**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure the Housekeeper (HK 1) did not run over the resident ' s foot with the laundry cart (a large, blue, storage device with wheels used to deliver residents ' clothing and clean linens in bulk) for one of two sampled residents (Resident 1). Resident 1 sustained left foot fracture. The facility failed to: 1. Ensure Housekeeper (HK 1) did not overfill a laundry cart (a large, blue, storage device with wheels used to deliver residents ' clothing and clean linens in bulk) with clean linen and clothing preventing HK1 to have a clear view when transporting the laundry cart around the facility. On 7/20/2024 HK 1 run over Resident 1 left foot with a laundry cart while transporting it to Station 2. 2. Ensure HK 1 followed the facility policy and procedure titled, Laundry Initiative Module 2: the Six-Step Laundry Process which indicated when delivering clean linen, the clean linen must not be stacked higher than the rim or top shelf of the linen cart and nothing shall be stacked on top of the cart or covering. As a result of this deficient practices Resident 1 sustained a fracture (broken bone) of the left medial (middle) cuneiform (bone in the mid foot) on 7/20/2024 at 7:00 a.m. Resident 1 was sent to a general acute care hospital (GACH) for an evaluation of the left foot fracture. Resident 1 once independent in ambulation (walking) became a wheelchair dependent for mobility after sustaining a left foot injury. Findings: During a review of Resident 1 ' s admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including type 2 diabetes (a problem in the way the body regulates and uses sugar as a fuel), unspecified nondisplaced (the bone typically stays aligned in an acceptable position for healing) fracture of neck of right humerus (upper arm bone), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest and can interfere with your daily life), and generalized anxiety disorder (extremely worried or nervous—even when there is little or no reason to worry about them). During a review of Resident 1 ' s Minimum Data Set ([MDS] a standardized assessment and care-screening tool) dated 6/12/2024, the MDS indicated Resident 1 ' s cognitive (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) skills for daily decision making were intact (not affected). The MDS indicated Resident 1 did not use any assistive devices for ambulation. The MDS indicated Resident 1 was able to walk 150 feet ([ft] a unit of measurement of length) with supervision or touching assistance (staff provides verbal cues and/or touching/steadying but the resident completes the activity). During a review of Resident 1 ' s Health Status Note dated 7/20/2024, the Health Status Note indicated the activity staff informed Licensed Vocational Nurse (LVN 1) Resident 1 was complaining of the left foot pain. The Registered Nurse (RN 1) and LVN 1 then assessed Resident 1 and noted Resident 1 had swelling on the left foot and she was not able to bear any weight on the left foot. Resident 1 informed nursing staff she was hit from behind by the big blue linen bucket by HK 1, while ambulating (walking) towards the double doors near the activities room. Resident 1 informed RN 1 and LVN 1 she did not tell anyone about the incident, because HK1 apologized and believed it was an accident. A STAT (immediate) x-ray (picture of the inside structures of the body), ice pack for left foot, and Motrin (medication for pain) was ordered on 7/20/2024 by Resident 1 ' s physician (MD 1). During a review of Resident 1 ' s Change of Condition ([COC] – documentation of a resident ' s sudden change from regular state of being) evaluation dated 7/20/2024, the COC evaluation indicated MD 1 was notified of Resident 1 ' s accident on 7/20/2024 at 12:45 p.m. During a review of Resident 1 ' s care plan initiated on 7/20/2024, focusing on Resident has left foot pain with swelling due to Resident 1 stating, she was bumped into from behind by the big blue laundry bucket, the care plan indicted the goal for Resident 1 was to have pain improving. The car plan interventions included for Resident 1 to wear a controlled ankle movement ([CAM] foot brace that limits ankle and foot movement) boot on the left foot at all times, except when sitting or lying, non-weight bearing (cannot put any weight on that part of the body) on the left foot and remind Resident 1 not to have weight bearing on the left foot. During a review of Resident 1 ' s Radiology (x-ray) Results Report, the Radiology Results Report indicated an x-ray of Resident 1 ' s left foot was done on 7/20/2024 at 2:24 p.m., and the results were reported to the facility on 7/21/2024 at 1:05 p.m. The x-ray report result was as follows: no definite fracture identified; radiologist suggested to obtain additional x-ray views of the foot for further evaluation. During a review of Resident 1 ' s Health Status Note on 7/21/2024, the Health Status Note indicated MD 1 was informed of Resident 1 ' s left foot x-ray results and ordered for Resident 1 to be transferred to the GACH for evaluation of left foot fracture. During a review of Resident 1 ' s GACH emergency room (ER) After Visit Summary, dated 7/21/2024, the ER ' s After-Visit Summary indicated Resident 1 was seen in the ER for foot pain and was diagnosed with a fracture of the left cuneiform bone and was to follow up with an orthopedic (bone doctor) physician in 3 days. Resident 1 was discharged back to the facility on the same day she was seen in the ER, 7/21/2024. The ER ' s After Visit Summary indicated cuneiform fractures could be caused by dropping a heavy object on the foot and could be treated by wearing a boot or brace for several weeks. During a review of Resident 1 ' s care plan initiated on 7/21/2024, focusing on Resident has actual pain and discomfort related to incident on 7/20/2024, facility staff accidently ran over her foot with a laundry cart, the care plan indicated the goals for Resident 1 included achieving an acceptable level of pain control. The care plan interventions included obtaining a STAT x-ray, assisting Resident 1 to a position of comfort, utilizing pillows for positioning, and medicating Resident 1 as ordered for pain. During a review of Resident 1 ' s After Visit Summary 1, from her orthopedic physician visit dated 7/29/2024, the After Visit Summary 1 indicated Resident 1 was to always wear the CAM boot except when sitting or lying, needed to be non-weight bearing (on the left foot) for four to six weeks, and would need to go back to the orthopedic physician in six weeks for a repeat x-ray. During a review of Resident 1 ' s Physician ' s Orders Summary Report, the Physician ' s Orders Summary Report indicated an order dated 7/29/2024 for no weight bearing on the left foot. During an observation on 8/5/2024 at 12:35 p.m., a blue laundry cart was parked in the hallway in front of the laundry room. The laundry cart was piled high with clean linens in plastic bags and covered with a white blanket. The approximate height of the laundry cart, including the clean linens was over 5 ft tall. When standing behind it, the laundry cart obstructs the view of the hallway ahead. During an observation and concurrent interview on 8/5/2024 at 12:40 p.m., Resident 1 was sitting at the bedside eating lunch with her foot in a black orthopedic boot. Resident 1 stated that on the day she got injured she was walking toward the double doors on her unit when HK 1 came walking down the hall with the large blue laundry cart piled high with clothing and hit her from behind and ran over her left foot with the laundry cart. Resident 1 stated after HK 1 ran over her foot with the laundry cart, Resident 1 walked to her room to lay down in bed because the pain was excruciating, and she wanted to forget about it. Resident 1 stated she went back to her room, so she did not cry in front of everyone because of the pain and did not tell anyone about it because it was an accident, Resident 1 stated that a little while later HK 1 came to her room and apologized for running over her foot. Resident 1 stated she was able to walk before the accident but now she needed to use a wheelchair to move around in the facility. During an interview on 8/5/2024 at 1:04 p.m., LVN 1 stated Resident 1 was able to walk with a steady gait prior to getting her foot ran over by the laundry cart but now they had to provide her with a wheelchair because she had orders not to bear any weight on the left foot. During an interview on 8/5/2024 at 1:08 p.m., Activities Staff (ACT 1) stated Resident 1 attended activities on 7/20/2024 for a coffee social and around 11 a.m., Resident 1 asked for help back to her room which was unusual for her. ACT 1 asked Resident 1 why she needed help back to her room because she is usually ambulatory without assistance. ACT 1 stated Resident 1 informed her she could not walk because she had a bump on her left foot. ACT 1 stated she called LVN 1 over for help and LVN 1 assessed Resident 1 ' s foot with RN 1 and placed Resident 1 in a wheelchair and took her to her room. During an interview on 8/5/2024 at 2:47 p.m., LVN 1 stated that before lunch time (between 11 a.m. and 12 p.m.) on 7/20/2024, ACT 1 informed her that something was wrong with Resident 1 ' s left foot. LVN 1 stated she removed Resident 1 ' s shoes and noted the resident ' s left foot was visibly swollen on the dorsal (top) part. LVN 1 stated Resident 1 stated that her left foot was ran over by a laundry cart that had stacks of clothes in it. LVN 1 stated Resident 1 ' s MD 1 was informed of what had happened to Resident 1 and that her left foot was swollen and tender to the touch. LVN 1 stated Resident 1 verbalized her left foot hurt a lot. During an interview on 8/5/2024 at 3:36 p.m., HK1 did not speak a commonly used language (English) and a housekeeping supervisor (HKS) was translating the interview with HK1. The HK1 stated she was pushing the blue laundry cart into Station 2 from through the double doors and she did not see Resident 1 but heard ouch! HK1 stated she stopped