**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to: 1.Ensure one out of six sampled residents (Resident 2) was free from mental abuse (the use of verbal or nonverbal conduct which causes or has the potential to cause the resident to experience humiliation, intimidation, fear, shame, agitation, or degradation). 2.Implement the facility Policy and Procedure (P&P) titled Abuse: Prevention of and Prohibition Against revised 12/2023, that indicated each resident had the right to be free of abuse. The P/P indicated the facility was to ensure the health and safety of each resident with regards to visitors, such as family members, friends, or other individuals subject to the resident's right to deny or withdraw consent at any time and to reasonable clinical and safety restrictions, by allowing Resident 2's alleged abuser, Family Member 4 (FM 4) access to Resident 2, when FM 4 came into the facility, and Resident 2's room and tried to force Resident 2 to talk to him (FM 4). As a result, Resident 2 suffered emotional distress requiring a new physician's order for Ativan (medication used to treat anxiety [a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities]) after Resident 2's alleged abuser, FM 4 gained access to the facility on 4/8/2025, proceeded to Resident 2's room and tried opening Resident 2's bedside curtains while she was receiving perineal (peri) care (washing the genitals). (Cross reference F609 and F610) Findings: During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was admitted to the facility on [DATE] with diagnoses including confirmed physical abuse, major depressive disorder (a mental health condition that causes a persistently low or depressed mood and a loss of interest in activities that once brought joy), and anxiety disorder. During a review of Resident 2's History and Physical (H&P) dated 3/15/2025, the H&P indicated Resident 2 was admitted to the facility from a general acute care hospital (GACH) due to adult physical abuse causing traumatic ecchymosis (bruising). The H&P indicated Adult Protective Services (APS - a government agency that investigates allegations of a vulnerable adult being or having been abused, neglected, or exploited by their caregivers), and the police had been notified of the abuse by the GACH. The H&P indicated it was unclear if Resident 2 was able to make her own medical decisions and she was making medical decisions with the help of her sister (FM 5). The H&P indicated do not give any information to FM 4, in the plan of treatment. During a review of Resident 2's care plan titled, At risk for re-traumatization related to (r/t) history of physical abuse by a close family member initiated on 3/18/2025, the Care Plan goals included Resident 2 would have no evidence of emotional, physical, and psychological problems. The Care Plan interventions included encouraging Resident 2 to attend care conferences, to express preferences and participate in the care planning process. During a review of Resident 2's Interdisciplinary Team (IDT, brings together knowledge from different health care disciplines to help people receive the care they need)- Care Plan Review dated 3/18/2025, the IDT Care Plan Review indicated Resident 2 had an APS case against FM 4 for physical abuse. The IDT Care Plan Review indicated Resident 2 expressed that she did not want any calls or visits from FM 4. Resident 2 also expressed she felt threatened by FM 4, and FM 4 should also be banned from calling or visiting her. Resident 2 expressed she did not want to be discharged home with FM 4 because of the abuse. The IDT documentation indicated FM 4 was verbally, emotionally, financially, and physically abusive towards Resident 2 for years and multiple police reports were filed but Resident 2 always took FM 4 back in until the last event (date no specified) that led to her most recent hospitalization and she decided to press charges against FM 4 and not return to their apartment. During a review of Resident 2's Minimum Data Set (MDS, a resident assessment tool) dated 3/21/2025, the MDS indicated Resident 2's cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) was intact. The MDS indicated Resident 2 was not receiving any medications for anxiety. During a review of Resident 2's Case Manager (CM) Progress Notes dated 3/18/2025, the Case Manager Progress Notes indicated the CM was notified FM 4 was at the facility to visit Resident 2. The CM Progress Notes indicated the CM had been notified by Resident 2 that she did not want visits from FM 4. The CM Progress Notes indicated the CM notified FM 4 of Resident 2's wishes, and FM 4 proceeded to walk towards Resident 2's room stating, that is a lie! I was just there yesterday, and I took a train and two buses to get here. The CM Progress Notes indicated the CM asked FM 4 to wait in the lobby so she (CM) could confirm Resident 2's wishes, and Resident 2 again stated she did not want any calls or visits from FM 4. The CM Progress Notes indicated the CM relayed the message to FM 4, and he became agitated using profanity (bad words). The CM Progress Notes indicated the Police had to be called before FM 4 agreed to leave the facility. The CM Progress Notes indicated Resident 2's chart was updated, and staffing was made aware of Resident 2's wishes to not have visits from FM 4. During a review of Resident 2's Social Services Summary Note dated 3/21/2025, the Social Services Summary Note indicated Resident 2 was verbally responsive with capacity to understand and make decisions. The Social Services Summary Note indicated Resident 2 was unable to sleep well, had anxiety and worries about FM 4 who was physically abusive towards her. During a review of Resident 2's CM Note dated 4/8/2025, the CM Note indicated after lunch (lunch was served by 12:30 p.m.) on 4/8/2025 the CM was notified FM 4 was outside of Resident 2's room. The CM reminded FM 4 of Resident 2's wishes, and he became hostile and aggressive pushing past the CM and two other staff (unknown) to enter Resident 2's room. The CM Note indicated Resident 2's privacy curtain was pulled around Resident 2's bed for privacy and FM 4 proceeded to try and pull back the curtain as nursing staff (Licensed Vocational Nurse [LVN]3) was holding it shut. FM 4 was shouting to Resident 2, It's me FM 4, stop saying you do not want to see me. I came here to see you, tell them it is okay for me to see you, tell them it is okay for me to be here. The CM Note indicated Resident 2 was physically shaking her head No and Resident 2 was visually upset and tearful as she kept her eyes closed and continued shaking her head No. The CM Note indicated staff (unknown) intervened to prevent further interaction with Resident 2 and the police were called. FM 4 was escorted out of the building by two male staff (unknown) as FM 4 was verbally cursing profanities. During a review of Resident 2's Change in Condition (COC) evaluation dated 4/8/2025, the COC indicated Resident 2 was experiencing emotional distress. The COC indicated Resident 2 reported feeling anxious after the visit from FM 4 and emotional support was provided. MD 3 was notified and ordered; 1. monitor Resident 2 for emotional distress and 2. Ativan oral tablet 0.5 milligrams (mg) by mouth every eight hours as needed for anxiety manifested by verbalization of anxiousness with mild tremors for three days. 3. Psych consultation related to depression and anxiety. During a review of Resident 2's Care Plan titled Potential for psychosocial well-being problem related to family discord (disagreement, or difference in opinion) dated 4/8/2025, the Care Plan goals included for Resident 2 not having any further indications of psychosocial wellbeing problems. The Care Plan interventions included allowing Resident 2 time to answer questions and to verbalize feelings and fears, consultation with behavioral health, and when conflict arises removing Resident 2 to a calm, safe environment and allowing Resident 2 to vent and share her feelings. During a review of Resident 2's medication administration record (MAR), the MAR indicated Resident 2 was given Ativan 0.5 mg one time on 4/9/2025 for feeling anxious. During a review of Resident 2's Medication Administration Note dated 4/9/2025, the Medication Administration Note indicated Resident 2 was visibly shaken and anxious. Resident 2 was requesting anti-anxiety medications and Resident 2 was given Ativan 0.5 mg. During a review of Resident 2's COC (Condition) Follow-up dated 4/9/2025, the COC Follow-Up indicated Resident 2 had increased anxiety due to FM 4 and Resident 2 was calmer after receiving the Ativan 0.5 mg. During an observation and concurrent interview on 4/14/2025 at 9:50 a.m., Resident 2's name was displayed at the entrance of her door. Resident 2 stated her mind was always wandering, and did not work like it used to. During an interview on 4/15/2025 at 3:17 p.m., Resident 2 declined to elaborate on how FM 4 abused her prior to her admission to the facility. Resident 2 stated she was scared just hearing FM 4's voice when he got into the facility and the situation was mentally exhausting, but she prayed for FM 4 every day and just wanted to move forward with her life. Resident 2 stated the facility provided her with a number to call for therapy, but she had yet to set up an appointment. During an interview on 4/17/2025 at 10:20 a.m., with the CM, the CM stated Resident 2 had come to their facility after a stay in the GACH from sustaining injuries due to being physically assaulted by FM 4. The CM stated Resident 2 had an open APS case against FM 4 prior to her admission to the facility. The CM stated Resident 2 had been dealing with the abuse for several years until she decided to cut ties with FM 4 when she was admitted to the GACH. The CM stated FM 4 had snuck into the facility two times that they know of; on 3/18/2025 and 4/8/2025. The CM stated Resident 2 became visibly shaken up just by the mention of FM 4 being in the vicinity of the facility. The CM stated the first instance FM 4 entered the facility on 3/18/2025, she (the CM) was alerted a male was in Resident 2's room being disruptive so she went to investigate and informed FM 4 he was not welcome at the facility, Resident 2 did not wish to see him, and the police were called. The CM stated the second time he came back to the facility on 4/8/2025, FM 4 was immediately spotted by staff, staff tried to stop him from entering Resident 2's room but he pushed his way into the room and was trying to pull the privacy curtain open, but LVN 3 was holding the privacy curtain shut. The CM stated Resident 2 was receiving peri care, and her privates were