**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a resident, who required two-person assistance (two staff members assisting the resident with care) for turning and repositioning in bed, was not turned and repositioned by one person and sustained an injury for one of ten sampled residents (Resident 1). The facility failed to: 1. Ensure a certified nursing assistant (CNA 1) did not turn and reposition Resident 1 by himself on 2/8/2025. 2. Ensure CNA 1 followed Resident 1's untitled Care Plan dated 10/2/2023, which indicated Resident 1 required two-person assistance with turning and repositioning and did not turn the resident without a second person assistance. As a result of these deficient practices Resident 1 sustained an acute (sudden onset) fracture (broken bone) of the distal (situated away from the center of the body or from the point of attachment) shaft (part of arm) of the left forearm (lower part of the arm) and was transferred to a general acute care hospital (GACH) on 2/28/2025 and was admitted to the GACH for observation. At the GACH Resident 1 was applied splint (soft, padded material that is used to secure the injury) to a left arm. Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] and readmitted [DATE] with diagnoses including anoxic (lack of oxygen causing tissue death) brain damage, age-related osteoporosis (bones become brittle and fragile), and contracture (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints ) of muscles. During a review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool) dated 12/6/2024, the MDS indicated Resident 1 was rarely or never understood. The MDS indicated Resident 1 had functional limitations in range of motion ([ROM], the extent or limit to which a part of the body can be moved around a joint or a fixed point) and had impairments on bilateral (both) upper extremities (arms) and lower extremities (legs) that interfered with functions of daily living or placed Resident 1 at risk for injury. The MDS indicated Resident 1 was totally dependent on staff in rolling from left to right (the ability to roll from laying on back to left side and right side and return to lying on back on the bed). During a review of Resident 1's untitled Care Plan initiated on 10/2/2023, the Care Plan indicated Resident 1 required two-person assistance with turning and repositioning, due to impaired mobility, and total dependence with bed mobility (the ability to move around in bed, including rolling, sitting up, and scooting). During a review of Resident 1's Alert Charting (Succeeding Documents for Change of Condition [COC] and Skilled Documentation about an event that has occurred with a resident ) dated 2/8/2025, the Alert Charting document indicated a restorative nursing assistant ([RNA] a certified nursing assistants that have additional training in specific therapeutic techniques) 1 alerted licensed vocational nurse (LVN) 1 of a potential incident with Resident 1 and certified nursing assistant 1 (CNA 1). The Alert Charting document indicated CNA 1 informed LVN 1 he was working with Resident 1 to change her bed sheets and in the process of turning the resident to her left side, he heard a discomforting, unnatural sound (indicating something was wrong) from what sounded like the left wrist or arm, so he asked RNA 1 to get LVN 1. The Alert Charting document indicated Resident 1's physician (MD 1) was notified and ordered a STAT (urgent) Xray (a photographic or digital image of the internal composition of something, especially a part of the body) of the left hand and left forearm. Resident 1 left the facility with emergency services (911) on 2/8/2025 at 3:54 p.m. to the GACH. During a review of Resident 1's Order Summary Report (the physician's orders), the Order Summary Report indicated a physician's order dated 2/8/2025 for a STAT Xray of the resident's left hand and left forearm and transfer the resident to GACH via 911 for further evaluation and treatment due to acute fracture of the distal forearm. During a review of Resident 1's Radiology (the medical specialty that uses medical imaging to diagnose diseases and guide treatment within the body) Results Report dated 2/8/2025, the Radiology Results Report indicated an Xray taken on 2/8/2025 of the left forearm indicated the resident had an acute fracture of the distal shaft of the left forearm, normal bony mineralization (the degree of bone density), and no osteoblastic (the cells that form new bones and grow and heal existing bones) or osteolytic lesion (a softened bone area) were noted. During a review of Resident 1's GACH's Emergency Department (ED) Note dated 2/8/2025, the ED Note indicated Resident 1 was brought to the ED via 911 for evaluation of a left forearm fracture. The ED Note indicated Resident 1 sustained a left forearm fracture while the resident was being moved in bed at the facility. The ED Note indicated Resident 1 had contractures (a stiffening/shortening at any joint that reduces the joint's range of motion) on all four limbs, left arm deformity and was positive for trauma on the left forearm. The ED Note indicated a left arm splint was applied, and Resident 1 was admitted to the GACH for observation. The ED Note indicated Resident 1 had a flat mood and affect (absence of an appropriate emotional response) and was bedridden with limbs contractures. During a review of Resident 1's untitled Care Plan initiated 2/14/2025, the Care Plan indicated Resident 1 had a fracture of the left forearm with a soft splint. The Care Plan indicated Resident 1 was at risk for pain and skin breakdown. The Care Plan goals for Resident 1 included monitoring (frequency not defined) Resident 1 for pain and ensure the resident would not have any adverse effects (an undesired effect) from the left forearm fracture. The Care Plan Interventions for Resident 1 included two-person assistance for all activities of daily living ([ADL] the everyday tasks that people perform to care for themselves) care, cradling (to support protectively) Resident 1's left arm while providing ADL care and repositioning to keep the left arm in alignment (how the head, shoulders, spine, hips, knees and ankles relate and line up with each other) with the left side of the body, turning Resident 1 to the right side and back only, and gentle handling of Resident 1 during ADL care. During a review of the Order Summary Report dated 2/17/2025, the Order Summary Report indicated an order dated 2/17/2025 for Norco (pain management) tablet 5-325 (strength) milligrams (mg, a unit of measurement), give one tablet via gastrostomy tube (GT, a tube inserted through the belly that brings nutrition directly to the stomach) every eight hours for pain management for 14 days. During an interview on 2/21/2025 at 12:13 p.m., CNA 1 stated on 2/8/2025 he (CNA 1) was going to change Resident 1's soiled adult incontinence (no voluntary control of urination and bowel movements) briefs (disposable, absorbent underwear that helps with urinary or bowel incontinence). CNA 1 stated it was around 