**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure, the resident, who was assessed as being a moderate risk for falls, did not fall for one of one sampled resident (Resident 89). The facility failed to: 1. Ensure a Certified Nurse Assistant (CNA 6) did not leave Resident 89 unsupervised when Resident 89 needed his soiled incontinence brief changed and left the resident's room to collect items for incontinence care. 2. Ensure CNA 6 followed the facility's policy and procedure (P&P) titled Answering the Call Light to summon other staff help by using the call light for assistance to get incontinence care items when CNA 6 was in the Resident 89's room. 3. Ensure Resident 89's room was changed closer to the nursing station for a closer observation/visibility as care planned. These deficient practices resulted in Resident 89 attempting to remove his soiled incontinence brief (diaper) himself and fall out of bed sustaining a left hip fracture and subsequent transfer to a General Acute Care Hospital (GACH) for evaluation and treatment on 8/8/2023. At the GACH Resident 89 was diagnosed with closed left basicervical (area located at the junction between the femoral [the bone of the thigh] neck [part of the bone that connects the head of the bone with the middle part of the bone] and intertrochanteric region [area where the femur changes from a vertical bone to a bone angling at a 45° angle]) femur fracture requiring left hip open reduction internal fixation ([ORIF]-a type of surgery used to hold the broken bone together) with cephalomedullary nail (a surgical devise to stabilize the fracture). Resident 89 returned to the facility on 8/11/2023 with 11 staples on the incision (surgical cut) measured 5.0 centimeters [(cm) a unit of measure] by 0.1 cm to superior (top) surgical site of left hip, seven staples on the incision measured 4.0 cm by 0.1cm to inferior (bottom) surgical site of a left hip. Findings: During a review of Resident 's 89 admission Record (Face Sheet), the Face Sheet indicated Resident 89 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including difficulty in walking, unspecified dementia (impaired ability to remember, think, or make decisions), spinal stenosis (space inside the backbone is too small) of lumbar region (lower part of the back) type 2 diabetes (a disease that occurs when a person's blood glucose, also called blood sugar, is too high) and transient ischemic attack [(TIA) a condition when blood supply to part of the brain was briefly interrupted). During a review of Resident 89's History and Physical (H/P), dated 8/12/2023, the H/P indicated, Resident 89 had the capacity to understand and make decisions. During a review of Resident 89's Minimum Data Set [(MDS), a standardized assessment and care-screening tool], dated 6/07/2023, the MDS indicated Resident 89's cognitive (ability to learn, remember, understand, and make decision) skills for daily decision making were mildly impaired. The MDS indicated, Resident 89 required extensive physical assistance from staff for bed mobility, transfer, walk in room, toilet use, and personal hygiene. The MDS indicated Resident 89 was frequently (seven or more episodes) incontinent with urinary continence and frequently (two or more episodes) incontinent of bowel. During a record review of Resident 89's Fall Risk Evaluation dated 6/07/2023 and timed at 5:00 p.m., the Fall Risk Evaluation indicated Resident 89 was scored seven (0-5 low risk, 6-20 medium risk, 21-45 high risk) which indicated moderate risk for falls. The Fall Risk Evaluation indicated to provide Resident 89 with safe environment, clutter free, necessary belonging within reach, and attend needs in a timely manner. During a review of Resident 89's GACH Emergency Department (ED) notes, dated 8/08/2023, and timed at 10:51 a.m., the ED notes indicated Resident 89 presented to the ED after rolling out of bed and landing on his left hip. The ED notes indicated Resident 89 was diagnosed with a nondisplaced intertrochanteric left hip fracture. The ED notes indicated Resident 89 undergo ORIF of the left hip. During a review of Resident 89's GACH Computerized tomography [(CT) computerized x-ray {a photographic or digital image of the internal composition of something}] scan dated 8/08/2023, CT scan indicated the resident had an acute nondisplaced intertrochanteric fracture of the proximal left femur neck fracture. During a review of the facility's Licensed Nurses Progress Note (LNPN), dated 8/07/2023, and timed at 9:56 p.m., the LNPN indicated Resident 89 was found lying on the floor in the resident's