10/22. LVN 2 acknowledged the OT progress notes dated 3/31/22 did not mention about the hand splint and stated, I don't see any. Resident 44's care plan was also reviewed and LVN 2 was unable to find a care plan addressing use of hand splint and range of motion exercise. Review of Resident 44's MDS dated [DATE] indicated, one side of upper extremities (UE) was impaired. Under section O, Restorative Nursing Program indicated, 0 on splint or brace assistance which means splint was not applied. 4A. Resident 65 was admitted on [DATE] with diagnoses including stroke and hemiplegia. Review of Resident 65's MDS dated [DATE] indicated, the staff assessment for mental status indicated Resident 65 was cognitively impaired. The functional limitation in ROM indicated, both sides of upper and lower extremities (UE/LE) were impaired. Review of Resident 65's physician's order for May 2022 indicated the following orders: a. 4/2/19 - RUE (right upper extremity) Splints: Wear when in bed. remove when up in chair. Remove splints to perform ADLs . b. 10/8/20 - RLE (right lower extremity) Splints: Wear in bed. Place towel around upper thigh and lower leg under Velcro attachments to decrease risk of skin breakdown. Remove splint if any skin irritation or redness. During an interview with CNA 4 on 5/3/22, at 4:14 PM, CNA 4 stated Resident 65 has a splint on the right arm and right thigh to prevent contractures when in bed. During an observation on 5/3/22 at 4:15 PM, Resident 65 was in bed, asleep and did not have a splint on the right arm thigh. During concurrent interview, CNA 4 acknowledged Resident 65 was not wearing a splint on the right arm and right thigh. CNA 4 went to check Resident 65's bedside drawer and closet but was unable to find the splint. CNA 4 stated, I don't know where it is (referring to the splint). I will look for it. During an interview with CNA 5 on 5/4/22, at 11:43 AM, CNA 5 stated, [Resident 65] has a splint but not anymore. The splint is missing. Review of Resident 65's TAR for February 2022 indicated under comments, 2/10/22 8AM CNA reported cannot find pt (patient) R (right) hand splint . CN (Charge Nurse) and physical therapy made aware. The comments dated 2/13/22, 2/14/22, 2/17/22, 2/22/22, 2/24/22, 2/26/22, and 2/27/22 (seven days) indicated RUE and RLE splint were missing. The TAR for March 2022, April 2022, and May 2022 indicated, RUE splint . FYI MISSING 2/10/22 OT AWARE. Review of Resident 65's OT progress notes dated 2/10/22 indicated, RUE splint reported missing by nursing. Nursing to look for splint prior to OT replacing. OT progress notes dated 3/1/22, CNA reports RUE/LE splint missing to OT. OT progress notes dated 5/4/22 indicated, LATE ENTRY FOR 3/16/22 Quarterly Assessment . Severe tone RUE/LE with decreased ROM . RUE/LE splint reordered . During an inteview with RS on 5/5/22, at 10:02 AM, RS acknowledged Resident 65's RUE and RLE splints were missing and stated she did not have a back up supply of the splint. Resident 65's care plan was reviewed, LVN 2 was unable to find a care plan addressing the use of splint. LVN 2 stated, The splint should be care planned. There should be an alternative approach for the missing splint. 4B. Resident 127 was admitted on [DATE] with diagnoses that include vegetative state secondary to subarachnoid bleed (bleeding in the space between your brain and the surrounding membrane) from cerebral aneurysm (a bulge or ballooning in a blood vessel in the brain) and chronic extremity contractures. Review of Resident 127's Interim History and Physical, dated 6/12/21 indicated Resident 127 had .no right upper extremity movement . Review of Resident 127's Physician's orders for May 2022 indicated, Date prescribed .5-22-2018 . Resting splint to right hand . with a Wearing Schedule indicating Resident 127 was to wear the splint from 10 AM to 6 PM, and 10 PM to 8 AM. Review of Resident 127's MDS, dated [DATE], indicated Resident 127 had functional limitations on both upper extremities and was totally dependent on nursing staff for all his activities of daily living; the same MDS also indicated that a splint or brace assistance was not applied to Resident 127. During a concurrent observation and interview on 5/4/22 at 2:47 PM with CNA 2, Resident 127 was lying in bed and slightly