**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure, for seven of seven residents (Residents 1, 16, 21, 22, 28, 29, and 151) reviewed for range of motion (ROM the full movement potential of a joint), a system or process was in place to: 1. Identify, assess, evaluate, and monitor residents with limited ROM and contractures (condition of shortening and hardening of muscles, tendons, or other tissue, often leading to (abnormality and stiffness of the joints); and 2. Provide an appropriate care and treatment to improve, maintain, or prevent contractures and/or limitation with ROM. On February 9, 2024, at 7:20 p.m., the Administrator (ADM), the Assistant Director of Nursing (ADON), and the Director of Staff Development (DSD) were verbally notified of the Immediate Jeopardy (IJ situation in which the provider's noncompliance with one or more requirements of participation has caused or likely to cause serious injury, harm, impairment, or death to a resident), due to the facility failure to identify, assess, evaluate, monitor, and provide appropriate care and treatment, for seven residents (Residents 1, 16, 21, 22, 28, 29, and 151) with limited ROM and/or contractures. These failures resulted in delayed identification of residents with limited ROM and/or contractures which delayed the provision of care and treatment for Residents 1, 16, 21, 22, 28, 29, and 151. This delayed in provision of care and treatment had placed the residents at risk for further decline in ROM and/contractures. On February 11, 2023, at 3:03 p.m., the ADM presented an acceptable plan of actions which included the following: - The seven residents identified to be affected by the deficient practice will be evaluated/screened by therapy on Monday 2/12/24, to determine if they are candidates for therapy services, or if restorative nursing (nursing interventions that promote the resident's ability to adapt and adjust to living as independently and safely as possible) services are required; - The results of the screening will be communicated to the physician on Monday 2/12/24 and the facility will obtain therapy/restorative nursing orders for all residents affected by the deficient practice to identify what interventions to implement to improve, maintain, or prevent further decline in range of motion; - Care Plans were initiated and will be updated after the therapy evaluation and subsequent Physician orders for the seven residents affected by the deficient practice; to address what interventions, equipment, services, and orders are in place to improve, maintain, or prevent further decline in range of motion; - All residents in the facility were assessed by the Registered Nurse for limited range of motion and/or contractures. Additional residents were identified as having some degree of limited range of motion; - All residents identified as having limited range of motion and/or contractures will be evaluated/screened by Therapy on Monday 2/12/24, to determine if they are candidates for therapy services, or if restorative nursing services are required; - A range of motion assessment will be completed by a Registered Nurse and documented on all new admissions entering the facility to identify residents with limited range of motion and/or contractures. Residents identified as having limited range of motion and/or contractures will be reported to the Physician for potential therapy screening or Restorative Nursing Program; - The range of motion assessment will be completed and documented quarterly by a Registered Nurse in conjunction with the comprehensive assessment, to evaluate and monitor any progress or decline in range of motion; - The interdisciplinary team will review the quarterly range of motion assessment at Care Plan meetings and update the care plan as needed/indicated. The interdisciplinary team includes the following members: Director of Staff Development (DSD), Assistant Director of Nursing (ADON), MDS Coordinator, Behavioral Specialist, Social Services Designee (SSD), Medical Records Director, Director of Nursing (DON), Infection Preventionist (IP), and Restorative Nursing Aide (RNA); - The facility Behavioral Specialist has been designated to oversee the facility Restorative Nursing Program; - All staff involved in the revised process for identifying, assessing, evaluating, monitoring, and implementing appropriate treatment for residents with limited ROM and/or contractures will be in serviced by the Director of Staff Development on 2/10 and 2/11/24; - Monthly QAPI (Quality Assurance and Performance Improvement data driven and proactive approach to quality improvement) meetings will now include evaluations of our system and process for identifying, assessing, evaluating, and monitoring residents with limited range of motion and/or contractures as well as the treatment and services provided to improve, maintain, or prevent further decline in range of motion; - Monthly QAPI meetings will now include evaluations of our system and process for identifying, assessing, evaluating, and monitoring residents with limited range of motion and/or contractures as well as the treatment and services provided to improve, maintain, or prevent further decline in range of motion; - This will include reports from the RNAs on treatment and services provided to residents with limited range of motion and/or contractures; - This will include reports from the Restorative Nursing