exposed while FM 4 was trying to pull the privacy curtain open. The CM stated FM 2's voice was very aggressive, very loud, caused a huge commotion and he was yelling to Resident 2, God dammit you know you want to see me, why are you telling them you do not want to see me! and Resident 2 was crying and very shaken up by the occurrence. The CM stated the way FM 4 was talking, acting, and the tone of voice he was using was verbally and emotionally abusive. The CM stated the abuse coordinator (administrator [ADM]) was aware of the situation that occurred on 4/8/2025. The CM stated she brought it up during a morning meeting with department heads that in GACHs, victims of violence do not have their names outside of their rooms for patient safety and the CM thought it would be a good idea to implement but she does not know what the facility did with that information. The CM stated she believed FM 4 found out what room Resident 2 was in by looking for and finding her name posted outside of her doorway. The CM stated they offered assistance to call a behavioral health self-referral number to set up an appointment for therapy, but the resident declined. During an interview on 4/17/2025 at 10:54 a.m., with the Social Services Director (SSD), the SSD stated Resident 2 became upset at the mention of FM 4's name so they had to respect her and not ask any questions because Resident 2 did not want to talk about any of the details. During an interview on 4/17/2025 at 1:42 p.m., with LVN 3, LVN 3 stated on 4/8/2025 FM 4 bypassed all the safety checks in the facility and snuck into the facility behind another resident's family member (unknown). LVN 3 stated she knew a Certified Nursing Assistant (CNA) (unknown) was providing peri care to Resident 2 at the time, so LVN 3 entered Resident 2's room to check on the resident before FM 4 abruptly made his way past the CM (who was at the doorway of Resident 2's room) and was trying to pull Resident 2's privacy curtain open. LVN 3 stated she was pleading with FM 4 to give Resident 2 some privacy and to let the staff get Resident 2 decent, but FM 4 was cussing at the staff, saying F (fuck), F the police and shouting at Resident 2 to let FM 4 in. LVN 3 stated FM 4 was shouting multiple things at Resident 2, but she couldn't exactly remember everything that was said. LVN 3 stated Resident 2 was visibly in fear, shaking, and traumatized. LVN 3 stated the interaction was verbal abuse and emotional abuse by the way he was talking to Resident 2 and the response Resident 2 had to the interaction. LVN 3 stated Resident 2 ended up needing Ativan because she was so shaken up. LVN 3 stated the abuse coordinator (ADM) was aware of the situation but was not sure if the incident was reported to necessary agencies other than the police because the police were called. During an interview on 4/18/2025 at 10:36 a.m., with the ADM, the ADM stated she was the abuse coordinator for the facility. The ADM stated the facility was informed an open APS case was filed against FM 4 for the abuse Resident 2 sustained. The ADM stated the police were called after the first incident 3/18/2025 and staff were notified not to let FM 4 in and to call the police if they saw him. The ADM stated the second incident on 4/8/2025 she was incorrectly informed after the incident had happened, that FM 4 did not enter Resident 2's room and staff were able to stop him from entering the room. The ADM stated from what she learned about the 4/8/2025 incident FM 4 was aggressive towards staff and just stated he wanted to see Resident 2, so she did not believe it was abuse but rather family dynamics. The ADM stated the incident was not reported to the state agency and a thorough investigation was not done but if she knew FM 4 entered the room and the details of the interaction she may have done things differently. The ADM read the details in Resident 2's medical record including the CM notes and COC dated 4/8/2025. The ADM stated she was not aware FM 4 entered Resident 2's room, was shouting towards Resident 2, and Resident 2 was shaking her head no and crying. The ADM stated it was important staff members reported accurate descriptions of events because that determined the course of action she takes and if an incident needed to be reported to the state agency. The ADM stated she unfortunately never spoke to Resident 2 herself regarding the situation. The ADM stated according to the facility's policy and procedure (P/P) titled Abuse: Prevention of and Prohibition Against definition of mental abuse, mental abuse included harassment. The ADM stated if there was an allegation of abuse, the incident needed to be thoroughly investigated and reported to the state agency right away. The ADM stated Resident 2 remained in the same room from the time of admission [DATE]) to the time of discharge (4/17/2025) and she could not find any evidence in Resident 2's chart she was offered a room change after the first incident on 3/18/2025, and the second incident on 4/8/2025 of FM 4 forcing his way into Resident 2's room for her safety. The ADM stated after the second incident on 4/8/2025, she (ADM) became worried about Resident 2's safety so she had the CM reach out to Resident 2's insurance to request a transfer to another facility but Resident 2's insurance declined. During a review of the facility's P/P titled Abuse: Prevention of and Prohibition Against revised 12/2023, the P/P indicated each resident had the right to be free of abuse. The P/P indicated abuse was the willful (the individual acted deliberately) infliction of injury, unreasonable confinement, intimidation, or punishment resulting in physical harm, pain, or mental anguish. The P/P indicated the facility was to ensure the health and safety of each resident with regards to visitors, such as family members, friends, or other individuals subject to the resident's right to deny or withdraw consent at any time and to reasonable clinical and safety restrictions. The P/P indicated mental abuse included, but was not limited to humiliation, harassment, and threats of punishment or deprivation. The P/P indicated the facility was to protect the resident from further abuse by making room changes as needed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure the resident who had a suspected deep tissue pressure injury (SDTI, suspected pressure injury where damage is occurring beneath the skin, but the surface skin may still appear intact. It's characterized by a purple or maroon localized area of discolored skin or a blood-filled blister due to damage to underlying soft tissues from pressure) to a right heel and left heel blister did not progress to unstageable (actual pressure injury covered by slough [(pale yellow, thick, tissue with fiber) and/or eschar [a piece of dead tissue that is cast off from the surface of the skin] pressure injury for one of 16 sampled residents (Resident 35). The facility failed to: 1. Ensure Resident 35's right heel SDTI did not decline to an unstageable pressure injury2. 2. Monitored and documented the presence of a left heel SDTI upon Resident 35's admission. 3. Documented weekly left heel SDTI wound assessments in Resident 35's medical record. 4. Referred Resident 35 to a wound care practitioner. 5. Provided Resident 35 with offload (minimizing or removing weight placed on the foot to help prevent and heal ulcer) measures including low air loss (LAL) mattrass and elevate heels over a pillow or heel protector boots, and provide supplements such as additional protein, Zinc, Vitamin C and a Multivitamin to promote left heel SDTI wound healing. 6. Notify Resident 35's physician when the left heel blister (a painful skin condition where fluid fills a space between layers of skin) was reclassified as a left heel SDTI on 3/26/2025. 7. Notify Resident 35's physician and complete a change of condition (COC) assessment when Resident 35's left heel SDTI was noted to have a foul (bad) odor, an area of eschar, and slough on 4/14/2025. 8. Ensure the interdisciplinary team (IDT, brings together knowledge from different health care disciplines to help people receive the care they need) including the Director of Nursing (DON), the treatment nurse (TXN) 1, and the registered dietician (RD) met and discussed interventions to promote Resident 35's left heel SDTI wound healing. These deficient practices resulted in Resident 35's left heel blister and right heel SDTI to progress to unstageable pressure injuries on 4/14/2025 and causing the resident pain. Resident 35 was admitted to a general acute care hospital (GACH) on 4/17/2025 with a chief complaint of heel pain and a primary diagnosis of a left heel unstageable pressure injury injury Resident 35 was treated with Vancomycin (medication to treat infection) intravenously (IV, into the vein) bacteria wound infections, Morphine for pain, and was given one liter of Normal Saline (medical grade saline solution) solution for hydration in the emergency department (ED) on 4/17/2025. Findings: During a review of Resident 35's admission Record, the admission Record indicated Resident 35 was admitted to the facility on [DATE] from the GACH with diagnoses of left femur (thigh bone) fracture (broken leg bone), fall, muscle weakness, difficulty in walking, joint replacement surgery, and type 2 diabetes (happens when the body cannot use insulin correctly and sugar builds up in the blood). During a review of Resident 35's GACH's Wound Care Consult notes dated 3/23/2025 the Wound Care Consult notes indicated Resident 35 had Stage II (may present as an intact blister)/ DTI with an intact fluid filled blister) measured 6.0 cm in length by 6.0 cm in width and a right heel SDTI with erythema (redness) measured 3.0 cm in length by 3.0 cm in width. The Wound Care Consult notes indicated Resident 35 required Pressure Injury Prevention Protocol including a waffle seat cushion (an air pressure redistribution cushion), or a low air loss mattress, turning and repositioning every two hours, and offload the heels over a pillow or heel protector boots. During a review of Resident 35's Initial admission Record dated 3/23/2025, the initial admission Record indicated treatment nurse (TXN) 2 conducted a skin integrity check. The admission Record indicated TXN 2 notified the physician (unspecified) of Resident 35's, left heel blister and right heel SDTI. Resident 35's Initial admission Record did not indicate a description, including the appearance and measurements of the left heel blister and the right heel SDTI upon admission. During a review of the admission Report- Skin Check (paper document) undated, the Skin Check document indicated Resident 