room. The LNPN indicated Resident 89 was complaining of pain of the left hip and the resident had a purple discoloration on the forehead. The LNPN indicated 911 (emergency number) was called and Resident 89 was transferred to GACH. During a review of Situation Background Assessment and Recommendation [(SBAR) communication framework that can help teams share information about the conditions of the resident] form and LNPN dated 8/07/2023, and timed at 9:51 p.m., the SBAR indicated, at around 8:30 p.m., clinical nurse (CN) summoned the registered nurse supervisor (RNS) to Resident 89's room. The CN observed Resident 89 lying on the floor. SBAR indicated Resident 89 complained of pain level five out of 10 on a zero to ten pain rating scale (0 is no pain and 10 is worse possible pain) of the left hip. SBAR indicated Resident 89 was transferred to the GACH for further evaluation at 8:45 p.m. During a review of Resident 89's Care Plan (CP) titled, Risk for fall related to balance problem during transition (sit to stand) initiated on 6/1/2023, the CP indicated the resident required assistance with walking and bed mobility. The CP indicated the goal for Resident 89 was to decrease significant injury as a result from falls and to minimize the risk for potential for fall related to resident's getting out of bed without waiting for staff assistance. The CP interventions included to provide Resident 89 with the adequate support from staff during activities of daily living (ADL) and transfers. The CP also indicated to move Resident 89 to a room close to the nursing station for a better visibility. During an interview on 10/05/2023 at 11:42 a.m. with Resident 89, the resident stated he called for assistance by using the call light and waited for a long time and no one came to help. Resident 89 stated he needed his soiled diaper changed. Resident 89 stated it felt like he was waiting for more than an hour. Resident 89 stated he just kept on pressing the call light and no one was responding to his call for help. Resident 89 stated, when CNA 6 came in response to his (Resident 89's) call light, CNA 6 saw his soiled diaper needed to be changed. Resident 89 stated CNA 6 did not change his diaper and told him (Resident 89) to wait until he (CNA 6) comes back and left the room. Resident 89 stated, he had been waiting for a long time, so he decided to remove his diaper by himself. Resident 89 stated, when he attempted to sit up in bed, he felt dizzy and rolled out of his bed to the floor. Resident 89 stated, he had severe pain to his left side and screamed in pain. During a phone interview on 10/05/2023, at 3:01 p.m., with CNA 6, CNA 6 stated on 8/07/2023 around 8:20 p.m., he answered Resident 89's call light and found Resident 89 trying to remove his diaper while in bed. CNA 6 stated to Resident 89 to leave the diaper on and left the room. CNA 6 stated he explained to Resident 89 that he would grab some towels and water to clean him. When CNA 6 came back, Resident 89 was on the floor adjacent to his bed laying on his back complaining of left-side pain. During an interview on 10/5/2023 at 3:24 p.m. with Licensed Vocational Nurse (LVN 3), LVN 3 stated Resident 89 can make his needs known to staff. LVN 3 stated Resident 89 was assessed as moderate risk for fall and should not be left alone and provided the care needed. LVN 3 stated the Director of Rehabilitation (DOR) assess the residents upon admission and staff should provide the residents with assistance based on the DOR assessment. During a concurrent interview and record review on 10/06/2023, at 8:41 a.m., with the DOR, the DOR reviewed Physical Therapy (PT) Discharge Summary, and stated, Resident 89 was able to safely ambulate using front-wheeled walker (assistive device) with supervision or touching assistance for proper sequencing (correct way of walking with assistive device) Physical Therapy Discharge summary dated from 6/20/2023 to 8/7/2023 indicated, Resident 89 required supervision or touching assistance with bed mobility, transfer, and ambulation. The DOR stated, there was a great possibility that Resident 89 could fall if Resident 89 gets out of bed by himself and/or walks by himself. The DOR stated, he did not recommend at all for Resident 89 to walk or get out of bed by himself. During a review of Resident 89's PT Discharge summary dated from 6/20/2023 to 8/7/2023, the PT Discharge Summary indicated, Resident 89 required supervision or touching assistance with bed mobility (roll left and right), transfer from bed to chair, ambulation, and picking up object. During a phone interview