Supervisor (Behavioral Specialist) on the quarterly and admission Range of Motion assessments completed; - This will include ongoing tracking and data analysis of residents whose Range of Motion has improved or declined; and - The Director of Nursing will report to the Administrator and Medical Director at the QAA (Quality Assessment and Assurance) committee quarterly on the activities of the QAPI committee with regard to range of motion and contractures. On February 12, 2024, at 5:50 p.m., the immediate jeopardy was removed in the presence of the ADM, the ADON, and the DSD, upon onsite verification of the implementation of the plan of actions. The facility was notified an extended survey would be conducted due to substandard quality of care issues. Findings: 1. On February 8, 2024, at 12:26 p.m., a concurrent observation and interview was conducted with Resident 1. Resident 1 was observed sitting in her wheelchair in the hallway with both hands flexed (bent) at the wrist and all fingers on both hands were clenched. Resident 1 was observed to be able to extend both hands with minimal effort but unable to open all her fingers except the right index finger. There was no adaptive device (any tool used to help people with disabilities or impairments) observed on Resident 1's bilateral hand. Resident 1 stated she used a device for both hands but only had one of them. She stated she did not receive any ROM exercises for both hands. On February 8, 2024, Resident 1's admission record was reviewed. Resident 1 was admitted to the facility on [DATE], with diagnoses which included venous insufficiency (occurs when leg veins do not allow blood to flow back up to the heart). A review of Resident 1's History and Physical, documented by the physician on October 16, 2022, indicated contractures of the left hand. In further review of Resident 1's medical record, there was no documented evidence interventions were initiated to address Resident 1's left hand contracture as identified by the physician on October 16, 2022. A review of Resident 1's Minimum Data Set (MDS an assessment tool), dated July 27, 2023, indicated the following: - Resident 1 had a BIMS (Brief Interview of Mental Status) of 7 (moderately impaired); and - Resident 1 had limitation in ROM to both upper extremities (part of the body that includes the arm, forearm, wrist and hand). In further review of Resident 1's medical record, there was no documented evidence an ongoing assessment, evaluation, and monitoring of Resident 1's limitation in ROM and/or contractures on both upper extremities were conducted by the facility. There was no documented evidence Resident 1's limitations in ROM on both upper extremities identified in the MDS assessment dated [DATE], were addressed for appropriate care and treatment. On February 9, 2024, at 12:08 p.m., Resident 1 was observed in the hallway with the Certified Restorative Nursing Assistant (CRNA) and Licensed Vocational Nurse (LVN) 3. Resident 1 was observed sitting on her wheelchair with a hand roll (used to prevent the fingers of the hand from being in a tight fist which could cause contracture) placed inside her right hand. There was no other device observed on Resident 1's left hand. In a concurrent interview with the CNRA, she stated Resident 1 was unable to extend both hands and fingers. She stated Resident 1 did not have an order for ROM exercises. In a concurrent interview with LVN 3, she stated Resident 1 had contractures of both hands and fingers. She stated she was not aware when Resident 1 developed the contractures on both hands. 2. On February 6, 2024, at 3:16 p.m., a concurrent observation and interview was conducted with Resident 16. Resident 16 was observed sitting in his wheelchair inside his room. Resident 16 was observed with both hands flexed at the wrist in a downward position with all fingers clenched. There was no adaptive device in place on both hands for Resident 16. Resident 16 was able to extend the left hand at the wrist but unable to open up his fingers on the left hand. Resident 16 was unable to extend the right hand and open his fingers. Resident 16 stated that he was not receiving exercises for his left or right hand and would like to get further treatment and care. On February 8, 2024, Resident 16's admission record was reviewed. Resident 16 was admitted to the facility on [DATE], with diagnoses which included hemiplegia (paralysis on one side of the body) and hemiparesis (weakness on one side of the body), neuralgia (nerve damage), and neuritis (inflammation of the nerve). A review of Resident 16's care plan dated October 2016, indicated, .has limited physical mobility r/t (related to) contractures of left hand .he will maintain current level of function through next review .Resident will receive ROM exercises as ordered by MD (MedicalDoctor/physician) .Encourage resident to wear hand rolls as tolerated . In further review of Resident 16's medical record, there was no documented evidence a physician order for ROM exercises and hand roll were initiated as indicated on the care plan. A review of History and Physical, documented by the physician, dated May 18, 2022, indicated Resident 16 had contractures of the left upper extremities. A review of Resident 16's MDS, dated October 8, 2022, indicated the following: - Resident 16 had a BIMS of 15 (no cognitive impairment); and - Resident 16 had limitation in ROM on one side