**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one of eight sampled residents (Resident 60) received appropriate services, did not acquire a decline (reduction) in range of motion (ROM, full movement potential of a joint) and did not develop a contracture (chronic loss of joint motion associated with deformity and joint stiffness) to both hands and both wrists. The facility failed to: 1. Provide appropriate monitoring of Resident 60's ROM on a quarterly basis to determine any changes in ROM in accordance with the facility's policy titled Joint Mobility Assessment, ([JMS] a brief assessment of a resident's ROM in both arms and both legs) which indicated, all residents shall be assessed for joint mobility limitations upon admission and reviewed every three months thereafter. 2. Ensure Restorative Nursing Assistant ([RNA 1] certified nursing aide program that helps residents to maintain their function and joint mobility) reported Resident 60's decline in ROM during restorative program ( nursing interventions that promote the resident's ability to adapt and adjust to living as independently and safely as possible ) sessions to the charge nurse (a licensed nurses in charge) in accordance with the facility's job description titled, Restorative Nursing Assistant. 3. Provide Resident 60 with passive range of motion ([PROM] a movement of a joint through the ROM with no effort from resident) exercises to both arms daily from March 2023 to October 2023 per physician's order and in accordance with the Occupational Therapy ([OT], profession that provides services to increase and/or maintain a person's capability to participate in everyday life activities) discharge recommendation made on 3/3/2023. 4. Ensure RNA 1 did not modify Resident 60's splints (rigid material or apparatus used to support and immobilize a broken bone or impaired joint) to both hands without notifying OT. These deficient practices resulted in Resident 60 developing contractures to both hands and both wrists, causing pain and placing Resident 60 at risk for physical, emotional, and psychosocial decline. Resident 60 was placed at risk to have a decline in ROM, improper fitting splints, ineffective interventions to maintain ROM, pain, and skin breakdown. Findings: During a review of Resident 60's admission Record, the admission Record indicated Resident 60 was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses including chronic respiratory failure (any condition that affects breathing function and result in lungs not functioning properly) and traumatic brain injury (damage to the brain from an external force that can cause temporary or permanent changes in brain function). During a review of Resident 60's OT's Joint Mobility Screening ([OT JMS, a brief joint mobility assessment of a resident's ROM in both arms and both legs completed by an OT), dated 1/5/2023, the OT JMS indicated Resident 60 had full PROM in both wrists, hands, fingers, and elbows and had moderate (26-50 percent [%] ROM loss) ROM limitations in both shoulders. During a review of Resident 60's OT's Evaluation and Plan of Treatment (OT Eval), dated 1/8/2023, the OT Eval indicated Resident 60's ROM in both elbows, forearms, wrists, and hands were within functional limits ([WFL]a sufficient movement without limitation). The OT Eval indicated Resident 60 had no contractures in both arms and was at risk for contracture development. During review of OT's Discharge summary dated [DATE], the OT's Discharge Summary indicated the OT recommended for Resident 60 to have RNA to provide PROM exercises to both arms and apply splints to both elbows, four to six hours daily or as tolerated. During a review of Resident 60's Order Summary Report, the Order Summary Report indicated a physician's order, dated 3/3/2023, for RNA to provide PROM exercises to Resident 60's both arms and both legs and apply splints to both elbows, four to six hours daily or as tolerated. During a review of Resident 60's RNA Survey Report (record of nursing assistant tasks) for March 2023, the RNA Survey Report indicated for the RNA to provide the resident with PROM exercises to both arms and both legs and apply splints to both elbows for four to six hours, daily or as tolerated. The squares on the RNA Survey Report had the letter X (resident was not seen for RNA treatment that day) on the following days: 3/4/2023, 3/5/2023, 3/11/2023, 3/12/2023, 3/18/2023, 3/19/2023, 3/25/2023, and 3/26/2023. During a review of Resident 60's RNA Survey Report for April 2023, the RNA Survey Report indicated for the RNA to provide the resident with PROM exercises to both arms and both legs and apply splints to both elbows for four to six hours, daily or as tolerated. The squares on the RNA Survey Report had the letter X on the following days: 4/1/2023, 4/2/2023, 4/8/2023, 4/9/2023, 4/15/2023, 4/16/2023, 4/22/2023, 4/23/2023, 4/29/2023, and 4/30/2023. During a review of Resident 60's RNA Survey Report for May 2023, the RNA Survey Report indicated for the RNA to provide the resident with PROM exercises to both arms and both legs and apply splints to both elbows for four to six hours, daily or as tolerated. The squares on the