35 had a right heel SDTI measured 1.5 cm in length by 0.5 cm in width and a 3.0 cm by 6.0 cm left heel blister. During a review of Resident 35's H&P dated 3/24/2025, the H&P (a thorough medal history from the patient obtained by a physician during a physical examination) indicated Resident 35 was able to make her own medical decisions. The H&P indicated Resident 35 was sent to the facility status post (after) left hip surgery due to a left hip fracture. The H&P indicated Resident 35 did not have any concerning rashes or lesions (wounds) at the time but did have a left hip surgical site. The H&P included a plan to monitor the wound (surgical site) per facility protocol and obtain a wound care evaluation as needed. The H&P indicated the facility's care staff was instructed to call the physician for any COC. During a review of Resident 35's care plan titled, Actual impairment to skin integrity related to left heel blister and left heel protector boot (cushioned boot that floats the heel to aid in healing of pressure injuries) dated 3/25/2025, the care plan indicated the goals for Resident 35 included reducing the risk for impairment to skin integrity by (body) positioning techniques, and adaptive equipment. The care plan interventions included avoiding scratching, keeping body parts from excessive moisture, keeping fingernails short, educating resident/ family/ and caregivers of causative factors and measures to prevent skin injury, and encouraging good nutrition and hydration to promote healthier skin. On 4/15/2025 the care plan for the left heel blister was updated to include, on 3/26/2025: patient was reassessed by TXN 1, the left heel blister was classified as SDTI with purple tissue. On 4/15/2025 the care plan interventions were updated to include left heel SDTI treatment as ordered, monitor/ document location, size and treatment of the skin injury, report abnormalities, failure to heal and signs and symptoms of infection to the physician, monitor for skin breakdown and off-load (minimizing or removing weight placed on the foot to help prevent and heal ulcers) as tolerated. During a review of Resident 35's Order Summary Report, the report indicated the following physician's wound care orders: - On 3/25/2025 for left heel blister, cleanse with NS pat dry, apply antibacterial ointment then apply gauze and wrap with kerlix (type of dressing). Every day shift. The order was discontinued on 3/26/2025. - On 3/25/2025 for right heel SDTI cleanse with NS, pat dry, apply oil emulsion dressing wrap (gauze wound dressing impregnated with a blend of oil and water), in kerlix. Ever day shift. The order was discontinued on 4/16/2025. - On 3/25/2025 for bilateral (both) heel apply protector boots as tolerated or as patient allows. Every day shift. -On 3/26/2025 for left heel SDTI: cleanse with NS, pat dry, apply sure prep (skin barrier ointment), apply abdominal (ABD) pad and cover with rolled gauze. Offload as tolerated, monitor for skin breakdown and notify the physician of any changes every day shift. The order was discontinued on 4/14/2025. -On 4/14/2025 for left heel SDTI: cleanse with NS, pat dry, apply Medihoney, calcium alginate dressing (ideal for wounds with moderate to heavy exudate [fluid that leaks out of blood vessels into nearby tissues]), dry dressing and cover with rolled gauze. Offload as tolerated, monitor for skin breakdown and notify the physician of any changes every day shift. The order was discontinued 4/16/2025. - On 4/14/2025 wound culture of the left heel, one time only. -On 4/16/2025 wound care consult for SDTI. -On 4/16/2025 for left heel unstageable pressure injury: cleanse with NS, pat dry, apply Medihoney, calcium alginate, dry dressing and cover with rolled gauze. Offload as tolerated, monitor for any signs for skin breakdown and notify the physician of any changes. -On 4/16/2025 for right heel unstageable pressure injury: cleanse with NS, pat dry, apply Medihoney, calcium alginate, dry dressing and cover with rolled gauze. Offload as tolerated, monitor for any signs for skin breakdown and notify the physician of any changes. During a review of Resident 35's Skin/ Wound Note dated 3/26/2025 (three days after admission), the note indicated Resident 35 was reassessed by TXN 1 and the left heel blister was classified as an SDTI with purple tissue. The note did not indicate measurements or a complete wound assessment describing the characteristics of the wound. The note did not indicate the physician was notified of the classified wound type or new treatment orders. Resident 35 did not have weekly Skin/Wound assessments documented in her medical record including all wounds and their progress as indicated in the facility's Wound Management and Prevention policy and procedure (P/P). During a review of Resident 35's MDS, dated [DATE], the MDS indicated Resident 35 had moderate cognitive impairment and required substantial/ maximal assistance (helper does more than half the effort) for bed mobility including rolling from left to right. The MDS indicated Resident 35 was at risk for pressure injuries and had two deep tissue injuries and zero unstageable pressure injuries with slough or eschar. During an observation on 4/14/2025 at 10 a.m., Resident 35 was lying in bed with her feet elevated on one pillow. Resident 35 did not have heel protector boots on, Resident 35 was not lying on a low air loss mattress. During an interview on 4/14/2025 at 10:11 a.m., Family Member (FM) 2 stated she was upset because Resident 35's left heel wound was getting worse. During an observation on 4/14/2025 at 1:44 p.m., TXN 1 was in Resident 35's room speaking to FM 3 at the bedside. Resident 35 was lying in bed crying in pain, saying her left foot hurt. Resident 35 was informing FM 3 she had chills (the feeling of being cold, though not necessarily in a cold environment, often accompanied by shivering or shaking). TXN 1 was obtaining a wound culture swab of Resident 35's left foot wound due to the foul odor of the wound. Resident 35's left heel was observed with the following and described by TXN 1 as: a large area of dark purple or black appearing eschar, surrounded by a pinkish red area of granulation tissue, and a small amount of yellowish white slough. During a review of Resident 35's wound culture (medical test to determine the kind of infectious agent), obtained from left foot on 4/14/2025, the wound culture results indicated Resident 35 had moderate growth of Proteus Mirablis (a gram-negative bacteria that can cause wound infections). During an interview on 4/15/2025 at 9:03 a.m., TXN 1 stated Resident 35's wounds were not being treated by a wound care practitioner. TXN 1 stated she noticed a change in appearance to Resident 35's left heel wound and a little bit of odor, so she obtained the wound culture on 4/14/2025. TXN 1 reviewed her wound care binder at the nurse's station where she tracked residents' wound progress but there was no information about Resident 35 in her wound care binder. TXN 1 reviewed Resident 35's medical record and stated there were no weekly skin/ wound documentation in the chart including measurements and appearance of the wounds. TXN 1 reviewed Resident 35's LN-Initial admission Assessment from 3/23/2025 and stated the documentation lacked a description of the wound appearance and the measurements of the wound. TXN 1 stated the initial assessment of the left heel wound indicated it was a left heel blister. TXN 1 stated when she assessed Resident 35 herself on 3/26/2025, she noted the wound to be a SDTI with 100% of the wound being purple boggy (a wound where the surrounding tissue feels soft, spongy, and possibly mushy to the touch, often due to increased fluid content) tissue. TXN 1 stated based on the documentation in the chart she did not have a good baseline (assessment of the wound upon admission) from admission to see if there had already been a decline in the wound status since admission because the documentation was lacking wound characteristics, so she reclassified the wound as an SDTI based on her assessment from 3/26/2025. During an interview on 4/16/2025 at 8:04 a.m., with FM 1, FM 1 stated when she was visiting Resident 35 on the evening of 4/13/2025, Resident 35 was complaining of pain to her left foot, and she noted a smell in Resident 35's room so she ripped off Resident 35's sock and bandage that was wrapped around the left heel. FM 1 stated she was shocked to see Resident 35's left heel wound looked worse, and the wound smelled. FM 1 stated she alerted staff (unknown) to the issue on 4/13/2025 and two staff came in to look at the wound and wrap it back up, but she was unsure who the staff were. FM 1 stated the wound looked much worse than it did when Resident 35 was admitted . FM 1 stated a wound culture was taken the next day (4/14/2025) but she did not know the results yet. FM 1 stated Resident 35 was complaining of worsening left heel pain for a few days. FM 1 stated Resident 1 was admitted from the GACH with heel protector boots and when she would go visit Resident 35, they would not be on and would be in Resident 35's closet and sometimes Resident 35's heels would be touching the bed. During an interview on 4/16/2025 at 11:16 a.m., TXN 1 stated Resident 35's left heel wound had a change in status on 4/14/2025. The wound had some drainage and had a smell, so the facility obtained an order for a wound culture. TXN 1 stated she did not inform the physician of the change in appearance of the wound; they just requested a wound culture due to the smell. TXN 1 stated Resident 35's left heel wound now had eschar or necrotic tissue which was not good for wound healing and usually needed to be debrided but debridement was not in her scope of practice so Resident 35 needed a wound care consultation. TXN 1 stated she had yet to request an order for a wound care consultation for Resident 35's wound because the results of the wound culture were not back yet. TXN 1 stated when a wound has eschar, they do not know how bad the wound really was underneath, and the wound could have been worse. TXN 1 stated DTIs could deteriorate rapidly with any pressure due to the fragility of the skin and it was important to be proactive with interventions and offload the heels for the best chance for wound healing. TXN 1 stated it was important to have accurate baseline assessments of wounds and wound interventions should be implemented immediately to keep the wound healthy, infection free, mitigate pain, and promote healing. TXN 1 stated it was the facility's policy to document weekly on the wound progress. TXN 1 stated it was important to have a description of