**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure two of two sampled residents (Resident 69 and Resident 13), who were investigated under the pressure ulcer (PU - damage to an area of the skin caused by prolonged pressure or friction, often over bony areas like the tailbone, heels or elbows) care area, received care consistent with professional standards of practice by failing to: 1. Prevent the worsening of a Stage Two (2) (an open, shallow wound that has damaged the epidermis [top layer of the skin] and the dermis [middle layer of the skin], with the fluid-filled blister appearing as a ruptured or intact blister containing fluid) fluid-filled blister (a painful skin condition where fluid fills a space between layers of skin) on Resident 69's left heel, initially identified on 8/22/2025. The facility failed to: a. Offload (to reduce or remove pressure on the affected area to promote healing and prevent further damage) Resident 69's left heel to relieve pressure and prevent the worsening of an existing Stage Two, fluid-filled blister on the left heel. b. Provide Resident 69 an alternating pressure pad (APP - alternating pressure mattress system used to prevent and treat PU, works by constantly changing the pressure points on a person's body to improve blood circulation and reduce the risk of tissue damage from prolonged, unrelieved pressure) to reduce pressure and friction that contribute to the development and progression of PU.These deficient practices resulted in Resident 69's Stage Two fluid-filled blister on the left heel becoming open, macerated (the skin surrounding the wound becomes soft, soggy, wrinkled due to excessive exposure to moisture - typically the fluid draining from the blister), and enlarged, causing pain and discomfort to Resident 69.Cross reference F656 2. Prevent Resident 13's left hand from skin injuries due to severe range of motion ([ROM] full movement potential of a joint) limitations including the inability to fully extend the left-hand fingers. This deficient practice had the potential for Resident 13's left hand to develop infections and pressure injuries (localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence). Cross reference F688. Findings: 1. During a review of Resident 69’s admission Record, the admission Record indicated the facility initially admitted Resident 69 on 1/15/2025 and re-admitted Resident 69 on 6/26/2025 with diagnoses including type two (2) diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing), hemiplegia (paralysis [inability to move] on one side of the body), and hemiparesis (a condition where there is weakness on one side of the body) following cerebral infarction (commonly known a stroke, caused by a blockage in a blood vessel in the brain, leading to brain tissue damage) affecting the right side and dysphagia (difficulty swallowing). During a review of Resident 69’s History and Physical (H&P- a comprehensive assessment of a resident’s medical condition), dated 6/27/2025, the H&P indicated Resident 69 had the capacity to understand and make decisions. During a review of Resident 69’s Minimum Data Set (MDS - a resident assessment tool) dated 6/30/2025, the MDS indicated that Resident 69 was usually understood by others and was also able to usually understand others. The MDS indicated Resident 69 was dependent on facility staff for Activities of Daily Living (ADLs- essential, basic self-care tasks required to live independently) including toileting, bathing, and lower body dressing and required maximal assistance from staff with mobility (movement) such as rolling from side to side, transitioning from lying to sitting on the side of the bed, sit-to-stand transfers, and toilet transfers. The MDS indicated Resident 69 did not have any PU at the time of assessment but was identified as being at risk for developing PU. During a review of Resident 69’s Braden Scale (a scoring tool used to predict resident’s risk of developing a pressure ulcer, total score ranges from six [6] to 23. A lower score indicating a higher risk of developing a pressure ulcer) dated 6/26/2025, timed at 10:21 p.m., the Braden Scale assessment score was 15, indicating Resident 69 was at moderate risk for developing pressure ulcer. During a review of Resident 69’s Care Plan, untitled, initiated on 6/27/2025, the Care Plan indicated that Resident 69 is at risk for pressure ulcer development and further skin breakdown related to type two DM, requires staff assistance with bed mobility and repositioning, incontinence (inability to control the flow of urine from the bladder [organ that stores the urine] or the escape of stool from the rectum [serves as temporary storage site for stool before it is eliminated from the body]), and decreased overall mobility. The interventions included were to administer treatments as ordered and monitor for effectiveness, encourage to turn and reposition and provide assistance as necessary. During a review of Resident 69’s Care Plan, titled “Alteration in Musculoskeletal (refers to muscles and skeleton) Status” initiated on 7/18/2025, the Care Plan indicated that Resident 69 required position changes to prevent pressure-related skin breakdown due to osteoarthritis (breakdown of cartilage [the protective tissue that cushions the ends of bones]) and osteoporosis (a condition in which bones become weak and brittle, making them more prone to fractures) of the right knee. During a review of Resident 69’s Change of Condition (COC- when there is a sudden change in a resident’s condition) Evaluation form completed by Treatment Nurse 1 (TN 1), dated 8/22/2025, timed at 2:54 p.m., the COC form indicated that Resident 69 had a fluid filled blister on the left heel measuring 3.2 centimeters (cm – unit of measure) in length x (by) 3.4 cm in width x unable to determine (UTD) depth. During a review of Resident 69’s Physician’s Order, dated 8/22/2025, the Physician’s Order indicated treatment for Resident 69’s fluid-filled blister on the left heel. The Physician’s Order indicated to cleanse the area with normal saline (a mixture of water and salt), pat dry, apply betadine external solution (brand name for povidone-iodine, a topical [applied directly to skin] antiseptic solution [substance that keeps the broken skin from getting infected] used to clean and disinfect the skin to prevent an infection from developing, thus promoting healing) topically and cover with dry dressing (wound covering that keeps the wound surface dry) every day shift for 30 days. During a review of Resident 69’s Care Plan titled “Has Actual Impairment to Skin Integrity,” initiated on 8/22/2025, the Care Plan indicated an intervention to float Resident 69’s heels. During an interview on 8/25/2025 at 9:03 a.m. with TN 1, outside of Resident 69’s room, TN 1 stated that he had just completed treatment for Resident 69’s fluid-filled blister on the left heel and that Resident 69 was currently attending an activity. TN 1 stated that the fluid-filled blister had been initially identified by Certified Nursing Assistant 5 (CNA 5) on 8/22/2025 during morning care and skin check on 8/22/2025, during the 7 a.m. to 3 p.m. shift. TN 1 stated that the blister was dry, intact, and stable (not worse, not better, not showing signs of infection) when TN 1 changed the dressing that morning (8/25/2025). TN 1 stated that current interventions included floating the heels and applying Betadine daily to promote drying and help prevent infection. TN 1 further stated that the blister most likely developed due to pressure from the bed and not offloading Resident 69’s heels. During an observation on 8/27/2025 at 8:30 a.m., in Resident 69’s room, Resident 69 was observed lying flat on a regular mattress, with both heels in direct contact with the mattress surface. There was no pillow or offloading