RNA Survey Report had the letter X on the following days: 5/6/2023, 5/7/2023, 5/13/2023, 5/14/2023, 5/20/2023, 5/21/2023, 5/27/2023, 5/28/2023. During a review of Resident 60's RNA Survey Report for June 2023, the RNA Survey Report indicated for the RNA to provide the resident with PROM exercises to both arms and both legs and apply splints to both elbows for four to six hours, daily or as tolerated. The squares on the RNA Survey Report had the letter X on the following days: 6/3/2023, 6/4/2023, 6/10/2023, 6/11/2023, 6/17/2023, 6/18/2023, 6/24/2023, and 6/25/2023. During a review of Resident 60's RNA Documentation Survey Report for July 2023, the RNA Survey Report indicated for the RNA to provide the resident with PROM exercises to both arms and both legs and apply splints to both elbows for four to six hours, daily or as tolerated. The squares on the RNA Survey Report had the letter X on the following days: 7/1/2023, 7/2/2023, 7/8/2023, 7/9/2023, 7/15/2023, 7/16/2023, 7/22/2023, 7/23/2023, 7/29/2023, and 7/30/2023. During a review of Resident 60's RNA Survey Report for August 2023, the RNA Survey Report indicated for the RNA to provide the resident with PROM exercises to both arms and both legs and apply splints to both elbows for four to six hours, daily or as tolerated. The squares on the RNA Survey Report had the letter X on the following days: 8/5/2023, 8/6/2023, 8/12/2023, 8/13/2023, 8/19/2023, 8/20/2023, 8/26/2023, and 8/27/2023. During a review of Resident 60's RNA Survey Report for September 2023, the RNA Survey Report indicated for the RNA to provide the resident with PROM exercises to both arms and both legs and apply splints to both elbows for four to six hours, daily or as tolerated. The squares on the RNA Survey Report had the letter X on the following days: 9/2/2023, 9/3/2023, 9/9/2023, 9/10/2023, 9/16/2023, 9/17/2023, 9/23/2023, 9/24/2023, and 9/30/2023. During a review of Resident 60's RNA Survey Report for October 2023, the RNA Survey Report indicated for the RNA to provide the resident with PROM exercises to both arms and both legs and apply splints to both elbows for four to six hours, daily or as tolerated. The square on the RNA Survey Report was blank on 10/2/2023. The squares on the RNA Survey Report had the letter X on the following days: 10/1/2023, 10/7/2023, 10/8/2023, 10/14/2023, 10/15/2023, 10/21/2023, 10/22/2023, 10/28/2023, and 10/29/2023. During a review of Resident 60's Minimum Data Set ([MDS], a standardized assessment and care-screening tool), dated 7/11/2024, the MDS indicated Resident 60 had moderately impaired cognitive (ability to think, understand, learn, and remember) skills for daily decision making. The MDS indicated Resident 60 was dependent (full staff performance) on staff with eating, oral hygiene, toilet hygiene, bathing, dressing, rolling to both sides, and transfers (moving from one surface to another). The MDS indicated Resident 60 had functional ROM limitations (limited ability to move a joint that interferes with daily functioning, including activities of daily living, or places the resident at risk of injury) in both arms and both legs. During a review of Resident 60's Annual OT JMS, dated 1/28/2024, the OT JMS indicated Resident 60 had severe (greater than 50 % ROM loss) ROM limitations in both wrists, both hands, both fingers, and both shoulders. The OT JMS indicated Resident 60 had minimal (less than 25% ROM loss) ROM limitations in both elbows. The OT JMS indicated Resident 60 had a minimal to severe loss of PROM to both arms and recommended a skilled OT evaluation. During a review of Resident 60's OT Eval, dated 1/30/2024, the OT Eval indicated Resident 60 was referred to OT services due to a decline in ROM and strength of both arms. The OT Eval indicated Resident 60 had contractures in both arms which affected Resident 60's functional skills (basic or everyday skills necessary for daily living) and required skilled therapy (services that require specialized training and experience of a licensed therapist or therapy assistant) to address the contractures. The OT Eval indicated Resident 60's ROM in the right arm was impaired at the shoulder, elbow, forearm, wrist, and hand. The OT Eval indicated Resident 60 had a right claw hand contracture (condition of the hand where the fingers of the hand are in a hyperextended position [the extension of a body part beyond it's normal limits] at the knuckle joints and bent at the fingertips) and had zero degrees of PROM (normal is 70 to 90 degrees ROM) at the right wrist in an upward position. The OT Eval indicated Resident 60's ROM in the left arm was impaired at the shoulder, wrist, and hand. The OT Eval indicated Resident 60 was unable to straighten the fingers of the left hand and indicated a two-inch gap between the fingertips of the left hand and crease in the palm of the hand. The OT Eval indicated Resident 60 had zero degrees of PROM at the left wrist into an upward position. The OT Eval indicated OT recommended Resident 60 wear splints to both hands. During a concurrent observation and interview on 8/20/2024 at 10:43 a.m., in Resident 60's room, Resident 60 was lying in bed. Resident 60's right