on 10/6/2023 at 8:54 a.m. with LVN 4, LVN 4 stated he remembered that on 8/7/2023 during 3 p.m. to11 p.m. shift at around 8 p.m. he heard a loud scream coming from Resident's 89's room when he (LVN 4) was attending to another resident. LVN 4 stated he walked to Resident 89's room and saw Resident 89 was lying on the floor, on his left side. LVN 4 stated, he remembers that Resident 89 needed moderate to maximum physical assistance from one staff. Resident 89's room was located about 40 feet away from the nursing station. LVN 4 stated, CNA 6 told him that CNA 6 walked out of Resident 89's room to get water and towel and when CNA 6 came back to Resident 89's room, Resident 89 was found on the floor. LVN 4 stated, Resident 89 was not supposed to be left alone when the resident needed help because Resident 89 has been trying to stand up by himself and tried to be independent. During an interview on 10/06/2023, at 12:11 p.m., with the Director of Nursing (DON), the DON stated, if a resident was at moderate risks for falls, she educated a resident to use a call light for assistance. The DON stated after Resident 89's fall on 8/8/2023 we moved the resident in a room closer to the nursing station. The DON stated the facility staff should answer a call light promptly especially when a resident is at the risk for fall. The DON sated the facility staff discuss and communicate with each other to identify the residents who were at a moderate to high risk for fall. The DON stated the facility staff should not left Resident 89 alone since CNA 6 noticed Resident 89 felt uncomfortable with having on a soiled diaper. The DON stated if staff noticed that the resident would try to clean himself or herself up, staff should stay with the resident and ask other staff (CNA/LVN) to get the needed supply. The DON stated CNA 6 should have used the call light to ask for staff assistance and not leave resident 89's room. During a review of the facility's undated P&P titled, Fall Prevention Program, revised 12/2007, the P&P indicated to assist resident with toileting needs upon rising before and after meals, before and after bed and as needed. During a review of the facility's P&P titled, Safety and Supervision of Residents revised 7/2017, the P&P indicated the care team shall target interventions to reduce individual risks related to hazards in the environment, including adequate supervision and assistive devices. During a review of the facility's undated P&P titled, Answering the Call Light. (undated) the P&P indicated staff to answer the resident's call as soon as possible. The P&P indicated, if assistance is needed when staff enter the room, summon help by using the call signal. During a review of the facility's P&P, titled Care Plans-Comprehensive, revised 09/2010, the P&P indicated, the facility's Care Planning/Interdisciplinary Team, in coordination with the resident, his/her family or representatives (sponsor), develops and maintains a comprehensive care plan for each resident that identifies the highest level of functioning the resident may be expected to attain.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure four of ten sampled residents (Resident 83, 20, 19, and 81) received appropriate services to prevent a decline in range of motion [(ROM) a full movement potential of a joint] and mobility. The facility failed to: 1. Ensure a Restorative Nursing Aide Program (RNA, nursing aide program that help residents to maintain their function and joint mobility) service was provided to Resident 83's right hand per Occupational Therapist [(OT), professional who provides services to increase and/or maintain a person's capability to participate in everyday life activities) recommendations upon discharge from therapy on 10/7/2021 and 2/2/2022. 2. Ensure Resident 83 was provided with ROM services based on the Joint Mobility Assessments, which indicated Resident 83's had a decline in right hand ROM. The Joint Mobility Assessments indicated Resident 83's right hand ROM was at a minimal loss on 1/21/2022, and 3/31/2022, and at severe loss on 7/1/2022, and on 10/5/2022. 3. Ensure Resident 20 was assisted out of bed in accordance with the resident's wishes to maintain and improve the resident's mobility. 4. Ensure Resident 19's physician's order for RNA contained information on the distance for the resident's ambulation with RNA to maintain the resident's mobility. 