the wound including all the wound characteristics and measurements upon baseline so the facility could have an accurate baseline to track the progress of the wound and to ensure the resident receives the proper interventions to prevent a decline in the wound. TXN 1 stated she reviewed Resident 35's care plans and the care plans were not updated until 4/15/2025 to include the reclassified SDTI staging of the left heel wound and to offload the heels. TXN 1 stated the care plan should have been updated when she reclassified the left heel wound as a SDTI on 3/26/2025. TXN 1 stated a comprehensive person-centered care plan for each wound was important because the facility needed to identify the problem, assess the risk associated with the problem, and implement interventions to prevent a decline in the wound and to promote wound healing. TXN 1 stated she was upset with herself because she did not perform a COC assessment and notify the physician of Resident 35's decline in wound appearance on 4/14/2025. TXN 1 stated there was a possibility of delay in care and treatment if the physician was not notified right away of a wound decline. TXN 1 stated she had not called Resident 1's physician to discuss Resident 35's wound status since she had been caring for Resident 35's wounds. During an interview on 4/16/2025 at 2:21 p.m., with the physician assistant (PA) 1 who was in the facility, PA 1 stated he had just been informed Resident 35 had worsening wounds. PA 1 stated he was going to put an order for Resident 35 to be seen by a wound care practitioner. PA 1 stated the physician or himself should have been notified right away of any new or changing wounds. PA 1 stated it was important residents with wounds that have eschar were seen by a wound care consultant so the appropriate interventions could be placed. During an interview on 4/16/2025 at 2:25 p.m., TXN 1 stated she was now staging Resident 35's left heel wound as an unstageable pressure injury due to the wound characteristics (slough and eschar). TXN 1 stated the definition of an unstageable pressure injury was the wound couldn't be staged. During an observation on 4/16/2025 at 2:42 p.m., TXN 1 measured the wound on Resident 35's left heel, the wound measured 6.5 cm length by 7.0 cm in width with a separate discoloration (redness) on the inner ankle. The wound had a large purplish black center, yellowish white area surrounding the dark area as well as a small area of granulation tissue (new pinkish red tissue). TXN 1 removed the dressing from the right heel and revealed a 3.3 cm in length by 5.0 cm in width wound that was purple with a translucent center. TXN 1 indicated she would be reclassifying the right heel wound as an unstageable pressure injury as well completing a COC for bilateral heels. During a review of Resident 35's COC evaluation dated 4/16/2025, the COC indicated Resident 35 had developed pain in both heels. Resident 35's left and right hells SDTI were reclassified as Unstageable pressure injuries. The left heel unstageable pressure injury measured 6.5 cm in length by 7.0 cm in width with 75 percent (%) of wound covered in eschar, 20% slough, and 5% granulation tissue with medial (inside) ankle discoloration. The right heel unstageable pressure injury measured 3.3 cm in length by 5.0 cm in width with purple intact tissue. The COC indicated FM 2 was requesting an x-ray (a type of diagnostic test using radiation that creates a picture of the inside of the body) of both feet to rule out effects to the bone. During a review of Resident 35's Nursing Progress Note dated 4/17/2025, the Progress Note indicated Resident 35 verbalized she was unable to sleep well the night prior due to left heel pain and had moderate pain at the time of evaluation on the left heel. The Progress Note indicated nursing offered Resident 35 to be transferred to the GACH for further evaluation of her pressure injury wounds and Resident 35 agreed to the transfer. During a review of Resident 35's Skin/ Wound Note dated 4/17/2025, the Skin/ Wound Note indicated treatment was halted due to patient expressing pain. The note indicated wound care was not resumed due to Resident 35's condition and pain level and Resident 35 was transferred to the GACH. During an interview on 4/17/2025 at 2:33 p.m., the DON stated she was not aware of Resident 35's wounds until this interview. The DON stated it was important she was notified of wound and the wound decline so she could review the chart and ensure the resident was receiving all appropriate interventions. The DON stated wounds needed to be assessed upon admission, for any changes, and weekly and all assessments needed to be recorded in the resident's chart. The DON stated the IDT had not met to discuss Resident 35's wounds. The DON stated there was a possibility the wounds could decline if the IDT did not meet to discuss important interventions needed. The DON reviewed Resident 35's medical record and stated weekly skin/ wound assessments had not been completed. The DON stated the LN- initial admission assessment should have included a wound description and measurements, and the initial assessment indicated Resident 35 was admitted with a left heel blister. The DON stated the physician should have been notified that the left heel blister was reclassified as a SDTI on 3/26/2025 but there was no evidence in the chart that the physician was informed. The DON stated it was important the physician was aware of wound changes so they could order any necessary interventions. The DON stated there was no COC or notification of the physician documented in Resident 35's chart related to the wound appearance and decline on 4/14/2025. The DON stated the treatment nurses (TXN 1 and TXN 2) were not competent in wound documentation and tracking as evidenced by the lack of documentation in Resident 35's chart and the failure to complete a COC when a decline in the wound was noted on 4/14/2025. The DON stated Resident 35 did not have an order for an LAL mattress. The DON stated Resident 35 had not been seen by a wound care consult. The DON stated the importance of a wound care consultation was to ensure they followed the progression of the wound closely, performed any necessary debridement's, and implemented interventions to help prevent a decline in the wound. The DON stated there was no evidence in Resident 35's chart that registered dietician was aware of Resident 35's wounds. During an interview on 4/17/2025 at 2:25 p.m., the case manager (CM) stated she requested an authorization for a wound care consultation for Resident 35 for the first time on 4/16/2025 when the order was placed. During a review of Resident 35's Registered Dietician Note dated 4/18/2025, Registered Dietician Note indicated Resident 35 had bilateral heel unstageable pressure injuries. The note indicated a nurse (unknown) had received a new physicians order (4/17/2025) for multivitamins with minerals, Vitamin C 500 mg, and Zinc 220 mg for 14 days and RD 2 recommended ProStat (liquid protein) 30 ml twice a day for wound healing. During a review of Resident 35's GACH's Wound Care Consult dated 4/18/2025, the GACH Wound Care Consult indicated Resident 35 was sent from the facility for worsening wounds to bilateral heels and bilateral heel pain. The Wound Care Consult indicated Resident 35 received Vancomycin, Morphine 4.0 mg intravenously (IV-into the vein), and 1.0 liter of NS in the ED. The Wound Care Consult indicated FM 2 reported Resident 35 had worsening wound to the left heel for one week with odor. The Wound Care Consult indicated Podiatry (the treatment of the feet and their ailments) was consulted for the left heel unstageable pressure injury. During an interview on 4/18/2025 at 7:26 a.m., FM 1 stated Resident 35 had been transferred to the GACH the night prior due to her wounds and was receiving IV fluids, pain medication, and antibiotics. FM 1 stated they were waiting for a specialist to come and look at Resident 35's heels to discuss if surgery was required to treat the wounds. FM 1 stated Resident 35 was feeling very anxious and upset because she thought they might have to cut her left foot off due to the wound. During an interview on 4/18/2025 at 1:17 p.m., RD 2 stated she was just made aware of Resident 35's wounds and was not aware that Resident 35 had wounds upon admission. RD 2 stated nutritional consultation was important for residents with wounds because they require more protein to promote wound healing. RD 2 stated there is a nutritional regimen they usually implement for wound healing that includes Vitamin C, Zinc, Multivitamins with minerals and ProStat (liquid protein) but it was not added for Resident 35 until 4/18/2025. During a review of the facility's P/P titled Change of Condition Reporting dated 4/2021, the P/P indicated changes in resident condition were to be reported to the physician and it was to be documented in the eInteract Change of Condition and/ or in the nurse's progress notes, the plan of care was to be updated. The P/P indicated any attempts to contact the physician would be documented in the resident's medical record. During a review of the facility's P/P titled Wound Management and Prevention dated 8/1/2021, the P/P indicated it was the facility's policy to ensure any resident that entered the facility had appropriate preventative measure taken to ensure the resident did not develop pressure ulcers, or that residents admitted with wound did not develop signs and symptoms of infection. The P/P indicated a plan of care was to be initiated to address areas of actual skin breakdown and the care plan was to be reviewed and revised as needed. The P/P indicated a report of all the wounds and their progress would be updated by the treatment nurse weekly. The P/P indicated the RD was to provide nutritional support when appropriate. During a review of the facility's Job Description- Director of Nursing dated 10/2021, the job description indicated the DON was to review nursing personnel medical record documentation to ensure that it was appropriately and accurately descriptive of the nursing care provided. The DON was to manage and direct all aspects of the nursing services department. The DON was to assist in the development of preliminary and comprehensive assessments of the nursing needs of each resident. During a review of the facility's Job Description- Treatment Nurse dated 12/17/2021, the job description indicated the treatment nurse was to make written and oral reports/ recommendations to the attending physician, Medical Director, or the DON concerning the status and care of the residents. The treatment nurse was to work with the IDT to develop a comprehensive assessment and care plan for all assigned residents. Examine the resident and or his/ her records and charts, and discriminate between normal and abnormal findings, to recognize when to refer the resident to a physician for evaluation, supervision, or directions. Initiate requests for consultation or referral.