arm was held out in front of her body at shoulder level with the elbow bent, wrist fully bent in a downward position, and fingers of the hand in a hyperextended (the extension of a body part beyond it's normal limits) position at the knuckles with the fingertips bent. Resident 60's left arm moved upwards to shoulder height, the elbow was slightly bent, and the hand was partially closed with the fingers bent at the knuckles and the fingertips. Resident 60 was observed shouting and asking for staff to assist in wrapping her right arm in a towel. Resident 60 stated she wanted her right arm wrapped in a towel because her arm was in pain, liked the warmth the towel provided to help with the pain, and needed the towel wrapped around the right forearm so she could use it to wipe her mouth since her both hands does not work. Licensed Vocational Nurse (LVN 5) was observed entering the room and wrapping Resident 60's right arm with a towel. LVN 5 stated Resident 60 constantly asked for her right arm to be wrapped in a towel and was unsure why. LVN 5 stated she thought Resident 60 liked her arm wrapped because the right arm was painful, and it helped her wipe her mouth since she could not bring her forearm to her mouth. LVN 5 stated Resident 60 was unable to use both hands for activities of daily living (ADLs, basic activities such as eating, bathing, and dressing) because they were contracted and required total care for mobility and ADLs. During an interview with RNA 1 on 8/20/2024 at 12:59 p.m., RNA 1 stated the Director of Nursing (DON), all available RNAs, and the Director of Rehabilitation (DOR) met monthly to discuss any concerns with residents receiving RNA services, including if any resident experienced a decline in ROM or mobility. RNA 1 stated any concerns or declines observed during RNA sessions should be immediately reported to charge nurse and the Rehabilitation Department (Rehab) for re-assessment. During an interview with the DOR on 8/20/2024 at 1:49 p.m., the DOR stated the facility monitored residents for changes and declines in ROM by JMS conducted upon admission and quarterly by the rehab department and quarterly by the MDS nurses along with report from staff of any observed changes or declines. The DOR stated the DOR, RNAs, Director of Staff Development (DSD), and the DON met monthly to discuss any concerns (in general) with residents receiving RNA services, including any declines, changes, or problems requiring re-assessment or intervention. During an observation of RNA session with Resident 60 in Resident 60's room on 8/21/2024 at 10:53 a.m., the resident was lying in bed with her right arm wrapped in a towel covering the hand, wrist, forearm, elbow, and lower half of the upper arm. Resident 60's right arm was held out in front of her body with the right elbow bent and the wrist bent downwards. Resident 60's left arm was resting at the side of her body with the elbow slightly bent, the wrist straight, and the fingers of the hand bent into a fist position. RNA 1 was observed attempted to assist Resident 60 with PROM exercises to the right arm, but Resident 60 reported increased pain and refused exercises. RNA 1 moved to the left side of the bed and provided PROM exercises to Resident 60's left shoulder, elbow, wrist, and hand. RNA 1 was unable to straighten all of Resident 60's fingers on the left hand and moved the left wrist in small motions side to side. Resident 60 stated she had pain with PROM exercises to the left wrist and hand with exercises. RNA 1 was observed attempted to place a hand splint (splint secured from the hand to the forearm to position the hand and wrist in a functional position) onto Resident 60's left arm but Resident 60 refused and stated the splint hurt. RNA 1 observed to bend the left-hand splint at the wrist and removed a cylindrical portion of the splint that supported the fingers of the hand. Resident 60 agreed to wear left hand splint after it was modified by RNA 1. RNA 1 placed the modified hand splint on Resident 60's left arm by securing the splint with straps around the wrist and forearm. The left-hand splint was observed not straightening or supporting the fingers of the hand. RNA 1 observed moved to the right side of the bed and tried to place a hand splint on Resident 60's right arm. Resident 60 refused and stated she wanted the cylindrical piece of the splint that supported the fingers removed because it hurt her hand. RNA 1 removed the cylindrical piece of the right-hand splint and placed it onto Resident 60's right arm by securing the splint with straps around the wrist and forearm. Observed the right-hand splint not straightening or supporting the fingers of the right hand. During an interview on 8/21/2024 at 11:15 a.m. RNA 1 stated Resident 60 had been occasionally complaining of pain in both hands and wrists during exercises and when trying to place splints on both hands for a long time but did not recall when it started. RNA 1 stated he modified both hand splints by bending the wrist portion of the left-hand splint and removing the cylindrical portion of both splints that stretched the fingers because Resident 60 was unable to tolerate the