the cart, walked around the cart, and saw Resident 1 there. HK 1 stated Resident 1 told her she (HK1) hit her with the laundry cart. HK1 stated she asked Resident 1 if she was okay and she said yes, she was okay. HK 1 stated she did not see Resident 1 walking in the hallway because the laundry cart was full of clean clothing, and it blocked her view. HK 1 stated the incident occurred around 7 a.m. on 7/20/2024. During an observation and concurrent interview on 8/6/2024 at 8:14 a.m., the blue laundry cart was parked in the hallway by the laundry room, the laundry cart was piled high with residents clothing in plastic bags on hangers and the plastic bags of clothes were covered by a white blanket. HK 1 was standing next to the blue laundry cart and the laundry cart and HK 1 was approximately the same height (HK 1 stated she was 5 ft tall). HK 1 with the scheduler (SCH) as a translator stated the blue laundry cart was the same laundry cart that she was pushing when she hit Resident 1. HK 1 stated the day of the accident, the laundry cart was piled high with clothing as it was during the observation. HK 1 acknowledged the laundry cart was piled too high and was blocking her visual field. During an interview on 8/6/2024 at 11:15 a.m., the Director of Rehabilitation ([DOR] – specializes in techniques to restore muscle function and movement) reviewed Resident 1 ' s Rehabilitation Evaluations from Physical Therapy (PT) and stated Resident 1 was previously discharged from PT Rehabilitation in February 2024 and was not using any assistive devices during that time and was able to walk 150 ft with hardly any assistance. The DOR stated Resident 1 had a high level of function at the time of discharge (2/2024) from Rehabilitation (rehab). The DOR stated Resident 1 was reevaluated for rehab services again on 7/23/2024 by PT and Occupational Therapy (OT) after her accident and now required a wheelchair and non-weight bearing on the left foot due to her injury. The DOR stated Resident 1 had a functional (ability to move and use a joint to perform activities of daily living) decline due to the left foot injury. During an interview on 8/6/2024 at 11:40 a.m., Resident 1 stated she was 5 ft 2 inches tall. Resident 1 stated she was feeling antsy from being stuck in her wheelchair because she likes to walk around. Resident 1 stated she was having a hard time propelling the wheelchair with her arms because she had an old right shoulder injury. Resident 1 stated she was stuck in her room since the accident unless staff pushed her around in the wheelchair. During an interview on 8/6/2024 at 12:06 p.m., the Director of Staff Development (DSD) stated to ensure resident safety, staff are to look around the carts when they are pushing them and not have the carts stacked too high, blocking their visual field. The DSD stated if the laundry cart was piled too high there was not a clear view, and someone could get hit with the cart. The DSD stated the accident between HK 1 and Resident 1 could have been prevented if HK 1 had a clear view and was able to see Resident 1. During an interview on 8/6/2024 at 12:37 p.m., the HKS stated HK 1 should have informed the charge nurse on duty or any nursing staff immediately about the accident, even if she thought Resident 1 was okay. The HKS stated the laundry carts should not be filled above the top of the cart. During an interview on 8/6/2024 at 2:15 p.m., the Director of Nursing (DON) stated Resident 1 was ambulatory prior to this incident and was now wearing a CAM boot and would be non-weight bearing for 4-6 weeks. During a review of the facility ' s P/P titled Laundry Initiative Module 2: the Six-Step Laundry Process revised 8/2024, the P/P indicated, when delivering clean linen, the clean linen must not be stacked higher than the rim or top shelf of the linen cart and nothing shall be stacked on top of the cart or covering.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide services to maintain mobility (ability to move) for two of eight sampled residents (Resident 61 and Resident 102) with limited range of motion ([ROM] full movement potential of a joint {where two bones meet}) and mobility by failing to: 1. Monitor and assess Resident 61's ROM in each joint of both arms and legs during the quarterly Rehab Screening (brief assessment of a resident's abilities) from 11/5/2021 to 6/12/2022 in accordance with the facility's policy titled, Resident Mobility and Range of Motion, which indicated the facility will identify the resident's ROM of the joints as part of the resident's comprehensive assessment. 2. Provide Resident 61 with passive range of motion ([PROM] a movement of joint through the ROM with no effort from the person) to the left arm from 2/2/2022 to 6/11/2022, as ordered by Resident 61's physician on 3/26/2019, and in accordance with the Resident 61's request documented in Resident 61's Rehab Screening, dated 2/2/2022. 3. Monitor and assess Resident 61's ROM in each joint of both arms and legs quarterly from 9/2/2022 to 4/2/2024 in accordance with the facility policy titled, Resident Mobility and Range of Motion after Resident 61's discharge from Occupational Therapy ([OT] profession that provides services to increase and/or maintain a person's capability to participate in everyday life activities) on 9/2/2022. 4. Perform PROM exercises on 6/25/2024 to Resident 61 left elbow, wrist, hand, and ankle and the right leg in accordance with the physician's orders, dated 1/23/2024, to provide PROM to the left arm and both legs as tolerated. 5. Monitor and assess Resident 102's ROM in each joint of both arms and legs during Resident 102's quarterly Rehab Screening, dated 4/5/2024. These failures resulted in Resident 61 developing ROM limitations in the left elbow, forearm, and wrist on 6/12/2022, causing Resident 61 to develop contractures (condition of shortening and hardening of muscles, tendons, or other tissue, often leading to joint stiffness) in the left elbow, forearm, and wrist, experience pain with movement of the left arm, and prevented Resident 61 from participating in activities of daily living ([ADL], tasks related to personal care including bathing, dressing, hygiene, eating, and mobility), including dressing in normal clothes and getting out of bed. These failure also had the potential for Resident 61 to develop ROM limitations in both legs and Resident 102 to experience a decline in ROM in both arms and both legs without detection and intervention. Findings: a. During a review of Resident 61's admission Record, the admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses including cerebral infarction (brain damage due to a loss of oxygen to the area) due to embolism (blood vessel blockage) of the right middle cerebral artery (largest of the major blood vessels in the brain), hemiplegia (paralysis of one side of the body) and hemiparesis (weakness of one side of the body), hypertensive (abnormally high blood pressure) heart disease, type 2 diabetes mellitus (high blood sugar), and major depressive disorder (depression, a mood disorder that causes a persistent feeling of sadness and loss of interest and can interfere with daily functioning). During a review of Resident 61's OT Evaluation and Plan of Treatment, dated 3/22/2019, the OT Evaluation indicated Resident 61's ROM in the right arm was within functional limits ([WFL] sufficient movement without significant limitation) and the left arm was impaired. The OT Evaluation indicated Resident 61's left arm ROM impairments included left shoulder flexion (lifting the arm upward) 30 to 90 degrees (30-90 degrees, normal 0-180 degrees), left elbow flexion (bending the elbow) 40-140 degrees (normal 0-150 degrees), left wrist (unspecified ROM), and left-hand ring finger and small finger had flexion (bending) contractures. The OT Evaluation indicated Resident 61 had limited strength in both arms with weakness in the left arm. Resident 61's OT Plan of Treatment indicated an OT Evaluation only (no OT intervention) with recommendations for Resident 61 to receive a Restorative Nursing Aide ([RNA] a certified nursing aide program that helps residents to maintain their function and joint mobility) program to provide PROM to the left shoulder, elbow, and hand, five times per week. During a review of Resident 61's Physical Therapy ([PT] profession aimed in the restoration, maintenance, and promotion of optimal physical function) Evaluation and Plan of Treatment, dated 3/22/2019, the PT Evaluation indicated Resident 61's both legs were WFL except for left ankle stiffness. Resident 61's PT Plan of Treatment indicated a PT evaluation only. During a review of Resident 61's Physician's Orders, dated 3/26/2019, the Physician's Orders indicated for the RNA to provide PROM to the resident's left arm in all available planes (movement side-to-side, front, and back, or rotational), five times per week as tolerated. Another physician's order, dated 3/26/2019, indicated for the RNA to provide Resident 61 with active assistive range of motion ([AAROM] use of muscles surrounding the joint to perform the exercise but required some help from a person or equipment) exercises to both legs and sit to stand transfers with one siderail use, five times per week as tolerated. During a review of Resident 61's physician's orders, dated 10/29/2021, the physician orders indicated for the RNA to provide PROM to the resident's left leg, five times per week as tolerated. During a review of Resident 61's Rehab Screening, dated 11/5/2021, the Rehab Screening indicated Resident 61's ROM in the right arm and right leg were WFL. The Rehab Screening indicated Resident 61's ROM in the left arm and left leg were impaired (unspecified). During a review of Resident 61's Minimum Data Set ([MDS] a standardized assessment and care screening tool), dated 11/9/2021, the MDS indicated Resident 61 had intact cognitive (ability to think, understand, learn, and remember) skills for daily decision making. The MDS indicated Resident 61 had ROM limitations in one arm and one