device (specialized footwear and mechanical supports designed to reduce pressure on a specific area of the foot) observed in place to offload Resident 69’s heels. During a concurrent observation and interview on 8/27/2025 at 8:40 a.m., with CNA 5, in Resident 69’s room, observed Resident 69’s both heels touching the mattress surface. CNA 5 stated that she (CNA 5) forgot to float Resident 69’s heels. CNA 5 stated that it is extremely important to offload Resident 69’s heels because of the existing blister on the left heel, which could open and worsen if not properly offloaded. CNA 5 then called CNA 6 to assist with transferring Resident 69. Resident 69 was assisted into a sitting position on the left side of the bed (feet not touching the floor) and was transferred to a wheelchair with assistance from both CNAs (CNA 5 and CNA 6). During a concurrent observation and interview on 8/28/2025 at 8:33 a.m. in the hallway near Resident 69’s room, observed Resident 69 sitting upright in her (Resident 69) wheelchair while being pushed by CNA 5. Observed a pillow was positioned behind Resident 69’s lower legs and heels, resting against the wheelchair’s footrests. CNA 5 stated she (CNA 5) was transporting Resident 69 to the activity and had placed the pillow for comfort. CNA 5 stated that she (CNA 5) did not realize that the pillow and footrests were in contact with Resident 69’s heels, which could potentially worsen the fluid-filled blister on Resident 69’s left heel. CNA 5 further stated that the pillow must have slipped down and then readjusted the pillow to ensure Resident 69’s heels were floating. During a concurrent observation and interview on 8/28/2025 at 1:07 p.m., with CNA 5, in Resident 69’s room, observed Resident 69 sitting upright in her (Resident 69) wheelchair next to her (Resident 69) bed with a pillow positioned behind Resident 69’s lower legs and heels and up against the wheelchair’s footrests. CNA 5 stated that the pillow must have slipped down again for an unknown period of time . CNA 5 then proceeded to readjust the pillow to ensure that Resident 69’s left heel was properly floated. During an interview on 8/28/2025 at 1:12 p.m. with TN 1, TN 1 stated Resident 69 has a care plan intervention in place to float her (Resident 69) heels and that the heels must remain floating at all times to prevent further skin breakdown. TN 1 stated that Resident 69 is at high risk for developing a pressure ulcer. TN 1 stated that upon Resident 69’s readmission to the facility on 6/26/2025, Resident 69 had a now healed non-blanchable redness (an area of skin that does not turn white when pressure is applied) on her (Resident 69) sacrum (triangular-shaped bone at the base of the spine) which has since healed. TN 1 further stated that it is his (TN 1) responsibility to recommend and obtain physician’s order for pressure relieving devices (reduces pressure on the affected area to promote healing and prevent further damage such as pressure ulcers) for residents identified as high risk for developing pressure ulcers. TN 1 stated he (TN 1) should have obtained an order for APP mattress when Resident 69 had the non-blanchable redness on the sacrum area identified on 6/26/2025 as it may have helped prevent further skin breakdown in other areas such as the development of fluid-filled blister on Resident 69’s left heel. During a concurrent observation and interview on 8/28/2025 at 1:37 p.m., with TN 1 and Treatment Nurse 2 (TN 2), in Resident 69’s room, observed TN 1 and TN 2 providing wound care to Resident 69’s left heel. TN 1 removed the dressing on Resident 69’s heel and stated that there was a light-yellow tinge on the dressing. TN 1 stated that the light-yellow tinge may have been caused by the betadine solution. While TN 1 repositioned Resident 69 to assess the left heel, a tear was observed rolling down Resident 69’s right cheek. TN 2 asked Resident 69 if she (Resident 69) was experiencing pain in her (Resident 69) left heel, to which Resident 69 responded “Yes, it hurts a lot.” TN 1 stated that the heel now appeared worse and described the left heel as a partial-thickness skin lesion (any abnormal lump, discoloration [any change in the normal color of the skin], sore [refers to pressure ulcer] or other change or on or in the skin that differs from the surrounding skin’s normal appearance) with a shallow open area and a pink wound bed (surface at the base of a wound), measuring three (3) cm x 3.8 cm x UTD, with the open lesion measuring 0.6 cm x 0.7 cm x UTD. TN 2 stated that when she (TN 2) last changed the dressing on 8/27/2025, the blister had been intact. TN 1 further stated that the use of an APP mattress, and consistent heel-floating could have prevented Resident 69’s pain and the worsening of the blister on Resident 69’s left heel. During an interview on 8/28/2025 at 4:37 p.m., with the Director of Nursing (DON), the DON stated that Resident 69’s pressure ulcer on her (Resident 69) left heel was avoidable. The DON stated that the licensed nurses should have obtained a physician’s order for an APP mattress, especially given that Resident 69 had a history of a pressure ulcer, mobility limitations and pain related to osteoarthritis. The DON stated that Resident 69’s heels should never have been resting flat on the bed. During a review of the facility provided APP Owner’s Manual, undated, the manual indicated that the APP is a flotation therapy device that provides pressure management to assist in the prevention and treatment of pressure injuries. During a review of the facility's Policy and Procedure (P&P) titled “Skin and Wound Monitoring and Management” last reviewed on 4/2025, the P&P indicated a resident who enters the facility without a pressure injury does not develop a pressure injury unless the individual’s clinical condition demonstrates it was unavoidable. The P&P defines stage 2 pressure injury as partial thickness skin loss with exposed dermis. The P&P further indicates to prevent pressure ulcers by repositioning and using pressure mattresses, wedges and pillows. 2. During a review of Resident 13’s admission Record, the admission Record indicated the facility admitted Resident 13 on 3/11/2025 with diagnoses including atherosclerotic heart disease (fatty deposits [plaque] build up inside the blood vessels that supply the heart making the vessels stiff and narrow), Major Depressive Disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), age-related cognitive (ability to think, understand, learn, and remember) decline, and anxiety disorder (mental health disorder characterized by feelings of worry or fear that are strong enough to interfere with one’s daily activities). During a review of Resident 13’s Physician’s Certification for Hospice (compassionate care for people who are near the end of life provided at the person’s home or within a health care facility) Benefit, dated 3/11/2025, the Physician’s Certification indicated Resident 13’s primary hospice diagnosis was atherosclerotic heart disease. During a review of Resident 13’s Minimum Data Set ([MDS] a resident assessment tool), dated 3/13/2025, the MDS indicated Resident 13 had clear speech, had limited ability to express ideas and wants, responded adequately to simple and direct communication only, and had severely impaired cognition. The MDS indicated Resident 13 had functional limitations in ROM (limited ability to move a joint that interferes with daily functioning or places the resident at risk of injury) in both arms and legs. The MDS indicated Resident 13 required setup or clean-up assistance (helper sets up or cleans up while resident completes the activity, helper assists only prior to or following the activity) for eating, partial/moderate assistance (helper does less than half the effort) for rolling to either side