9 a.m. and all the other CNAs were busy with other residents' morning care. CNA 1 stated RNA 1 was putting splints on other residents (unknown), and LVN 1 was busy passing medication. CNA 1 stated there was no one available to help him to turn Resident 1. CNA 1 stated Resident 1 required a two-person assistance, but he could not get anyone to help him to turn Resident 1, so he felt confident he could turn the resident alone, and he did it. CNA 1 stated Resident 1 resided in the subacute unit (a level of care needed by a patient who does not require hospital acute care but who requires more intensive licensed skilled nursing care than is provided to the majority of patients in a skilled nursing facility) and needed two-person assistance when turning due to the resident being stiff, Resident 1's inability to help with turning, presence of medical devices including gastrostomy tube ([GT] and tracheostomy [surgically created opening in the trachea [windpipe]), and having contractures. CNA 1 stated that the subacute unit was very busy with residents' care due to the complexity of the residents, and he was instructed to call a licensed nurse for help if a CNA could not assist him, but the LVNs were busy as well. CNA 1 stated this was not the first time he was unable to obtain help to turn Resident 1. CNA 1 stated on /2/28/2025 when he was changing Resident 1, he was standing on the right side of Resident 1's bed and he put one of his hands behind resident 1's right shoulder and one hand behind Resident 1's right knee and began to turn her to the left side when he heard a loud cracking sound. CNA 1 stated he did not know where the cracking sound came from, so he pulled her onto her back carefully. CNA 1 stated Resident 1 had a deformity (contracture) in her left wrist that caused her left land to point outward away from her body and after the loud cracking noise. CNA 1 stated he noticed the resident's left hand and wrist appeared more open and looser than normal, meaning the arm was able to move a little more towards the body when it usually could not. CNA 1 stated RNA 1 just happened to enter the room at that time and he asked her to call LVN 1 for help. CNA 1 stated when repositioning Resident 1 with a two-person assistance you were able to see where the resident's limbs were including the contracted left hand and wrist from both sides of the bed to ensure you knew where the arm was always. CNA 1 stated they were able to turn and reposition Resident 1 more carefully using a two-person assistance. During an interview on 2/21/2025 at 1:07 p.m., RNA 1 stated on 2/8/2025 CNA 1 asked her to call LVN 1 for help, so she did, CNA 1 told her (RNA 1) he heard a pop. RNA 1 stated Resident 1 was very stiff, and staff had to take extra precautions when working with the resident because the stiffness made it hard to move and reposition Resident 1. RNA 1 stated it was kind of scary to move the resident's limbs around due to the severity of stiffness Resident 1 had and staff had to be extra gentle and take precautions when moving her around. RNA 1 stated Resident 1 was supposed to be a two-person assistance because she was very fragile, so they needed two-people to turn her safely. RNA 1 stated CNA 1 was a big guy, and he may have assumed he could turn the resident by himself without an assistance because the resident was a small lady. RNA 1 stated it gets kind of hard because there was usually three CNAs on the subacute unit during the day shift (7 a.m. to 3 p.m.) and if two were helping each other, she does not know who was helping the third CNA. During an interview on 2/21/2025 at 1:45 p.m., MD 1 stated facility staff had to take precautions with this resident population and be careful with the residents because they do not respond appropriately to pain due to anoxic brain damage so staff could not tell if the resident was in pain. MD 1 stated there was an increased risk for fracture in residents with brittle (break or shatter easily) bones, so facility staff had to handle these residents gently, turn the residents carefully, and not rush care. During an observation and concurrent interview in Resident 1's room on 2/21/2025 at 2:16 p.m., with LVN 2, LVN 2 was observed to uncover Resident 1's left arm while Resident 1 was in bed. Resident 1 was observed to have a splint on her left forearm. LVN 2 stated the facility staff could not tell if Resident 1 was in pain, so they were giving her around the clock (regularly scheduled) Norco at this time for pain from the fracture. LVN 2 stated Resident 1's left hand and wrist were contracted causing the left hand to point outwards. During an interview on 2/21/2025 at 2:18 p.m., CNA 2 stated they usually need two-person assistance for the residents on the subacute unit due to their health status but sometimes everyone was busy, so you must keep going to get your work done and do the work alone. During an interview on 2/21/2025 at 2:26 p.m., the director of rehabilitation ([DOR] a medical specialty that helps people regain abilities lost due to injury, disease, or surgery) stated she reviewed Resident 1's rehabilitative services Discharge (DC) Summary from June 2023 and the DC Summary indicated Resident 1 was totally dependent on staff for bed mobility. The DOR stated a total dependence meant the resident could not help with the activity at all and often the resident would be two-person assist. The DOR stated due to Resident 1's stiffness and posturing (involuntary and abnormal positioning of the body due to preserved motor reflexes) it can be harder to turn her. The DOR stated Resident 1 had a left wrist contracture which abnormally pointed away from her body and when you turned Resident 1, you had to ensure all her limbs were out of the way. The DOR stated Resident 1's left arm at the shoulder was internally rotated (causes the associated limb to rotate internally or toward the body) which caused the left hand and wrist to point out away from the body, so you had to adjust the arm and help it become midline prior to turning. During an interview on 2/21/2025 at 2:52 p.m., the director of staff development (DSD) stated if the resident was assessed as a two-person assistance on the care plan, they should be a two-person assistance for resident safety. The DSD stated most subacute residents should be a two-person assistance they do not want medical devices getting dislodged, or they have contractures, so they do not want any injuries. During an interview on 2/21/2025 at 3:26 p.m., the director of nursing (DON) stated Resident 1 had a flat affect but after she was readmitted back from the hospital with the fracture, they noticed some facial grimacing (a facial expression of pain) and an order from MD 1 for Norco 5-325 mg for 14 days was received. The DON stated the plan was to reevaluate her in two weeks to see if she still required the Norco. The DON stated residents with osteoporosis needed to be handled gently. The DON reviewed Resident 1's care plans and stated Resident 1 had a Care Plan to prevent skin