stretch the splints provided due to tightness and pain in both hands and wrists. RNA 1 stated he had been providing exercises to Resident 60's both arms since last year and noticed both hands and wrists were intermittently (irregular intervals) getting tighter and more painful with exercises. RNA 1 stated he did not report the changes in Resident 60's ROM to a charge nurse. RNA 1 stated he should have informed the charge nurse and DOR and should have discussed the decline in Resident 60's ROM of both hands and both wrists in the RNA monthly meetings but did not. RNA 1 stated he thought he told the DOR at some point but was unsure and stated he had no documented evidence to indicate the charge nurse or DOR was informed of Resident 60's ROM changes. RNA 1 stated he should not have modified the splints without notifying the DOR. RNA 1 stated he should have stopped trying to put the splints on Resident 60's both hands when they did not fit properly and Resident 60 complained of pain, notified the Rehab Department (Rehab), and waited for the OT to reassess the resident to check for any changes and modify the splints if needed. RNA 1 stated if RNAs modified splints without notifying the licensed therapist (OT), the resident could potentially be harmed since RNAs did not have the proper training and qualifications to modify splints and determine the type of splint a resident need. During an interview on 8/21/2024 at 11:50 a.m., the DOR who, was an OT, confirmed OT fitted and issued a hand-splints to Resident 60. The DOR stated the purpose of splints was for contracture management and to increase ROM. The DOR stated Rehab issued splints to residents in the facility. The DOR stated the licensed therapist assessed the resident to determine the appropriate type of splint, set goals to determine if a resident tolerated the splint, established the splint wear schedule (length of time and frequency a person can tolerate wearing the splint for safety, comfort, and maximal benefits), and eventually transitioned the resident to the RNA program. The DOR stated if the splints prescribed by the therapist were no longer fitting appropriately or no longer tolerated by the resident due to issues such as pain, the RNA should inform Rehab department, and charge nurse for OT to re-assess the resident splint. The DOR stated licensed therapists were the only staff members who should modify splints. The DOR stated she was unaware Resident 60 had a decline in ROM in both wrists and hands and was not informed by RNA Resident 60's hand splints were not fitting appropriately. The DOR stated if RNAs modified splints without notifying Rehab, the splint may not fit appropriately, and the splinting intervention may not be effective. During an interview on 8/21/2024 at 12:04 p.m. the Director of Staff Development (DSD) stated the facility monitor residents for changes in ROM by the JMS's conducted by Rehab and nursing, communication with the RNAs in the monthly RNA meetings, and reports from any staff of any noticeable changes or declines in function. The DSD stated RNAs must notify the charge nurse of any changes in a resident's function such as increased pain, decrease in ROM, or if a splint was not fitting correctly to ensure the proper protocol was followed to ensure the resident received the appropriate treatment. The DSD stated RNAs were not allowed to modify splints because RNAs did not have the qualifications or training to determine the type of splint the residents needed. The DSD stated if a splint was not fitting correctly, it could indicate an area of concern that may require re-assessment. The DSD stated if RNAs modified splints without notifying Rehab department, it could cause skin breakdown and decline in ROM leading to further contracture development. The DSD stated once the charge nurse was notified, the charge nurse will complete a Change of Condition ([COC] a major decline or improvement in a resident's status that will not resolve itself without intervention) evaluation and notify the physician and licensed therapist for re-assessment. During a concurrent interview and record review of Resident 60's clinical record with the DOR on 8/21/2024 at 2:59 p.m., the DOR stated Resident 60 was admitted to the facility on [DATE] with no ROM limitations and no contractures to both wrists, hands, and fingers. The DOR reviewed Resident 60's admission OT JMS, dated 1/5/2023, and confirmed Resident 60 had full ROM of both wrists, hands, and fingers. The DOR reviewed Resident 60's OT Eval, dated 1/8/2023, and confirmed Resident 60 had WFL ROM on both elbows, wrists, and hands which meant Resident 60 had sufficient ROM to perform ADLs. The DOR reviewed Resident 60's OT Discharge summary, dated [DATE], and stated Resident 60 was discharged from OT services with recommendations for an RNA program for PROM to both arms and application of splints to both elbows for four to six hours, daily. The DOR stated daily meant seven times a week. The DOR stated she recommended elbow splints to both arms at the time of discharge from OT services because Resident 60 had tightness from increased muscle tone (amount of tension in the muscles) in both