turned to his right side. Resident 127 had a contracture of the right hand with his wrist bent inwards towards his forearm Resident 127 did not have a splint applied to his right hand. CNA 2 stated, He (Resident 127) does not have a splint, only towel roll (referring to hand roll) on the right hand . CNA 2 proceeded to get a washcloth, rolled it, and applied it on Resident 127's right hand. CNA 2 stated he was not sure which hand needed a splint and was not aware of Resident 127's wearing schedule for the splint. CNA 2 stated, I don't know the order. The splint, nobody told me. The wearing schedule of the splint was not posted in Resident 127's room. During a concurrent observation and interview with RN 6 on 5/5/22 at 11:30 AM, Resident 127 was lying bed with his eyes open he did not have a splint applied to his right hand. During an interview on 5/5/22 at 11:45 AM, the Registered Nurse (RN 6) stated, Nobody reported that it (splint) has been missing. They (nursing staff) said it's been missing a long time, about a month ago. They (nursing staff) can't tell me specifically when. RN 6 stated that the use of splint for Resident 127 is to prevent further flexion and more contractures. During an interview on 5/6/22 at 11:32 AM, the RS stated that the use of splint to Resident 127's right hand was to limit him (Resident 127) from going into further decline and to prevent his fingers from going into his skin. During an interview on 5/6/22 at 11:53 AM, the Director of Nursing (DON) stated that not applying the splint to residents as prescribed could contribute to further contractures. Review of the facility policy and procedure titled, Splinting, revised on 4/17 indicated, Splinting is used to protect joints and surrounding soft tissue. This can be accomplished by maintaining joints at position of rest, preventing positions that contribute to contracture and/or deformity, protecting the system of arches within the hand and increasing or maintaining ROM in the joint . The Occupational Therapist shall assess patient's need for splints with the following considerations: To protect joints and surrounding soft tissue; To increase hand function; To maintain range of motion . The Occupational Therapists shall then evaluate for type of splint required by patient . A splint handout with precautions and wearing schedule will be posted in resident's room . The Occupational Therapists shall train nursing staff/patient/caregivers/family members on donning/doffing the splint, cleaning of the splint, precautions (reddened areas) and wearing schedule . 5. Resident 76 was admitted on [DATE] with diagnoses including stroke, hemiplegia (paralysis of one side of the body) and chronic pain (persistent pain that lasts weeks to years). Review of Resident 76's MDS dated [DATE] indicated, Resident 76 has impairment on one side of UE and both sides of LE. Under section O, Restorative Nursing Program indicated 0 on both AROM and PROM, splint or brace assistance. Review of OT's quarterly assessment dated [DATE] indicated, .R (right) hand contractures [with] limited use of L (left) hand. R feet plantar [check mark symbol] contractures LUE shoulder [check mark symbol] AROM 0-120, RUE PROM 0-90 . During an observation on 5/2/22, at 11:17 AM, Resident 76 was in bed with a rolled towel on the right hand. Resident 76's right hand and fingers were bent and curled inward. Review of Resident 76's physician's order for May 2022 indicated, Range of Motion exercise to right upper extremity daily for flexion of contractures was ordered on 12/3/19. During an interview with CNA 9 on 5/4/22, at 2:53 PM, CNA 9 stated she provide ROM exercises five to eight minutes for both upper and lower extremities to Resident 76 during ADL care. CNA 9 added, Resident 76 has pain on the right arm/hand due to contractures and a rolled towel is applied every day. Review of Resident 76's care plan for pain revised on 3/13/22 indicated, Potential for pain or discomfort r/t (related to) Disease processes, Limited Mobility . Approach . Moving hands and feet a little . Review of the TAR for May 2022 indicated, an FYI (for your information) under the treatment order Range of Motion exercise to right upper extremity daily for flexion of contractures. During interview with LVN 2 and concurrent review Resident 76's care plan on 5/4/22, at 3:05 PM, LVN 2 was unable to find a care plan addressing the application of rolled towel on the right hand and range of motion exercises. LVN 2 acknowledged and stated the care plan should indicate the interventions provided to the resident. Review of the facility's policy and procedure titled, Range of Motion, revised on 8/2020, indicated, Purpose: 1. To maintain and improve muscle strength and tone . 