in bed, and substantial/maximal assistance (helper does more than half the effort) for toileting, upper and lower body dressing, and toilet transfers. The MDS indicated Resident 13 was dependent (helper does all the effort, resident does none of the effort to complete the activity, or the assistance of two or more helpers is required to complete the activity) for transferring from lying to sitting on the side of the bed and chair/bed-to-chair transfers. The MDS indicated Resident 13 was at risk of developing pressure injuries. During a review of Resident 13’s initial JME, dated 3/18/2025, completed by Occupational Therapist (OT - profession aimed to increase or maintain a person's capability of participating in everyday life activities [occupations]) 2 (OT 2), the JME indicated Resident 13 had moderate ROM limitation (50% to 75% range intact – means the joint is restricted to between half and three-quarters of its normal, full ROM) in the right hip and minimum ROM limitation (75 to 100% range intact – means the joint or body part has a minimum of 75% of its normal, healthy ROM to 100% no limitation at all) in both shoulders, the right elbow, the left hip, and both knees. The JME indicated Resident 13 had no ROM limitations in the left elbow, both wrists, both fingers (hands), and both ankles. During a review of Resident 13’s Hospice Updated Assessment, dated 4/3/2025, 4/17/2025, 5/1/2025, 5/15/2025, and 5/29/2025, the Hospice Updated Assessment indicated Resident 13 had ROM loss (unspecified location). During a review of Resident 13’s quarterly JME, dated 6/2/2025 and completed by Occupational Therapist 1 (OT 1), the JME indicated Resident 13 had severe ROM limitation (0-25% range intact) in the left-hand fingers, moderate ROM limitation in the right hip, and minimum ROM limitations in the left shoulder, the left hip, and both knees. During a review of Resident 13’s MDS, dated [DATE], the MDS indicated Resident 13 had clear speech, had limited ability to express ideas and wants, responded adequately to simple and direct communication only, and had severely impaired cognition. The MDS indicated Resident 13 had functional limitations in ROM in one arm and both legs. The MDS indicated Resident 13 required supervision or touching assistance (helper provides verbal cues and/or touching and/or steadying assistance as resident completes the activity) for eating and substantial/maximal assistance for upper body dressing, rolling to either side in bed, and transferring from lying to sitting on the side of the bed. The MDS indicated Resident 13 was dependent for toileting and lower body dressing. The MDS indicated Resident 13 was at risk of developing pressure injuries. During a review of Resident 13’s Census List (record of hospitalizations, room changes, and payer source changes), the Census List indicated Resident 13 had a room change on 6/12/2025. During a review of Resident 13’s Hospice Updated Assessment, dated 7/10/2025 and 7/24/2025, the Hospice Updated Assessment indicated Resident 13 had ROM loss (unspecified location) and contractures (unspecified location). During a review of Resident 13’s physician’s orders, dated 8/19/2025, the physician’s orders indicated to start the Restorative Nursing Aide ([RNA] nursing aide program that helps residents to maintain their function and joint mobility) program on 8/20/2025 for passive range of motion ([PROM] movement of a joint through the range of motion with no effort from person) to both arms and legs, five times per week as tolerated. During a review of Resident 13’s quarterly JME, dated 8/21/2025, the JME indicated Resident 13 had severe ROM limitation in the left-hand fingers, moderate ROM limitation in the right hip, and minimum ROM limitation in the left shoulder, the left hip, and both knees. During a review of Resident 13’s Change in Condition (CIC) Evaluation, dated 8/25/2025, the CIC Evaluation indicated Resident 13 had small cut with scant (little) bleeding from nails being trimmed at the left ring finger. The CIC Evaluation indicated Resident 13’s physician was notified to cleanse the left ring finger with normal saline (sterile solution of salt water), pat dry, apply Betadine external solution (topical chemical substance used to prevent and treat skin infections), and cover with a dry dressing. During an interview on 8/26/2025 at 9:36 a.m. with the Director of Rehabilitation (DOR), the DOR stated the JME was completed quarterly by the therapy staff to monitor the residents’ ROM and mobility. The DOR stated the purpose of the JME was to ensure the residents (in general) maintained their ROM, prevent the development of contractures, and prevent the worsening of contractures. The DOR stated ROM limitations and contractures could cause skin injuries and could affect the residents’ comfort and quality of life. During a concurrent observation and interview on 8/26/2025 at 11:10 a.m. in the resident’s room, Resident 13 was lying in bed and had oxygen running through the nasal cannula (a small plastic tube, which fits into the person’s nostrils for providing supplemental oxygen). Resident 13 was observed using the right hand to hold a towel over Resident 13’s nose and mouth. Resident 13 stated the towel was over the nose and mouth to protect Resident 13 from germs. Resident 13’s left arm, body, and both legs were covered with a blanket. During a concurrent observation and interview on 8/27/2025 at 11:13 a.m. with Restorative Nursing Assistant 2 (RNA 2) in the resident’s room, Resident 13’s RNA program was observed. Resident 13 spoke clearly but expressed disorganized thoughts while lying in bed. RNA 2 stated Resident 13 had behaviors of not complying with the exercises. Resident 13 was observed bending and extending both legs and raising both arms overhead without any assistance. Resident 13’s left hand was observed in a closed fist position with three tarnished rings on the left ring finger. Resident 13’s left-hand fingernails, including an adhesive bandage on the tip of the ring finger, slightly touched the palm. Resident 13’s left hand did not have any device applied to the palm to prevent the fingernails from touching the palm. Resident 13 stated, “We are not doing any exercises today,” but agreed to an observation of the skin on the left palm. Resident 13 used the right hand to extend the left-hand fingers but could not completely straighten the fingers, which remained in bent positions at all joints. Resident 13’s left-hand palm had intact skin. During a concurrent interview and record review on 8/27/2025 at 12:49 p.m. with OT 1, Resident 13’s JME, dated 3/18/2025 and 6/2/2025, was reviewed. OT 1 stated Resident 13 was admitted to the facility with hospice care services on 3/11/2025 and never received therapy services. OT 1 reviewed Resident 13’s JME, dated 3/18/2025, and stated the JME indicated Resident 13 had moderate ROM limitation in the right hip and minimum ROM in both shoulders, the right elbow, the left hip, and both knees. OT 1 stated the JME did not indicate any recommendations for the ROM limitations. OT 1 reviewed Resident 13’s JME, dated 6/2/2025, and stated the JME indicated Resident 13 had severe ROM limitation in the left-hand fingers, moderate ROM limitation in the right hip, and minimum ROM limitations in the left shoulder, the left hip, and both knees. OT 1 stated residents under hospice care, from OT 1’s experience, did not receive any intervention including RNA services. During a concurrent observation and interview on 8/27/2025 at 2:31 p.m. with Certified Nursing Assistant 1 (CNA 1) in the resident’s room, Resident 13’s left hand was observed. Resident 13’s left hand was in a closed fist position without any device placed between the fingernails and the left-hand palm. Resident 13 continued to wear three tarnished