elbows. The DOR stated any additional splinting to both arms were unnecessary because Resident 60 had no ROM limitations to both wrists and both hands at the time. The DOR reviewed Resident 60's Annual OT JMS, dated 1/28/2024, and confirmed Resident 60 had severe ROM limitations in both wrists and both hands and recommended an OT evaluation for skilled therapy services. The DOR reviewed Resident 60's OT evaluation, dated 1/30/2024, and confirmed Resident 60 had contractures to both hands and both wrists and recommended resting hand splints to both hands for contracture management. The DOR stated Resident 60 had a decline in ROM and developed contractures to both hands and both wrists while in the facility. The DOR stated she was never notified by RNA or nursing staff of any declines in Resident 60's ROM of both arms. The DOR stated Resident 60's contractures to both hands and both wrists could have been prevented if nursing staff or RNA notified Rehab once they noticed a decline in Resident 60's ROM and if there were more frequent JMSs conducted to detect declines in ROM since Rehab only performed JMSs upon admission and annually. During a concurrent interview and record review of Resident 60's clinical record with the DSD on 8/22/2024 at 2:03 p.m., the DSD stated the purpose of RNA services was to maintain a resident's current functional ability and prevent any declines in ADLs, mobility, and ROM. The DSD reviewed Resident 60's physician's orders and RNA Survey Reports for the months of March 2023 to October 2023. The DSD confirmed Resident 60 had physician's orders for RNA to provide PROM exercises to both arms and apply splints to both elbows, four to six hours daily, from March 2023 to October 2023. The DSD stated daily meant seven times a week. The DSD stated a blank square and the letter X on the RNA Survey Report indicated the resident was not seen for RNA treatment that day. The DSD confirmed Resident 60 missed the following number of scheduled RNA services for the following months: 1. Nine days for the month of March 2023. 2. Ten days for the month of April 2023. 3.Eight days for the month of May 2023, 4. Eight days for the month of June 2023. 5. Ten days for month of July 2023. 6. Eight days for the month of August 2023, 7. Nine days for the month of September 2023. 8. Ten days for the month of October 2023. The DSD stated Resident 60 did not receive RNA treatments as ordered by the physician for unknown reasons. The DSD stated it was important for RNA to provide services as prescribed by the physician because missed treatments could place residents at risk for a functional decline and contractures. During a concurrent interview and record review on 8/23/2024 at 10:39 a.m., with the Minimum Data Set Nurse (MDSN) on 8/23/2024 at 10:39 a.m., Resident 60's clinical record was reviewed. The MDSN stated the facility monitor for changes in joint ROM through JMSs performed by nursing and Rehab. The MDSN stated Rehab performed a detailed JMS of a resident's arms and legs upon admission and annually. The MDSN stated the MDSN and Minimum Data Set Assistant performed quarterly JMSs to assess a resident's general ROM in both arms and both legs to check for declines and checked the effectiveness of the services the resident was receiving such as RNA or skilled therapy. The MDSN stated any declines in ROM found in the nursing quarterly JMS were reported to Rehab for further assessment and a COC process would be initiated. The MDSN reviewed Resident 60's clinical record and confirmed no nursing quarterly JMS to monitor for ROM declines were conducted for Resident 60 between Resident 60's admission on [DATE], on OT JMS, dated 1/4/2024, and the annual OT JMS, dated 1/28/2024. The MDSN stated Resident 60 should have had nursing quarterly JMSs to check Resident 60's ROM declines and completed in the months of 4/2023, 7/2023, and 10/2023 but did not. The MDSN stated the only JMSs Resident 60 received in the year of 2023 was by the Rehab upon admission [DATE]) and was not monitored quarterly throughout the year per facility policy. The MDSN stated the facility had three opportunities in 2023 when the nursing quarterly JMSs were due to detect a decline in Resident 60's arms and check if the current RNA program was effective but did not because the quarterly nursing JMSs were not done. The MDSN stated it was important to complete JMSs upon admission, quarterly, and annually to monitor for any declines in ROM and to ensure the facility could identify and provide the appropriate services the resident needs. The MDSN stated if joint ROM was not monitored routinely, the resident could have a functional decline and develop contractures. During a concurrent interview and record review on 8/23/2024 at 1:11 p.m., the DON stated the facility monitor for changes in ROM by multiple JMSs performed by nursing or Rehab upon admission, quarterly, and annually and by staff observation and report of any declines to the appropriate staff. The DON stated any change of condition noticed during routine nursing care or during RNA sessions such as a decline in ROM must be reported to the charge nurse who then completed a COC evaluation