leg. During a review of Resident 61's Rehab Screening, dated 2/2/2022, and 5/2/2022 the Rehab Screening indicated Resident 61's ROM in the right arm and right leg were WFL. The Rehab Screening indicated Resident 61's ROM in the left arm and left leg were impaired (unspecified). The Rehab Screening indicated Resident 61 had left-sided hemiplegia with noted hypertonicity (increased tightness in the muscles). The Rehab Screening indicated Resident 61 verbalized a wish to continue with the RNA program for PROM to both arms and both legs. The Rehab Screening indicated Resident 61 was receiving RNA for PROM to the left arm and left leg, five times per week as tolerated. During a review of Resident 61's Documentation Survey Report (record of nursing assistant tasks) for RNA, dated for the month of 2/2022, 3/2022, and 4/2022, the Documentation Survey Report indicated Resident 61 received RNA for PROM to the left leg, five times per week as tolerated. The Documentation Survey Report did not include documentation from 2/2022 thru 4/2022 RNA for PROM to the left arm as ordered by Resident 61's physician (3/26/2019) and as indicated in the Rehab Screening, dated 2/2/2022. During a review of Resident 61's Documentation Survey Report (record of nursing assistant tasks) for RNA, dated for the months 5/2022 and 6/2022, the Documentation Survey Report indicated Resident 61 received RNA for PROM to the left leg, five times per week as tolerated. The Documentation Survey Report did not include documentation from 5/2022 thru 6/2022 RNA for PROM to the left arm as ordered by Resident 61's physician (3/26/2019) and indicated in the Rehab Screenings, dated 2/2/2022 and 5/2/2022. During a review of Resident 61's Rehab Screening, dated 6/12/2022, the Rehab Screening indicated Resident 61 required an OT Evaluation. During a review of Resident 61's OT Evaluation and Plan of Treatment, dated 6/12/2022, the OT Evaluation indicated Resident 61's ROM in the right arm was WFL but Resident 61's left arm ROM was impaired. The OT Evaluation indicated Resident 61's left arm ROM impairments included shoulder flexion 0-80 degrees, shoulder abduction (lifting the arm up and away from the body) 0-45 degrees (normal 0-180 degrees), elbow positioned in extension (straightened elbow) with 10 degrees of motion, wrist positioned in flexion (bent downward) to 90 degrees, wrist extension (bending the wrist upward) to neutral (wrist straightens but unable to bend further upward), the forearm positioned in increased pronation (rotation of the forearm that results in the palm facing downward), and the left-hand middle, ring, and small fingers were positioned in flexion. The OT Plan of Treatment included to provide therapeutic exercises (movement prescribed to correct impairments and restore muscle function), neuromuscular reeducation (technique used to restore movement patterns through repetitive motion to retrain the brain), therapeutic activities (tasks that improve the ability to perform ADLs), self-care management training, and orthotic (also known as a splint, material used to restrict, protect, or immobilize a part of the body to support function, assist and/or increase range of motion) management and training, five times per week for 30 days. During a review on Resident 61's PT Evaluation and Plan of Treatment, dated 6/11/2022, the PT Evaluation indicated Resident 61's ROM in the right leg, left hip, and left knee were WFL. The PT Evaluation indicated Resident 61's left ankle dorsiflexion (bending the ankle toward the body, normal 0-20 degrees) was impaired and positioned in 10 degrees of plantarflexion (ankle bent away from the body). The PT Plan of Treatment included therapeutic exercise, neuromuscular reeducation, and therapeutic activities five times per week. During a review of Resident 61's OT Discharge summary, dated [DATE], the OT Discharge Summary indicated Resident 61 tolerated wearing the left-hand wrist, hand, finger orthosis ([WHFO], material secured with straps that extends from the fingers to the forearm to properly position the fingers and wrist and prevent contractures) for five hours daily and the RNA (unknown) demonstrated 100 percent (%) good return demonstration of the left arm PROM exercises with prolonged stretch to maintain joint mobility, good hygiene, and prevent contractures. The OT Discharge Summary indicated recommendations for the RNA to provide Resident 61 with AAROM to the right arm, PROM to the left arm, and application of the left-hand WHFO for four to six hours, seven days a week as tolerated. During a review of Resident 61's PT Discharge summary, dated [DATE], the PT Discharge Summary indicated Resident 61 tolerated wearing pressure relief ankle-foot orthosis ([PRAFO] a device worn on the calf and foot to suspend the heel and hold the ankle in neutral [90 degree] position) to the left ankle for two hours five times per week. The PT Discharge Summary indicated recommendations for the RNA to provide Resident 61 with PROM of both legs and to apply the left ankle PRAFO as tolerated with skin checks, five times per week as tolerated. During a review of Resident 61's Physician's Orders, dated 7/29/2022, the physician's orders indicated the order for the RNA to perform AAROM to Resident 61's right arm, PROM to Resident 61's left arm, and to apply the left-hand WFHO for four to six hours as tolerated, seven days per week. Another physician's orders, dated 7/29/2022, indicated the order for the RNA to perform PROM to both of Resident 61's legs and to apply the left ankle PRAFO, five times per week as tolerated. During a review of Resident 61's PT Evaluation and Plan of Treatment, dated 8/19/2022, the PT Evaluation indicated Resident 61's ROM in the right leg was WFL but impaired on the left hip, knee, and ankle. The PT Evaluation indicated the ROM in Resident 61's left leg included left hip flexion 0-60 (bending the leg at the hip joint toward the body, normal 0-120), left knee fixed (immovable) into extension (straightening out the knee, normal 0-135 degrees), and the left ankle was positioned in 10 degrees of plantarflexion. During a review of Resident 61's OT Evaluation and Plan of Treatment, dated 8/20/2022, the OT Evaluation indicated Resident 61's ROM in the right arm was WFL but Resident 61's ROM in the left arm was impaired. The OT Evaluation and Plan of Treatment indicated Resident 61's left arm ROM impairments included shoulder flexion 0-70 degrees, shoulder abduction 0-45 degrees, elbow positioned in extension with 10 degrees of motion, wrist positioned in flexion to 90 degrees, wrist extension to neutral, the forearm positioned in increased pronation, and left-hand middle, ring, and small fingers were positioned in flexion. The OT Plan of Treatment included to provide therapeutic exercises, neuromuscular reeducation, therapeutic activities, and orthotic management and training, four times per week for two weeks. During a review of Resident 61's PT Discharge summary, dated [DATE], the PT Discharge Summary indicated Resident 61 tolerated wearing the left ankle PRAFO for two hours five times a week. The PT Discharge Summary indicated recommendations for the RNA to provide Resident 61 with PROM of both legs and to apply the left ankle PRAFO as tolerated with skin checks, five times per week as tolerated. During a review of Resident 61's Physician's Orders, dated 8/25/2022, the physician's orders indicated the order for the RNA to provide Resident 61 with PROM to both legs and to apply the left ankle PRAFO for two hours with skin checks, five times per week. During a review of Resident 61's OT Discharge summary, dated [DATE], the OT Discharge Summary indicated Resident 61 tolerated wearing the left-hand WHFO for four-and-a half hours (4.5 hours) and the RNA (unknown) demonstrated 100% good return demonstration of applying and removing Resident 61's left-hand WHFO. The OT Discharge recommendations included for the RNA to perform PROM to Resident 61's left arm and apply the left-hand WHFO for four to six hours, seven times per week. During a review of Resident 61's Physician Orders, dated 9/15/2022, the physician orders indicated for the RNA to provide PROM to Resident 61's left arm and to apply the left-hand WHFO for four to six hours, seven times per week as tolerated. During a review of Resident 61's Rehab Screening, dated 10/24/2022, 1/18/2023, 4/18/2023, 7/13/2023, and 10/12/2023, the Rehab Screen indicated Resident 61's ROM in the right arm and right leg were WFL and Resident 61's ROM in the left arm and left leg were impaired (unspecified). The Rehab Screenings indicated for Resident 61 to continue with the RNA program for the left arm and left leg exercises and application of the left-hand WHFO and left ankle PRAFO. During a review of Resident 61's Progress Note for Rehab Screening, dated 1/10/2024, the Progress Note for Rehab Screening indicated Resident 61's ROM in the right arm and right leg were WFL and Resident 61's ROM in the left arm and left leg were impaired (unspecified). The Progress Note indicated to continue with the established RNA program of left arm and left leg PROM exercises and application of the left hand WHFO and left ankle PRAFO. During a review of Resident 61's Physician's Order, dated 1/23/2024, the Physician's Order indicated there was an order for the RNA to perform PROM to both legs and apply the left ankle PRAFO for two hours, five times per week as tolerated. The physician's order, dated 1/23/2024, also indicated for the RNA to provide Resident 61 with PROM to the left arm and apply the left hand WHFO for four to six hours, seven days per week as tolerated. During a review of Resident 61's Progress Note for Rehab Screening, dated 4/2/2024, the Progress Note for Rehab Screening indicated Resident 61's ROM in the right arm and right leg were WFL and Resident 61's ROM in the left arm and left leg were impaired (unspecified). The Progress Note for Rehab Screening indicated Resident 61 did not have any significant decline with mobility, ADLs, and ROM (from the last Rehab