5. Ensure Resident 81's physician's order for RNA contained information on the distance for the resident's ambulation with RNA to maintain the resident's mobility. These failures resulted in Resident 83's loss of ROM in right hand and developing contracture (chronic loss of joint motion associated with deformity and joint stiffness) and pain. As a result of these failures, Residents 19, 20, and 81 were placed at risk to experience physical, emotional, and functional mobility decline. Findings: A. During a review of Resident 83's admission Record (AR), the AR indicated Resident 83 was admitted to the facility on [DATE] with diagnoses including right sided hemiplegia (weakness to one side of the body) and hemiparesis (inability to move one side of the body) following an intracerebral hemorrhage (bleeding in the brain), functional quadriplegia (inability to move due to severe physical disability or medical condition), and aphasia (loss of ability to understand or express speech, caused by brain damage). A review of Resident 83's Minimum Data Set (MDS), a standardized assessment and a care-screening tool, dated 9/30/2021, the MDS indicated Resident 83 had impaired cognitive skills (ability to think, understand, learn, and remember) for daily decision making and was non-verbal. The MDS indicated Resident 83 required extensive assistance (resident involved in activity, staff provide weight-bearing support) from staff for bed mobility (moving in bed to and from different positions such as side to side), dressing, toileting, and personal hygiene and required a total assistance (full staff assistance) from staff for transfers (moving from one surface to another such as a bed or chair), eating, and bathing. The MDS indicated Resident 83 had functional limitations in ROM on one arm (shoulder, elbow, wrist, hand), and both legs (hip, knee, ankle, foot). During a review of a document titled, Occupational Therapy HMO Evaluation and Plan of Treatment (OT Evaluation), dated 9/26/2021, the OT Evaluation indicated Resident 83 had the right-hand ROM within normal limits [(WNL), no joint mobility limitations] but did not have the strength to move the right hand independently. A review of Resident 83's OT Discharge summary, dated [DATE], indicated OT recommended Resident 83 to have an RNA program upon discharge from OT therapy, to maintain current function and joint mobility. During a review of Resident 83's physician's orders, there were no physician's order for Resident 83 to have RNA services as recommended by OT on 10/7/2021. A review of Resident 83's quarterly Joint Mobility Evaluation conducted by the Director of Rehabilitation (DOR), dated 12/20/2021, indicated Resident 83's right hand/fingers ROM were within functional limits [(WFL), sufficient joint movement to functionally complete daily routines] with 1-25% ROM impairment. The Joint Mobility Limitation Key on the Joint Mobility Evaluation form indicated WFL limitation represented variance (decline) due to normal aging process allowed up to 25%. A review of Resident 83's Joint Mobility Evaluation (JME), dated 1/21/2022, indicated Resident 83's right hand/fingers had minimal ROM limitations (26-50% ROM impairment). The JME additional comments specified the resident's right hand had a contracture, which was indicative of a decline since prior ROM evaluation on 12/20/2021. A review of Resident 83's physician's orders, dated 1/27/2022, indicated OT evaluation was ordered. A review of the 'Occupational Therapy HMO Evaluation and Plan of Treatment,' dated 1/28/2022, indicated Resident 83's right hand ROM was impaired with minimal swelling. A review of Resident 83's OT Discharge Summary (DS), dated 2/2/2022, indicated OT recommended Resident 83 to have an RNA program upon discharge from OT therapy. During a review of Resident 83's physician's orders (PO), the PO indicated there were no physician's order for Resident 83 to receive RNA services as OT recommended on 2/2/2022. A review of Resident 83's quarterly JME, dated 3/31/2022, indicated Resident 83's right hand/fingers had minimal ROM limitations (26-50% ROM impairment). Additional comments indicated, (Baseline) passive Range of Motion (PROM- movement at a given joint with full assistance from another person). A review of Resident 83's quarterly JME, dated 7/1/2022, indicated Resident 83's right hand/fingers had severe ROM limitations (76-100% ROM impairment). During a review of Resident 83's physician's orders (PO), dated 7/7/2022, the PO indicated the order for RNA to perform PROM to both arms and both legs three times per week indefinitely as recommended by the Rehabilitation department. During a review of Resident 83's RNA documentation, from 7/2022 to 10/2022, the RNA documentation indicated an RNA provided PROM