issues that indicated Resident 1 was a two-person assist. The DON stated if the care plan indicated Resident 1 was a two-person assistance for turning and repositioning, she should have had two people assisting her to turn and reposition. During a review of the facility's policy and procedure (P/P) titled Turning a Resident on His/ Her Side Away from You, dated 10/2020, the P/P indicated the purpose of this procedure was to provide comfort to the resident and to promote good body alignment. The P/P indicated to review the resident's care plan to assess for any special needs of the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide services to five of 13 sampled residents (Resident 76, 48, 61, 68, and 54) with limited range of motion ([ROM] full movement potential of a joint [where two bones meet]) and mobility (ability to move) by failing to: 1.Provide Occupational Therapy ([OT] profession aimed to increase or maintain a person's capability of participating in everyday life activities [occupations]) services after identifying ROM impairments (unspecified) in both arms and indicating Resident 76 could benefit from skilled services (therapy services performed by licensed therapists and necessary to treat illness and injury) for contracture (a stiffening/shortening at any joint that reduces the joint's range of motion) prevention management during the OT Evaluation, dated 8/7/2024. 2.Provide Physical Therapy ([PT] profession aimed in the restoration, maintenance, and promotion of optimal physical function) services after identifying a ROM decline in both ankles and indicating Resident 76 could benefit from skilled services to address limitations in both ankles during the PT Evaluation, dated 8/7/2024. 3.Provide PT services after identifying further ROM decline in the right knee and both ankles and indicating Resident 76 could benefit from skilled services to address limitations in both ankles during the PT Evaluation, dated 9/9/2024. 4.Perform an accurate quarterly Joint Mobility Screen ([JMS] brief assessment of a resident's range of motion in both arms and both legs) of Resident 76's ROM in both arms and legs on 10/31/2024 and 1/27/2025. 5.Perform a quarterly JMS of Resident 48's ROM in both arms and legs between 11/21/2023 and 5/20/2024. 6.Provide an OT Evaluation after identifying a decline in both of Resident 48's elbows during the quarterly JMS, dated 5/20/2024, and prior to the application of both elbow extension (straightening) splints (material used to restrict, protect, or immobilize a part of the body to support function, assist and/or increase range of motion) for four to six hours (4-6 hours) in accordance with professional standards. 7.Provide an OT Evaluation prior to applying Resident 61's right elbow extension splint (a device that immobilizes a joint in an extended position) for 4-6 hours in accordance with professional standards on 6/20/2024. 8.Identify Resident 61's ROM decline in the left hand and left ankle since JMS on 12/23/2024. 9.Provide PROM to Resident 68's arms and legs since admission to hospice (specialized care designed to give supportive care to people in the final phase of a terminal illness with a focus on comfort, quality of life rather than cure, and free of pain to live each day as fully as possible) on 1/9/2025. 10.Ensure Resident 54 received RNA services as ordered for the resident. Findings: a. During a review of Resident 76's General Acute Care Hospital (GACH) Documents Review Report, the GACH Documents Review Report indicted Resident 76 was admitted to the GACH on 3/27/2024 and found to have a meningioma (brain tumor). The GACH Documents Review Report indicated Resident 76 underwent surgical removal of the meningioma on 4/2/2024, partial removal of the skull on 4/3/2024, and placement of a tracheostomy tube (hole made through the front of the neck and into the windpipe [trachea] to enable the resident to breath) on 4/13/2024. During a review of Resident 76's GACH Discharge Medication Orders, dated 4/25/2024, the GACH Discharge Medication Orders indicated to discharge Resident 76 to a sub-acute (level of care that does not require hospitalization but requires more intensive skilled nursing care including medical equipment, supplies, and treatments such as ventilators [medical device to help support or replace breathing) with gastrostomy tube feeding [G-tube feeding, a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems]). The GACH Discharge Medication Orders indicated Resident 76 had a helmet and both ankle foot orthosis ([AFO] brace to position the foot and ankle) boots. During a review of Resident 76's admission Record, the admission Record indicated the facility admitted Resident 76 on 4/25/2024 with diagnoses including severe hypoxic ischemic encephalopathy (brain injury that occurs when the brain does not receive enough oxygen [hypoxia] and blood flow [ischemia]), cerebral infarction (brain damage due to loss of oxygen to the area) of the right posterior cerebral artery ([PCA] blood vessel that supplies blood and oxygen to a portion of the brain), cerebral edema (swelling of brain tissue due to excessive fluid), and attention to the G-tube. During a review of Resident 76's History and Physical (H&P), dated 4/26/2024, the H&P indicated Resident 76's diagnoses included a meningioma, surgical removal of the meningioma, and cerebral infarct with left sided weakness. The H&P indicated Resident 76 did not have the capacity to understand and make decisions. During a review of Resident 76's JMS, dated 4/26/2024, the JMS indicated Resident 76 had full/functional ROM in all joints of both arms and legs, including both shoulders, elbows, wrists, hands, hips, knees, and ankles. Resident 76's JMS indicated skilled rehabilitation services (therapy given to restore an individual back to their highest possible level of physical, mental, and psychosocial well-being) were not indicated (reason not indicated) and Resident 76 would benefit from the Restorative Nursing Aide ([RNA] certified nursing aide program that helps residents to maintain their function and joint mobility) program. During a review of Resident 76's physician orders, dated 4/26/2024, the physician orders indicated for the RNA to assist Resident 76 with passive range of motion ([PROM] movement of joint through the ROM from an external force with no effort from the person) exercises to both arms and legs, five times per week for three months or as tolerated. During a review of Resident 76's Rehab Progress Notes, dated 5/8/2024 written by the Director of Rehabilitation (DOR), the Rehab Progress Notes indicated Resident 76's family requested both AFOs for Resident 76 (date of family's request not documented). The Rehab Progress Notes indicated the DOR assessed Resident 76's ROM and muscle tone (amount of tension or resistance in muscles) to determine if Resident 76 could benefit from the AFOs. The Rehab Progress Notes indicated Resident 76 had normal tone and did not have any signs of foot drop (difficulty lifting the front