3. To prevent contractures . Procedure/Responsibilities 1. Licensed personnel are to supervise nursing assistants in ROM. 2. Physical Therapy is to be called for initial evaluation, if necessary. ROM is a nursing measure . 4. ROM exercise doe not take the place of position change and support for dependent parts . 7. Do not bring the joint/limb motion to the point of pain . 9. Each joint is moved through its range 3-5 times per treatment . In-Service Education: 1. All nursing staff are instructed in the techniques of active and passive ROM . 2. All resident will receive ROM every 4 hours between the hours of 0900 and 2100 every day. 3. Passive ROM may be ordered as a nursing order . Documentation: CNA Flowsheet. Review of facility's policy and procedure titled, Plan of Care, revised on 9/2019, indicated, . 1. The comprehensive plan of care shall include: a. the frequency at which care, services, treatments, and interventions will occur . d. Current needs, problems, goals, care, treatment and services . 3. The evaluation of the resident's progress is made based upon the care plan goals and the resident's plan of care, treatment and services. 6. Resident 111 was admitted on [DATE] with diagnoses including hemorrhagic stroke (an emergency condition in which a ruptured blood vessel causes bleeding inside the brain) and quadriplegia (paralysis of both sides of the body). Review of Resident 111's MDS dated [DATE] indicated both sides of upper and lower extremities (UE/LE) were impaired. Under Restorative Nursing Program indicated, 0 on both AROM and PROM, splint or brace assistance. During an observation on 5/4/22, at 3:08 PM, Resident 111's Private Caregiver (PCG) 1 was observed putting on a white rolled towel on resident's right hand. Resident 111's wrist/hand were bent and his fingers were curled inward. During concurrent interview, PCG 1 explained he's putting a hand roll for Resident 111 due to contractures on the hands and fingers. PCG 1 also stated she provide ROM exercises to Resident 111 at night during ADL care. During an interview with Resident 111's PCG 2 on 5/5/22, at 8:55 AM, PCG 2 stated he used to assist Resident 111 with ROM exercises using the Active Passive Trainer (APT, are electric exercise machines used for the improvement of physical abilities and can be operated in either active or passive mode) machine. PCG 2 pointed at the APT machine behind the privacy curtain. PCG 2 stated the APT machine was last used few months ago. PCG 2 also stated, [Resident 111] contractures became harder. The exercise hurts him. PCG 2 explained that they are waiting for the special shoes for Resident 111 prior to resuming use of APT machine. PCG 2 added, the shoes the resident had was hurting him. During an interview with LVN 2 on 5/5/22, at 9:01 AM, LVN 2 stated Resident 111 has a private caregiver doing passive ROM and mostly providing care for the resident. LVN 2 added, I don't know about that machine (referring to the APT machine). The family provided it. I will ask the caregiver. During an interview with RN 6 on 5/5/22, at 9:30 AM, RN 6 stated, [Name of Resident 111] family provided the APT machine. The private caregivers were assisting him (referring to Resident 111) with the exercise. RN 6 also stated the private caregivers reported they stopped using the APT machine due to increased stiffness of the upper and lower extremities. During an interview with RN 6 on 5/5/22, at 9:32 AM, RN 6 stated the rehab provided PROM training to the caregivers and the use of APT machine. During concurrent record review, RN 6 was unable to find training records on the use of APT machine for Resident 111's private caregivers (PCG 1 and PCG2). RN 6 stated, I don't see their names in chart. During concurrent interview and further review of Resident 111's record, on 5/5/22, at 9:34 AM, RN 6 was