rings on the left ring finger. CNA 1 stated the treatment nurse (unspecified) put on the adhesive bandage to the tip of Resident 13’s left-hand ring finger. During a follow-up interview on 8/27/2025 at 2:39 p.m. with CNA 1, CNA 1 stated Resident 13 had been assigned to CNA 1 for the past three months after Resident 13 moved from another bedroom to Resident 13’s current room. CNA 1 stated Resident 13’s left hand did not have a closed fist when Resident 13 moved to the current room. CNA 1 stated Resident 13 started developing a closed fist to the left hand approximately one month ago (unknown date) and reported it to the charge nurse (unknown). During a telephone interview on 8/27/2025 at 3:42 p.m. with FM 1 and Family Member 2 (FM 2), FM 1 stated Resident 13 hid the left-hand during family visits. FM 1 described Resident 13’s left-hand as curled up, stiff, and unable to open. FM 1 stated Resident 13’s left hand did not have a closed fist position upon admission to the facility and developed the closed fist shortly after (unknown date) Resident 13’s admission. During a concurrent observation an interview on 8/28/2025 at 9:18 a.m. with Treatment Nurse 2 (TN 2) in the resident’s room, Resident 13 was lying in bed and observed without any device in the left hand to prevent the fingernails from touching the palm. TN 2 stated Resident 13 was unable to fully open the left-hand fingers. TN 2 stated the fingernails were cut to prevent them from digging into the skin of Resident 13’s left palm since the fingers were bent. TN 2 stated Resident 13 did not have anything placed in the left-hand to protect the skin from the fingernails. TN 2 also stated Resident 13’s rings could erode (break down) and open the skin underneath the left ring finger. During an interview on 8/28/2025 at 9:26 a.m. with Restorative Nursing Assistant 1 (RNA 1), RNA 1 stated Resident 13’s nails were cut on Sunday (8/24/2025) after noticing the left hand was moist and had some redness in the palm. RNA 1 stated moisture in Resident 13’s left hand was not hygienic and could cause an infection. RNA 1 stated Resident 13’s left-hand fingernails needed to be cut to prevent them from pushing into the skin. RNA 1 stated Resident 13 used the right hand to push a towel inside the left hand to clean. RNA 1 stated Resident 13 did not have a splint (material used to restrict, protect, or immobilize a part of the body to support function, assist and/or increase range of motion) or any other device to place in the left hand. During an interview on 8/28/2025 at 9:38 a.m. with CNA 1, CNA 1 stated Resident 13 did not have any device to place in the left-hand palm. CNA 1 stated a towel was sometimes placed in the left hand but Resident 13 could remove the towel. During a telephone interview on 8/28/2025 at 9:56 a.m. with Treatment Nurse 3 (TN 3), TN 3 stated Resident 13’s CIC Evaluation for the left-hand finger cut was written on 8/25/2025 but occurred on 8/24/2025. TN 3 stated someone else (unknown) had already cut Resident 13’s left-hand fingernails on 8/24/2025 but they were still too long. TN 3 stated Resident 13’s left-hand fingers were in a bent position and could be extended enough to trim the nails. TN 3 stated TN 3 was present in Resident 13’s room while a LVN (unknown name) trimmed Resident 13’s nails and cut the left ring finger too much causing it to bleed. TN 3 stated Resident 13’s physician was contacted and agreed to the application of Betadine for the cut. During a telephone interview on 8/28/2025 at 10:24 a.m. with Resident 13’s Hospice RN, the Hospice RN stated Resident 13 had a left-hand contracture and a left-hand skin cut. The Hospice RN stated Resident 13’s left-hand contracture had developed “a few weeks if not a few months” ago (from the date of the interview). The Hospice RN stated the biggest concern would be to prevent Resident 13 from developing any skin issues from the contractures since the left hand was in a closed position, which could cause fungal issues in the palm and skin tears wherever Resident 13’s nails make contact. The Hospice RN stated Resident 13 did not have any skin issues prior to the left-hand skin cut. During an interview on 8/28/2025 at 12:35 p.m. with OT 1 and the DON, Resident 13’s JME, dated 3/18/2025 and 6/2/2025, was reviewed. The DON and OT 1 reviewed Resident 13’s JME, dated 3/18/2025, and stated Resident 13 did not have any ROM limitations in the left-hand fingers. The DON and OT 1 reviewed Resident 13’s JME, dated 6/2/2025, and stated Resident 13 had severe ROM limitations in the left-hand fingers. OT 1 stated nursing was not notified regarding Resident 13’s “substantial decline” of ROM in the left hand because of OT 1’s misinformation that intervention was not supposed to be provided to residents under hospice care. During an interview on 8/28/2025 at 2:01 p.m. with the DON, the DON stated residents were not supposed to develop contractures because it would affect their quality of life and activities of daily living ([ADLs] routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). The DON stated the development contractures placed residents at higher risk for pressure injury. During an interview on 8/28/2025 at 2:45 p.m. with the DON, the DON stated cutting Resident 13’s fingernails prevented the nails from digging into the palm which could cut the skin. The DON stated the rings worn on Resident 13’s left ring finger could get stuck, cause pressure, and cause swelling since the fingers were in a bent position. The DON stated Resident 13’s left hand ROM limitations increased the resident’s potential for skin injuries. During a telephone interview on 8/28/2025 at 3:09 p.m. with Resident 13’s primary physician (Hospice MD), the Hospice MD stated the hospice goal included to maintain Resident 13’s comfort. The Hospice MD stated the hospice team had an internal discussion a few weeks or one month ago (from the interview date) about Resident 13’s closed fist position on the left hand. The Hospice MD was unaware of Resident 13’s JME, dated 6/2/2025, which identified Resident 13’s severe ROM loss in the left-hand. Hospice MD stated, “I would have appreciated if this was reported to me at least.” The Hospice MD stated a one-time OT evaluation could have been ordered for recommendations, including braces (material used to restrict, protect, or immobilize a part of the body to support function, assist and/or increase range of motion), towel rolls, or any conservative measures to prevent Resident 13’s ROM in the left hand from worsening and to prevent the development of any wounds from the closed fist position. During a review of the facility’s policy and procedure (P&P) titled, “Skin and Wound Monitoring and Man

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide services to maintain range of motion (ROM- full movement potential of a joint) and mobility (ability to move) for two of four sampled residents (Resident 13 and Resident 69) reviewed under the Position/Mobility care area by failing to: 1. Provide Resident 13 with ROM exercises to both arms and legs following the identification of ROM limitations on the initial Joint Mobility Evaluation (JME- brief assessment of a resident's ROM in each joint of both arms and legs), dated 3/18/2025. 2. Implement interventions including ROM exercises and the use of devices to prevent further ROM loss and ensure skin protection after worsening ROM was identified in Resident 13's left-hand fingers progressing from no ROM limitation (means 100 percent [%] range intact) to severe ROM limitation (zero [0] to 25% - means the joint can only move through a minimal portion of its normal, healthy range - a measurement of zero would mean the joint has no movement at all [full stiffness], 25% means the joint can only move a quarter of the way) on the quarterly JME, dated 6/2/2025. 