of the upper and lower extremities (part of the body the includes the hip, thigh, knee, leg, ankle, and foot). A review of Resident 16's MDS, dated October 13, 2023, indicated Resident 16 had impairment on both side of the upper extremities and one side of the lower extremities. In further review of Resident 16's medical record, there was no documented evidence an ongoing assessment, evaluation, and monitoring of Resident 16's limitation in ROM on both side of the upper extremities and one side of the lower extremities was conducted by the facility. There was no documented evidence Resident 16's limitation in ROM identified on the resident's MDS assessment on October 13, 2023, was addressed for appropriate care and treatment. On February 9, 2024, at 12:08 p.m. Resident 16 was observed in the hallway with the CRNA and LVN 3. Resident 16 was observed sitting in his wheelchair with both hands flexed at the wrist in downward position with all fingers clenched. Resident 16 was able to extend the left hand at the wrist in upward motion but unable to extend fingers. Resident 16 was observed unable to extend the right hand at the wrist nor extend the fingers. In a concurrent interview with the CRNA, she stated she provided daily ROM exercises for both Resident 16's hands without a specific ROM order. She stated nobody had been evaluating the RNA services she provided to the residents with limitation in ROM. She stated there were no instructions on which specific exercises were needed based on the status of Resident 16's ROM. In a concurrent interview with LVN 3, she stated Resident 16 had range of motion limitations on both hands since admission. 3. On February 6, 2024, at 3:31 p.m., Resident 21 was observed lying in bed with both hands flexed at the wrist and all fingers on both hands were clenched. Resident 21 was observed with a hand roll placed inside the palm of the right hand. On February 8, 2024, Resident's 21's admission record was reviewed. Resident 21 was admitted to the facility on [DATE], with diagnoses which included polyosteoarthritis (pain and stiffness affecting five or more joints). A review of Resident 21's Order Summary Report, indicated the following: - Order Date: 9/14/2020 .ROM exercises to Right hand 5x (five times) a week as tolerated .; and - Order Date: 9/21/2020 .Administer right hand brace (a device designed to keep a specific joint or area of your body from moving too much) for 8 hours per day as tolerated one time a day for hand contractures and remove per schedule . A review of Resident 21's MDS, dated July 7, 2023, indicated Resident 21 had no limitation in ROM on both upper and lower extremities. A review of Resident 21's History and Physical, documented by the physician on July 10, 2023, indicated no limitation in ROM on both lower and upper and lower extremities. A review of Resident 21's MDS, dated January 7, 2024, indicated Resident 21 had limitation in ROM on one side of the upper extremities. A review of Resident 21's Monthly Physician Progress Notes, documented by the physician on February 5, 2024, indicated no limitation in ROM of the bilateral upper and lower extremities. In further review of Resident 21's medical record, there was no documented evidence an ongoing assessment, evaluation, and monitoring of Resident 21's limitation in ROM on one side of the upper extremities was conducted by the facility. On February 9, 2024, at 11:45 a.m., Resident 21 was observed in her room with the CRNA and LVN 4. Resident 21 was observed lying in bed with her lower legs flexed at the knee towards her chest. Resident 21 was observed with both hands flexed at the wrist and all fingers clenched. In a concurrent interview with the CNRA, she stated Resident 21 was unable to extend her right hand at the wrist nor open her fingers. She stated Resident 21 was able to extend and open her fingers on the left hand. She further stated Resident 21 had difficulty extending her knees on both sides. The CRNA stated Resident 21 was the only resident in the facility with an order for ROM exercises for her right hand. However, she stated she performed daily ROM exercises for both hands, and ROM exercises on knees without a specific order or instructions on how to perform it. She stated nobody had been evaluating the RNA services she provided to the residents with limitation in ROM. In a concurrent interview with LVN 4, he stated Resident 21 had contractures on the right hand and fingers. LVN 4 stated Resident 21 had difficulty extending both knees and required assistance. 4. On February 6, 2024, at 10:13 a.m., Resident 22 was observed in her room, side lying in bed with both knees flexed towards her chest. On February 8, 2024, Resident 22's admission record reviewed. Resident 22 was admitted to the facility on [DATE], with diagnoses which included chronic (long term) pain syndrome ( broad term that covers long-lasting pain and inflammation that can happen after an injury or a medical event). A review of Resident 22's MDS, indicated the following: - April 3, 2022; Resident 22 had no limitation in ROM on upper and lower extremities; and - July 5, 20223, October 3, 2023, and January 3, 2024; Resident 22 had limitation in ROM on both lower extremities. In further review of Resident 22's medical record, there was no documented evidence an ongoing assessment, evaluation, and monitoring of Resident 22's limitations in ROM on both lower