unable to find an order, assessment, and care plan for the use of APT machine. RN 6 stated, I don't see about the machine over here (referring to the OT progress notes). It's not in the order. It's not in the care plan. It's not mentioned in the OT assessment. During an interview with RS on 5/5/22, at 9:55 AM, RS stated Resident 111 had a decline with ROM on 1/27/22. RS explained Resident 111 has APT machine in the room for home exercise which helps maintain ROM of the resident. RS added, The nursing staff has nothing to do with the home exercise program (referring to APT machine). The caregivers assist him (Resident 111) with it (APT machine). RS further stated, [Name of a caregiver] is using the APT but not PCG 2. RS stated she provides training to the private caregivers on how to perform ROM exercise and the use of APT machine for Resident 111. RS acknowledged the training was not documented in Resident 111's chart. Review of the Active Passive Trainer user's manual revised on 01/2020, indicated, . 3.1 Indications: The Active Passive Trainers are intended to be operated by persons of most physiques and ages. In case the user has limited strength in the arm or cognitive impairment, it is required to have an attendant present during exercise . 3.3 Contraindications . In case of any disease or physical complaints, a healthcare provider should be consulted before participating in any exercise program . In case of recurring discomforts, consult with a health care provider . Review of facility's policy and procedure titled, Education for Patient and Caregiver, revised on 4/2017, indicated, The Therapist and Therapist Assistant will instruct patient, family, and caregiver regarding home exercise programs and safe assistance techniques for functional mobility . The Therapist and Therapist Assistant will complete the following: 1. Provide on-going patient education during treatment sessions regarding safe techniques for home exercise and functional mobility . 3. Provide written instructions with pictures for patient and family when appropriate. The handout will be signed by the therapist/assistant and a contact number will be provided . 5. Document all patient/family education and training in progress notes. include the name and relationship of the family member/caregiver that was instructed. 6. Monitor and document the patient's or caregiver's ability to understand and follow through accurately. Request return demonstration of patient's/caregiver's when appropriate . 7. Resident 66 was admitted on [DATE] with diagnoses that include ischemic stroke (occurs when a vessel supplying blood to the brain is obstructed) with left hemiplegia (paralysis on side of the body). Review of Resident 66's MDS, dated [DATE], indicated Resident 66 had functional limitations on one side of the upper extremities and on both lower extremities and was totally dependent on nursing staff for all his activities of daily living. Review of Resident 66's Physician's orders for May 2022 indicated, 01-16-2018 . Apply hand roll to: Left hand contracture to prevent further limitations .Q (every) shift . During an observation and interview with CNA 2 on 5/4/22 at 11 AM, Resident 66 was in bed, awake, and turned to his left side. Resident 66 had a contracture of the left hand with his fingers bent inwards towards his palm. CNA 2 stated Resident 66 is unable to stretch his left fingers and use his left hand. There was no hand roll applied to the left hand or fingers of Resident 66. CNA 2 stated, He (Resident 66) does not have it. We don't have a hand roll. During a concurrent review of clinical records of Resident 66 and interview on 5/4/22 at 11:16 AM, RN 6 reviewed Resident 66's ADL Functional/Rehabilitation Potential care plan (CP), dated 3/12/22. The CP did not include interventions addres[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2c. During a concurrent observation and interview, on 2/14/22, at 10:47 AM, observed a sign at the door of room [ROOM NUMBER] indicated room out of order: don't use. CNA 1 stated room [ROOM NUMBER]'s bathroom is out of order, and they moved the resident to another room yesterday (2/13/22). There were two holes on the wall near the shower head exposing the pipes. Also observed the bathroom floor linoleum with bubble