3. Report and address Resident 13's ROM decline in the left hand, observed during daily care from 6/12/2025 to 8/28/2025, to the primary care physician, in accordance with Resident 13's care plan titled, Risk for Alteration (changes) in Episodes of Comfort. 4. Follow the facility's policy and procedures (P&P) titled, ROM and Contracture (a stiffening or shortening at any joint that reduces the joint's range of motion) Prevention to ensure that Resident 13, who was receiving hospice care (compassionate care for people who are near the end of life provided at the person's home or within a health care facility), maintained and/or improved their ROM. 5. Follow the facility's P&P titled, Restorative Program (focuses on implementing nursing interventions to improve or maintain a resident's ability to perform Activities of Daily Living [ADL, basic tasks that individuals perform to maintain their daily lives and independence]) to restore or maintain Resident 13's mobility skills and ROM. These deficient practices resulted in Resident 13, who was admitted to the facility on hospice care, not receiving any interventions to prevent ROM decline from 3/18/2025 to 8/21/2025 (a period of five months), leading to the development of contractures in the fingers of the left hand and placed Resident 13 at increased risk for infection and pressure injury (a localized area of skin damage that develops when prolonged pressure is applied to a specific area of the body) in the left-hand. 6. Provide Resident 69 with the Restorative Nursing Aide ([RNA] nursing aide program that helps residents to maintain their function and joint mobility) program for sit-to-stand transfers on 8/26/2025 in accordance with the physician's orders, dated 8/22/2025. These failures also had the potential for Resident 69 to experience a decline in mobility. Cross reference F580, F656, and F686. Findings: a. During a review of Resident 13's admission Record, the admission Record indicated the facility admitted Resident 13 on 3/11/2025 with diagnoses including atherosclerotic heart disease (fatty deposits [plaque] build up inside the blood vessels that supply the heart making the vessels stiff and narrow), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), age-related cognitive (ability to think, understand, learn, and remember) decline, and anxiety disorder (mental health disorder characterized by feelings of worry or fear that are strong enough to interfere with one's daily activities). During a review of Resident 13's Physician's Certification for Hospice Benefit, dated 3/11/2025, the Physician's Certification indicated Resident 13's primary hospice diagnosis was atherosclerotic heart disease. During a review of Resident 13's Minimum Data Set (MDS - a resident assessment tool), dated 3/13/2025, the MDS indicated Resident 13 had clear speech, had limited ability to express ideas and wants, responded adequately to simple and direct communication only, and had severely impaired cognition (ability to think, understand, learn, and remember). The MDS indicated Resident 13 had functional limitations in ROM (limited ability to move a joint that interferes with daily functioning or places the resident at risk of injury) in both arms and legs. The MDS indicated Resident 13 required setup or clean-up assistance (helper sets up or cleans up while resident completes the activity, helper assists only prior to or following the activity) for eating, partial/moderate assistance (helper does less than half the effort) for rolling to either side in bed, and substantial/maximal assistance (helper does more than half the effort) from staff with toileting, upper and lower body dressing, and toilet transfers. The MDS indicated Resident 13 was dependent (helper does all the effort, resident does none of the effort to complete the activity, or the assistance of two or more helpers is required to complete the activity) for transferring from a lying to a sitting position on the side of the bed as well as for bed-to-chair and chair-to-bed transfers. During a review of Resident 13's Care Plan titled, Risk for Alteration in Episodes of Comfort due to admission under hospice care, dated 3/12/2025, the care plan interventions included to observe and report changes including decreased functional abilities, decreased ROM, and withdrawal or resistance to care. During a review of Resident 13's initial JME, dated 3/18/2025, completed by Occupational Therapist (OT - professional aimed to increase or maintain a person's capability of participating in everyday life activities [occupations]) 2 (OT 2), the JME indicated Resident 13 had moderate ROM limitation (50% to 75% range intact - means the joint is restricted to between half and three-quarters of its normal, full ROM) in the right hip and minimum ROM limitation (75 to 100% range intact - means the joint or body part has a minimum of 75% of its normal, healthy ROM to 100% no limitation at all) in both shoulders, the right elbow, the left hip, and both knees. The JME indicated Resident 13 had no ROM limitations in the left elbow, both wrists, both fingers (hands), and both ankles. During a review of Resident 13's Hospice Updated Assessment, dated 4/3/2025, 4/17/2025, 5/1/2025, 5/15/2025, and 5/29/2025, the Hospice Updated Assessment indicated Resident 13 had a loss of ROM (unspecified location). During a review of Resident 13's Hospice Health Aide (HA - a person who provides personal care and basic health-related services to individuals in their homes) Visit Notes, dated 5/5/2025, 5/8/2025, 5/12/2025, 5/15/2025, 5/22/2025, and 5/26/2025, the Hospice HA Visit Notes indicated Resident 13 received assistance with toileting, dressing, and feeding but refused bed baths. The Hospice HA Visit Note included a section for exercises, including active range of motion (AROM - performance of an exercise to move a joint without any assistance or effort of another person) and passive range of motion (PROM - movement of a joint through the range of motion with no effort from person), which was blank. During a review of Resident 13's Nursing Progress Notes from 3/11/2025 to 6/2/2025, the Nursing Progress Notes did not indicate any reported changes in ROM for Resident 13. During a review of Resident 13's quarterly JME, dated 6/2/2025, completed by Occupational Therapist 1 (OT 1), the JME indicated Resident 13 had severe ROM limitation in the left-hand fingers, moderate ROM limitation in the right hip, and minimum ROM limitations in the left shoulder, the left hip, and both knees. The JME indicated Resident 13 had no ROM limitation in the right shoulder, both elbows, both wrists, right-hand fingers, and both ankles. The JME indicated Resident 13 was on hospice care. During a review of Resident 13's MDS, dated [DATE], the MDS indicated Resident 13 had clear speech, had limited ability to express ideas and wants, responded adequately to simple and direct communication only, and had severely impaired cognition. The MDS indicated Resident 13 had functional limitations in ROM in one arm and both legs. The MDS indicated Resident 13 required supervision or touching assistance (helper provides verbal cues and/or touching and/or steadying assistance as resident completes the activity) for eating and substantial/maximal assistance for upper body dressing, rolling to either side in bed, and transferring from a lying to a sitting position on the side of the bed. The MDS indicated Resident 13 was dependent on staff for toileting and lower body dressing. During a review of Resident 13's Census List (record of hospitalizations, room changes, and payer source changes), the Census List indicated Resident 13 had a room change on 6/12/2025. During a review of Resident 13's Hospice HA Visit Notes, dated 7/3/2025, 7/7/2025, and 7/10/2025, the