and notified the physician and licensed therapist for re-assessment. The DON reviewed Resident 60's admission OT JMSs, dated 1/5/2023, and confirmed Resident 60 had full ROM of both wrists, hands, and fingers upon admission to the facility. The DON reviewed Resident 60's OT Evaluation, dated 1/8/2024, and confirmed Resident 60 had WFL ROM in both elbows, wrists, and hands upon admission to the facility. The DON reviewed Resident 60's OT Discharge summary, dated [DATE], and confirmed Resident 60 was discharged from OT services with recommendations for an RNA program for PROM to both arms and application of splints to both elbows for four to six hours, daily. The DON stated daily meant Resident 60 should be receiving RNA services seven times a week. The DON reviewed Resident 60's RNA Survey Reports from March 2023 to October 2023 and confirmed Resident 60 did not receive RNA services 7 days a week as ordered from March 2023 to October 2023. The DON reviewed Resident 60's Annual OT JMS, dated 1/28/2024, and confirmed Resident 60 had severe ROM limitations in both wrists and both hands and a skilled OT evaluation was recommended. The DON reviewed Resident 60's OT Eval, dated 1/30/2024, and confirmed Resident 60 had contractures to both hands and both wrists and OT recommended hand splints to both hands for contracture management. The DON reviewed Resident 60's clinical record and confirmed no quarterly JMSs were completed by nursing or the Rehab to monitor for ROM declines between the admission, OT JMS, dated 1/4/2024, and the annual OT JMS, dated 1/28/2024. The DON stated Resident 60 had a decline in ROM and developed contractures to both hands and wrists while in the facility. The DON stated she was never notified by RNA or nursing of any declines in Resident 60's ROM of both arms. The DON stated RNA should have notified the change nurse or discussed Resident 60's decline in ROM in the monthly RNA meetings to ensure a COC was completed, the physician was notified, and OT re-assessed Resident 60 to ensure the proper interventions were provided to prevent the contractures. The DON stated the quarterly JMSs should have been done every three months after admission to monitor for declines in ROM and ensure the appropriate services were provided to prevent contractures but were not done. The DON stated the facility could have caught the decline in ROM of Resident 60's both hands and both wrists earlier if quarterly JMSs were done and could have prevented the contractures. The DON stated the development of Resident 60's both wrists and both hands contractures was avoidable. The DON stated Resident 60's contractures could have been prevented if RNA reported the decline in Resident 60's ROM to both hands and both wrists to the charge nurse, if the quarterly JMSs were completed to monitor for ROM declines, and if RNA provided RNA services for PROM and splinting seven times a week as ordered by the physician. During an interview on 8/23/2024 at 1:11 p.m., the DON stated Rehab assessed and issued splints to the residents in the facility. The DON stated Rehab was the only staff in the facility who should modify splints since it was their expertise. The DON stated Rehab assessed splints specific to each resident and determined the appropriateness of the splint, resident's tolerance to the splint, and made any adjustments as necessary. The DON stated RNAs cannot modify splints because they did not have the knowledge and qualifications to determine what residents need. The DON stated if splints were not fitting correctly and required modification, the RNA should notify Rehab and charge nurse, a Change of Condition (COC, major decline or improvement in a resident's status that will not resolve itself without intervention) evaluation would be completed, the physician would be notified, and Rehab would re-assess the resident and modify the splint as needed. During a review of the facility's Policy and Procedure (P&P) undated, titled, Joint Mobility Assessment, the P&P indicated the purpose of the Joint Mobility Assessment was to determine a resident's ROM for all major joints and to implement plans of care to increase, maintain, or reduce a decline in joint mobility. The P&P indicated all residents shall be assessed for joint mobility limitations upon admission and reviewed every three months thereafter. The P&P indicated limitations in the joint mobility shall be defined in the following terms: WNL describes full ROM, no limitations, resident has access to 100% normal ROM .and severe which represented limitations in joint mobility greater than 75% to approximately 100% of the normal ROM. The P&P indicated the licensed nurse shall assess the program's effectiveness and the resident response to treatment on a weekly basis in the licensed weekly summary. The P&P indicated therapy evaluations may be requested if programs provide ineffective or complications occur requiring therapy expertise. During a review of the facility's undated P&P titled, Resident Mobility and Range of Motion, revised 7/2017, the P&P indicated residents would not experience an avoidable reduction in ROM and residents with limited ROM would receive