like raised areas. During an interview with the EVSS, on 2/14/22, at 11:42 AM, the EVSS stated there was a leakage which started around mid January (1/17/22). He stated, the engineer came the same day, had to cut through the wall to find the source of the leakage and had done the repair, but they are waiting for the engineer to come patch the holes. The EVSS stated he had no documentation regarding the repairs as it was more of a verbal thing. During an observation on 2/14/22, at 11:25 AM, in the room [ROOM NUMBER] bathroom, observed a blackish substance around the base of the toilet bowl. Also observed the linoleum flooring with greyish stains. During an observation on 2/14/22, at 11:45 AM, in the room [ROOM NUMBER] bathroom, observed a defined blackish substance around the base of the toilet bowl. Also observed a dark colored raised area on the floor linoleum, under the sink pipe. Also observed that the Formica covering the bathroom's sink cabinet was chipped at the edges. Based on observation, interview, and record review, the facility failed to maintain a sanitary, comfortable and homelike environment when: 1. The linoleum flooring in room [ROOM NUMBER]'s bathroom were torn, cracked, and peeling off around the base of the toilet exposing the subfloor and had a pungent musty odor. 2. 20 of 41 resident bathroom flooring (Rooms 101, 105, 111, 201, 206, 208, 301, 302, 305, 306, 308, 309, 310, 311, 401, 403, 406, 407, 408 and 410) were damaged and discolored. 3. There was an evidence of stagnant, dark colored liquid in the shower room (number) 3 with pungent musty odor on the missing tiles. The pungent musty odor had caused Resident 91 to feel sick and want to throw up. In addition, exposure to unpleasant odor, unsanitary, unkempt, and uncomfortable environment could affect mood, anxiety and stress level of other residents, staff, families, and visitors in the facility. Findings: 1. During the initial tour, on 2/7/22, at 9:58 AM, in room [ROOM NUMBER], Resident 91 was sitting on his wheelchair by the bed watching television. Resident 91 expressed his concerns regarding the damaged linoleum flooring and the pungent odor coming from the bathroom. Resident 91 stated, The linoleum is broken. It was not fixed. They cover it with the rug and it smells. Review of Resident 91's clinical record indicated, he was admitted in the facility on 10/25/13. The Minimum Data Set (MDS, a resident assessment tool) dated 1/4/22 indicated Resident 91 was cognitively intact. During an observation, on 2/7/22, at 10:05 AM, in room [ROOM NUMBER]'s bathroom, the linoleum flooring was torn and ripped around the base of the toilet, exposing the subfloor. A black, rectangular scraper mat was placed over the areas with torn and ripped linoleum. The mat appeared wet with a pungent musty odor. The linoleum behind the base of the toilet was bulging and tearing apart. Portion of the caulking (a material used to seal joints or seams against leakage in various structures and piping) at the base of the toilet was missing and had a build-up of red-orange, dark brown, and black colored matter. During an interview, on 2/7/22, at 10:08 AM, Resident 91 stated, It's been like that for a long time. They never fixed it (refering to the damaged bathroom floor). During an interview, with Certified Nursing Assistant (CNA) 2 on 2/7/22, at 10:10 AM, CNA 2 acknowledged the damaged linoleum flooring in room [ROOM NUMBER]'s bathroom and stated, The toilet bowl is leaking and the floor is rotten. It's been like that for years. No action. During an interview, on 2/8/22, at 9:46 AM, Resident 91 stated, It smells like pee and poop. It makes me feel sick. I want to throw up. Resident 91 added, the pee and poop smell is more notable in the afternoon and at night. Resident 91 further stated, the smell of the bathroom and the torn linoleum flooring in his bathroom (room [ROOM NUMBER]) and other resident bathrooms were discussed in the previous resident council meetings. Resident 91 added, the nurses, Environmental Services Supervisor (EVSS), engineering, maintenance, previous Director of Nursing (DON) and Executive Director for Continuum Care (EDCC) were all aware of the issue. During an interview, on 2/8/22, at 9:54 AM, CNA 5 stated, It's been like that since I started working