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide services to improve or maintain range of motion ([ROM] full movement potential of a joint) and mobility (ability to move) for three of five sampled residents (Resident 40, 4, and 34) with ROM and mobility concerns by failing to: 1. Provide Resident 40 with a Physical Therapy ([PT] profession aimed in the restoration, maintenance, and promotion of optimal physical function) screening or evaluation in accordance with the PT Job Description when the facility identified Resident 40's decline in ability to perform sit-to-stand (ability to come to a standing position from sitting) transfers on 10/4/2024. 2. Provide Resident 40 with interventions to improve the ability to perform sit-to-stand transfers on 10/4/2024 in accordance with facility's policy and procedure (P&P) for Quality of Care titled, ROM and Contracture (a stiffening/shortening at any joint that reduces the joint's range of motion) Prevention. 3. Provide Resident 40 with active assistive range of motion ([AAROM] use of muscles surrounding the joint to perform the exercise but requires some help from a person or equipment) to both arms and legs on 4/15/2025 in accordance with the physician order for Restorative Nursing Aide ([RNA] nursing aide program that helps residents to maintain their function and joint mobility), dated 10/4/2024. 4. Provide Resident 40 with a right-hand splint (material used to restrict, protect, or immobilize a part of the body to support function, assist and/or increase range of motion) to prevent further ROM decline in accordance with the facility's P&P for Quality of Care titled, ROM and Contracture Prevention. 5. Accurately assess Resident 4's right-hand during the Joint Mobility Evaluation ([JME] brief assessment of a resident's range of motion in both arms and both legs), dated 4/14/25. 6. Provide Resident 4 with passive range of motion ([PROM] movement of a joint through the ROM with no effort from person) exercises to both wrists during the Restorative Nursing Aide ([RNA] nursing aide program that helps residents to maintain their function and joint mobility) session on 4/15/25 in accordance with the physician's order, dated 10/25/2023. 7. Provide Resident 34 with ROM exercises to both wrists, hands, and ankles during the RNA session on 4/15/25 in accordance with the physician's order, dated 12/9/2024. These failures resulted in Resident 40 losing the ability to stand and had the potential for Resident 40 to experience further ROM decline in the right hand, causing Resident 40 to feel frustrated and debilitated. These failures also had the potential for Resident 4 and 34 to experience a ROM decline in both arms and legs. Findings: During a review of Resident 40's admission Record, the admission Record indicated Resident 40 was initially admitted on [DATE] and re-admitted on [DATE] with diagnoses including muscle weakness, diabetes mellitus (a disorder characterized by difficulty in blood sugar control and poor wound healing), peripheral vascular disease ([PVD] a slow progressive narrowing of the blood flow to the arms and legs), and difficulty walking. During a review of Resident 40's physician order, dated 12/16/2023, the physician order indicated for the RNA to provide Resident 40 with AAROM to both arms and legs, four times a week as tolerated. During a review of Resident 40's physician order, dated 1/27/2024 and revised 4/10/2024, the physician order indicated for the RNA to provide Resident 40 with sit-to-stand transfers using the front wheeled walker ([FWW] an assistive device with two front wheels used for stability when walking), four times per week as tolerated. During a review of Resident 40's Restorative Nursing records (record of daily RNA sessions) from 4/10/2024 to 10/4/2024, the RNA records indicated Resident 40 received AAROM to both arms and legs, four times per week, and sit-to-stand with the FWW, four times per week as tolerated. During a review of Resident 40's RNA Weekly Progress Report (summary of RNA sessions for the given week with written narrative comments), dated 5/2/2024, the RNA Weekly Progress Report comments indicated Resident 40 performed sit-to-stand transfers with two-person assistance and held a standing position for 20-35 seconds. During a review of Resident 40's RNA Weekly Progress Report, dated 5/9/2024, the RNA Weekly Progress Report comments indicated Resident 40 performed sit-to-stand transfers using a FWW and held a standing position for 10 seconds. During a review of Resident 40's RNA Weekly Progress Report, dated 5/16/2024, the RNA Weekly Progress Report comments indicated Resident 40 performed sit-to-stand transfers two-person assistance and held a standing position for 30-60 seconds. During a review of Resident 40's RNA Weekly Progress Report, dated 6/6/2024, the RNA Weekly Progress Report indicated Resident 40 performed two repetitions of sit-to-stand transfers using a FWW with two-person assistance. During a review of Resident 40's quarterly Joint Mobility Evaluation ([JME] brief assessment of a resident's range of motion in both arms and both legs), dated 6/28/2024, the JME indicated Resident 40's current intervention included RNA for AAROM of both arms and legs, four times per week, and sit-to-stand, four times per week. The JME indicated Resident 40 had moderate ROM limitations (50-75 percent [%] ROM intact; 25-50% ROM loss) in both shoulders for flexion (raising arms upward in front of the body), the right shoulder for abduction (raising arm upward at the side of the body), the right fingers, and both hips. The JME indicated Resident 40 had minimum ROM limitations (75-100% ROM intact; 0-25% ROM loss) in the left shoulder for abduction, the right elbow, the left fingers, and both knees. During a review of Resident 40's RNA Weekly Progress Report, dated 7/4/2024, 7/11/2024, 7/18/2024, and 7/25/2024, the RNA Weekly Progress Reports indicated Resident 40 performed three repetitions of sit-to-stand transfers using a FWW and two-person assistance. During a review of Resident 40's RNA Weekly Progress Report, dated 8/1/2024, 8/8/2024, 8/15/2024, 8/22/2024, and 8/29/2024, the RNA Weekly Progress Reports indicated Resident 40 performed three repetitions of sit-to-stand transfers using a FWW and two-person assistance. During a review of Resident 40's RNA Weekly Progress Report, dated 9/5/2024 and 9/19/2024, the RNA Weekly Progress Report indicated Resident 40 performed two to three repetitions of sit-to-stand transfers using a FWW. During a review of Resident 40's RNA Weekly Progress Report, dated 9/26/2024, the RNA Weekly Progress Report indicated Resident 40 performed three sets of sit-to-stand transfers using a FWW. During a review of Resident 40's quarterly JME, dated 10/1/2024, the JME indicated Resident 40's current intervention included RNA for AAROM of both arms and legs, four times per week, and sit-to-stand, four times per week. The JME indicated Resident 40 had moderate ROM limitations in both shoulders for flexion, the right shoulder for abduction, the right fingers, and both hips. The JME indicated Resident 40 had minimum ROM limitations in the left shoulder into abduction, the right elbow, the left fingers, and both knees. The JME indicated Resident 40 did not have any changes in ROM since the last assessment on 6/28/2024. During a review of Resident 40's Progress Notes, a late entry Progress Note, dated 10/4/2024 at 11:08 a.m. by the Assistant Director of Rehabilitation (ADOR), the Progress Notes indicated Resident 40 had decreased strength and stability during two-person transfers with the Certified Nursing Assistants (CNAs). The Progress Note indicated the ADOR educated Resident 40 on the benefits and safety with the use of a mechanical lift (device used to lift and/or transfer a person's entire body from one surface to another surface) and/or sit-to-stand mechanical lift (device used to lift a person from a sitting position to a standing position to transfer from one surface to another surface) to reduce risk for fall and/or injury to Resident 40 or staff. During a review of Resident 40's physician order, dated 10/4/2024 at 11:10 a.m. by Physical Therapist 1 (PT 1), the physician order indicated to discontinue Resident 40's RNA to perform sit-to-stand transfers with a FWW, four times per week as tolerated. During a review of Resident 40's Change in Condition (CIC) Evaluation, dated 10/4/2024 at 11:34 a.m. entered by Licensed Vocational Nurse 4 (LVN 4), the CIC Evaluation indicated Resident 40 had a decline with RNA for sit-to-stand transfers. The CIC Evaluation indicated Resident 40 was unable to perform the sit-to-stand transfer and safely put back to bed. The CIC Evaluation indicated Resident 40's family member (FM 1) was notified on 10/4/2024 at 11:53 a.m. The CIC Evaluation also indicated Resident 40's Nurse Practitioner (NP) 1 was notified of the decline in sit-to-stand transfers on 10/4/2024 at 11:34 a.m. The CIC Evaluation indicated NP 1 provided recommendations to continue to monitor and did not provide any new orders. During a review of Resident 40's Progress Notes, a late entry Progress Note, dated 10/4/2024 at 11:35 AM (entered on 10/11/2024 at 1:03 p.m.) by the Assistant Director of Nursing (ADON), the Progress note indicated NP 1 provided a new RNA order to provide Resident 40 with AAROM to both arms and legs, every day, five days per week as tolerated. During a review of Resident 40's physician's order, dated 10/4/2024, the physician's order indicated for RNA to provide AAROM to both arms and legs, every day, five times per week as tolerated. During a review of Resident 40's Interdisciplinary Team ([IDT] group of individuals from different professional disciplines who collaborate to address a shared problem or goal for a resident) Care Plan Review, dated 12/17/2024, the IDT-Care Plan Review was not completed. During a review of Resident 40's quarterly JME, dated 1/1/2025, the JME indicated Resident 40's current intervention indicated RNA for AAROM of both arms and legs, four times per week, and sit-to-stand, four times per week. The JME indicated Resident 40 had moderate ROM limitations in both shoulders for flexion, both shoulders for abduction, and the right fingers. The JME indicated Resident 40 had minimum ROM limitations