Hospice HA Visit Notes section for exercise, including AROM and PROM exercises, was blank. During a review of Resident 13's Hospice Updated Assessment, dated 7/10/2025, the Hospice Updated Assessment indicated Resident 13 had a loss of ROM (unspecified location) and contractures (unspecified location). During a review of Resident 13's Hospice HA Visit Notes, dated 7/14/2025, 7/17/2025, 7/21/2025, 7/24/2025, the Hospice HA Visit Notes section for exercise, including AROM and PROM exercises, was blank. During a review of Resident 13's Hospice Updated Assessment, dated 7/24/2025, the Hospice Updated Assessment indicated Resident 13 had had a loss of ROM (unspecified location) and contractures (unspecified location). During a review of Resident 13's Hospice HA Visit Notes, dated 7/28/2025 and 7/31/2025, the Hospice HA Visit Notes included a section for exercises, including AROM and PROM exercises, was blank. During a review of Resident 13's Physician's Orders, dated 8/19/2025, the Physician's Orders indicated to start the Restorative Nursing Assistant Program (RNA Program- nursing aide program that helps residents to maintain their function and joint mobility) on 8/20/2025 for PROM to both arms and legs, five times per week as tolerated. During a review of Resident 13's quarterly JME, dated 8/21/2025, the JME indicated Resident 13 had severe ROM limitation in the left-hand fingers, moderate ROM limitation in the right hip, and minimum ROM limitation in the left shoulder, the left hip, and both knees. The JME indicated Resident 13 had no ROM limitations in the right shoulder, both elbows, both wrists, right-hand fingers, and both ankles. During a review of Resident 13's Documentation Survey Report (record of nursing assistant tasks) for 8/2025, the Documentation Survey Report indicated that the Restorative Nursing Assistant (RNA - a specialized role for Certified Nursing Assistants [CNA] who receive additional training to help residents regain or maintain physical function and mobility) began providing PROM exercises to both arms and legs on 8/25/2025. During a review of Resident 13's Change in Condition (CIC - when there is a sudden change in a resident's condition) Evaluation, dated 8/25/2025, the CIC Evaluation indicated Resident 13 had a small cut with scant (little) bleeding from the nails being trimmed on the left ring finger. The CIC Evaluation indicated Resident 13's physician was notified with orders to cleanse the left ring finger with normal saline (a mixture of water and salt), pat dry, apply Betadine external solution (brand name for povidone-iodine, a topical [applied directly to skin] antiseptic solution [substance that keeps the broken skin from getting infected] used to clean and disinfect the skin to prevent an infection from developing, thus promoting healing), and cover with a dry dressing (wound covering that keeps the wound surface dry). During an interview on 8/26/2025 at 9:36 a.m., with the Director of Rehabilitation (DOR), the DOR stated the JME was completed upon admission and quarterly by the either the Physical Therapist (PT - professional aimed in the restoration, maintenance, and promotion of optimal physical function) or OT to monitor residents' ROM and mobility. The DOR stated the purpose of the JME was to ensure residents maintained their ROM, prevent the development of contractures, and prevent the worsening of existing contractures. The DOR stated the therapy staff (PT or OT) collaborated with nursing to determine appropriate interventions, including requesting physician orders for a therapy evaluation when changes were identified on the JME. The DOR stated that ROM limitations and contractures can lead to skin injuries and could affect the residents' comfort and quality of life. During a concurrent observation and interview on 8/26/2025 at 11:10 a.m., in Resident 13's room, observed Resident 13 lying in bed and had oxygen running through the nasal cannula (a small plastic tube that is inserted into the person's nostrils to deliver supplemental oxygen). Resident 13 was observed moving at the right shoulder, elbow, wrist, and hand joints. Resident 13's left arm, body, and both legs were covered with a blanket. During a concurrent observation and interview on 8/27/2025 at 11:13 a.m., with Restorative Nursing Assistant 2 (RNA 2), in Resident 13's room, Resident 13's RNA program was observed. Resident 13 spoke clearly but expressed disorganized thoughts while lying in bed. RNA 2 stated Resident 13 had behaviors of not complying with ROM exercises. Resident 13 was observed bending and extending both legs and raising both arms overhead without any assistance. Resident 13's left hand was observed in a closed fist position, with the left-hand fingernails, including an adhesive bandage (known as Band-Aid, a medical dressing that consists of adhesive strip [a strip of material coated with an adhesive that sticks to the skin] to protect would from infection and dirt) on the tip of the left ring finger, slightly touching the palm. Resident 13's left hand did not have any device applied to the palm to prevent the fingernails from touching the palm. Resident 13 stated, We are not doing any exercises today, but agreed to an observation of the skin on the left palm. Resident 13 used the right hand to extend the left-hand fingers but could not completely straighten the fingers, which remained in bent positions at all joints. During a concurrent interview and record review on 8/27/2025 at 12:49 p.m., with OT 1, Resident 13's JME dated 3/18/2025, 6/2/2025, and 8/21/2025, and Physician's Orders for RNA dated 8/19/2025 were reviewed. OT 1 stated Resident 13 was admitted to the facility under hospice care on 3/11/2025 and had never received any therapy (PT, OT, and Speech Language and Pathology (SLP-profession aimed in the prevention, assessment, and treatment of speech, language, communicative, and swallowing disorders) services. OT 1 reviewed Resident 13's JME, dated 3/18/2025, and stated the JME indicated Resident 13 had moderate ROM limitation in the right hip and minimum ROM limitation in both shoulders, the right elbow, the left hip, and both knees. OT 1 stated the JME did not indicate any recommendations to address Resident 13's ROM limitations. OT 1 reviewed Resident 13's JME, dated 6/2/2025, and stated the JME indicated Resident 13 had severe ROM limitation in the left-hand fingers, moderate ROM limitation in the right hip, and minimum ROM limitation in the left shoulder, the left hip, and both knees. OT 1, who performed Resident 13's JME on 6/2/2025, stated there were no recommendations to address Resident 13's ROM limitations since Resident 13 was under hospice care. OT 1 stated residents under hospice care, from OT 1's experience, did not receive any therapy and RNA services. OT 1 stated the DOR (unavailable for further interview) placed the physician's order, dated 8/19/2025, for RNA to provide PROM to both arm and legs. OT 1 reviewed Resident 13's JME, dated 8/21/2025, and stated the JME indicated Resident 13 had severe ROM limitation in the left-hand fingers, moderate ROM limitation in the right hip, and minimum ROM limitation in the left shoulder, the left hip, and both knees. During a concurrent observation and interview on 8/27/2025 at 2:31 p.m., with Certified Nursing Assistant 1 (CNA 1), in Resident 13's room, Resident 13's left hand was observed. Resident 13's left-hand fingers were in a closed fist position without any device placed between the fingernails and the palm. During a follow-up interview on 8/27/2025 at 2:39 p.m., with CNA 1, CNA 1 stated Resident 13 had been assigned to CNA 1 during the day shift for the past three months after Resident 13 moved from another room to Resident 13's current room. CNA 1 stated Resident 13's left hand did not have a