to Resident 83's both arms and both legs three times per week with start date on 7/8/2022. A review of Resident 83's quarterly JME, dated 10/5/2022, indicated Resident 83's right hand/fingers had severe ROM limitations (76-100% ROM limitations). During a review of Resident 83's physician's orders (PO), dated 10/26/22, the PO indicated the order for OT evaluation and treatment. During a review of a document titled Occupational Therapy HMO Evaluation and Plan of Treatment (OT Evaluation), dated 10/27/2022, the OT Evaluation indicated Resident 83 was referred to OT due to .decrease in strength and decrease in ROM especially right-hand, causing change in ADL participation related to risk of contracture. The evaluation listed measures to implement (to prevent) right hand contracture. The OT evaluation indicated the ROM of all fingers of Resident 83's right hand was impaired and included the following assessments: 1. Right thumb interphalangeal (IP, joint below the fingernail of the thumb) extension (straightening the joint): 0-30 degrees (30-degree range, normal range is 0-80 degrees). 2. Right index finger proximal interphalangeal (PIP, joint of the finger in between the fingertip joint and the large knuckle joint) PIP extension: 80-90 degrees (10-degree range, normal range is 0-100 degrees). 3. Right middle finger PIP extension: 80-90 degrees (10-degree range, normal range is 100 degrees). 4. Right ring finger PIP extension: 80-100 degrees (20-degree range, normal range is 100 degrees). 5. Right little finger PIP extension: 70-80 degrees (10-degree range, normal range is 100 degrees). OT evaluation further indicated the treatment plan indicated need for skilled therapeutic intervention, including ROM and splints to the right hand to address ROM loss and developing right hand contracture. During an interview with the DOR, an Occupational Therapist (OT), on 10/26/2022, at 1:29 PM, the DOR stated Resident 83 was evaluated by OT earlier that day. The DOR stated OT recommended a skilled therapy program and right-hand splints due to right hand ROM loss and high risk for contracture development. During a concurrent interview and record review of Resident 83's OT evaluations and Joint Mobility Screens with the DOR on 10/28/2022, at 9:30 AM, the DOR confirmed Resident 83 was admitted to the facility with normal right-hand ROM. The DOR confirmed OT Discharge Summaries on 10/7/2021 and 2/2/2022 recommended an RNA program at the time of discharge from the OT therapy to maintain Resident 83's current level of function. The DOR stated an RNA program should have been ordered on 10/7/2021 and 2/2/2022 based on OT discharge recommendations. The DOR confirmed there was the only RNA order in Resident 83's medical record dated 7/7/2022. The DOR confirmed Resident 83's Joint Mobility Assessments showed a progressive increase in right hand ROM limitations on 1/21/2022 (minimal limitations), 3/31/2022 (minimal limitations), 7/1/2022 (severe limitations), and 10/5/2022 (severe limitations). The DOR confirmed an OT evaluation should have been but was not ordered again until 10/26/2022. During a concurrent observation, in the presence of DOR, and interview on 10/28/2022, at 1:14 PM, in Resident 83's room, Resident 83 was lying in bed with the right arm resting on a pillow. Resident 83's right hand observed to have minimal swelling and was positioned in a tight fist with the thumb tucked inside the palm. Resident 83 was awake, non-verbal, and had difficulty following simple instructions. The DOR was observed unable to unclench Resident 83's right hand and had difficulty measuring the finger lengths due to Resident 83 experiencing pain. Resident 83 observed grimacing, moaning, grunting, and reaching across the body with the left arm several times to try to stop the DOR from continuing right-hand ROM. The DOR stated Resident 83 appeared to be in pain and annoyed with ROM attempts. The DOR stated Resident 83's right hand felt very stiff, the fingers could not be straightened, and the PIP joints of all the fingers had a hard end feel (felt hard/stiff at the end of the joint range). During a concurrent interview and record review with the Director of Nursing (DON) on 10/28/2022, at 2:23 PM, the DON stated there were no RNA orders and no RNA flowsheets for Resident 83 prior to 7/7/2022. The DON stated Resident 83 did not receive RNA services until after 7/7/2022 (9 months after the first OT's recommendation for RNA dated 10/7/21) as RNA was not allowed to provide services without a physician's order. During an interview with Restorative Nursing Aide 2 (RNA 