extremities was conducted by the facility. There was no documented evidence Resident 22's limitations in ROM on both lower extremities identified on multiple MDS assessments (April 3, 2022; July 5, 2023; October 3, 2023; and January 3, 2024) were addressed for appropriate care and treatment. On February 9, 2024, at 9:30 a.m., Resident 22 was observed in her room with the CRNA and LVN 4. Resident 22 was observed lying in bed on her right side with both lower legs flexed at the knee towards her chest. The CRNA was observed performing passive (requires assistance from staff) ROM to both lower extremities, but resident was unable to fully extend both legs. In a concurrent interview with the CRNA, she stated she provided daily ROM exercises for Resident 22 without specific order or instructions on how to perform it. She further stated nobody had been evaluating the RNA services she provided to the residents. In a concurrent interview with LVN 4, he stated Resident 22 had limitations in ROM on both lower extremities. LVN 4 stated he was not sure how long and when resident developed limitations on both lower extremities. 5. On February 8, 2024, Resident 28's admission record was reviewed. Resident 28 was admitted to the facility on [DATE], with diagnoses which included contractures of the right hand, hemiplegia, and hemiparesis of the right side. A review of Resident 28's care plan, dated November 1, 2016, indicated, .has right side hemiplegia and contracture of right hand and right ankle .will remain free from complication r/t (related to) hemiplegia and contracture through next review .monitor/document/report PRN (as needed) any (sic) of immobility: contractures forming or worsening .Resident will receive ROM exercises as ordered by MD . A review of Resident 28's MDS, dated August 6, 2023, indicated Resident 28 had limitations in ROM on one side of the upper and lower extremities. A review of Resident 28's Monthly Physician Progress Notes, documented by the physician, dated January 9, 2024, indicated Resident 28 had contractures of the right upper extremities. In further review of Resident 28's medical record, there was no documented evidence an ongoing assessment, evaluation, and monitoring of Resident 28's limitations in ROM on one side of upper and lower extremities was conducted by the facility. There was no documented evidence Resident 28's limitations in ROM on one side of upper and lower extremities identified on the MDS assessment was addressed for appropriate care and treatment. On February 9, 2024, at 11:50 a.m., Resident 28 was observed in her room with the CRNA and LVN 4. Resident 28 was observed lying in bed asleep. In a concurrent interview with the CRNA, she stated Resident 28 had contractures of her right hand and right ankle but was unable to provide the extent of her ROM limitations. She stated she provided daily ROM exercises for Resident 28's right hand and ankle without a specific order or instructions on how to perform it. She stated nobody had been evaluating the RNA services she provided to the residents with limitation in ROM. In a concurrent interview with LVN 4, he stated Resident 28 had contractures of the right hand and ankle but not sure when she developed the contractures. 6. On February 9, 2024, at 12:04 p.m., Resident 29 was observed in his room with the CRNA and LVN 4. Resident 29 was observed lying in bed with both hands flexed at the wrist and fingers clenched. The CRNA was observed attempting to perform ROM exercises to both hands for Resident 29, but the resident refused. In a concurrent interview with the CRNA, she stated Resident 29 was unable to extend both hands at the wrist and open all fingers. She stated she provided ROM exercises to Resident 29 on both hands and fingers without a specific order or instructions on how to perform it. She stated nobody had been evaluating the RNA services she provided to the residents with limitation in ROM. In a concurrent interview with LVN 3, Resident 29 had contractures of both hands and fingers and was not sure when the resident developed the contractures. On February 9, 2024, Resident 29's record was reviewed. Resident 29 was admitted to the facility on [DATE], with diagnoses which included dementia (cognitive impairment). A review of Resident 29's History and Physical, documented by the physician on May 18, 2022, indicated no limitations in ROM on both upper extremities. A review of Resident 29's MDS, dated March 3, 2023, indicated Resident 29 had no limitations in ROM on upper and lower extremities. A review of Resident 29's MDS, dated June 2, 2023, indicated Resident 29 had limitations in ROM on one side of the upper extremity. In further review of Resident 29's medical record, there was no documented evidence an ongoing assessment, evaluation, and monitoring of Resident 29's limitations in ROM on both upper extremities was conducted by the facility. There was no documented evidence Resident 29's limitations in ROM on both upper extremities identified on the MDS assessment was addressed for appropriate care and treatment. 