closed fist when Resident 13 moved to the current room. CNA 1 stated Resident 13 started developing a closed fist to the left hand approximately one month ago (unknown date) and reported it (unknown date) to the charge nurse (unknown). During a telephone interview on 8/27/2025 at 3:42 p.m., with Resident 13's responsible Family Member 1 (FM 1) and Family Member 2 (FM 2), FM 1 stated Resident 13 hid the left hand during family visits. FM 1 described Resident 13's left hand as curled up, stiff, and unable to open. FM 1 stated Resident 13's left hand did not have a closed fist position upon admission to the facility and developed it shortly after (unknown date) Resident 13's admission. FM 1 stated FM 1 contacted (unable to recall when) Resident 13's Hospice Registered Nurse (Hospice RN) and the facility's nurse (unknown) about Resident 13's left hand. FM 1 stated the Hospice RN looked at Resident 13's left hand, informed FM 1 that the left hand was contracted, and stated to FM 1 that nothing could be done. FM 1 stated the family was not aware that the facility provided RNA services for ROM exercises and was never offered any RNA services for Resident 13. During a review of Resident 13's Nursing Progress Notes from 6/3/2025 to 8/28/2025, the Nursing Progress Notes did not indicate any reported changes in ROM for Resident 13. During an interview on 8/28/2025 at 9:06 a.m., with CNA 1, CNA 1 stated Resident 13 developed the closed fist on the left hand within the month (8/2025). CNA 1 stated Resident 13's inability to open the left-hand fingers was reported (unknown date and time) to Licensed Vocational Nurse 1 (LVN 1). During an interview on 8/28/2025 at 9:12 a.m., with LVN 1, LVN 1 stated a CNA, possibly CNA 1, reported (unable to recall specific date) discoloration (a change in the normal color of the skin) to Resident 13's left hand, which was reported to Resident 13's hospice care. LVN 1 stated no one informed LVN 1 that Resident 13's left hand was positioned in a closed fist and unable to extend the fingers. LVN 1 stated Resident 13 often refused care and had not noticed the left hand since Resident 13 covered the left arm. During a concurrent observation and interview on 8/28/2025 at 9:18 a.m., with Treatment Nurse 2 (TN 2), in Resident 13's room, Resident 13's left-hand fingers were observed. TN 2 stated Resident 13 was unable to fully open the left-hand fingers. TN 2 stated Resident 13's left hand had a skin cut on the tip of the ring finger near the nail bed and another skin cut on the side of the nail bed (area of the nail on which the nail rests). TN 2 stated the nails were cut to prevent them from digging into the skin of Resident 13's left-hand palm since the fingers were bent. During a telephone interview on 8/28/2025 at 9:56 a.m., with Treatment Nurse 3 (TN 3), TN 3 stated Resident 13's CIC Evaluation for the left-hand fingernail cut was documented on 8/25/2025 but occurred on 8/24/2025. TN 3 stated TN 3 was present in Resident 13's room while an LVN (unknown name) trimmed Resident 13's nails on 8/24/2025. TN 3 stated Resident 13's left-hand fingers were in a bent position and could be extended enough to trim the nails. During a telephone interview on 8/28/2025 at 10:24 a.m., with Resident 13's Hospice RN, the Hospice RN stated Resident 13 had a left-hand contracture and a left-hand skin cut. The Hospice RN stated Resident 13's left-hand contracture had developed a few weeks if not a few months ago (from the date of the interview). The Hospice RN stated the biggest concern would be to prevent Resident 13 from developing any skin issues from the contractures since the left hand was in a closed position, which could cause fungal issues in the palm and skin tears wherever Resident 13's nails make contact. The Hospice RN stated providing basic ROM to Resident 13 during care was encouraged during the Hospice HA visits and was not aware the facility had a program to provide ROM exercises. During an interview on 8/28/2025 at 12:35 p.m., with OT 1 and the Director of Nursing (DON), Resident 13's JME dated 3/18/2025 and 6/2/2025, the Nursing Progress Notes dated 3/11/2025 to 8/28/2025, the Care Plan titled, Risk for Alteration in Episodes of Comfort, dated 3/12/2025, and Physician's Order for RNA dated 8/20/2025 were reviewed. The DON and OT 1 stated Resident 13 had ROM limitations on Resident 13's JME, dated 3/18/2025, on multiple joints of both arms and legs. OT 1 stated RNA services were not provided to Resident 13 after the JME, dated 3/18/2025, since it was OT 1's experience and misunderstanding that residents under hospice care did not receive RNA services for ROM exercises. The DON and OT 1 reviewed Resident 13's JME, dated 6/2/2025, and stated Resident 13 had severe ROM limitations in the left-hand fingers. OT 1 stated OT 1 did not notify a licensed nurse regarding Resident 13's substantial decline in ROM in the left hand after the JME on 6/2/2025. OT 1 stated the facility did not provide any ROM following the JME on 6/2/2025 because of OT 1's misinformation that RNA services should not be offered to residents receiving hospice care. The DON reviewed all of Resident 13's Nursing Progress Notes since admission to the facility on 3/11/2025 and did not locate any Nursing Progress Notes documenting Resident 13's severe ROM limitation in left hand. The DON reviewed Resident 13's care plan titled, Risk for Alteration in Episodes of Comfort, and stated the facility did not follow the care plan intervention to observe and report changes including Resident 13's decline in ROM after the JME on 6/2/2025 and during daily care since the Nursing Progress Notes did not indicate any decline in Resident 13's left hand ROM. The DON stated Resident 13 had physician's orders, dated 8/19/2025, to start RNA for PROM exercises on 8/20/2025. Both the DON and OT 1 stated that Resident 13 did not receive any ROM exercises for five months from the initial JME on 3/18/2025 to 8/20/2025. OT 1 stated the facility should have provided RNA for ROM exercises upon admission since Resident 13 had ROM limitations and was at risk of developing further ROM limitations. Both the DON and OT 1 stated that Resident 13's significant ROM loss in the left hand was preventable. During a concurrent interview and record review on 8/28/2025 at 2:01 p.m., with the DON, Resident 13's JME dated 3/18/2025, and the facility's P&P titled, ROM and Contracture Prevention, dated as reviewed on 1/2025 and 3/2025, were reviewed. The DON reviewed Resident 13's JME, dated 3/18/2025, and stated ROM limitations were identified in both arms and legs. The DON reviewed the facility's P&P titled, ROM and Contracture Prevention and stated that all of the facility's residents, including Resident 13 receiving hospice care, should maintain and/or improve their ROM and prevent further ROM limitations. The DON stated that the facility's RNA program provides ROM exercises to prevent ROM decline. The DON stated that the facility should have implemented the RNA Program for Resident 13 to prevent ROM decline but failed to do so. During a concurrent interview and record review on 8/28/2025 at 2:29 p.m., with the DON, Resident 13's Hospice HA Visit Notes (located in the hospice care binder), dated 5/5/2025, 5/8/2025, 5/12/2025, 5/15/2025, 5/22/2025, 5/26/2025, 7/3/2025, 7/7/2025, 7/10/2025, 7/14/2025, 7/17/2025, 7/21/2025, and 7/24/2025, were reviewed. The DON stated that the Hospice HA Visit Notes did not indicate that Resident 13 received any exercises, including PROM and AROM exercises. The DON further stated Resident 13 was at increased risk for developing ROM limitations and contractures since the facility and the Hospice HA did not provide ROM exercises. During an interview on 8/28/2025 at 2:45 p.m., with the DON, the DON stated the facility staff, including