2) and Restorative Nursing Aide 3 (RNA 3) on 10/28/22, at 2:33 PM, RNA 2 and RNA 3 stated they began right hand ROM exercises with Resident 83 in 7/2022. RNA 2 and RNA 3 stated Resident 83's right hand was held in a fist and felt very stiff. RNA 2 and RNA 3 stated Resident 83 did not tolerate right hand ROM exercises well due to pain and they had not been able to straighten Resident 83's fingers since RNA services began in 7/2022. During an interview with the DOR on 10/28/2022, at 2:45 PM, the DOR stated there was no Restorative Referral/Assessment form for Resident 83 in their records. The DOR stated Resident 83 was not transitioned to RNA upon discharge from OT if a Restorative Referral/Assessment form was not completed. The DOR stated monthly meetings with RNA were recently implemented so that no one gets missed like this. During a concurrent interview and record review with the DON on 10/28/2022, at 5:15 PM, the DON stated the decline in Resident 83's right hand ROM could have been avoided if the appropriate ROM services were provided. The DON confirmed Resident 83 was admitted to the facility with no right-hand ROM limitations. The DON confirmed Resident 83 developed significant right hand ROM loss since admission due to lack of ROM services. The DON confirmed Resident 83 did not receive RNA services in accordance with OT discharge recommendations for RNA program on 10/7/2021 and 2/2/2022. The DON stated OT should have evaluated Resident 83 once the Joint Mobility Assessments identified a decline in right hand ROM from minimal to severe. During a review of the facility's policy and procedure (P/P) titled, Resident Mobility and Range of Motion, revised on 7/2017, the P/P indicated the residents will not experience an avoidable reduction in range of motion (ROM). Residents with limited range of motion will receive treatment and services to increase and/or prevent a further decrease in ROM. The P/P indicated the interventions may include therapies, the provision of necessary equipment, and/or exercises and will be based on professional standards of practice and be consistent with state laws and practice acts. B. During a review of Resident 20's admission Record (AR), the AR indicated Resident 20 was re-admitted to the facility on [DATE] with diagnoses including but not limited Type 2 diabetes mellitus (condition in which the body does not metabolize blood sugar correctly), psychomotor deficit (slowing down of thoughts and physical movements) following cerebral infarction (stroke, blockage of the flow of blood to the brain, causing or resulting in brain tissue death), and muscle weakness. A review of Resident 20's Minimum Data Set (MDS), a standardized assessment and care-screening tool, dated 10/21/2021, indicated Resident 20 had impaired cognitive skills (ability to think, understand, learn, and remember) for daily decision making. The MDS indicated Resident 20 required extensive assistance (resident involved in activity, staff provide weight-bearing support) from staff for bed mobility (moving in bed to and from different positions such as side to side), dressing, eating, toileting, and personal hygiene and required a total assistance (full staff assistance) from staff for transfers (moving from one surface to another such as a bed or chair) and bathing. The MDS indicated Resident 20 had functional range of motion [(ROM), full movement potential of a joint)] impairments on both arms (shoulder, elbow, wrist, hand) and both legs (hip, knee, ankle, foot). A review of Resident 20's care plan, dated 10/21/2021 and revised on 4/29/2022, indicated Resident 20 had a self-care deficit and was at risk for skin injury related to bowel and bladder incontinence (having no or insufficient voluntary control over urination or defecation) and needed assistance for bed mobility and transfers. The care plan indicated a goal for Resident 20 was to maximize functional mobility in the next three months. The care plan did not have documented interventions for staff to implement to maintain or improve Resident 20's mobility. A review of Resident 20's Interdisciplinary Team (IDT) meeting notes dated 10/21/2022 indicated Resident 20 and his caregiver were present at the meeting and nursing staff addressed his concern regarding getting up and being out of bed more often. During an observation and interview with Resident 20 on 10/26/2022, at 11:44 AM, Resident 20 was lying in bed with blankets covering both legs. Resident 20 stated he was only assisted out of bed two times a week for baths and wanted to get out of bed more often. Resident 20 