here (referring to the broken linoleum flooring in room [ROOM NUMBER]'s bathroom). CNA 5 also stated he's been working at the facility for more than two months now and has not seen someone fixed the flooring. During an interview, on 2/8/22, at 10:13 AM, the Environmental Services Technician (EVST) 1 stated he was aware of the damaged linoleum flooring in room [ROOM NUMBER] and was instructed to clean and mop the bathroom floor with Clorox bleach (a brand of disinfecting solution) every morning. EVST 1 further stated, I don't know about the mat. I did not put it there. During an observation, on 2/8/22, at 10:18 AM, in room [ROOM NUMBER]'s bathroom, the EVSS lifted the black mat covering the exposed subfloor showing a build-up of white, gray, green, and black colored matter underneath. During concurrent interview, the EVSS stated, This (referring to the torn linoleum flooring) started about a year ago when the toilet was leaking on and off. That area (pointing at the subfloor and surrounding base of the toilet) is rotten. That's from the leak. The EVSS explained, there were missing caulking around the base of the toilet. The water started to leak and seeped through the cracks causing the bubble and moisture under the linoleum flooring. In addition, the EVSS acknowledged that he personally placed the black mat on the torn linoleum flooring to prevent the urine from dripping on the subfloor which will further the rot. The EVSS acknowledged Resident 91 has verbalized about the pungent odor coming from the bathroom and stated, the EVS staff cleaned the bathroom daily and changed the mat two to three times a week. According to an article titled, Odors and health, retrieved from https://www.health.ny.gov/publications/6500/index.htm, dated October 2019, indicated, . In some cases, odors can be used to tell whether there is a problem that needs to be fixed. For instance, mold problems, sewage backups and gas leaks in the home can all be detected by their odor, even if they can't be seen . Exposure to odors could result in health effects ranging from none, to mild discomfort, to more serious symptoms. Some chemicals with strong odors may cause eye, nose, throat or lung irritation. Strong odors may cause some people to feel a burning sensation that leads to coughing, wheezing or other breathing problems. People who smell strong odors may get headaches or feel dizzy or nauseous. If an odor lasts a long time or keeps occurring, it also could affect mood, anxiety and stress level . Try to find the source if you have unpleasant indoor odors . If you have a musty smell, check for moisture problems that could lead to mold growth. The way to control indoor odors is to find the source and remove it, or contain it in some way so that it doesn't release odors . 2a. During an observation, on 2/7/22, at 10:28 AM, in room [ROOM NUMBER]'s bathroom, the caulking and linoleum around the base of the toilet were chipped, cracked, peeling off, bulging with a buildup of dark brown, black and dark red-orange colored matter. The linoleum surrounding the base of the toilet had a grayish-black and brown colored markings. During an observation, on 2/8/22, at 10:38 AM, in room [ROOM NUMBER]'s bathroom, the caulking and linoleum around the base of the toilet were torn, cracked, bulging and pulling away from the floor exposing the subfloor. The linoleum close by the baseboard and the wall was bulging and had a light brown stains or markings. There was a buildup of dark brown and black colored matter around the base of the toilet and in between cracks and tears of the linoleum. During an observation, on 2/8/22, at 10:40 AM, in room [ROOM NUMBER] and 410's shared bathroom, the caulking around the base of the toilet were missing and had a buildup of dark brown and black colored matter. The linoleum surrounding the base of the toilet had a white, yellowish-brown markings and gray discoloration. During an observation, on 2/8/22, at 10:43 AM, in room [ROOM NUMBER]'s bathroom, there was a buildup of dark brown, black, and dark orange colored matter on the caulking and around the base of the toilet. The linoleum around the toilet and close to the baseboard were cracked and bulging. The bolts anchoring the base of the toilet had a crusty orange and brown colored