part of the foot). The Rehab Progress Notes indicated the DOR did not recommend both AFOs since Resident 76's ankle ROM was within normal limits ([WNL] normal joint movement) and application of both AFOs might affect Resident 76's skin integrity. During a review of Resident 76's SBAR ([Situation, Background, Assessment, and Recommendation] communication tool used by healthcare workers when there is a change of condition among residents) and Initial COC (Change of Condition) Alert Charting and Skilled Documentation, dated 5/20/2024, the SBAR indicated Resident 76's family was at bedside with concerns of redness and discoloration above the resident's right eye. The SBAR indicated Resident 76's physician was contacted, and the physician recommended Resident 76 be transferred to the GACH for further evaluation. During a review of Resident 76's Nurses Notes, dated 5/20/2024, the Nurses Notes indicated Resident 76 was transferred to the GACH in stable condition with helmet placed. The Nurses Notes indicated Resident 76 did not have any signs or symptoms of bleeding, discomfort, or distress. During a review of Resident 76's Census (record of hospitalizations, room changes, and payor source changes), the Census indicated the facility re-admitted Resident 76 on 5/25/2024. During a review of Resident 76's JMS, dated 5/29/2024, the JMS indicated Resident 76 had full/functional ROM in all joints in both arms and legs, including both shoulders, elbows, wrists, hands, hips, knees, and ankles. The JMS indicated Resident 76's skilled rehabilitation services were not indicated (reason not indicated) and would benefit from the RNA program. During a review of Resident 76's physician orders, dated 5/29/2024, the physician orders indicated for the RNA to assist Resident 76 with PROM exercises to both arms and legs, five times per week for three months or as tolerated. During a review of Resident 76's Personal Inventory Update, dated 7/10/2024, the Personal Inventory Update included three foam baseballs. During a review of Resident 76's JMS, dated 8/2/2024, the JMS indicated Resident 76 had full/functional ROM in all joints in both arms and legs, including both shoulders, elbows, wrists, hands, hips, knees, and ankles. The JMS indicated Resident 76 had an RNA ROM program. During a review of Resident 76's OT Evaluation and Plan of Treatment, dated 8/7/2024 (five days after the JMS on 8/2/2024) written by Occupational Therapist 1 (OT 1), the OT Evaluation indicated Resident 76's prior level of function (ability prior to admission to the facility) was independent. The OT Evaluation indicated Resident 76 had impaired ROM (unspecified) in both shoulders, elbows/forearms, wrists, and hands. The OT Evaluation indicated Resident 76 had rigidity (muscle stiffness), hypertonicity (muscle with abnormally increased muscle tone, resulting in stiffness and difficulty moving), and swelling in both arms. The OT Evaluation indicated Resident 76's skin was intact without any observable issues. The OT Evaluation indicated Resident 76 could benefit from continued skilled services for neuromuscular retraining (technique used to restore movement patterns through repetitive motion to retrain the brain), cognitive (relating to the ability to think, understand, learn, and remember) and visual retraining, and contracture prevention management. The OT Evaluation indicated Resident 76 was at risk for further decline in function, immobility, and muscle atrophy (loss of muscle mass) without skilled therapy intervention. During a review of Resident 76's PT Evaluation and Plan of Treatment, dated 8/7/2024 (five days after the JMS on 8/2/2024) written by Physical Therapist 2 (PT 2), the PT Evaluation indicated Resident 76's prior level of function was independent with all functional mobility and walked without an assistive device. The PT Evaluation indicated Resident 76 was referred to PT for assessment of mobility and function. The PT Evaluation indicated Resident 76's ROM in both hips and knees were within functional limits ([WFL] sufficient movement without significant limitation). The PT Evaluation indicated both of Resident 76's ankles had impaired ROM with the right ankle measuring negative 20 degrees (-20 degrees) of dorsiflexion (bending the ankle toward the body, normal 0 to 20 degrees) and the left ankle measuring -15 degrees of dorsiflexion. The PT Evaluation indicated Resident 76 was alert, non-verbal, had left-sided neglect (condition after a brain injury where a person is not aware of the left side), had left-sided hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body), and had left leg hypertonicity. The PT Evaluation indicated Resident 76 had been bed bound since 3/2024, had limitations in both ankles into dorsiflexion, and both ankles exhibited foot drop while lying in bed. The PT Evaluation indicated Resident 76 would benefit from continued skilled PT services to address limitations in ankle dorsiflexion, improve muscle strength, and provide education on positioning and bed mobility. The PT Evaluation indicated Resident 76 was at risk for immobility, further decline in function, pressure injuries, decreased skin integrity, muscle atrophy, and increased muscle tone without skilled therapy intervention. During a review of Resident 76's Census, the Census indicated Resident 76 moved from the facility's sub-acute area (Nursing Station 2) to Nursing Station 1 on 8/17/2024. During a review of Resident 76's PT Evaluation and Plan of Treatment, dated 9/9/20204 written by PT 2, the PT Evaluation indicated Resident 76 was referred to PT for assessment of mobility and function. The PT Evaluation indicated Resident 76's ROM in both hips and left knee were WFL. The PT Evaluation indicated Resident 76's right knee and both ankles had impaired ROM with right knee extension measuring -30 degrees of extension (normal 0 degrees), right ankle measuring -30 degrees of dorsiflexion, and left ankle measuring -35 degrees of dorsiflexion. The PT Evaluation indicated Resident 76 had been bed bound since 3/2024, had limitations in the right knee and both ankle joints, and exhibited foot drop with right knee flexion (bent) while lying in bed. The PT Evaluation indicated Resident 76 was at risk for immobility, further decline in function, pressure injuries, decreased skin integrity, muscle atrophy, and increased muscle tone without skilled therapy intervention. During a review of Resident 76's JMS, dated 10/31/2024 (after ROM limitations were identified on 8/7/2024 and 9/9/2024) and 1/27/2025, the JMS indicated Resident 76 had full/functional ROM in all joints in both arms and legs, including both shoulders, elbows, wrists, hands, hips, knees, and ankles. The JMS indicated Resident 76 had an RNA ROM program. During a review of Resident 76's Minimum Data Set ([MDS] a resident assessment tool), dated 1/27/2025, the MDS indicated Resident 76 did not have any speech, rarely/never expressed ideas and wants, rarely/never understood verbal content, and was severely impaired for daily decision