Screening on 1/10/2024) and to continue with RNA. During a review of Resident 61's MDS, dated [DATE], the MDS indicated Resident 61 had clear speech, expressed ideas, and wants, understood verbal content, and had intact cognition. The MDS indicated Resident 61 had ROM limitations in one arm and one leg and was dependent on staff for showering/bathing, upper body dressing, lower body dressing, rolling to either side in bed, and tub/shower transfers. The MDS indicated chair/bed-to-chair transfers were not attempted with Resident 61 due to medical condition or safety concerns. During a review of Resident 61's Restorative Administration Record (record of RNA tasks) for 6/2024, the Restorative Administration Record indicated the RNA provided Resident 61 with PROM to both legs and applied the left ankle PRAFO, five times per week for two hours. The Restorative Administration Record also indicated the RNA provided PROM to the left arm and applied the left-hand WHFO for four to six hours, seven times per week. During an interview on 6/24/2024 at 9:14 a.m. with the Director of Rehabilitation (DOR), the DOR stated the Rehab Screening (in general) were completed on admission, quarterly, after a fall, after a change in the resident's condition, and from RNA referrals. The DOR stated the Rehab Screening monitored whether a resident had any declines in ROM, development of contractures, and decline in levels of assistance. The DOR stated the Rehab Screening indicated whether the extremity (arm and leg) was impaired. The DOR stated the Rehab Screening did not include a measurement of the resident's ROM at each joint. During a concurrent observation and interview on 6/24/2024 at 11:14 a.m. with Resident 61 in the room, Resident 61 was observed in bed and had active movement in the right arm. Resident 61 stated being unable to move the left side of the body and felt pain when Resident 61 tried to move the left side. Resident 61 stated the staff did not provide any ROM exercises (unknown length of time). During a concurrent observation and interview on 6/24/2024 at 1:34 p.m. in Resident 61's room, the resident was observed being awake in bed and wearing a hospital gown. Resident 61 stated he was unable to move the left arm and left leg since admission to the facility and did not receive exercises to arm and leg every day (unknown length of time). During a concurrent observation and interview on 6/25/2024 at 8:57 a.m. with Restorative Nursing Aide (RNA 1) in Resident 61's room, the resident was observed in bed awake and requested to receive pain medication prior to RNA exercises. Resident 61 stated he was having the left arm and the left leg pain level 10 out of 10 on a pain scale rating from zero to ten (a pain screening tool using numerical value to assess the level of pain ranging from 0 to 3-mild pain, from 4 to 6- moderate pain, and from 7 to 9-severe pain, and 10- the worse pain possible). During an observation on 6/25/2024 at 11:06 a.m. with RNA 1 in Resident 61's room, the resident was observed in bed, awake in a hospital gown with the left arm positioned directly on the left side of Resident 61's body. Resident 61's left shoulder was rotated toward the body, the left elbow was in an extended position, the forearm was excessively rotated inward in a position that made the left-hand palm face away from Resident 61's body, the wrist was bent downward in a 90-degree position, and the left-hand middle, ring, and small fingers had a claw-like appearance. RNA 1 was observed standing on the left side of Resident 61's bed and performing ROM exercises to the left arm, including shoulder flexion and shoulder abduction (lifting the arm up and away from the body). RNA 1 was observed not performing any ROM exercises to Resident 61's left elbow, forearm, wrist, and hand. Resident 61's left leg was observed straight on the bed and the left ankle was bent away from the body. RNA 1 was observed performing ROM exercises to Resident 61's left leg, including ROM into hip flexion with the knee extended and hip abduction (moving the leg away from the body) with the knee extended. RNA 1 was observed attempting to bend Resident 61's left knee but Resident 61 immediately complained of pain. Resident 61 agreed to allow RNA 1 to continue with ROM exercises to the left knee despite the pain. RNA 1 was observed not performing any ROM exercises to Resident 61's left ankle. Resident 61 declined to wear the left-hand WHFO and left ankle PRAFO splints (material used to restrict, protect, or immobilize a part of the body to support function, assist and/or increase range of motion). RNA 1 stated the last time Resident 61 wore both splints was on 6/21/2024. During an interview on 6/25/2024 at 11:14 a.m. RNA 1 stated he provided Resident 61 with PROM exercises to the left shoulder. RNA 1 stated PROM was not provided to Resident 61's left elbow, wrist, and hand because Resident 61 cannot bend at those joints. RNA 1 stated he forgot to perform PROM to the left ankle. During an interview on 6/25/2024 at 1:17 p.m., RNA 1 stated he usually provided Resident 61 with PROM exercises to the left shoulder, hip, knee, and ankle but forgot to perform PROM of the left ankle on 6/25/2024. RNA 1 stated Resident 61 refused the application of the left-hand WHFO and left ankle PRAFO splints on 6/25/2024. During a concurrent interview and record review on 6/25/2024 at 1:39 p.m. with RNA 1, Resident 61's Restorative Administration Record for the month of 6/2024 was reviewed. The Restorative Administration Record for Resident 61 indicated for the RNA to provide PROM to both legs. RNA 1 stated he did not provide PROM to Resident 61's right leg today (6/25/2024) because he (RNA 1) felt nervous. During an observation on 6/26/2024 at 8:35 a.m. in Resident 61's room, the resident was observed in bed, awake in a hospital gown, and asked to be turned to the left side. The Director of Nursing (DON) and Central Supply (CS) came to Resident 61's bedside to assist Resident 61 with turning toward the left. Resident 61 asked the DON and CS to be careful with the left arm due to pain. During an interview on 6/26/2024 at 9:37 a.m. a CS stated she was also a CNA. CS stated Resident 61 was repositioned to turn toward the left side and had pain in the left arm because of the left arm contracture. During a concurrent interview and record review on 6/26/2024 at 10:00 a.m. with the DOR, Resident 61's OT Evaluation, dated 3/22/2019, was reviewed. The DOR stated Resident 61 was admitted to the facility on [DATE] and received an OT Evaluation on 3/22/2019. The DOR reviewed Resident 61's OT Evaluation and stated Resident 61's ROM in the right arm was WFL which meant Resident 61 could use right arm functionally without limitations. The DOR stated Resident 61's ROM in the left shoulder was 30-90 degrees which meant Resident 61's left arm could be lifted to shoulder height. The DOR stated Resident 61's left elbow ROM was 40-140 degrees which meant Resident 61's left elbow could not completely straighten but could bend completely. The DOR stated Resident 61's left-hand ring finger and small finger were contracted into flexion. The DOR stated Resident 61 could partially move the left arm. The DOR stated Resident 61 did not receive OT therapy and was referred to the RNA program for PROM exercises to the left shoulder, elbow, and hand, five times per week. During a concurrent interview and record review on 6/26/2024 at 10:55 a.m. with the DOR, Resident 61's OT Evaluation, dated 6/12/2022, was reviewed. The DOR reviewed Resident 61's OT Evaluation, dated 6/12/2022, and stated Resident 61 was found to have a decline in ROM. The DOR stated Resident 61's right arm ROM was WFL but had impaired ROM in the left arm. The DOR stated Resident 61's left shoulder ROM included shoulder flexion 0-80 degrees and shoulder abduction 0-45 degrees. The DOR stated Resident 61's left elbow was positioned in complete extension, could bend 10 degrees, but could not completely bend. The DOR stated Resident 61's left forearm was positioned in increased pronation but stated Resident 61's OT Evaluation did not include ROM measurements of the left forearm. The DOR stated Resident 61's left wrist was positioned in 90 degrees of flexion but could extend the wrist to neutral. The DOR stated Resident 61's ROM in the left thumb and index finger were WFL but stated Resident 61's middle, ring, and small fingers were in bent positions. During a concurrent interview and record review on 6/26/2024 at 11:16 a.m. with the DOR, Resident 61's OT Discharge summary, dated [DATE], was reviewed. The DOR stated the OT Discharge Summary indicated Resident 61 wore a left-hand WHFO for five hours and the RNA (unknown) demonstrated 100 % competence in performing Resident 61's left arm ROM exercises. The OT Discharge recommendations included RNA for PROM of the left arm and application of the left-hand WHFO splint for four to six hours. The DOR stated the PROM exercises the RNA should be performing with Resident 61 included shoulder flexion and extension (returning the arm downward), shoulder abduction and adduction (returning the arm downward to the side of the body), elbow flexion and extension, wrist flexion and extension (bending the wrist upward), forearm supination (rotating the forearm that results in the palm facing upward), and finger flexion and extension. During a concurrent interview and record review on 6/26/2024 at 12:23 p.m. with the DOR, Resident 61's OT Evaluation, dated 8/20/2022, and OT Discharge summary, dated [DATE], was reviewed. The DOR stated Resident 61's left arm ROM on 8/20/2022 did not change from the OT Evaluation, dated 6/12/2022. The DOR stated Resident 61's OT Discharge summary, dated [DATE], indicated Resident 61 wore the left-hand WHFO for 4.5 hours and the RNA (unknown) demonstrated 100% competence in applying the left-hand WHFO. The DOR stated Resident 61's OT Discharge recommendations included for RNA to provide PROM to the left arm and the application of the left hand WHFO for four to six hours, seven times