treatment and services to increase and/or prevent a further decrease in ROM. The P&P indicated nursing would identify the resident's current ROM of his or her joints and limitations in movement as part of the comprehensive assessment and develop a plan of care to include specific interventions, exercises, and therapies to maintain, prevent avoidable decline in, and/or improve ROM. During a review of the facility's job description titled, Restorative Nursing Assistant, dated 1/27/2022, the job description indicated RNA assisted residents in reaching their maximal potential in collaboration with the Therapy Department and under the supervision of the Charge Nurse. The RNA job description indicated the RNA's essential duties and responsibilities included reporting and charting significant changes in a resident's condition and notifying the OT and Physical Therapy of any

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a resident, who had a diagnosis of dementia (progressive loss of memory), did not go missing from the facility unnoticed for almost 24 hours for one of two sampled residents (Resident A). The facility failed to: Ensure the facility had a system to alert staff when the door to the entrance of the facility was opened after 5 p.m., to ensure no resident left the facility unnoticed. Resident A, who was diagnosed with dementia (a brain disease marked by memory disorders, personality changes and impaired reasoning), other medical conditions, and a heart pacemaker (a device that generates electrical impulses to the heart to contract), eloped from the facility ' s front entrance on 3/14/2022 at 8:29 p.m. On 3/15/2022, the day after Resident A eloped from the facility, Resident A was found unresponsive in a parking lot approximately 12 miles away from the facility and was transported to a general acute care hospital (GACH) for evaluation, care, and treatment. This deficient practice resulted in Resident A eloping from the facility, becoming unresponsive and requiring treatment at a General Acute Care Hospital (GACH) for a drug overdose and placed Resident A at risk of remaining missing, exposure to harsh environmental conditions, including excessive heat and/or cold, hypothermia (occurs when the body loses heat faster than it can produce heat, causing a dangerously low body temperature), harm, and/or death due to his medical conditions, use of illicit drugs (illegal use), and possible motor vehicle accident and death. Findings: During a review of Resident A ' s admission Records (face sheet), the face sheet indicated Resident A was originally admitted to the facility on [DATE] and last readmitted on [DATE] with diagnoses included diabetes mellitus ([DM] a chronic condition associated with abnormally high levels of sugar in the blood), encephalopathy (brain disease, damage, or malfunction), hypertension ([HTN] high blood pressure, a condition in which the force of the blood against the artery walls was too high), glaucoma (a group of eye conditions that damage the nerve in the eye often leading to blindness), hearing loss, anxiety disorder (extreme worry or fear), and dementia. The face sheet indicated Resident A ' s primary decision maker was a family member. During a review of Resident A ' s history and physical (H/P), dated 5/27/2021, the H/P indicated Resident A could make his needs known but could not make medical decisions. During a review of Resident A ' s Minimum Data Set (MDS), a standardized assessment and care-screening tool, dated 3/7/2022, the MDS indicated Resident A ' s cognitive skills (thought process) for daily decision-making were moderately impaired. According to the MDS, Resident A required an extensive one-person physical assistance to complete his activities of daily living ([ADL] tasks such as eating, bathing, dressing, grooming and toileting) and was occasionally incontinent (involuntary voiding of urine and stool) of bowel and bladder functions. During a review of Resident A ' s Physician ' s Orders, dated 5/27/2021, the Physician ' s Order indicated Resident A did not have the capacity to understand and actively participate in decision making. The physician orders indicated Resident A ' s medications included the following: 1. Regular Insulin 2 to 8 units (an indication of measurement [dose] for insulin [a medications that lowers the level of blood sugar]) on a sliding scale (Insulin dose varies based on a patient ' s blood glucose level) for diabetes mellitus to cover elevated glucose levels twice a day. 2. Metoprolol 25 milligram ([mg] unit of measurement) every 12 hours for hypertension. 