making. The MDS indicated Resident 76 did not have any ROM limitations in both arms and legs. The MDS indicated Resident 76 was dependent (helper does all of the effort or the assistance of two or more helpers is required for the resident to complete the activity) for oral hygiene, toileting, bathing, dressing, rolling to either side in bed, and chair/bed-to-chair transfers. During an interview on 2/4/2025 at 8:53 a.m., with the DOR, the DOR stated the residents (in general) received a JMS upon admission to the facility and on a quarterly basis. The DOR stated the purpose of the JMS was to identify any changes in ROM to prevent ROM limitations and the development of contractures. The DOR described contractures as limitations in motion caused by muscle tone and/or shortening of soft tissues. The DOR stated contractures could be managed with early detection with the use of splints (material used to restrict, protect, or immobilize a part of the body to support function, assist and/or increase range of motion). The DOR stated the purpose of splints included placing the joints in the most optimal position to prevent the development of a contracture or to prevent contractures from worsening if already present. The DOR stated ROM limitations and contractures could affect a resident's skin integrity including the development of wounds, cause fractures due to increased muscle tone, and cause pain. During a concurrent observation and interview on 2/4/2025 at 4:29 p.m., with Resident 76's Family (Family1), in Resident 76's room, Resident 76 was lying in bed, without any splints on both arms and legs. Family 1 stated Resident 76's health insurance did not cover services (unspecified) Resident 76 was supposed to receive. Family 1 stated Resident 76 received ROM exercises; Family 1 stated did not know if the exercises were completed daily. Family 1 stated Resident 76 was admitted to the facility with boots on both feet and the facility staff (unidentified) informed Family 1 that Resident 76 did not need the boots since Resident 76's ankle joints were not locked up. During an observation of Resident 76's RNA session on 2/5/2025 at 8:01 a.m., in Resident 76's room, RNA 1 stood on the right side of the bed to perform ROM exercises to the right shoulder, elbow, forearm, wrist, and hand. RNA 1 performed ROM exercises to the right leg, including hip abduction (moving the leg at the hip joint away from the body), hip flexion (bending the leg at the hip joint toward the body) with the knee extended (straightened), knee flexion, ankle rotation clockwise and counterclockwise, and ankle dorsiflexion. RNA 1 was observed unable to fully bend Resident 76's right knee, which was limited to less than 90 degrees. RNA 1 was observed unable to fully bend Resident 76's right ankle into dorsiflexion and the resident's right ankle remained in plantarflexion. RNA 1 walked to the left side of Resident 76's bed to perform ROM exercises to the left shoulder, elbow, forearm, wrist, and hand. RNA 1 performed ROM exercises on the left leg, including hip abduction, hip flexion with knee flexion, ankle rotation clockwise and counterclockwise, and ankle dorsiflexion. RNA 1 was observed unable to fully bend Resident 76's left ankle into dorsiflexion and the left ankle remained in plantarflexion. RNA 1 placed small pillows underneath both of Resident 76's arms and placed a soft doll inside Resident 76's right hand. During an interview on 2/5/2025 at 8:27 a.m., with RNA 1, RNA 1 stated Resident 76 received PROM exercises to both arms and legs. RNA 1 stated Resident 76's right knee required gentler ROM, and the left arm and leg were tighter than the right side. RNA 1 stated Resident 76 did not wear any splints. During a concurrent interview and record review on 2/5/2025 at 3:26 p.m., with the DOR, Resident 76's JMS, dated 4/26/2024, Rehab Notes, dated 5/8/2024, Census, and OT Evaluation, dated 8/7/2024, were reviewed. The DOR stated Resident 76 was admitted to the facility on [DATE], received a JMS on 4/26/2024, and was referred to the RNA program for PROM to both arms and legs. The DOR stated Resident 76 was not a therapy candidate due to Resident 76's inability to follow directions and inability to move without assistance. The DOR reviewed Resident 76's Rehab Notes, dated 5/8/2024, and stated the DOR performed a screen of both legs after Resident 76's family requested AFOs. The DOR stated AFOs were not recommend for Resident 76 since Resident 76 did not have any signs of foot drop. The DOR reviewed Resident 76's Census and stated Resident 76 was discharged to the hospital on 5/20/2024, readmitted to the facility on [DATE], and remained at the facility since readmission. The DOR reviewed the OT Evaluation, dated 8/7/2024, which indicated Resident 76 had unspecified ROM limitations in both arms and would benefit from skilled rehabilitation services. The DOR stated the OT Evaluation was submitted to Resident 76's health insurance and Resident 76 did not receive OT treatment due to the health insurance's denial for services. The DOR stated Resident 76 continued to receive RNA services for PROM exercises. During a concurrent interview and record review on 2/5/2025 at 3:45 p.m., with the DOR, Resident 76's PT Evaluations, dated 8/7/2024 and 9/9/2024, and the JMS, dated 10/31/2024 and 1/27/2025, were reviewed. The DOR stated the PT Evaluation, dated 8/7/2024, indicated Resident 76 had ROM limitations in both ankles which were positioned in plantarflexion. The DOR stated there should have been a recommendation for ankle splints or ROM only depending on Resident 76's skin integrity. The DOR reviewed the PT Evaluation, dated 9/9/2024, and stated Resident 76 had increased tone in the right leg and was positioned in more plantarflexion at both ankles. The DOR stated the PT Evaluation indicated Resident 76 would benefit from further PT services but did not receive services since Resident 76's health insurance denied further services. The DOR stated the JMS on 10/31/2024 and 1/27/2025 (after ROM limitations were already identified) indicated Resident 76 had Full/Functional ROM in all joints of both arms and legs. During a concurrent observation and interview on 2/5/2025 at 3:59 p.m., with the DOR outside Resident 76's bedroom, Resident 76's ankles were visible from the doorway. The DOR stated Resident 76's ankles were positioned in plantarflexion. The DOR stated the facility did not provide any additional PT intervention to prevent Resident 76's plantarflexion after the family's request for AFOs on 5/8/2024 and after identifying the ROM limitation twice during the PT Evaluations, dated 8/7/2024 and 9/9/2024. The DOR stated the facility did not provide additional intervention and did not have any documentation AFO boots were trialed to determine Resident 76's wear tolerance (amount of time a person could wear a splint before experiencing discomfort or skin irritation). The DOR stated Resident 76 developed plantarflexion ROM limitations while in the facility and stated they were