per week. During a concurrent interview and record review on 6/26/2024 at 12:48 p.m. with the DOR, Resident 61's physician's orders, dated 1/23/2024, for RNA were reviewed. The DOR stated Resident 61's physician's orders indicated the order for the RNA to provide PROM to both legs, PROM to the left arm, and application of the left-arm WHFO and left ankle PRAFO. During a concurrent interview and record review on 6/26/2024 at 1:20 p.m. with the DOR, Resident 61's quarterly Rehab Screening, dated 11/5/2021, 2/2/2022, 5/2/2022, 6/12/2022, 8/1/2022, 10/24/2022, 1/18/2023, 4/18/2023, 5/31/2023, 7/13/2023, 10/12/2023, 1/10/2024, and 4/2/2024, were reviewed. The DOR stated Resident 61's Rehab Screening did not include ROM measurements because measuring a resident's ROM was an assessment and not a part of the screening. The DOR stated the RNAs provided ROM exercises to the residents (in general) and will verbally inform the DOR during weekly meetings whether the resident had a change in ROM and whether the resident did not tolerate wearing the splints. The DOR stated the quarterly Rehab Screening (in general) indicated whether a resident had an impairment in the arms and legs but did not indicate which joint was impaired and the severity of the impairment. During a concurrent observation and interview on 6/26/2024 at 1:37 p.m. with the DOR, in Resident 61's room, the resident was in bed wearing a hospital gown with the left arm positioned on the side of the body. Resident 61's left shoulder was rotated toward the body, the left elbow was in an extended position, the forearm was excessively rotated inward in a position that made the left-hand palm face away from Resident 61's body, the wrist was bent downward in a 90-degree position, and the left-hand middle, ring, and small fingers had a claw-like appearance. Resident 61 stated feeling pain throughout the left arm. Resident 61 allowed the DOR to move the left arm. The DOR stated Resident 61's ROM for left shoulder flexion was 0-70 degrees, left shoulder abduction was 0-45 degrees, left elbow ROM was 170-180 degrees, the left wrist moved from a flexed position to neutral, and the left thumb and index fingers were WFL. The DOR attempted to rotate Resident 61's left forearm into supination but Resident 61 immediately screamed in pain. The DOR stated Resident 61's left forearm ROM had a decline in ROM since the DOR could usually move the left forearm to neutral (rotating the forearm that results in the palm facing the body). The DOR stated the RNAs should be performing PROM to Resident 61's left shoulder, elbow, forearm, wrist, and hand prior to applying the left-hand WHFO. During an interview on 6/26/2024 at 1:45 p.m. the DOR stated the purpose of performing PROM to Resident 61's left arm was to maintain ROM, joint mobility, and prevent contractures. The DOR stated Resident 61's complaint of pain in the left arm and screaming in pain during forearm supination indicated Resident 61's left arm has not been moved (exercised). The DOR stated Resident 61's left arm experienced a ROM decline and increased pain. During a concurrent observation and interview on 6/27/2024 at 1:20 p.m. with Resident 61 in the bedroom, Resident 61 was in bed, awake in a hospital gown with the left arm positioned directly to the side of Resident 61's body. Resident 61 stated the left arm had some pain at rest that sharply increased when someone touched or moved the left arm for exercises. Resident 61 stated he wanted and encouraged the facility staff to perform left arm exercises (in general) but did not remember anyone performing any exercises to the left arm. Resident 61 stated he did not remember when or how long the left arm had a twisted appearance but stated it did not happen overnight. During an interview on 6/27/2024 at 1:42 p.m. a Certified Nursing Assistant (CNA 5) in Resident 61's room, CNA 5 stated Resident 61 was dressed in a hospital gown because Resident 61 had pain in the left arm, preventing Resident 61 from putting on a shirt. CNA 5 stated Resident 61 did not like to get out of bed because Resident 61 felt pain throughout the body. Resident 61 stated the left arm pain prevented Resident 61 from getting dressed and getting out of bed. During a concurrent interview and record review on 6/27/2024 at 5:16 p.m. with the DON and DOR, Resident 61's Census List, OT Evaluation, dated 3/22/2019, Rehab Screening, dated 2/2/2022 and 5/2/2022, Documentation Survey Report for RNA for 2/2022, 3/2022, 4/2022, 5/2022, and 6/2022, and OT Evaluation, dated 6/12/2022, were reviewed. The DON and DOR reviewed Resident 61's Census List and stated Resident 61 never left the facility after admission on [DATE]. The DON and DOR reviewed Resident 61's OT Evaluation, dated 3/22/2019, which indicated Resident 61's ROM in the right arm was WFL but had impaired ROM in Resident 61's left shoulder, left elbow into extension but could bend completely, and left ring finger and small finger. The DON and DOR reviewed Resident 61's Rehab Screening, dated 2/2/2022. The DON stated the Rehab Screening, dated 2/2/2022, indicated the ROM in Resident 61's left arm and left leg were impaired but did not indicate which joints were impaired and the severity of the impairments. The DON stated Resident 61's Rehab Screening, dated 2/2/2022, indicated Resident 61 wanted an RNA program for ROM to both arms and both legs. The DON and DOR reviewed Resident 61's Documentation Survey Report for RNA from 2/2022 to 5/2022. The DOR stated Resident 61 did not receive PROM to the left arm from 2/2022 to 5/2022. The DOR and DON reviewed Resident 61's Rehab Screen, dated 5/2/2022. The DON stated the Rehab Screening, dated 5/2/2022, indicated the ROM in Resident 61's left arm and left leg were impaired but did not indicate which joints were impaired and the severity of the impairmen[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure, residents, assessed at risk for falls, did not have a fall, for one of three sampled residents (Resident 1). The facility failed to: 1. Ensure a Certified Nurse Assistant (CNA 3) did not leave Resident 1 unsupervised when Resident 1 was sitting at the edge of the bed. 2. Ensure CNA 3 followed the facility's policy and procedure (P&P) titled Answering the Call Light which indicated to call another staff for help by using the call light for assistance. CNA 3 left Resident 1 sitting at the edge of her bed unattended and went to the resident's restroom to get some gloves. 3. Ensure staff followed Resident 1's care plan titled Resident at risk for fall related to poor safety awareness, cognitive (ability to think, understand, learn, and remember) loss, and visual limitation which indicated staff will assist Resident 1 getting in and out of bed, and perform frequent visual checks. The deficient practices resulted in an unavoidable fall on 5/4/2024 and Resident 1 sustained a right inferior pubic ramus fracture (crack or break in the pelvis [basin-shaped complex of bones that connect the trunk and the legs]). Resident 1 was hospitalized at the General Acute Care hospital (GACH) for orthopedic ([ortho] field of medicine specialize in injuries of the muscles, bones, joints, ligaments, and tendons) evaluation and management from 5/4/2024 and discharged back to the facility on 5/6/2024. Findings: A review of Resident 1's admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including hypertensive heart disease with heart failure (heart muscle is unable to pump enough blood to meet the body's needs for blood and oxygen), osteoporosis (condition in which bones become weak and brittle), dementia (loss of memory, language, problem-solving and other thinking abilities) and difficulty in walking. A review of Resident 1's Minimum Data Set ([MDS] a standardized assessment and care-screening tool), dated 2/9/2024, indicated Resident 1's cognitive skills for daily decision making was moderately impaired. The MDS indicated Resident 1 required maximal assistance (helper gets more than half the effort) from staff for upper body dressing, lower body dressing and personal hygiene and moderate assistance (helper does less than half the effort) on oral hygiene, toileting hygiene, toileting, and showering. The MDS indicated Resident 1 required moderate assistance walking 150 feet. The MDS indicated Resident 1 used walker for assistance in moving. The MDS indicated Resident 1 was incontinent (inability to control bladder and bowel functions) of urine and bowel. The MDS also indicated Resident 1 had a history of falls with injuries. A review of Resident 1's care plan titled Resident at risk for fall related to poor safety awareness, cognitive loss, and visual limitation dated 1/24/2024 indicated Resident 1 will minimize episode of falls through the next review date of 5/17/2024. The Care Plan indicated interventions including fall mat (a rectangular floor pads with inner surface made of foam or other cushiony materials used to provide a softer place for the resident to land when falling especially if the resident falls from the bed) while resident in bed, provide extensive assistance to the resident with getting in and out of bed, and frequent visual check. A review of Resident 1's care plan titled Resident at risk for ADL Self-care performance deficit related to impaired function and mobility, cognition, diagnosis of dementia, and depression (persistent feeling of sadness and loss of interest in activities) dated 3/23/18, indicated staff will assist Resident 1 with activities of daily living ([ADLs] daily self-care activities) as needed. A review of Nursing Progress Note dated 5/4/24 timed at 11:15 a.m., indicated Resident 1 fell on 5/4/2024 at 11:06 a.m., due to Resident 1 not asking for assistance. The Nursing Progress Note indicated Resident 1 complained of a pain level of 10 out of 10, on a zero to ten pain rating scale (where 0 indicates no pain and 10 was worse possible pain) to the right side of her head, right arm, and right leg. The Nursing Progress Note indicated Resident 1 was observed with facial grimacing (distort face in an expression usually of pain) and holding the right side of her ribcage (bones in the chest). The Nursing Progress Note indicated 911 (a phone number used to contact emergency services) was called and the resident was transferred to the GACH on 5/4/2023 at 12:15 p.m. A review of Resident 1's Interdisciplinary Team ([IDT] team members from different departments working together with a common purpose to set goals and make decisions that ensure residents receive the best care) note dated 5/4/24 timed at 11:30 a.m., indicated on 5/4/24 at around 11:06 a.m., Resident 1 was observed on the floor by the foot of the bed towards the left side. The IDT note indicated Resident 1's roommate witnessed the fall and stated Resident 1 was sitting at the edge of the bed, reached to her walker with one hand and when Resident 1 grabbed the walker, she lost her balance and fell backwards. A review of Resident 1's GACH History and Physical indicated Resident 1's Computed Tomography ([CT] an imaging test used to detect internal injuries) of the chest, abdomen, and pelvis on 5/4/2024 at 7:27 p.m. indicated a right inferior pubic ramus fracture. A review of Resident 1's GACH report titled Medicine for Discharge Summary under 48 hours, dated 5/6/2024, indicated Resident 1 was admitted for further orthopedic ([ortho] field of medicine specialize in injuries of the muscles, bones, joints, ligaments, and tendons) evaluation and management from 5/4/2024 and discharged back to the facility on 5/6/2024. The report indicated based on Resident 1's imaging results, the ortho did not recommend surgical intervention, the resident's pubic rami fracture will be treated conservatively. The report indicated recommendations including weightbearing (amount of weight a resident put on an injured body part) as tolerated to right lower extremity, elevate and ice right hip as needed, always use assistive devices with ambulation, Lovenox (medication to prevent blood clots), for 2 weeks after discharge, and follow-up with ortho as outpatient in 3 to 4 weeks, for repeat imaging and to discuss advancing weight bearing. During an interview on 5/16/24 at 12: 20 p.m., Resident 1 stated one day, she slipped and fell in her room. The resident could not remember the date and time. During an interview on 5/16/2024 at 1:15 p.m., with the Director of Nursing (DON) in Resident 1's room, the DON stated Resident 1 had history of multiple falls. The DON stated Resident 1 had a fall in 1/2024 (cannot remember the exact date). The DON stated prior to Resident 1's fall on 5/4/2024, Resident 1 used a rollator walker (a device used to walk with wheels and a seat) where she sat but was discontinued after the resident fell on 5/4/2024. The DON stated Resident 1 needed assistance form staff on getting up from a sitting position, and ambulating (walking). The DON stated CNA 3 should not have left Resident 1 sitting at the foot of the bed unattended. The DON stated Resident 1's fall was avoidable if CNA 3 did not leave Resident 1 unattended on 5/4/2024. During an interview on 5/16/24 at 2:20 p.m., with CNA 1, CNA 1 stated she was in another room when she heard a loud noise coming from Resident 1's room. CNA 1 stated when she entered Resident 1's room, Resident 1 was on the floor. CNA 1 stated Housekeeper 1 and CNA 3 got the resident up and took Resident 1 to the dining room. CNA 1 stated Resident 1 was sitting in the dining room when she started complaining of headache and the resident was observed with a big bump on the right side of her head. During an interview on 5/21/24 at 12:40 p.m., with CNA 3 stated on 5/4/24 at around 11 a.m., when she entered Resident 1's room, Resident 1 was sitting up at the foot of the bed. CNA 3 stated she asked Housekeeper 1 to watch and talk to Resident 1 while she went to the bathroom to grab a pair of gloves. CNA 3 stated when she left Resident 1, Resident 1 got up to walk with her rollator walker and fell. CNA 3 stated Resident 1 slipped, fell, and hit her head. CNA 3 stated she should not have left Resident 1 unattended while sitting at the foot of the bed and ready to get up. CNA 3 stated she should have asked another staff to get her a pair of gloves and not leave Resident 1. CNA 3 stated she should have assisted Resident 1 to a wheelchair to ensure her safety. CNA 3 stated Resident 1 fell on the left side of her bed and hit her head on the bedside table. CNA 3 stated she (CNA 1) came in after she heard a noise coming from Resident 1's room. CNA 3 stated Resident 1 complained of headache, LVN (unknown) was notified and 911 was called. CNA 3 stated an ambulance arrived and took Resident 1 to GACH on 5/4/2024 around 12 p.m. CNA 3 stated Resident 1's fall was avoidable if she did not leave her unattended. CNA 3 stated Resident 1 should have had a wheelchair instead of a rollator walker to prevent further falls. During an interview on 5/21/24 at 12:44 p.m., with Occupational Therapy (OT, profession that provides services to increase and/or maintain a person's capability to participate in everyday life activities) 1, OT 1 stated Resident 1 required a one-person assistance to get in and out of the bed and going to the bathroom. OT 1 stated CNA and licensed staff were instructed not to leave Resident 1 by herself as she was a high risk for fall. A review of facility's policy and procedures (P&P) titled Falls Management dated 5/26/2021, indicated residents will be assessed for fall risk as part of the nursing assessment process. Those determined to be at risk will receive appropriate interventions to reduce risk and minimize injury. A review of facility's P&P titled Answering the Call Light revised on 9/2022, indicated If assistance is needed when you (staff) enter the room, summon help by using the call signal.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a resident, who experienced a change of condition (COC), was continuously monitored/assessed and transferred to a General Acute Care Hospital (GACH) during a window of time when interventions to prevent a major stroke and/or reduce damage to the brain would have been effective, for one of four sampled residents (Resident 1). The facility failed to: 1. Ensure Resident 1's status was continuously assessed and monitored after the resident had a COC, as ordered by the physician on [DATE]. 2. Assess and recognize sooner than seven hours after Resident 1's COC that the intervention of providing IV fluids to Resident 1 was not effective, preventing a timely transfer of Resident 1 to the GACH during a window of time when interventions to prevent a major stroke and/or reduce damage to the brain would have been effective. This deficient practice resulted in Resident 1 being unmonitored for over seven hours and in delay of Resident 1's evaluation and treatment. Resident 1 was transferred to a GACH over seven hours after the resident's initial COC at the facility and was admitted to the GACH's intensive care unit ([ICU] a unit in the hospital that provides the critical care and life support for acutely ill and injured patients), where he was intubated (insertion of a tube either through the mouth or nose into the airway to aid with breathing, deliver anesthesia or medications) for eight days. Resident 1 was diagnosed with an acute cerebral vascular accident ([CVA] a disruption of blood to the cells in the brain [stroke]) and was deemed outside of the treatment window (within three hours of having a stroke, or for some eligible patients, up to 4.5 hours after the onset of a stroke) for treatment using tissue plasminogen activator ([tPA] a drug often used to treat CVA, when given in a timely matter can reduce damage to the brain by restoring blood flow to brains regions affected by a stroke). Resident 1 expired on [DATE] at 1 a.m. Findings: During a review of Resident 1's admission Record, (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE] with a diagnosis including encephalopathy (altered brain function) and chronic kidney disease ([CKD] when the kidneys are damaged and cannot filter blood). During a review of Resident 1's Minimum Data Set ([MDS] a standardized assessment and care-screening tool), dated [DATE], the MDS indicated Resident 1's cognitive (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) skills for daily decision-making were severely impaired. The MDS indicated Resident 1 had clear speech, was usually understood, and had the ability to understand others. During a review of Resident 1's Change of Condition (COC) note, dated [DATE] and timed at 12:30 p.m., the COC indicated Resident 1 was usually more alert and talkative but became less responsive to staff and to stimuli (anything that triggers a physical or behavioral change). The COC indicated Resident 1 had a sudden an altered level of consciousness ([ALOC] when a patient is not as awake, alert, or able to understand or react as normal). The COC indicated Resident 1's physician was notified and an order for intravenous ([IV] a method of putting drugs or other substance through a needle or tube inserted into a vein) fluids was obtained. During a review of Resident 1's Progress Notes (PN), dated [DATE] and timed at 12:30 p.m., the PN indicated Resident 1's physician was notified that Resident 1 was less responsive to staff and to stimuli, would not open his eyes, his mucous membranes appeared dry, there was visible skin tenting (when the skin is pinched and it stays up in a tent shape once you let it go, people who are dehydrated may experience this) and Resident 1 had only urinated twice since midnight ([DATE]). The PN indicated Resident 1's vital signs ([v/s] measurements of the body's most basic functions, the main ones being; temperature, pulse rate, breathing rate and blood pressure) were as follows: 1. Blood pressure was 176/92 millimeters of mercury ([mm Hg] a unit of measurement, normal range less than 130/80 for a male over 65). 2. Heart rate 73 beats per minute ([bpm] normal range 60- 100 bpm). 3. Respirations 18 breaths per minute ([bpm] normal range 12-18 bpm). 