in the right elbow, the left fingers, both hips, and both knees. The JME indicated Resident 40 had improvement in both hips and a decline in the left shoulder for abduction. The JME indicated for Resident 40 to continue with the RNA program for ROM and monitor (unspecified). During a review of Resident 40's Minimum Data Set ([MDS] a resident assessment tool), dated 2/7/2025, the MDS indicated Resident 40 had clear speech, expressed ideas and wants, understood verbal content, and had intact cognition (clear ability to think, understand, learn, and remember). The MDS indicated Resident 40 had functional ROM limitations (limited ability to move a joint that interferes with daily functioning or places the resident at risk of injury) in one arm and both legs. The MDS indicated Resident 40 required setup or clean-up assistance for eating, substantial/maximal assistance (helper does more than half the effort) for bathing, dressing, rolling to either side in bed, and moving from lying in bed to sitting at the side of the bed, and dependent (helper does all the effort, resident does none of the effort to complete the activity, or the assistance of two or more helpers is required to complete the activity) for chair/bed-to-chair transfers. During an interview on 4/14/2025 at 9:42 a.m., with the Director of Rehabilitation (DOR), the DOR stated the purpose of PT (in general) included returning residents to their prior level of function with therapeutic exercises (movement prescribed to correct impairments and restore muscle function), gait (manner of walking) training, and strengthening. The DOR stated RNA was a maintenance program to maintain a resident's level of mobility which included the provision of ROM exercises, ambulation (the act of walking), and application of splints. The DOR stated maintaining a resident's mobility (in general) provided the resident with dignity (quality of being worthy of honor or respect) and quality of life. During a review of Resident 40's quarterly JME, dated 4/14/2025 at 2:31 p.m., the JME indicated Resident 40's current intervention included RNA for AAROM of both arms and legs, five times per week. The JME indicated Resident 40 had moderate ROM limitations in the right shoulder for flexion, both shoulders for abduction, and the right fingers. The JME indicated Resident 40 had minimum ROM limitations in the left shoulder into flexion, the right elbow, the left fingers, both hips, and both knees. The JME indicated Resident 40 had improvement in left shoulder flexion from moderate limitations to minimum ROM limitations since the last assessment on 1/1/2025. During a concurrent observation and interview on 4/15/2025 at 9:01 a.m. with Resident 40 in the bedroom, Resident 40 was lying awake in bed with the head-of-bed (HOB) elevated and had fluent speech. Resident 40 moved both arms at the shoulder, elbow, and wrist joints without any assistance. Resident 40 stated both hands used to look normal and constantly felt cold. The large knuckles of each finger on Resident 40's right-hand was observed in a bent position and unable to fully straighten. The middle joint of each finger on Resident 40s right-hand were hyperextended (excessive backward bending), which caused the tip joints of each finger to slightly bend. Resident 40 bent the right-hand fingers but was unable to make a full fist. Resident 40 stated both hands were normal until about one year ago when both hands started feeling cold. Resident 40 stated the facility has never provided any splints to the right-hand. Resident 40 was observed with more active movement in the left-hand than the right-hand. Resident 40 moved the left-hand into a fist and extended the fingers. Resident 40's left-hand had minimal ROM limitations when extending the fingers, which included hyperextension of the large knuckles of the index and ring fingers, a slight bend in the middle joints of each finger, and abduction (movement away from the other fingers) of the small finger. Resident 40 stated both hands made him feel handicapped. Resident 40 stated the RNAs performed exercises to both hips, knees, ankles, shoulders, elbows, and hands. A folded-up manual wheelchair was observed on the right side of Resident 40's bed. A FWW was also observed leaning against the wall next to Resident 40's nightstand. Resident 40 stated the facility transferred him to the wheelchair during the weekdays using a sit-to-stand mechanical lift. Resident 40 stated he used to walk with the therapists from the therapy room and down the hallway using the FWW but stated the facility had not attempted to walk with him anymore for over one year. During an observation on 4/15/2025 at 9:54 a.m. with Restorative Nursing Aide 2 (RNA 2), Resident 40's RNA session was observed. Resident 40 was lying awake in bed with the HOB elevated. RNA 2 lowered the HOB to place Resident 40's bed in a flat position. RNA 2 performed ROM exercises to both legs, including hip flexion (bending the leg at the hip joint toward the body) with the knee extended (straight), hip abduction (moving the leg at the hip joint away from the body), hip flexion with knee flexion, and right ankle dorsiflexion (bending the ankle toward the body). RNA 2 performed ROM exercises to Resident 40's right arm, including shoulder flexion, elbow flexion and extension, wrist rotation, thumb extension and flexion, and right-hand flexion. RNA 2 was unable to completely extend Resident 40's right elbow and the right fingers at the large knuckles. RNA 2 performed ROM exercises to Resident 40's left arm, including shoulder flexion, elbow flexion and extension, wrist rotation, and thumb extension and flexion. RNA 2 encouraged Resident 40 to perform active range of motion ([AROM] performance of ROM of a joint without any assistance or effort of another person) of the left hand into complete finger extension and flexion. During an interview on 4/15/2025 at 10:16 a.m., with RNA 2, RNA 2 stated she provided passive range of motion ([PROM] movement of a joint through the ROM with no effort from person) to both of Resident 40's arms and legs and AROM the left hand during the RNA session. RNA 2 stated she used to perform sit-to-stand transfers with Resident 40, but the therapist (unspecified) changed Resident 40's RNA program to ROM since it was unsafe for Resident 40 to perform sit-to-stand. During an interview on 4/15/2025 at 2:27 p.m., with the DOR, the DOR described PROM exercises as ROM provided to residents who did not have the physical ability to perform ROM exercises. The DOR stated AAROM exercises were when the resident can perform the ROM exercises but required assistance to finish or initiate the motion. During a concurrent interview and record review on 4/15/2025 at 3:29 p.m., with the DOR, Resident 40's physician's orders for RNA were reviewed. The DOR stated Resident 40 had a physician's order, dated 1/26/2024 and re-ordered on 4/10/2024, for the RNA to perform sit-to-stand transfers, four times per week. The DOR stated Resident 40's physician's order for RNA to perform sit-to-stand transfers was discontinued on 10/4/2024. The DOR stated the physician's order, dated 10/4/2024, indicated for RNA to provide Resident 40 with AAROM to both arms and legs, five times per week. During an interview and record review on 4/15/2025 at 4:15 p.m., with the DOR, Resident 40's CIC Evaluation, dated 10/4/2024, was reviewed. The DOR stated LVN 4 completed the CIC Evaluation but no longer worked at the facility. The DOR stated the CIC Evaluation indicated Resident 40 had a decline due to the resident's inability to perform sit-to-stand transfers. The DOR stated the CIC Evaluation indicated NP 1 was notified, did not provide any new orders, and continue to monitor Resident 40. The DOR stated Resident 40 did not receive a Rehab Screen (brief assessment to determine if a therapy evaluation was needed) on 10/4/2024. During an interview on 4/16/2025 at 10:57 a.m., with Resident 40, Resident 40 stated the facility did not inform him when they stopped RNA for sit-to-stand transfers. Resident 40 did not recall performing sit-to-stand transfers with the RNAs that often. Resident 40 stated he did not ask any questions and went along with the RNA program. Resident 40 stated there was one occurrence (unspecified date) when the RNAs thought the resident was going to fall. Resident 40 stated PT 1, who did not work at the facility anymore, observed the RNAs assist the resident with the sit-to-stand transfer, told Resident 40 that he was not strong enough to do the transfer, and told Resident 40 the sit-to-stand mechanical lift would be used for transfers. Resident 40 stated he did not discuss stopping RNA for sit-to-stand transfers with NP 1 and did not receive any additional therapy to maintain his ability to stand. During a telephone interview on 4/16/2025 at 11:19 a.m., with FM 1, FM 1 stated Resident 40's right-hand had limited motion for at least one year. FM 1 stated Resident 40 was left-handed and constantly felt cold in both hands. FM 1 stated Resident 40 used the left-hand more often and kept the right-hand clenched in a fist under the blanket. FM 1 was aware that the facility stopped physically transferring Resident 40 to the wheelchair and used the sit-to-stand mechanical lift for transfers. FM 1 stated she was not aware the facility stopped the RNA program for Resident 40 to perform sit-to-stand transfers. During an interview on 4/16/2025 at 12:49 p.m., with RNA 2, RNA 2 stated Resident 40 used to require two-person assistance during RNA for sit-to-stand transfers. RNA 2 stated Resident 40's ability to maintain his standing balance would vary. RNA 2 stated Resident 40's inability to stand during RNA sessions was reported to the charge nurse (unable to recall which nurse) and the DOR. RNA 2 stated either PT 1 (no longer worked at the facility) or Occupational Therapist 1 ([OT] professional aimed to increase or maintain a person's capability of participating in everyday life activities [occupations]) changed Resident 40's RNA program to discontinue sit-to-stand transfers. During an observation on 4/16/2025 at 1:25 p.m., with Certified Nursing Assistant 4 (CNA 4) and RNA 2 in Resident 40's room, Resident 40's transfer from the bed to the wheelchair using the sit-to-stand mechanical lift was observed. RNA 2 stood on the right side of the bed while CNA 4 stood on the left side of the bed. Both CNA 4 and RNA 2 assisted Resident 40 from lying in bed to sitting on the right side of the bed. RNA 2 and CNA 4 placed and fastened a cloth sling around Resident 40's waist. Cloth loops were sewn onto the cloth sling. RNA 2 fastened the loop to