preventable. During an interview on 2/6/2025 at 8:25 a.m., with PT 2, PT 2 stated the types of splints the PTs usually recommended at the facility included hip abduction wedges (placed in-between legs to prevent legs from rubbing together), knee extension splints, AFOs for walking, and PRAFOs ([Passive Range Ankle Foot Orthoses] device worn on the calf and foot to suspend the heel and hold the ankle in a neutral [90-degree] position). PT 1 stated PRAFOs were recommended (in general) for residents who can potentially have skin integrity issues and develop contractures. PT 1 stated the professional standard to provide a splint to a resident (in general) included performing a ROM assessment, assessing skin integrity and muscle tone, and determining a resident's response to the splint, which included applying the splint initially for 30 minutes after performing skin checks and then gradually applying the splint for more time to determine the resident's splint wearing tolerance. PT 1 stated the purpose of splints included contracture prevention, especially for immobilized patients who have been bed bound and do not have the ability to reposition themselves. During a concurrent observation and interview on 2/6/2025 at 8:49 a.m., with PT 2 in Resident 76's room, PT 2 assessed Resident 76's hands and both legs. Resident 76 was observed lying in bed with both ankles positioned in plantarflexion. PT 2 stood on the right side of Resident 76's bed to move the right leg at the hip, knee, and ankle joints. PT 2 bent Resident 76's right knee and measured the knee ROM using a goniometer (device that measures joint ROM). PT 2 stated Resident 76 had 42 degrees of knee flexion (normal 135 degrees) and had increased muscle tone. PT 2 stated Resident 76 used to have more ROM in the right knee. PT 2 bent Resident 76's right ankle into dorsiflexion which measured 24 degrees of plantarflexion (or -24 degrees of dorsiflexion). PT 2 walked to the left side of Resident 76's bed to move the left leg at the hip, knee, and ankles joints. PT 2 bent Resident 76's left ankle into dorsiflexion which measured 29 degrees of plantarflexion (or -29 degrees of dorsiflexion). PT 2 described both of Resident 76's hands as closed into a fist with some swelling. PT 2 extended Resident 76's left-hand fingers and stated Resident 76's fingernails were digging into the skin of the left palm. Resident 76's left palm was observed with redness and a small scab (dry, rough protective crust that forms over a wound). PT 2 described Resident 76's left-hand scab as a previous wound that was healing. PT 2 stated Resident 76's left hand was resistive to movement as PT 2 attempted to place a rolled towel inside the left hand. PT 2 extended Resident 76's right-hand fingers and stated the middle finger was unable to completely extend at the fingertip joint. During a concurrent interview and record review on 2/6/2025 at 9:43 a.m., with PT 2, Resident 76's PT Evaluations, dated 8/7/2024 and 9/9/2024, and JMS, dated 1/27/2025, were reviewed. PT 2 reviewed the PT Evaluation, dated 8/7/2024, and stated Resident 76 had ROM impairments in both ankles. PT 2 stated Resident 76 was receiving RNA ROM exercises to prevent worsening ROM of both ankles. PT 2 stated Resident 76 would have benefitted from PT services, including splints since the RNAs were not qualified in determining wear tolerance. PT 2 stated Resident 76 did not receive additional PT because the health insurance did not authorize therapy services. PT 2 reviewed the PT Evaluation, dated 9/9/2024, and stated Resident 76's right knee was unable to fully extend and had full flexion. PT 2 stated feeling surprised today (during the assessment) that Resident 76's right knee extended fully and had limitations in knee flexion. PT 2 stated Resident 76's PT Evaluation, dated 9/9/2024, indicated Resident 76 continued to have ROM limitations in both ankles, including the inability to bend both ankles to neutral (90-degree position) and were positioned in plantarflexion. PT 2 stated Resident 76 did not receive PT services after the PT Evaluation, dated 9/9/2024, because the health insurance did not authorize therapy services. PT 2 stated Resident 76 would have benefited from therapy services to delay further progression of the contractures after both PT Evaluations. PT 2 reviewed Resident 76's JMS, dated 1/27/2025 (10 days prior to interview), and stated Resident 76's ROM has declined. PT 2 stated Resident 76 had ROM limitations in both hands with the left hand worse than the right hand. PT 2 stated Resident 76 was developing a right knee extension contracture due to limitations into knee flexion and had plantarflexion contractures of both ankles. During a review of the Physiatrist (medical doctor who specializes in physical medicine and rehabilitation) Consultation, dated 2/6/2025 written by Medical Doctor 1 (MD 1), the Physiatrist Consultation indicated Resident 76 was at-risk for joint contractures of both hands due to positioning and recommended hand rolls (soft roll positioned in the palm of the hand and fastened with a strap) and to continue the RNA program for ROM to prevent contractures. The Physiatrist Consultation indicated Resident 76 had plantarflexion contractures in both ankles and recommended to use heel protectors to offload pressure and prevent skin breakdown (tissue damage caused by friction [surfaces rubbing against each other], shear [straight produced by pressure], moisture, or pressure) and to continue the RNA program for PROM to both legs to prevent worsening contractures. The Physiatrist Consultation indicated splinting the plantarflexion contractures would not likely provide functional progress since Resident 76 was not likely to ambulate. During an interview on 2/6/2025 at 1:54 p.m., with MD 1, MD 1 stated Resident 76 was assessed today (date of interview) due to the facility's concerns of contractures. MD 1 stated Resident 76's hands were positioned in a flexion and the fingertip joints of the left hand were bent and digging into the palm, causing redness in the palm. MD 1 stated the facility needed to monitor the resident's the hands closely, protect the left palm, and provide ROM exercises. MD 1 stated Resident 76 had plantarflexion contractures in both ankles which could have been prevented with PROM and splinting. During a concurrent interview and record review on 2/6/2025 at 2:52 p.m., with OT 1, Resident 76's OT Evaluation, dated 8/7/2024, was reviewed. OT 1 stated the OT Evaluation indicated Resident 76's ROM in both arms were impaired because of increased muscle tone and stiffness and did not have actual ROM limitations. OT 1 did not know the reason Resident 76 did not receive skilled services at the facility in accordance with OT 1's recommendations. During an interview on 2/7/2025 at 11:07 a.m., with the DOR, the DOR stated Resident 76 did not receive therapy at the facility because they did not receive authorization from Resident 76's health insurance to provide services. During a telephone interview on 2/7/2025 