3. Norvasc 5 mg every day for hypertension. During a record review of Resident A ' s medication administration record (MAR) dated 3/14/2022 at 9:00 p.m. until 3/15/2022, (the 24 hours the resident was missing from the facility) Resident A did not receive any of the above medications to control his blood pressure and blood sugar levels. During a review of the facility ' s Investigation/Accident Known/Unknown Origin Form, dated 3/14/2022, the form indicated at 9 p.m., on 3/14/2022, Resident A was not in his bed. According to the Investigation Form, the facility ' s staff searched inside and outside of the facility for Resident A, which included staff driving around the facility ' s area and contacting local hospitals, but Resident A was not found. During a review of the GACH ' s Emergency Department (ED) notes, dated 3/15/2022 and timed at 5:06 p.m., the ED notes indicated Resident A presented for evaluation of a suspected drug overdose. Per EMS ([emergency medical services/ambulance or paramedic services] used to provide urgent pre-hospital treatment and stabilization for serious illness and injuries), Resident A was found unresponsive in a parking lot and was given Narcan (a medicine that rapidly reverses the effects of an opioid [a substance used to treat moderate to severe pain] overdose in an emergency) prior to arrival to the ED. During a review of Resident A ' s GACH laboratory results obtained on 3/15/2022 at 8:39 p.m., the laboratory results indicated Resident A tested positive for opiates in his urine. According to the ED note, Resident A was discharged to another skilled nursing facility on 3/16/2022. During a review of Resident A ' s care plans (CPs), there was no indication of a plan of care in place with interventions to address Resident A ' s confusion and forgetfulness and to ensure Resident A was kept safe and supervised. During an interview on 3/16/2022 at 3 p.m., the Director of Nursing (DON) stated Resident A was alert and oriented to his name, place, and time but had episodes of forgetfulness. The DON stated Resident A could make his needs known but could not make medical decisions. The DON confirmed that should have been but there was no plan of care developed with intervention to address Resident A ' s forgetfulness and confusion to ensure Resident A ' s safety. During an interview on 3/16/2022 at 3:14 p.m., the Administrator (ADM) stated on 3/14/2022 at approximately 9 p.m. a certified nursing assistant (CNA 1) was assisting another resident. When CNA 1 finished with that resident, she went to Resident A ' s room but did not find him there. The ADM stated it was reported, Resident A was last seen at the nursing station socializing with other residents at approximately 8 p.m. The ADM stated CNA 1 looked around the facility and when she could not find Resident A she reported it to the licensed vocational nurse (LVN 2) who was the charge nurse. The ADM stated a search was conducted in all the residents ' rooms, bathrooms, dining room, rehabilitation room, the break room, and the facility ' s parking lot but they could not locate Resident A. The ADM stated staff got in their personal cars and searched the surrounding cities but did not find Resident A. The ADM stated they reviewed the facility ' s camera footage and they saw Resident A leave the facility through the facility ' s front entrance at 8:29 p.m., on 3/14/2022. The ADM stated the receptionist was at the front desk until 5 p.m., and then locks the front entrance when she leaves. The ADM stated the front door only has a wander guard (a system that sounds alarms when an at-risk wanderer approaches a monitored door) and Resident A was not assessed at risk for wandering so he did not have a wander guard device in place. The ADM stated the front door was locked to prevent unauthorized persons from entering the facility after 5 p.m., but there was no alarm on the front door to alert staff the door was being opened from inside the facility. During an interview on 3/16/2022 at 4:21 p.m., CNA 1 stated Resident A was independent but had some confusion and forgetfulness. CNA 1 stated on the night Resident A eloped from the facility (3/14/2022) she went to Resident A ' s room at approximately 8:45 p.m., to check on Resident A ' s roommate (Resident B), and Resident A was not there. CNA 1 stated after she completed care with Resident B she went to look for Resident A but could not find him and reported to LVN 2, the charge nurse. CNA 1 stated they looked inside and outside of the building and could not find Resident A. CNA 1 stated Resident A did not have a behavior of going outside the facility. CNA 1 stated Resident A would usually talk to the other residents and then go back to his room. During an interview on 6/17/2022 at 2:10 p.m., the DON stated the only doors in the facility that alarms when opened from the inside were the facility ' s emergency doors. The DON stated the front door has a wander guard alarm on it and would only activate the alarm if a resident with a wander guard device activated it. The DON stated when the receptionist leaves at 6 p.m., the front door was locked from the outside only and there was no alarm to alert staff the door was being opened from the inside. DON was not able to provide a policy and procedure (P/P) regarding supervision of residents with dementia and forgetfulness. During an interview on 6/21/2022 at 5:23 p.m., LVN 2 stated Resident A was alert to his name and surroundings but had periods of confusion and forgetfulness. LVN 2 stated Resident A usually sat at or near the nursing station talking to other residents, conversing in a confused manner. LVN 2 stated on his shift, 3 p.m. to 11 p.m., Resident A did not have a behavior of attempting to leave the facility.