a right-sided hook on the sit-to-stand mechanical lift and then attached another loop to a left-sided hook on the sit-to-stand mechanical lift. RNA 2 used a controller to lift Resident 40 from a seated position at the edge of the bed to a standing position. Resident 40's knees were extended but Resident 40 did not stand upright. Both of Resident 40's hips were bent and positioned behind Resident 40's torso (main part of the body comprised of the chest, abdomen, pelvis, and back) and legs. RNA 2 turned the sit-to-stand mechanical lift toward Resident 40's wheelchair. CNA 4 secured Resident 40's wheelchair as RNA 2 lowered Resident 40 into a seated position. During an interview on 4/16/2025 at 1:47 p.m., with Occupational Therapist 2 (OT 2), OT 2 stated ROM loss could be prevented with ROM exercises and application of splints. OT 2 stated splints prevented the development of contractures (a stiffening/shortening at any joint that reduces the joint's range of motion) and prevented further contractures if a resident already had contractures. During an observation and interview on 4/16/2025 at 2:04 p.m., with OT 2, Resident 40's hands were observed while Resident 40 sat in the wheelchair. OT 2 stated the large knuckles of Resident 40's right-hand were in a bent position to approximately 60 degrees (normal 0-90 degrees), the middle joints of each finger were hyperextended, and the tip joints of each finger were bent. OT 2 asked Resident 40 to make a fist with the right-hand. OT 2 stated Resident 40's right-hand fingers slightly bent with the thumb having the most motion. OT 2 asked Resident 40 to move the left-hand into a fist and to touch the thumb to the tip of each finger. OT 2 stated Resident 40's left-hand motion was within functional limits (sufficient joint movement without significant limitation). During an interview on 4/16/2025 at 2:12 p.m., with OT 2, OT 2 stated Resident 40's right hand was not normal due to significant limitation in the large knuckles and hyperextension of the middle joints. OT 2 stated Resident 40 would benefit from a splint to prevent further contractures in the right hand. During a telephone interview on 4/16/2025 at 4:06 p.m., with Resident 40's physician (MD 1), MD 1 stated he would try to determine the reason for a resident's decline (in general) to perform sit-to-stand transfers with RNA and usually recommended additional therapy to improve mobility after a discussion with the resident if the facility notified MD 1 of a decline. MD 1 stated he would absolutely recommend additional therapy for Resident 40 if Resident 40 experienced a decline in the ability to perform sit-to-stand transfers with RNA. MD 1 stated the therapists usually contacted MD 1 directly for additional therapy orders but did not contact MD 1 regarding Resident 40. MD 1 stated NP 1 usually assessed the residents at the facility. During an interview on 4/17/2025 at 10:06 a.m., with Resident 40, Resident 40 stated he felt frustrated that he could not stand anymore. Resident 40 stated he did not have a choice and would find a way to stand by himself even if it was not safe. During an interview on 4/17/2025 at 10:18 a.m., with the Director of Nursing (DON) and the DOR, the DON stated the DON, and the Director of Staff Development (DSD) oversaw the RNA program. The DON stated the RNA program maintained a resident's mobility after a resident's discharge from therapy services. The DOR stated maintaining a resident's mobility (in general) was important to a resident's quality of life. The DOR stated the facility needed to perform an assessment if a resident experienced a decline in mobility while on RNA to determine the reason for the decline. The DON stated the assessment of a resident's decline would include an interview with the resident, an interview with the RNA, and a discussion during the IDT meeting to determine if there was a true decline. During an interview and record review on 4/17/2025 at 10:42 a.m., with the DON, ADON, and DOR, Resident 40's discontinued physician's order for RNA to perform sit-to-stand, dated 10/4/2024, CIC Evaluation, dated 10/4/2024, physician order for RNA to perform AAROM to both arms and legs, dated 10/4/2024, physician (MD) progress notes from 10/2024, and nurse practitioner (NP) progress notes from 10/2024 and 11/5/2024, were reviewed. The ADON stated Resident 40's decline in performing sit-to-stand transfers with RNA was reported to LVN 4, who no longer worked at the facility. The ADON stated NP 1 was notified of Resident 40's decline with RNA and NP 1 recommended to monitor Resident 40. The DON reviewed Resident 40's discontinued physician order for RNA and stated PT 1 discontinued the RNA order for sit-to-stand in the electronic medical record. The ADON stated she spoke to NP 1 in-person on 10/4/2024 (unspecified time) and the conversation with NP 1 was documented on 10/11/2024 as a late entry. The ADON stated NP 1 recommended to discontinue Resident 40's RNA for sit-to-stand transfers after NP 1 spoke with Resident 40. The ADON stated NP 1 recommended for Resident 40 to receive RNA for AAROM to both arms and legs. The ADON reviewed Resident 40's NP progress notes, including all of NP 1's progress notes, and did not locate any documentation from 10/2024 regarding Resident 40's decline with sit-to-stand transfers. The ADON reviewed Resident 40's NP 1's progress note, dated 11/5/2024, which did not include Resident 40's decline with RNA for sit-to-stand transfers. The ADON reviewed Resident 40's MD progress notes and did not locate any documentation from 10/2024 regarding Resident 40's decline with sit-to-stand transfers. During an interview and record review on 4/17/2025 at 11:05 a.m., with the DON and the DOR, Resident 40's Rehab Screen documentation was reviewed. The DOR stated Resident 40 experienced a decline in mobility since the RNA program was changed from sit-to-stand transfers to AAROM to both arms and legs. The DOR stated Resident 40 did not receive a Rehab Screen when the decline in mobility was identified on 10/4/2024. The DON stated the facility did not provide any intervention after Resident 40's decline on 10/4/2024 to maintain Resident 40's ability to perform sit-to-stand transfers. During an interview and record review on 4/17/2025 at 11:18 a.m., with the DON and the DOR, Resident 40's IDT meeting notes, including the IDT-Care Plan Review dated 12/17/2024, were reviewed. The DON stated there was no documentation the IDT discussed Resident 40's decline in mobility when the decline was identified on 10/4/2024. The DON stated Resident 40's IDT-Care Plan Review, dated 12/17/2024, was not completed. During an interview on 4/17/2025 at 11:39 a.m., with the DON, the DON stated PT 1 discontinued Resident 40's RNA order for sit-to-stand transfer (on 10/4/2024). The DON stated the PT would be the best person to maintain Resident 40's mobility. During an interview on 4/17/2025 at 11:59 a.m., with the DON and the DOR, the facility's P&P for Quality of Care titled, ROM and Contracture Prevention, was reviewed which indicated the facility ensured residents received services, care and equipment to maintain and/or improve their highest level of ROM and mobility unless a reduction is clinical unavoidable. The DON stated Resident 40's highest practicable level of mobility was to perform sit-to-stand. The DON declined to answer the question regarding whether Resident 40's decline in mobility was preventable. During a concurrent observation and interview on 4/17/2025 at 1:07 p.m. with RNA 2 and the DOR, Resident 40 sat in the wheelchair while RNA 2 wheeled Resident 40 into the hallway facing the hallway's siderail. The DOR placed a vinyl gait belt (assistive device placed around a person's waist to assist with safe transferring between surfaces or while walking) around Resident 40's waist. The DOR was standing on the left side of Resident 40 while RNA 2 was on the right side. Resident 40 extended both arms and grabbed the hallway siderail as the DOR and RNA 2 physically assisted Resident 40 upward toward standing. Resident 40's hips were bent and positioned behind Resident 40's torso and legs in a squatting position. The DOR attempted to physically push both of Resident 40's hips upward and forward but Resident 40 did not stand upright. The DOR and RNA 2 assisted Resident 40 back to sitting in the wheelchair and appeared physically tired. The DOR and RNA 2 stated Resident 40 required complete physical assistance to attempt to stand. RNA 2 stated Resident 40 used to stand before with maximum assistance of two-persons. Resident 40 stated, That's the perfect word, 'before,' because I have not stood in a while. During a telephone interview on 4/17/2025 at 1:57 p.m. with NP 1, NP 1 stated she did not recall the facility reporting Resident 40's inability to perform sit-to-stand with RNA. NP 1 stated the facility would typically request a therapy evaluation if a resident (in general) had decline in mobility. NP 1 stated a therapy evaluation would have been approved if the facility requested it for Resident 40's decline in ability to perform sit-to-stand. During a concurrent interview and record review with Restorative Nursing Aide 1 (RNA 1) and RNA 2 on 4/17/2025 at 2:20 p.m., Resident 40's RNA Weekly Progress Reports from 5/2024 to 10/2024 were reviewed. RNA 2 stated Resident 40 used to require full physical assistance to perform sit-to-stand, stood upright, and required physical assistance to maintain the standing position. RNA 1 stated Resident 40's ability to perform sit-to-stand changed every session. RNA 1 reviewed Resident 40's RNA Weekly Progress Report, dated 5/2/2024, which indicated Resident 40 stood for 20-35 seconds. RNA 1 stated Resident 40 stood upright for 20-35 seconds with full physical assistance from both RNAs. RNA 1 reviewed Resident 40's RNA Weekly Progress Report, dated 5/9/2024, which indicated Resident 40 stood for 10 seconds with good balance. RNA 1 stated Resident 40 had good balance because he stood more upright than usual and did not need as much assistance from RNAs. RNA 1 reviewed Resident 40's RNA Weekly Progress Report, dated 5/16/2024, and stated Resident 40 required two-person assistance for the sit-to-stand transfer and assistance to maintain standing for 30-60 seconds. Both RNA 1 and RNA 2 reviewed Resident 40's RNA Weekly Progress Reports from 6/2024 to 9/2024 and stated Resident 40 required two-person assistance to perform sit-to-stand transfers and to maintain standing. RNA 1 stated Resident 40 was unable to stand fully on 10/4/2024 which was reported to the charge nurse, the DOR, and the PT (unspecified). RNA 1 and RNA 2 stated the therapists would usually do a screen and determined the next steps. b. During a review of Resident 4's admission Record (AR), the AR indicated Resident 4 was admitted on [DATE] with diagnoses including vascular dementia (impaired supply of blood to the brain causing progressive state of decline in mental abilities), dysphagia (difficulty swallowing), and difficulty in walking. During a review of Resident 4's Annual Nurse Practitioner (NP) Pr[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility's nursing staff failed to ensure one of four sampled residents (Resident 1), who required an extensive two-person physical assist during toileting, was supervised while in the bathroom. CNA 2 left Resident 1 alone in the bathroom while she attended to another resident. Resident 1 became frustrated when no one came to his assistance, attempted to leave the bathroom, and fell from the shower chair As a result of Resident 1 falling from the shower chair he hit the floor causing pain to his back, right hip, and right leg. Resident 1 was transferred to a General Acute Care Hospital (GACH) where he was diagnosed with a fracture of the vertebrae (a series of small bones that form the backbone). 