stated he told nursing staff numerous times he wanted to get out of bed more often, but not assistance was provided to get the resident out of bed more than two time a week. Resident 20 stated it was important for him to get out of bed often because it made him feel good and he wanted to go home. During an interview with Restorative Nursing Aide 1 (RNA 1) on 10/26/22, at 12:05 PM, RNA 1 stated Resident 20 spent most of the day in bed and got out of bed two times a week. During an interview with Certified Nurse Assistant 7 (CNA 7) on 10/26/22, at 1:13 PM, CNA 7 stated Resident 20 got out of bed about two times a week. During an interview and record review with the Assistant Director of Nursing (ADON), Minimum Data Set Nurse (MDSN), and Quality Assurance Nurse (QAN) on 10/26/2022, at 3:31 PM, the ADON, MDSN, and QAN confirmed there were no interventions in Resident 20's care plan to address the resident's mobility. The ADON, MDSN, and QAN confirmed Resident 20 required assistance in mobility and Activities of Daily Living [(ADL), basic activities such as eating, dressing, and toileting], was at risk for skin breakdown, and had a history of pressure ulcers (injuries to the skin and underlying tissue due to long periods of pressure). The ADON, MDSN, and QAN stated Resident 20 was at risk for further skin breakdown, contracture development, and a decline in mobility since interventions addressing mobility were neither care planned nor implemented. During an interview and record review of the IDT meeting Progress Notes with the Director of Nursing (DON) on 10/27/2022, at 4:14 PM, the DON confirmed Resident 20 informed staff he wanted to get out of bed more often. The DON stated a care plan for mobility should have been created and implemented to address Resident 20's wishes and needs. The DON stated if a resident's needs were not addressed and mobility was not care planned, the staff would not know to assist the resident out of bed which could potentially lead to an emotional and physical decline. C. During a review of Resident 19's admission Record (AR), the AR indicated Resident 19 was admitted to the facility on [DATE] with diagnoses including cervicalgia (neck pain), muscle weakness, and dysphagia (difficulty swallowing). A review of Resident 19's Minimum Data Set (MDS), an assessment and care-screening tool, dated 7/27/2022, indicated Resident 19 had impaired cognitive skills (ability to think, understand, learn, and remember) for daily decision making. The MDS indicated Resident 19 required extensive assistance (resident involved in activity, staff provide weight-bearing support) from staff for bed mobility (moving in bed to and from different positions such as side to side), transfers (moving from one surface to another such as a bed or chair), dressing, eating, toileting, and personal hygiene and required a total assistance (full staff assistance) from staff for bathing. A review of Resident 19's Physical Therapy [(PT), profession aimed in the restoration, maintenance, and promotion of optimal physical function] Discharge summary, dated [DATE], indicated Resident 19 walked 100 feet with contact guard assistance (occasional physical contact provided to maintain balance or stability) to minimal assistance (about 25% physical assistance provided to perform the task) with a front wheel walker [(FWW) mobility device used for steadying assistance and support while walking] at the time of discharge. The PT discharge recommendations included a referral of Resident 19 to the Restorative Nursing Aide Program [(RNA), nursing aide program that help residents to maintain their function and joint mobility] for ambulation (walking). A review of Resident 19's physician's orders, dated 8/3/2022, indicated order for RNA for ambulation. During an interview and record review of Resident 19's RNA order with the Director of Rehabilitation (DOR) on 10/26/22, at 1:29 PM, the DOR stated the physician's order for RNA did not indicate walking distance. The DOR stated the physician's order for Resident 19 ambulation with RNA did not indicate the distance thus allowed the resident to walk to the resident's own tolerance. DOR stated Resident 19 was not monitor for an improvement or decline in mobility. During an interview and record review of Resident 19's RNA order with the Director of Nursing (DON) on 10/27/2022, at 2:56 PM, the DON stated the physician's order for ambulation with RNA did not include monitoring the resident for improvement or decline in mobility because the order did not indicate a walking distance. The DON stated not monitoring