4. Temperature was 97.7 degrees Fahrenheit ([F] scale for measuring temperature, normal range 97.8 F-99.1 F). 5. Blood sugar was 126 milligrams per deciliter ([mg/dl] a unit of measurement; amount of glucose (sugar) in the blood]) normal range 90-130 mg/dl). During a review of PN dated [DATE] and timed at 12:30 p.m., the PN indicated Resident 1's physician ordered Resident 1 to receive 2000 milliliters [(ml) unit of liquid measurement) of Normal Saline ([NS] a mixture of sodium [salt]) chloride and water) 0.9% at the rate of 100 ml/per hour and to continue monitoring. At 2 p.m., (one hour and thirty minutes after Resident 1's initial COC assessment) the PN indicated Resident 1's IV was removed due to Resident 1's activity, the resident responded to physical stimuli and was able to open both his eyes with a focused stare. During a review of Resident 1's electronic Medication Administration Record (eMAR) note, dated [DATE] and timed at 3:16 p.m., the eMAR indicated to monitor and document every shift, and report to the physician (MD) Resident 1's signs and symptoms of dehydration including tenting skin, new onset of confusion, dizziness on sitting and standing, increased pulse, headache, fatigue, weakness and dizziness. The eMAR note indicated an endorsement was made to the incoming evening shift nurse indicating Resident 1 was extremely fatigued (tired), responsive but could not keep his eyes open and Resident 1's physician ordered IV hydration. A review of Resident 1's PNs dated [DATE], indicated there were no additional assessments of Resident 1's v/s, urinary status, skin, lips, mucous membranes, or the resident's cognitive status. During a review of Resident 1's eMAR, dated [DATE] and timed at 7:54 p.m., (seven hours and 25 minutes after Resident 1's initial COC assessment) the eMAR indicated Resident 1 was not verbally responsive at this time. Resident 1's eMAR notes and PNs indicated there was no documentation of another assessment or continued monitoring after Resident 1's initial COC at 12:30 p.m. During a review of Resident 1's Health Status Note (HSN), dated [DATE] and timed at 8:45 p.m., (eight hours and 15 minutes after Resident 1's initial COC assessment), the HSN indicated Resident 1 remained in a sleeping state and was not easy to arouse. The HSN indicated due to Resident 1's continued altered status, Resident 1's physician instructed staff to transfer Resident 1 to a GACH for further evaluation. During a review of Resident 1's Physician's Orders (PO), dated [DATE], the PO indicated to transfer Resident 1 via 911 for further evaluation. During a review of the GACH's Emergency Department (ED) notes, dated [DATE], the GACH's ED notes indicated Resident 1 arrived at the ED at 9:05 p.m., and was intubated upon arrival to protect his airway. During a review of the ED's Physical Exam (PE), the PE indicated Resident 1's Glasgow Coma Scale ([GCS] a clinical scale used to reliably measure a person's level of consciousness after a brain injury, severe=8 or less, moderate=9-12, mild=13-15) was a 6, his pupils were pinpoint (indicates a problem with your health), he was only moving his left upper extremity, bilateral lower extremities and he had right sided facial droop. During a review of GACH's History of Present Illness (HPI), the HPI indicated Resident 1 was not a candidate for tPA as he was outside the window for treatment. As confirmed during a neurology consult and by a neuro-interventionalist (a doctor who specializes in treatments of the brain, neck, and spine). During a review of the GACH's Computed Tomography ([CT] a procedure that uses a computer linked to an x-ray machine to make a series of detailed pictures of areas inside the body) report dated [DATE] and timed at 9:22 p.m., the CT report indicated Resident 1 suffered a left middle carotid artery ([MCA] a major artery that supplies blood to the brain) occlusion (complete or partial blockage of a blood vessel). During a review of Resident 1's GACH Discharge Summary (DS) dated [DATE] and timed at 5:37 p.m., the DS indicated intervention was not deemed appropriate for Resident 1 as it would not provide any meaningful benefit to quality of life, as his prognosis was already grim given the large size of infarct (blockage in blood supply). The DS indicated Resident 1's family was made aware and came to the decision to initiate comfort care (care to control pain and other symptoms so the patient can be as comfortable as possible). The DS indicated Resident 1 passed away on [DATE]. During a telephone interview with Resident 1's Responsible Party (RP) on [DATE] at 2:38 p.m., the RP stated she was present when Resident 1 had a COC ([DATE]). The RP stated, at approximately 11:30 a.m., she was talking to Resident 1 when the resident suddenly stopped talking. The RP stated she left Resident 1 and found a nurse and reported what happened, and that nurse grabbed another nurse to check on Resident 1. The RP stated the nurse told her Resident 1 looked dehydrated, they called Resident 1's physician and obtained an order to start Resident 1 on IV fluids. The RP stated she left the facility and returned at approximately 7:30 p.m., the same day and when she went to see Resident 1 she found the resident in the same condition as the resident was at 11:30 a.m. The RP stated she went to get a nurse and asked why Resident 1 was still in the same condition, the nurse checked Resident 1 and stated Resident 1 needed to be transferred out immediately. The RP stated the GACH told her Resident 1 had suffered a major stroke. During an interview with Registered Nurse 1 (RN 1) on [DATE] at 4:01 p.m., RN 1 stated when a resident has a sudden change of consciousness it is important call 911 as soon as possible. If it is a possible stroke, time becomes an important factor when treating the stroke. During an interview with the Director of Nursing (DON) on [DATE] at 2:06 p.m., the DON stated if a resident has a COC, we call the MD to report the resident's status and obtain orders as needed. The DON stated we continue to monitor the resident to see if the interventions that were implemented worked. The DON stated the resident's COC is reported to the oncoming nurses during their huddle, so incoming nurses will continue to monitor the resident. The DON stated if a resident is known to be verbal, suddenly stops talking and only responds to painful stimuli, we need to escalate the situation and call 911 immediately. The DON stated she was unaware of Resident 1's COC until later that evening. The DON stated when she assessed Resident 1, Resident 1 was not responding verbally but was able to move, he was able to squeeze my hands but was very weak. During an interview with Licensed Vocational Nurse 4 (LVN 4) on [DATE] at 3:43 p.m., LVN 4 stated at the beginning of shift, a report is given about all residents who had COCs during the outgoing shift, so the incoming shift knows to monitor and document any changes and/or if the interventions are working for the resident. LVN 4 stated any residents with COCs need to be monitored closely. During an interview with LVN 5 on [DATE] at 11:20 a.m., LVN 5 stated it is important to continue monitoring residents with any COC and to document any findings weather there is a change or not. During a phone interview with RN 2 on [DATE] at 2:52 p.m., RN 2 stated she reported her findings to Resident 1's physician after assessing Resident 1. RN 2 stated when she assessed Resident 1 there was nothing indicating a stroke, so she thought he had an infection or was dehydrated. RN 2 stated, Resident 1 was moving around a lot and was very active. RN 2 stated she did not remember if she reported that Resident 1 could not speak to Resident 1's physicians or if she endorsed his status to the incoming shift. During a review of the facility's LVN Job Description (JD), dated 8/2011, the JD indicated that qualifications include being knowledgeable of nursing/medical practices and procedures. Safety concerns are identified, and appropriate actions are taken to maintain a safe environment including recognizing emergency situations and appropriate action is instituted in a timely matter. During a review of the facility's RN Supervisor JD, dated 8/2011, the JD indicated the RN's responsibilities included performing assessments and identifying changes in resident's physical or psychological condition. During a review of the facility's Policy and Procedure (P&P), titled Change of Condition, Resident, revised 11/2017, the P&P indicated it is the policy of this facility to identify, inform the physician and resident or resident representative, and intervene to provide medical or nursing care for a resident experiencing an acute medical change of condition in a timely and effective matter. In the event of a life-threatening situation or serious injury, the charge nurse may elect to contact emergency personnel services to assist with care and possible transport to an acute hospital. The staff will continue to monitor and document resident's condition at a minimum of every shift for 72 hours and as needed, until the acute episode has subsided, and the resident is stable. According to The National Institute of Neurological Disorders and Stroke, https://www.ninds.nih.gov/health-information/public-education/know-stroke/patients-and-caregivers. Ischemic strokes, the most common type, can be treated with the drug t-PA, which dissolves blood clots obstructing blood flow to the brain. The window of opportunity to start treatment is three hours, but patients need to get to the hospital within 60 minutes to be evaluated and receive treatment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure a certified nursing assistant (CNA 1), used the assistance of another staff member when transferring the resident, with a mechanical lift from the bed to a chair to prevent the resident from sustaining a fall with injuries for one of three sample residents (Resident 1). The facility failed to: 1. Ensure CNA 1 used the assistance of another staff member to transfer Resident 1 from bed to a chair utilizing a mechanical lift as indicated in Resident's Minimum Data Set (MDS), a standardized assessment and care planning tool, dated 1/1/2023. 