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 diagnoses of cerebral infarction (stroke), hemiplegia (paralysis to one side of the body), hemiparesis (a slight paralysis or weakness on one side of the body), diabetes mellitus ([DM] a chronic condition associated with abnormally high levels of sugar in the blood) and hypertension ([HTN] high blood pressure). During a review of Resident 1's Minimum Data Set ([MDS] a standardized assessment and care screening tool), dated 9/14/2022, the MDS indicated Resident 1 was able to make independent decisions that were reasonable and consistent and Resident 1 required an extensive two-person physical assist to complete his activities of daily living ([ADLs] task such as eating, bathing, dressing, grooming and toileting). The MDS indicated Resident 1 was not steady when moving from a seated to standing position, moving on and off the toilet, surface to surface transfers, and could only stabilize with staff assistance. During a review of Resident 1's Fall Risk Evaluation (FRE) dated 9/14/2023, the FRE indicated Resident 1 was a medium risk for falls due to balance problems while walking and/or standing, use of psychotropic (drug that affect a person's mental state) medication, use of hypoglycemics (drugs that lowers blood sugar levels) and use of antihypertensive (drugs that lowers the blood pressure) medications. During a review of Resident 1's Care Plan (CP), dated 12/14/2022, the CP indicated Resident 1 has actual self-care performance deficits related to his disease process. The CP's goal was for Resident 1 to be supervised and assisted during his ADLs. The CP's interventions indicated Resident 1 required extensive assistance to transfer onto and off of the toilet with one to two staff support. During a review of Resident 1's CP, dated 12/14/2022, the CP indicated Resident 1 had impaired physical functioning, impulsive behavior, and poor safety awareness. The CPs goal indicated Resident 1 was to have minimal injury and/or would not sustain serious injury. The CP's interventions indicated to provide a safe environment and reminders to Resident 1 of safety precautions. During a review of Resident 1's Situation Background Assessment Recommendation ([SBAR] a tool and a guide to communicate a patient's information with other healthcare professionals) dated 10/7/2022 and timed at 4:40 p.m., the SBAR indicated Resident 1 was heard screaming for help at 3:45 p.m., (10/7/2023) and found sitting on the floor by the bathroom door after scooting in the bathroom chair and was in no pain and discomfort. During a review of Resident 1's Diagnostic Result (DR) dated 10/13/2023 and timed at 5:16 p.m., the DR indicated Resident 1's x-ray of his right femur (hipbone) and the right femur (thigh bone) were negative for a fracture (break in the bone) or dislocation (bones pushed out of their proper place). During a review of Resident 1's Progress Notes (PN) dated 10/21/2022 and timed at 2:32 p.m., by the Nurse Practitioner, the PN indicated Resident 1 had no initial injury from Resident 1's fall on 10/7/2022 but began complaining of right lower extremity/hip pain during mobility with physical therapy (PT). Due to continued complaints of pain an order was placed for an urgent CT ([computed tomography] a computerized x-ray in which a narrow beam of x-rays is aimed at ta patient and quickly rotated around the body) of the pelvis and right femur to rule of fracture. During a review of Resident 1's Physician's Order (PO), dated 10/21/2022, the PO indicated to transfer Resident 1 to a GACH's emergency room (ER) on 10/22/2022 for CT of the right hip and the right femur. During a review of Resident 1's Nurse Progress Notes (NPN) dated 10/22/2022 and timed at 4:32 p.m., the NPN indicated Resident 1 was transferred to the hospital for computerized scanning of the right hip and the right leg. During a review of the GACH Face Sheet, dated 10/22/2022, the Face Sheet indicated Resident 1 was admitted to the GACH on 10/22/2023 at 7:54 p.m. During a review of the GACH's CT scan dated 10/23/2022 and timed at 1:37 a.m., the CT scan indicated Resident 1 had an acute comminuted fracture (bone broken in two places) anterior column (directed forward) of the 4th lumbar spine with 15% loss of vertebral (backbone) height with no retropulsion (no displacement of bone into the spinal canal [a bony channel located in the vertebral column that protects the spinal cord and nerve roots]). During a review of GACH's Neurosurgery (surgery performed on the nervous system, especially the brain and spinal cord) Consult (NC) dated 10/25/2022 and timed at 6:10 p.m., the NC indicated an order for Resident 1 to wear a brace used to limit motion in the thoracic, lumbar (relating to the lower part of the back) and sacral (tailbone) regions of the spine) and an order for a lumbar MRI ([magnetic resonance imaging] a procedure that uses radio waves and a computer to make a series of detailed pictures of areas inside the body). During an observation and interview on 5/19/2023 at 11:51 a.m., Resident 1 was sitting in his bed and observed with a contracted (tightening of the muscles causing stiffness) right knee. Resident 1 stated his right leg felt stiffer since he fell, and he was frustrated because it was hard for him to sit up in his wheelchair and roll himself around the facility like he did before he fell. Resident 1 stated, CNA 2 helped him to the bathroom but left him there alone and said she would be back. Resident 1 stated he finished using the toilet and put on the call light, but CNA 2 did not come back right away (unknown amount of time). Resident 1 stated the shower chair he was sitting on was uncomfortable and he needed to be cleaned so he tried to leave the bathroom to find CNA 2. Resident 1 stated he tipped over out of the shower chair onto the floor and hit his bottom, back and maybe his right leg and right hip on the floor. During a telephone interview on 10/28/2022 at 7:38 a.m., with Resident 1's Responsible Party (RP), the RP stated Resident 1 was in the GACH and told him that he (Resident 1) was having extreme pain in his back. The RP stated he was concerned that Resident 1 wasn't being supervised and assisted by the nursing staff in the facility while he was using the toilet. The RP stated Resident 1 was alert but was unsteady on his feet and could be forgetful and impatient and required constant supervision. During a telephone interview on 10/26/2022 at 1:22 p.m., with CNA 2, CNA 2 stated Resident 1 needed maximum assist by 1 person when using the toilet. CNA 2 stated Resident 1 understood the need to use the call light although she observed Resident 1 was being more impatient and more frustrated with the nurses lately. CNA 2 stated she assisted Resident 1 to the bathroom and left him to go assist another resident in another room. CNA 2 stated when she was on her way back to assist Resident 1 in the bathroom, she heard Resident 1 scream, heard a sound of commotion (disturbing noise) and when she entered Resident 1's room, she found him sitting on the floor outside the bathroom. CNA 2 stated Resident 1 was freaking out (losing emotional control because of extreme shock and fear) and yelling for help. During an interview on 10/26/2022 at 11:23 a.m., with Restorative Nursing Assistant (RNA) 1, RNA 1 stated Resident 1 was alert and coherent but was impatient and the staff should not leave Resident 1 alone in the bathroom because Resident 1 may try to do things beyond his capacity. During an interview and a concurrent record review on 10/26/2022 at 11:32 a.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 stated Resident 1 required maximum assistance with ADL care. Prior to his fall, he could move in his bed using his left extremities (left arm and leg) however, after Resident 1 fell he mostly wanted to stay in bed, probably because of pain. During an interview on 10/26/2022 at 3:43 p.m., with Registered Nurse Supervisor (RNS) 2, RNS 2 stated Resident 1 required maximum assistance with 1 to 2 persons during ADL care and Resident 1 needed supervision and assistance while using the toilet and routine personal hygiene to always ensure Resident 1's safety. During an interview on 5/19/2023 at 12:25 p.m., with RNS 1, RNS 1 stated Resident 1 was readmitted at the facility on 10/30/2022 with an order to wear a back brace when he was out of bed. RNS 1 stated all nursing assistants were reminded during huddle at the start of the shift to ensure safety precautions for all residents, and it was a basic rule for all nurses to never leave a resident alone in the bathroom because the resident might forget to call for help, try to get up unassisted, perform tasks beyond their capabilities and end up falling and hurting themselves. During an interview on 5/19/2023 at 1:15 p.m., with the Administrator (ADM), the ADM stated there was no policy related to resident Supervision and/or accident prevention. During an interview on 5/19/2023 at 1:27 p.m., with the Director of Nursing Services (DNS), the DNS stated CNA 2 should not have left Resident 1 in the bathroom alone because of safety reasons. During a review of the facility's Policy and Procedure titled Quality of Care- ADL, Services to carry out, revised 11/2007, the P/P indicated the facility provides the appropriate treatment and services to the residents to maintain and improve their abilities and this includes but not limited to grooming and personal hygiene.