Resident 19's mobility could lead to a potential decline in function, mobility, and activities of daily living (ADLs). During an interview and record review of Resident 19's RNA order with the Physical Therapist (PT) on 10/28/2022, at 11:01 AM, the PT stated residents were transitioned to RNA services to maintain function and prevent a decline in mobility. The PT stated the physician's order for RNA should contain the task, walking distance, frequency, and the assistive device used for walking to monitor whether a resident was maintaining mobility. D. During a review of Resident 81's admission Record (AR), the AR indicated the facility admitted Resident 81 on 3/17/2022 with diagnoses including hemiplegia (weakness to one side of the body) and hemiparesis (inability to move one side of the body) following a cerebral infarction (stroke, blockage of the flow of blood brain, causing or resulting in brain tissue death), epilepsy (disorder that causes episodes of seizures or altered consciousness), and Type 2 diabetes mellitus (condition in which the body does not metabolize blood sugar correctly. A review of Resident 81's Minimum Data Set (MDS), a standardized assessment and care-screening tool, dated 3/23/2022, indicated Resident 81 had short term and long-term memory problems and had modified independence in cognitive skills (ability to think, understand, learn, and remember) for daily decision making with some difficulty in new situations only. The MDS indicated Resident 81 required extensive assistance (resident involved in activity, staff provide weight-bearing support) from staff for bed mobility (moving in bed to and from different positions such as side to side), transfers (moving from one surface to another such as a bed or chair), dressing, toileting, and personal hygiene and required total assistance (full staff assistance) for bathing. Resident 81 did not walk during the assessment period. A review of Resident 81's Physical Therapy [(PT), profession aimed in the restoration, maintenance, and promotion of optimal physical function] Discharge summary, dated [DATE], indicated Resident 81 walked 150 feet with minimal assistance (about 25% physical assistance provided to perform the task) with a quad cane (mobility device with four tips that provides a broader base of support to assist with walking) at the time of discharge. A review of Resident 81's physician's orders, dated 4/1/2022, indicated a physician's order for Restorative Nursing Aide Program [(RNA), nursing aide program that help residents to maintain their function and joint mobility] to perform ambulation (walking) exercises using a quad cane and ankle foot orthosis [(AFO), an orthotic device designed to correct or address problems with the ankle and foot] three times a week, as tolerated. During an interview and record review of Resident 81's RNA order with the Director of Rehabilitation (DOR) on 10/26/22, at 1:29 PM, the DOR stated the physician's order for RNA did not indicate a walking distance. The DOR stated the physician's order for RNA not indicating distance allowed residents to walk to their own tolerance and not being monitored for an improvement or decline in mobility. During an interview and record review of Resident 81's RNA order with the Director of Nursing (DON) on 10/27/2022, at 2:56 PM, the DON stated the physician's order for RNA did not include the resident's monitoring for improvement or decline in mobility because the order did not indicate a walking distance. The DON stated not monitoring Resident 81's mobility could lead to a potential decline in function, mobility, and activities of daily living (ADLs). During an interview and record review of Resident 81's RNA order with the Physical Therapist (PT) on 10/28/2022, at 11:01 AM, the PT stated the physician's order for RNA should contain the task, walking distance, frequency, and the assistive device used for walking to monitor whether a resident was maintaining mobility. During a review of the facility's policy and procedure (P/P) titled, Resident Mobility and Range of Motion, revised on 7/2017, the P/P indicated the residents with limited range of motion will receive treatment and services to increase and/or prevent a further decrease in ROM. Residents with limited mobility will receive appropriate services, equipment, and assistance to maintain or improve mobility unless reduction in mobility is unavoidable. The P/P indicated the care plan will include specific interventions, exercises and therapies to maintain, prevent avoidable decline in, and/or improve mobility and range of motion