the CNAs, should have reported Resident 13's loss of ROM in the left hand, as the facility provided daily care to Resident 13. During a telephone interview on 8/28/2025 at 3:09 p.m., with Resident 13's primary physician (Hospice MD), the Hospice MD stated the hospice goal included maintaining Resident 13's comfort. The Hospice MD stated that the loss of ROM in Resident 13's left hand could have been slowed down with daily ROM exercises. The Hospice MD stated that hospice staff were unaware the facility had an RNA program that provided ROM exercises at least five times per week. The Hospice MD stated that the facility could have provided ROM exercises to Resident 13, as tolerated, and if the resident was not in any pain. The Hospice MD stated that the hospice team had discussed the closed fist position of Resident 13's left hand during an internal meeting a few weeks or one month prior (from the interview date, unable to recall specific date). The Hospice MD was unaware of Resident 13's JME, dated 6/2/2025, which identified Resident 13's severe ROM loss in the left-hand. Hospice MD stated, I would have appreciated if this was reported to me at least. The Hospice MD further stated that a one-time OT evaluation could have been ordered to provide recommendations such as braces (material used to restrict, protect, or immobilize a part of the body to support function, assist and/or increase ROM), towel rolls, or other conservative measures to prevent further ROM decline in Resident 13's left hand and minimize the risk of wound development from the closed fist position. During a review of the facility's P&P titled, ROM and Contracture Prevention, reviewed on 1/2025 and 3/2025, the P&P indicated the facility ensured residents receive services, care, and equipment to assure Every resident maintains, and/or improves their highest level of ROM and mobility, unless a reduction is clinically unavoidable. The P&P also indicated Every resident with limited range of motion and mobility maintains or improves function unless reduced ROM and mobility is unavoidable based on the resident's clinical condition. During a review of the facility's P&P titled, Restorative Program, last revised on 1/2025, the P&P indicated the facility provided a Restorative Program to restore or maintain a resident's mobility skills and ROM to maximum independence and safety. b. During a review of Resident 69's admission Record, the admission Record indicated the facility admitted Resident 69 on 6/26/2025 with diagnoses including Type 2 diabetes mellitus ([DM] disorder characterized by difficulty in blood sugar control and poor wound healing), unspecified fall, abnormalities of gait (manner of walking) and mobility, and hemiparesis (weakness of the arm, leg, and trunk on the same side of the body) following cerebral infarction (brain damage due to a loss of oxygen to the area) affecting the right dominant side. During a review of Resident 69 Physical Therapy ([PT] profession aimed in restoration, maintenance, and promotion of optimal physical function) Evaluation and Plan of Treatment, dated 6/27/20225, the PT Evaluation indicated Resident 69's range of motion ([ROM] full movement potential of a joint) in both legs were within functional limits ([WFL] sufficient joint movement without significant limitation). The PT Evaluation indicated Resident 69 required substantial/maximal assistance (helper does more than half the effort) for rolling, transferring from lying to sitting on the side of the bed, chair/bed-to-chair transfers, and sit-to-stand transfers. During a review of Resident 69's Minimum Data Set ([MDS] a federally mandated resident assessment tool), dated 6/30/2025, the MDS indicated Resident 69 had clear speech, had difficulty expressing ideas and wants, understood verbal content, and had severely impaired cognition (clear ability to think, understand, learn, and remember). The MDS indicated Resident 69 did not have any functional limitations in ROM (limited ability to move a joint that interferes with daily functioning or places the resident at risk of injury) on both arms and legs. The MDS also indicated Resident 69 required partial/moderate assistance (helper does less than half the effort) for hygiene and substantial/maximal assistance for transferring from lying to sitting on the bed, chair/bed-to-chair transfers, and sit-to-stand transfers. During a review of Resident 69's PT Discharge summary, dated [DATE], the PT Discharge Summary indicated Resident 69 required substantial/maximal assistance for sit-to-stand transfers and chair/bed-to-chair transfers. The PT Discharge Summary indicated recommendations for the RNA program for passive range of motion ([PROM] movement of a joint through the range of motion with no effort from person) to both legs and sit-to-stand mobility using side rails, five times per week as tolerated. During a review of Resident 69's physician's orders, dated 8/22/2025, the physician's orders indicated for the RNA program to provide PROM to both legs and sit-to-stand mobility using side rails, five times per week as tolerated. During an observation on 8/26/2025 at 1:14 p.m. in the bedroom, Resident 69 was fully dressed and sleeping while sitting up in a wheelchair next to the bed. During an observation on 8/27/2025 at 9:11 a.m. in the bedroom, Resident 69 was fully dressed and sleeping while sitting up in a wheelchair next to the bed. Resident 69 was observed wearing socks without any grip on the sole. During an observation on 8/27/2025 at 9:14 a.m. in the bedroom with Restorative Nursing Assistant 1 (RNA 1), Resident 69's RNA program was observed. Resident 69 was sitting up in the wheelchair with Resident 69's body leaning against the wheelchair's right armrest. Resident 69 woke up to RNA 1's voice and agreeable to the leg exercises. RNA 1 sat directly in front of Resident 69's wheelchair and performed ROM exercises to both legs while Resident 69 kept both eyes closed. During an observation on 8/27/2025 at 10:40 a.m. in the bedroom with RNA 1, RNA 1 removed Resident 69's socks and replaced them with non-skid socks. Resident 69's left heel was observed wrapped in dressing. During a concurrent observation and interview on 8/27/2025 at 10:54 a.m., RNA 1 and Restorative Nursing Assistant 2 (RNA 2) wheeled Resident 69 into the hallway and positioned the wheelchair facing the hallway's handrail. RNA 1 stood on Resident 69's right side while RNA 2 stood on the left side. Resident 69 reached both arms forward and held onto the hallway handrail as RNA 1 and RNA 2 physically assisted Resident 69 to stand. Resident 69's hips were approximately six inches above the wheelchair seat and unable to stand fully with RNA 1 and RNA 2's physical assistance. RNA 1 stated Resident 69 had pain while attempting to stand. Licensed Vocational Nurse 7 (LVN 7) observed Resident 69's second attempt to perform sit-to-stand transfers. Resident 69 attempted to stand with RNA 1 and RNA 2's physical assistance, started to moan, and did not place any weight on the left heel. LVN 7 stated RNA 1 and RNA 2 cannot even lift Resident 69 to stand. RNA 1 stated Resident 69 could place weight through the right leg but only put weight on the left toes. RNA 1 stated Resident 69 required the assistance of two-persons for sit-to-stand transfers and could not remember the last time Resident 69 received RNA for sit-to-stand transfers. RNA 1 stated Resident 69 did not receive RNA for sit-to-stand transfers yesterday (8/26/2025) and assisted Certified Nursing Assistant 5 (CNA 5) with transferring Resident 69 from the wheelchair to the bed. During an interview on 8/28/2025 at 11:09 a.m. with RNA 1, RNA 1 stated RNA 1 forgot to provide Resident 69 with the RNA program for sit-to-[TRUNCATED]

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