at 12:14 p.m., with Family 1, Family 1 stated Resident 76's hands have been in closed fists since admission to the facility. Family 1 stated he brought balls and dolls to the facility so the staff could place them and open both of Resident 76's hands. Family 1 stated the GACH discharged Resident 76 to the facility with splints that kept both ankles at 90-degree angles but Resident 76 did not wear them. Family 1 stated the facility found the splints but the therapist (unidentified) informed Family 1 that the splints would hinder the ankles more than help. Family 1 stated the facility did not provide therapy services due to Resident 76's health insurance. Family 1 stated feeling frustrated Resident 76 did not receive any therapy services and should have received therapy to work with the muscles early. During an interview on 2/7/2025 at 3:17 p.m., with the Director of Nursing (DON), the DON stated the purpose of therapy services (in general) was to assist residents in regaining strength, to prevent any decline in ROM to prevent contractures, prevent decline in mobility, activities of daily living ([ADLs] tasks related to personal care including bathing, dressing, hygiene, eating, and mobility), and speech. During a concurrent interview and record review on 2/7/2025 at 3:52 p.m., with the DON, Resident 76's PT and OT Evaluations, dated 8/7/2024, and the facility's policies and procedures (P&P) tilted, Rehabilitation Policy and Procedures, revised 12/30/2019, and Resident Mobility and Range of Motion, revised 7/2017, were reviewed. The DON reviewed Resident 76's PT and OT Evaluations, dated 8/7/2024, and stated the facility did not have any documentation therapy services were provided after the evaluations. The DON stated splints could prevent plantarflexion contractures in addition to ROM. The DON stated Resident 76 did not receive any therapy services to determine whether splints were appropriate. The DON reviewed the facility's P&Ps and stated the P&Ps did not indicate health insurance authorization was necessary prior to providing further intervention to prevent ROM loss. The DON stated the purpose of preventing contractures (in general) was to prevent pain, further impairment in mobility, and fractures. During a concurrent interview and record review on 2/7/2025 at 4:57 p.m. with the DON, Resident 76's JMS dated 1/27/2025 and Physiatrist Consult, dated 2/6/2025, were reviewed. The DON stated the JMS, dated 1/27/2025, indicated both of Resident 76's ankles had full/functional ROM and the Physiatrist Consult, dated 2/6/2025 (10 days after the JMS) indicated Resident 76 had plantarflexion contractures of both ankles. The DON stated Resident 76's JMS was inaccurate. The DON stated an inaccurate JMS would not identify ROM loss and would prevent treatment of ROM loss. During a review of the facility's P&P titled, Rehabilitation Policy and Procedures: Evaluation and Plan of Care, revised 12/30/2019, the P&P indicated the evaluating clinician was responsible to complete the written treatment plan. During a review of the facility's P&P titled, Resident Mobility and Range of Motion, revised 7/2017, the P&P indicated residents will not experience an avoidable reduction in ROM and residents with limited ROM will receive treatment and services to increase and/or prevent a further decrease in ROM. The P&P also indicated intervention may include therapies, the provision of necessary equipment, and/or exercises and will be based on professional standards of practice. b. During a review of Resident 48's admission Record, the admission Record indicated the facility originally admitted Resident 48 on 8/7/2020 and re-admitted on [DATE]. The admission Record indicated Resident 48's diagnoses included respiratory failure (serious condition that develops when the lungs cannot get oxygen into the blood), encephalopathy (disease that affects the brain, causing changes in its function), cerebral infarction (brain damage due to a loss of oxygen to the area), dysphagia (difficulty swallowing), attention to tracheostomy (hole made through the front of the neck an into the windpipe [trachea] to allow air into the lungs), and attention to gastrostomy ([G-tube] surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for peop[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the resident was free of physical and verbal abuse for one of seven sampled residents (Resident 1). The facility failed to: 1. Ensure Resident 1 was not verbally and physically abused by Resident 7. 2. Adhere to its policy and procedure titled, Abuse Prevention Program, which indicated the residents have the right to be free from abuse including verbal and physical abuse. Resident 7 verbally and physically abused Resident 1 by telling Resident 1 to shut up and placing a pillow over Resident 1 ' s face. This deficient practice resulted in Resident 1 being verbally and physically abused, feeling violated and fearful for her life. Findings: During a review of Resident 1 ' s admission Record (face sheet), the face sheet indicated Resident 1 was admitted to the facility on [DATE] with a diagnosis including chronic obstructive pulmonary disease (a disease that block the airflow and make it difficult to breathe) and a history of cerebral infarction (lack of adequate blood supply to the brain cells, depriving the oxygen supply and nutrients, which can cause parts of the brain to die). During a review of Resident 1 ' s Minimum Data Set (MDS), a standardized assessment and care-screening tool (an assessment of a resident's functional capabilities and helps the nursing staff to identify health problems), dated 9/16/2022, the MDS indicated Resident 1 ' s cognition (thought process) was intact, and she was able to make independent decisions that were reasonable. The MDS indicated Resident 1 was totally dependent on staff with a one-person physical assistance to complete activities of daily living (ADLs) tasks such as repositioning, mobility, transfer, bathing, and hygiene, and is incontinent (inability to control) of both bowel and bladder functions. During a telephone interview on 12/20/2022 at 7:06 a.m., the Resident 1 ' s responsible party (RP 1), RP 1 stated she came to visit Resident 1 at the facility on 12/19/2022 after 11:30 a.m. RP 1 stated she observed Resident 1 ' s room door was closed, and she could hear Resident 1 calling the nurse from outside the door. RP 1 stated when she opened the door, she saw Resident 1 upset and her pillow was on the floor. RP 1 stated Resident 1 told her there was a guy who shoved the pillow on her face pressing her nose as if to choke (suffocating) her and told her to shut up and then left the room. RP 1 stated Resident 1 was in distress and trembling in fear as she could see how much this affected her. RP 1 stated, I was upset as to how someone can disrespect and lay his hands on an elderly without mercy. RP 1 stated she reported the incident to the nursing staff (charge nurses) immediately on 12/19/2022. During an interview on 12/20/2022 at 12:20 p.m. with