7. On February 6, 2024, at 3:30 p.m., an observation and concurrent interview was conducted with Resident 151. Resident 151 was observed sitting in her wheelchair inside her room. Resident 151 was observed with both ankles extended in downward position. Resident 151 was observed not able to flex both ankles upward. In a concurrent interview with Resident 151, she stated she had foot drop (difficulty lifting the front part of the foot) on both of her feet and would like to have therapy. She further stated she would like to walk again. She stated she did not receive any exercises and therapy for her foot drop since admission to the facility. On February 8, 2024, Resident 151's admission record was reviewed. Resident 151 was admitted to the facility on [DATE], with diagnoses which included difficulty walking, and muscle wasting. A review of Resident 151's History and Physical, documented by the physician, on January 22, 2024, indicated Resident 151 had weakness and bilateral (both) foot drop. In further review of Resident 151's medical record, there was no documented evidence the physician addressed Resident 151's bilateral foot drop for further care and treatment. A review of the Resident 151's MDS, dated February 1, 2024, indicated the following: - Resident 151 had a BIMS (Brief Interview of Mental Status) score of 12 (moderate cognitive impairment); and - Resident 151 had limitations in ROM on both lower extremities. In further review of Resident 151's medical record, there was no documented evidence Resident 151's bilateral foot drop was addressed for appropriate care and treatment. On February 9, 2024, at 12:01 p.m. Resident 151 was observed in the hallway with the CRNA and LVN 4. Resident 151 was observed sitting in her wheelchair with both feet extended in a downward position. In a concurrent interview with the CRNA, she stated Resident 151 had bilateral foot drop since admission. She further stated Resident 151 did not have an order for any ROM exercises. In a concurrent interview with LVN 3, she stated Resident 151 had bilateral foot drop and was unable to flex both ankles upward. She further stated Resident 151 had this condition since admission. On February 9, 2024, at 4:50 p.m., a concurrent interview and record review was conducted with the ADON and the DSD. The ADON and the DSD stated all residents were to be assessed for any contractures and/or limitation with their ROM upon admission. The ADON and the DSD stated any contractures and/or limitation with ROM noted would be documented in the resident's record and referred to the physician for further care and treatment. The ADON and the DSD stated residents with contractures and/or limitations with ROM were discussed during care plan meeting quarterly. The ADON stated any decline in the resident's ROM would be discussed at least during their weekly stand up meeting. She stated the CRNA maintains the list of residents receiving RNA services for limitations in ROM. She stated she did not provide oversight of the RNA services being provided to the residents. The ADON and the DSD stated only Resident 21 had an order for ROM exercises. However, she stated CRNA provided daily ROM exercises for other residents even without specific order or instructions on how to perform it. The ADON and the DSD stated the IDT would determine the necessary care and treatment each resident with contractures and/or with limitation with ROM would receive. The ADON and the DSD were not able to provide documentation of any ongoing assessment, evaluation, monitoring, and provision of care and treatment for the contractures and/or limitations with ROM for Residents 1, 16, 21, 22, 28, 29, and 151. The DSD stated the facility had been trying to develop a program to address resident's limitation with ROM and/or contractures for several years but it never happened. On February 12, 2024, at 9:55 a.m., an interview with the facility Medical Doctor was conducted. He stated all residents with contractures or limitation with their ROM should be documented in the resident's medical record. He stated resident with contractures or limitation with their ROM should be assessed, evaluated, and monitored regularly to ensure appropriate treatment and care was provided. He further stated routine assessment and evaluation was important to maintain or prevent further decline and/or to identify any new onset of contractures or limitation with ROM for the residents. He stated the seven residents identified were not assessed or evaluated routinely and it should have been done and documented. The facility's policy and procedure titled Restorative Nursing Policy & Procedure, dated November 04, 2016, was reviewed. The policy indicated, .Restorative Nursing Shall include nursing interventions that promotes the resident's ability to adapt and adjust to living as independently as possible. This concept activity focuses on achieving and maintain optimal physical, mental and psychological functioning .Licensed Nurse shall implement, coordinate and supervise the activities in the restorative nursing program .The restorative program has to be an integrated part of resident's plan of care with clearly measurable goals and interventions and periodically evaluated by a licensed nurse .Restorative aide's will chart weekly in residents EMR (electronic medical record) .Restorative aide will chart weekly in residents EMR .track the daily minutes .Monitor Weekly Progress .Summaries overall achievements weekly .Restorative aide supervisor must review notes on a weekly basis .resident progress or setbacks evaluated weekly .Goals of care plan must be evaluate (sic) and revised as needed .The Interdisciplinary Team (IDT) quarterly assess/evaluates the resident restorative nursing program .