matter. During a concurrent interview, and record review, on 2/8/22, at 11:01 AM, the undated Service Requester form indicated, Submit Service Request . Priority: 2-Normal . Short Description: remove and replace broken floor in r/r rms 403, and 406. The EVSS stated there were two bathrooms that needed new floor and that includes room [ROOM NUMBER]. When asked for the date of the service request was submitted, the EVSS stated, I just sent it out today (2/8/22). The EVSS then wrote 2/8/22 at the bottom right of the Service Requester form to indicate the date it was submitted. When asked for the maintenance log, the EVSS was unable to provide one. He acknowledged he did not have a log for the work order or service request submitted through the Service Requester. During an interview, on 2/8/22, at 11:48 AM, the EDCC stated the Director of Facilities has the access to the work order log in the main hospital and should be responsible in following up the work orders. The EDCC acknowledged she was aware of the bathroom floor issues and stated a ticket was sent to the corporate to get a quote for the new floor. Review of the letter document dated and signed on 2/8/22 by the EDCC, indicated, Plan for fixing 403 and 406: Director of Facilities (and team) will get a new quote for fixing both bathroom floors by 2/15. Submit for local and corporate approval 2/17. Start work as soon as materials arrive. During an interview, on 2/14/22, at 10:42 AM, the Maintenance Supervisor (MS) stated he was verbally made aware of the leak and broken floor in room [ROOM NUMBER] by the EVSS. The work order don't go to me. Nursing will report verbally. The MS further explained, all staff have access to the work order email through Maintenance Connection online system in case there is something that needed to be fixed or replaced. When asked if a work order was submitted for room [ROOM NUMBER], MS stated he cannot remember when it was submitted. The MS acknowledged he does not have a log nor access of the pending work orders until he get a notification from the Director of Facilities or engineering department that a service request had been fixed and/or completed. During an interview, on 2/14/22, at 11:44 AM, the EDCC stated the EVS, Director of Facilities, Chief/Assistant Chief of Engineering, and Nursing conduct the environmental rounds every quarter. The EDCC further stated, the identified list of things needed to be fixed and will be prioritized accordingly. During an interview, on 2/14/22, at 12:09 PM, the Medical Director (MD) stated, I am not aware of the floor issues before. I just knew it now. We don't talk about it in QAPI (Quality Assurance and Performance Improvement) but will do it now. I'm embarrassed. Review of the facility document titled, Work Order Status, dated 8/1/21 to 2/9/22, indicated, .Work order # - SMCCS-438255 - remove and replace broken floor tile in r/r/rms 403, and 406 . The document did not indicate the status and date the work order was submitted. Review of the facility's policy and procedure titled, Maintenance Strategies and Frequencies, dated 6/5/17, indicated, .A work order system is used to manage planned maintenance activities. Work orders are issued for maintenance performed by the Facilities Department in-house staff and by contractors. The Facilities Director manages the worker order generation and completion process. 1. A Facilities Engineer performs assigned activities and return completed documentation to managers. Activities completed by contractors are tracked to assure the activities are completed in accordance with the terms of a contract . 4. The Facilities Director provides weekly assignments for all tasks schedule dint he system. Components maintained by corrective maintenance will be repaired on request, by work orders. 5. The Facilities Director will provide regular reports to determine percentage of activities completed, and identify problems associated with the individual work assignments and departmental and equipment trends . 7. All documentation of the maintenance activity will be completed by the Facilities Engineer, reviewed by the appropriate supervisor, and filed or the information entered into the work order system. Work orders for maintenance activities not completed will remain open until finalized. 