2. Ensure the nursing staff followed Resident 1's care plan titled Activities of Daily Living (ADL) Self Care Performance Deficit related to amputation . and provided Resident 1 with two staff total assistance during the resident's transfers from bed to a chair. 3. Ensure a minimum of two staff members used a mechanical lift to transfer Resident 1 from a bed to chair to reduce the risk of residents' injury per facility's policy titled Lifting Residents by Use of Mechanical Device. 4. Ensure CNA 1 followed the facility's policy titled Standards of Certified Nursing Assistant Practice, which stipulated that CNAs must assist one another in caring for residents when lifting, transferring and/or turning a resident. 5. Ensure CNA 1 followed the facility's policy titled Moving a Resident, Bed to Chair/Chair to Bed, which stipulated if the resident cannot stand alone, two persons (one on each side) should use a mechanical lift to move the resident. This deficient practice resulted in Resident 1 sliding out of the mechanical lift approximately 3.0 feet onto the floor, and sustaining fractures of the 10th, 11th and 12th left ribs. Resident 1 also suffered emotional distress due to the fall. Resident 1 was transferred to a General Acute Care Hospital (GACH) for emergent care due to complaints of pain on the left chest area. Findings: A review of Resident 1's Face Sheet (admission Record) indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including atrial fibrillation (irregular and often rapid heart rhythm that can lead to blood clots), end staged renal disease (ESRD- permanent kidney failure that requires a regular course of dialysis [mechanical way of removing waste products and toxins the kidneys are no longer able to filter] or a kidney transplant), cerebral vascular disease ([CVD] interruption in the flow of blood to the brain, causing damage or death to brain tissue) with hemiplegia (severe weakness of one side of the body that can impact upper, lower limbs and facial muscles) and depression (persistent sadness and a lack of interest or pleasure in previously rewarding or enjoyable activities). A review of the MDS, dated [DATE], indicated Resident 1's cognitive (mental process by which knowledge is acquired, including perception, intuition, and reasoning) skills for daily decision making were intact. The MDS indicated Resident 1 depended on total assistance from two staff members during all transfers from one surface to another, including to or from bed, chair, wheelchair, and standing position. A review of Resident 1's care plan (CP) titled Activities of Daily Living (ADL) dated 6/20/2022, indicated Resident 1 had an ADL Self Care Performance Deficit related to (r/t) amputation (surgical removal of part of the body) of left leg below knee. One of the CP's listed goals for Resident 1 was to improve current level of function in transfers. One of the interventions was to provide Resident 1 with a total assistance from staff with transfers. During a concurrent observation and interview on 2/6/2023 at 11:14 a.m., Resident 1 was observed sitting in his wheelchair by his bed. Resident 1 was alert, and oriented to name, time, and place. Resident 1 stated, he remembered the fall incident on 1/17/2023. Resident 1 stated, CNA 1 did not place the sling from the mechanical lift on him correctly to prevent him from sliding out of the sling. Resident 1 stated, he told CNA 1that if CNA 1 did not cross the leg straps (of the sling), he (Resident 1) would slide out of the sling. Resident 1 stated, CNA1 did not respond and ignored his comment. Resident 1 stated that after he was lifted approximately three feet, he began to slide out of the sling onto the floor. Resident 1 stated he fell on the left side of his back. Resident 1 stated that after he fell, CNA 1 left the room without saying a word. Resident 1 stated he felt sad and felt left out. Resident 1 stated he felt pain on his back and neck. During an interview on 2/2/2023 at 12:40 p.m., the Director of Nursing (DON) stated she was notified by CNA 2 that Resident 1 was lying on the floor. DON stated she immediately assessed Resident 1, and did not observe any swelling or bruises on his body. DON stated she notified Resident 1's physician and received an order to transfer Resident 1 to the GACH immediately. DON stated CNA1 should have asked for assistance from other staff to transfer Residents 1 because two people physical assistance was required to transfer the resident with a mechanical lift to ensure the resident's safety. A review of Resident 1's Nurses Progress Note (NPN), dated 1/17/2023 and timed at 9:33 a.m., indicated Resident 1 was laying on the floor on his back with his head toward the window. The NPN indicated Resident 1 complained of pain to neck and back area and the resident stated he slipped out of the sling. The NPN indicated the Emergency Medical Service [(EMS)- emergency response personnel)] was called and Resident 1 was kept in a comfortable position on the floor. Resident 1 was then transported by EMS on a gurney to GACH for further evaluation. A review of Resident 1's Vital Signs Record, after his fall, dated 1/17/2023 at 09:30 a.m., indicated blood pressure was 161/67 mmHg (a normal blood pressure level is less than 120/80 mmHg) and pain level rated 6 out of 10 on a pain scale (numerical scale, 0 being no pain, and 10 being the worst possible pain). A review of Resident 1's Physician's Order Summary Report (POSR) with an order dated 1/17/2023 at 4:55 p.m., indicated an order to transfer Resident 1 to a GACH. A review of Resident 1's Emergency Department (ED) Notes and History and Physical (H&P) from the GACH dated 1/17/2023 at 10:25 a.m., indicated Resident 1 reported falling onto his left flank (area of body between the ribs and the hip). The H&P indicated Resident 1 presented to ED as status post (after) fall, slip out of mechanical lift during transfer from bed to a chair. The H&P stated, Resident 1 was currently complaining of a left flank and left upper/middle back pain. During a review of Resident 1's GACH's ED note dated 1/17/2023, at 1:11 p.m., the ED note indicated Resident 1 was admitted to the Telemetry unit (unit in a hospital where patients are constantly monitored with electronic equipment) and diagnosed with multiple rib fractures (break in bone) on the left side. During a review of Resident 1's Computerized Tomography [(CT) procedure that uses a computer linked to an x-ray machine to make a series of detailed pictures of areas inside the body) scan of abdomen and pelvis report dated 1/17/2023 at 11:42 a.m., the report indicated a fracture of the posterior (back position) and posterolateral (outside portion of the back) 10th, 11th and 12th left ribs, not significantly displaced. Compression deformity (occurs when the fractured vertebra (one of the bony or cartilaginous [made of connective tissue] collapses shortening and tilting the vertebra forward) of the first lumbar [(L1) the first of the vertebrae connected from the rib cage to the hip bone] segments composing the spinal column [part of the body that carries signals that control the body's movements and convey sensations]). During a review of Resident 1's GACH's Discharge Summary Note (DSN) dated 1/18/2023, the DSN indicated Resident 1 was discharged to the skilled nursing facility on 1/18/2023 at 10:11 p.m. The DSN indicated Resident 1 was discharged in stable condition. A review of Resident 1's POSR, dated 1/19/2023 indicated an order for orthopedic (branch of medicine dealing with the correction of deformities of bones or muscles) physician consultation for the lumbar spine (L1) compression deformity and posterolateral 10th -12th left rib fracture. A review of Resident 1's POSR, dated 1/26/2023, indicated an order for physical therapy ([PT] therapy focused on improving the residents' ability to move their body) services every day, five times a week, for 30 days for therapy exercise and therapy activity. The POSR indicated an order for occupational therapy ([OT] therapy focused on improving the residents' ability to perform activities of daily living). On 2/3/2023 at 11:35 a.m., and 12:30 p.m., this surveyor attempted to contact CNA 1 for an interview However, CNA 1 did not respond. During an interview on 2/2/2023 at 1:35 p.m., CNA 3 stated Resident 1 preferred the mechanical lift when staff transferred him from the bed to a wheelchair. CNA 3 stated Resident 1 required two people to assist him with transfer and CNA 1 should have asked another person to assist transferring Resident 1 to ensure resident 's safety. During an interview on 2/2/2023 at 12:40 p.m., the DON stated she was covering for the Director of Staff Development (DSD) on 1/17/2023, and CNA 1 was from a registry (an agency that provides temporary staff as needed). The DON stated, she went over registry staff orientation with CNA 1 including use of mechanical lifts. The DON stated, she did not give further training on how to use the mechanical lift step by step to CNA 1 because CNA1 stated he already knew how to use it and that he had used the mechanical lift before. During a review of the facility's policy and procedure (P/P) titled, Lifting Residents by Use of Mechanical Device. Revised 11/2012, the P/P indicated a minimum of two staff members should be used to reduce the risk of residents' injury. During a review of the facility's P/P titled, Standards of Certified Nursing Assistant Practice, revised 11/2012, the P/P indicated CNA's will assist one another in caring for residents when lifting, transferring and/or turning a resident. During a review of the facility's P/P titled, Moving a Resident, Bed to Chair/Chair to Bed, revised 11/2012, the P/P indicated if the resident cannot stand alone, two persons (one on each side) should lock arms with the resident, gently stand and turn the resident and sit him/her in the chair or use mechanical lift or sit to stand lift.