Resident 1, Resident 1 stated, I was calling a nurse in a loud voice when a guy with white hair, long beard, and wearing a green dress (gown) came inside my room, told me to shut up, and picked up my pillow and pressed the pillow hard on my face. Resident 1 stated she was scared for her life and felt violated of what the guy did to her. Resident 1 stated she saw the same man standing outside her door the day before (12/19/2022) and remembered he closed the door to her room. During a review of Resident 7 ' s admission Record (face sheet), the face sheet indicated Resident 7 was admitted to the facility on [DATE] with a diagnosis including aftercare of ileostomy (a surgical procedure creating an opening through the stomach to empty intestinal wastes to an external pouch [bag; for drainage] placed over the opening) and diabetes mellitus (elevated sugar levels in the blood and urine). During a review of Resident 7 ' s MDS dated [DATE], the MDS indicated Resident 7 was able to make independent decisions that were consistent and reasonable. According to the MDS, Resident 7 required extensive assistance of a one-person physical assist to complete ADLs tasks such as locomotion (movement) on unit and off unit, bathing, and toilet use. During a review of Resident 7 ' s Physical Therapy Evaluation and Notes, dated 12/13/2022, the Physical Therapy Treatment Notes indicated Resident 7 was able to ambulate at 175 feet with no assistive device. On 12/22/2022 at 11:07 a.m., during a review of the facility ' s video camera surveillance (a system of monitoring activity in an area or building using a television system in real time), with the administrator (ADM), the video surveillance showed on 12/19/2022 between the hours of 7:50 a.m. to 9:05 a.m., Resident 7, who has white hair and a long beard, was wearing a green gown walking steadily, with no assistive device, out of his room. Resident 7 was standing by the nursing station and later sat down by the reception sitting area. At 11:02 a.m. on the same day, the video surveillance showed Resident 7 walking in the hallway, without any assistive device, towards Resident 1 ' s door and appeared to speak to someone inside the room of Resident 1. Resident 7 then walked back into his room. At 11:07 a.m., of the same day, the surveillance video showed Resident 7 walking out of his room while wearing a pair of gloves, went towards Resident 1 ' s room and closed the door and then went back to his room. At 11:17 a.m., on the same day, the video surveillance showed Resident 7 walking out of his room with gloves on both hands, holding a small bag, and disposed the gloves and bag, inside the housekeeper ' s bin which was across the hall, and then Resident 7 walked back into his room. According to the video surveillance camera, the door of Resident 1 remained closed on the same day (12/19/2022), from 11:07 a.m. to 11:27 a.m., until a woman (RP 1) appeared walking towards the room of Resident 1, knocked on the door and subsequently opened the resident ' s door. During a telephone interview on 12/22/2022 at 1:43 p.m. with Resident 7, Resident 7 stated he stayed at the facility for a month, and he recovered well after surgery (ileostomy). Resident 7 stated he was discharged home on [DATE]. Resident 7 stated during his stay at the facility, he had no problems with his activities of daily living and was able to move in and out of bed, walk at the facility and use the bathroom without help or any assistive device. Resident 7 stated during his stay, he would always hear Resident 1 in the next room, hollering for a nurse anytime of the day or night and it always annoyed him. Resident 7 stated when he used the bathroom, since he shared a bathroom with both Residents 1 and 2 (females) he would shout out Shut up! at Resident 1 from inside of the bathroom. Resident 7 stated the bathroom has locks from inside of both doors (his room and the room of Residents 1 and 2). Resident 7 denied closing the door of Resident 1 on 12/19/2022 at 11:07 a.m. (which Resident 7 was observed closing Resident 1 ' s door on the surveillance camera on 12/19/2022 at 11:07 a.m.). During an interview on 12/23/2022 at 10:06 a.m. with Certified Nursing Assistant 4 (CNA 4), CNA 4 stated she has seen Resident 7 leave his room and stand by Resident 1 ' s door and shout at Resident 1 to shut up. CNA 4 stated she had also seen Resident 7 opened the bathroom door and shouted at Resident 1, telling her, Shut up! CNA 4 could not remember the exact dates these incidents occurred, but she stated when it happened, she informed the licensed nurses immediately. CNA 4 stated she was concerned because Resident 7 was disrespectful to not only Resident 1 but also her roommate (Resident 2), by opening the bathroom door shouting at Resident 1. CNA 4 stated, Anything could happen to Residents 1 and 2, such as other form of abuse, even death, because Residents 1 and 2 cannot defend themselves. During a concurrent observation and interview while looking at the shared bathroom on 12/23/2022 at 10:38 a.m. with the Licensed Vocational Nurse (LVN 1) confirmed the shared bathroom doors of Resident 1 and 2 both females and Resident 7 a male, are easily accessible through both rooms. LVN 1 confirmed Resident 7 was ambulatory, used the bathroom frequently which gave Resident 7 access to both Residents 1 and 2 ' s room through the shared bathroom. LVN 1 stated, This was a safety issue, and it was the facility ' s duty to protect the residents. During an interview on 12/23/2022 at 10:53 a.m. with the Registered Nurse Supervisor (RNS), the RNS confirmed the accessibility of the shared bathroom doors of Resident 1, Resident 2, and Resident 7. The RNS stated no one knows of Resident 7 ' s intentions nor his mindset and Resident 1 and Resident 2 could have been really harmed. The RNS stated it was the duty of the facility and its staff to protect the residents because most of them are vulnerable. During an interview on 1/3/2023 at 10:33 a.m. with the ADM, the ADM confirmed the bathroom was shared with the residents being male and female. The ADM remained silent when asked how vulnerable residents such as Residents 1 and 2 could protect themselves from a male resident who can access their room at any time. The ADM stated Resident 7 was in the facility for a month and the Social Services Director (SSD) had done an investigation and interviewed Residents 1 and Resident 7 when the incident was reported by RP 1. The ADM stated Resident 7 was moved to a different room after it was reported, because we agree now Resident 1 description matched Resident 7 ' s description of the perpetrator. During a review of the facility ' s policy and procedure (P/P), revised in 1/2022 and titled, Abuse Prevention Program, the P/P indicated the facility ' s residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation and this includes, but not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual, or physical abuse and physical or chemical restraint not required to treat the resident ' s symptoms.