2b. During an observation, on 2/10/22, at 10:42 AM, in room [ROOM NUMBER]'s bathroom, observed black and brownish liquid substance surrounding the base of the toilet bowl. The black and brownish substance was seeping out from the base of the toilet bowl. The bolts anchoring the base of the toilet had a crusty orange and brown colored matter. During an observation, on 2/10/22, at 10:44 AM, the base of the toilet in room [ROOM NUMBER]'s bathroom, had a flaking white grout. Observed brownish liquid substance seeping out from the base of the toilet bowl. During an observation on 2/10/22, at 10:47 AM, the base of the toilet in room [ROOM NUMBER]'s bathroom, had a flaking white grout. Observed brownish liquid substance seeping out from the base of the toilet bowl. 2d. During observations on 2/14/22, at 10:15 AM, in room [ROOM NUMBER], 302, 305, 306, 308, 310, and 311 bathrooms, the linoleum flooring at the junction of the base of the toilet bowl and the flooring, had gaps around the base of the toilet bowl. The gaps contained a buildup of dark brown colored substance. During an interview with EVST 4, on 2/14/22, at 10:20 AM, EVST 4 acknowledged that rooms 301, 302, 305, 306, 308, 310, and 311 bathrooms had a dark colored substance at the junction of the base of the toilet bowl and the linoleum flooring. He stated that the Skilled Nursing Facility (SNF) trained staff to use bleach to clean the flooring gaps at the junction of the base of the toilet bowl and the flooring in the bathrooms. He said, afternoon environmental services staff are required to terminally clean shower rooms every afternoon. 3. During observations on 2/14/22, at 9:30 AM, in the company of EVSS, the SNF placed a sign outside the door of Shower room [ROOM NUMBER] indicating that staff not use the shower room to shower residents. EVSS used a tape measure to measure the size of the missing tiles on the floor. He counted 21 missing tiles each measuring 1/2 x 1/2 inches (in) size. The missing tiles were located next to each other in the form of a square and next to the drainage plate and were visible upon entering Shower room [ROOM NUMBER]. The floor space missing tiles contained sheer stagnant liquid with pungent smell. A black substance was visible through the sheer liquid, at the bottom of the floor spaces missing the tiles. During concurrent interview on with EVSS on 2/14/22, at 9:45 AM, EVSS acknowledged that the floor of Shower room [ROOM NUMBER] had 21 ceramic tiles, 1/2 x 1/2 in size missing from the floor. He agreed that the space where the tiles were missing contained sheer stagnant liquid with a black substance visible at the bottom of the space missing the tiles. He stated that the SNF contracted with few bidders for the opportunity to work in replacing the missing tiles. He said the facility was aware that the tiles were missing, was trying to replace the missing tiles, and was waiting for contract bidders to give the SNF requested bids. He stated, the main SNF has documentation of the requested contractor bids. During an interview with CNA 3, on 2/14/22 at 4:30 PM, in Shower room [ROOM NUMBER], CNA 3 stated, I would not shower my residents in the moldy shower room. She said CNAs working during the day shift showered resident in the shower room with the tiles missing on the floor of the shower room. During an interview with Registered Nurse (RN) 4, on 2/14/22, at 4:35 p. m, in Shower room [ROOM NUMBER], RN 4 acknowledged that CNAs showered residents in Shower room [ROOM NUMBER] while the tiles were missing from the floor. She stated that the SNF trained staff to submit a work order to replace the missing floor tiles, and to continue to use the shower room to shower residents while waiting for the SNF to replace the missing tiles. During a review of undated facility document titled, Work-order Status. SMCC Open Work Order List, the Work Order Status. SMCC Open Work Order List indicated that the SNF documented (1) on 9/16/21, at 12:01 PM, Third request to replace missing floor tile in Shower #3 in 300 hall, (2) on 12/7/21, at 9:01 AM, Leaking water from the shower cap on Shower 3 at 300 hall. Please check out, (3) on 1/13/22, at 8:04 AM, 300 shower drain plugged. and (4) on 1/18/22, at 10:45 AM, Shower drain clogged in 300 hallway.