**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide services to three of seven sampled residents (Resident 43, 5, and 18) 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. Obtain baseline (initial measurement taken at an early point and used for comparison over time to monitor changes) ROM measurements of Resident 43's both arms and legs upon admission on [DATE] using the Joint Mobility Assessment ([JMA] brief assessment of a resident's range of motion in both arms and both legs) in accordance with the facility's policy titled, Joint Mobility and Screening and Assessment revised on 1/25/2024. 2. Obtain a baseline ROM measurement of Resident 43's left arm during the Occupational Therapy ([OT] profession aimed to increase or maintain a person's capability of participating in everyday life activities [occupations]) Evaluation on 8/14/2023. 3. Assess Resident 43's left wrist hand orthosis ([WHO] material secured with straps that extends from the fingers to the forearm to properly position the fingers and wrist and prevent contractures [condition of shortening and hardening of muscles, tendons, or other tissue, often leading to joint stiffness]) for fit and wear tolerance (amount of time a person can wear an orthosis before experience discomfort or any other side effects) of up to eight (8) hours upon discharge from OT services on 9/10/2023 in accordance with professional standards (guidelines that outline the practices, skills, and qualifications that professionals in a given field should follow), including assessment of the orthosis (external medical device used for supporting, immobilizing and treating joints) for fit and wear tolerance. 4. Provide Resident 43 with Restorative Nursing Assistant ([RNA] certified nursing aide program that helps residents to maintain their function and joint mobility) services from 9/11/2023 to 9/20/2023 (10 days) and from 10/20/2023 to 11/30/2023 (over one month) for passive range of motion ([PROM] movement of joint through the ROM from an external force with no effort from the person) exercises to the left arm and the application of Resident 43's left WHO in accordance with the OT Discharge Summary recommendations on 9/10/2023. 5. Monitor ROM changes in both of Resident 43's arms and legs from 9/11/2023 to 4/1/2024 (over 6 months). 6. Apply Resident 43's left WHO on 9/30/2024. 7. Perform ROM exercises to Resident 43's left elbow on 10/1/2024. 8. Obtain baseline ROM measurements of Resident 5's arms and legs upon admission on [DATE] in accordance with the facility's policy and procedure titled Joint Mobility Screening and Assessment, revised on 1/25/2024. 9. Obtain baseline ROM measurements of Resident 5's legs during the Physical Therapy ([PT] profession aimed in the restoration, maintenance, and promotion of optimal physical function) Evaluation on 10/26/2023. 10. Obtain baseline ROM measurements of Resident 5's arms during the OT Evaluation on 10/27/2023. 11. Monitor ROM changes in both of Resident 5's arms and legs from 10/26/2023 to 8/19/2024 (10 months). 12. Position Resident 18's hips at midline (line through the body that divides it into halves that are mirror images of each other) while lying in bed. These failures resulted in: 1. Resident 43 developing ROM limitations in the left shoulder, elbow, and hand, including the development of a left-hand contracture. 2. Placing Resident 5 and 18 at risk to develop further ROM limitations which would affect the residents' ability to participate in activities of daily living ([ADLs] tasks related to personal care including bathing, dressing, hygiene, eating, and mobility). Findings: a. During a review of Resident 43's admission Record, the admission Record indicated Resident 43 was initially admitted to the facility on [DATE] with diagnoses including end stage renal disease ([ESRD] irreversible kidney failure), dependence on renal (kidney) dialysis (treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed), and hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) affecting the left nondominant side (less often used during completion of daily living tasks). During a review of Resident 43's PT Evaluation and Plan of Treatment, dated 8/13/2023, the PT Evaluation indicated Resident 43 fell from the bed and had a right-side brain hemorrhage (bleeding), which caused weakness on the left side of Resident 43's body. The PT Evaluation indicated the ROM in both of Resident 43's legs were within functional limits ([WFL] sufficient movement without significant limitation). During a review of Resident 43's OT Evaluation and Plan of Treatment, dated 8/14/2023, the OT Evaluation indicated Resident 43's ROM in the right arm, left wrist, and left hand were WFL. The OT Evaluation indicated Resident 43's ROM in the left shoulder and elbow was impaired (unspecified). During a review of Resident 43's Minimum Data Set ([MDS] a federally mandated resident assessment tool), dated 8/16/2023, the MDS indicated Resident 43 had functional ROM impairments in one arm and one leg. During a review of Resident 43's PT Discharge summary, dated [DATE], the PT Discharge Summary indicated Resident 43 was dependent (required more than 75 percent [%] physical assistance to perform the task) with bed mobility and transfers, requiring a mechanical lift (a device that helps residents who have difficulty moving on their own to be transferred or moved from one place to another) for transfers. The PT Discharge Summary recommendations indicated for Resident 43 to receive an RNA program for PROM exercises to both legs. During a review of Resident 43's OT Discharge summary, dated [DATE], the OT Discharge Summary indicated Resident 43 required moderate assistance (required between 26 to 50% physical assistance to perform the task) for hygiene, grooming, and self-feeding. The OT Discharge Summary recommendations indicated for Resident 43 to receive an RNA program for PROM exercises to the left arm and application of a left WHO. The OT Discharge Summary did not include an OT goal related to monitoring Resident 43's wear tolerance of the left WHO. During a review of Resident 43's Documentation Survey Report (record of nursing assistant tasks) for RNA, dated 9/2023, the Documentation Survey Report indicated Resident 43 started receiving PROM on both arms and legs and application of the left WHO for up to 8 hours, five times per week, on 9/21/2023 (10 days after OT Discharge Resident 43). During a review of Resident 43's Nurses Progress Notes, dated 10/19/2023, the Nurses Progress Notes indicated Resident 43 was transferred to a general acute care hospital (GACH) to replace Resident 43's permanent catheter ([PermaCath]- flexible tube interested into a blood vessel in the neck or upper chest and threaded to the right side of the heart) for dialysis. During a review of Resident 43's Documentation Survey Report for RNA, dated 10/2023, the Documentation Survey Report indicated Resident 43 stopped receiving PROM on both arms and legs and application of the left WHO for up to 8 hours, five times per week, on 10/20/2023. During a review of Resident 43's Physician Orders, dated 10/20/2023, the Physician Orders indicated to readmit Resident 43 to the facility and resume all medications. The Physician's Orders did not include an RNA task for Resident 43 upon their admission to the facility on [DATE]. During a review of Resident 43's MDS, dated [DATE], the MDS indicated Resident 43 had functional ROM impairments in one arm and one leg (unspecified side). During a review of Resident 43's Documentation Survey Report, dated 12/2023, the Documentation Survey Report indicated Resident 43 started receiving RNA program for PROM on both arms and legs and application of the left WHO for up to 8 hours, five times per week, on 12/1/2023 (over one month from the last treatment and application of WHO). During a review of Resident 43's MDS, dated [DATE], the MDS indicated Resident 43 had functional ROM impairments in one arm and one leg (unspecified side). During a review of Resident 43's OT Evaluation and Plan of Treatment, dated 4/1/2024, the OT Evaluation indicated Resident 43 had WFL ROM in the left arm but impaired (unspecified) ROM in the left shoulder, elbow/forearm, wrist, and hand. The OT Evaluation indicated Resident 43 had a contracture in the left hand, limiting Resident 43's ability to grasp and release. During a review of Resident 43's OT Discharge summary, dated [DATE] and signed on 4/16/2024, the OT Discharge Summary indicated Resident 43 went to GACH. During a review of Resident 43's Change in Condition ([CIC] a sudden, clinically important deviation from a patient's baseline in physical, cognitive (ability to think, understand, learn, and remember) behavioral, or functional status which without immediate intervention, may result in complications or death ) Evaluation, dated 4/8/2024, the CIC Evaluation indicated Resident 43 refused dialysis in the morning, vomited multiple times, and refused meals. The CIC Evaluation indicated the physician ordered Resident 43's transfer to GACH. During a review of Resident 43's Nurses Progress Notes, dated 4/11/2024, the Nurses Progress Notes indicated Resident 43 was readmitted to the facility on [DATE]. During a review of Resident 43's Joint Mobility Assessment (JMA), dated 4/12/2024, the JMA indicated Resident 43's ROM was within normal limits ([WNL] normal ROM for that joint) at all joints of the right arm and both legs. The JMA indicated Resident 43's ROM was minimally impaired (51 to 75% available range for that joint) for left wrist flexion (bending the wrist downward) and left wrist extension (bending the wrist upward), moderately impaired (26 to 50% available range for that joint) for the left elbow flexion (bending the elbow) and extension (straightening the elbow), and severely impaired (less than 25% available range for that joint) for left shoulder flexion (lifting the arm upward), left shoulder abduction (lifting the arm up and away from the body), left hand/fingers flexion (bending the fingers toward the palm), and left hand/fingers extension (straightening out the fingers). During a review of Resident 43's OT Evaluation and Plan of Treatment, dated 4/12/2024, the OT Evaluation indicated Resident 46 had WFL ROM in the right arm but impaired (unspecified) ROM in the left shoulder, elbow/forearm, wrist, and hand. The OT Evaluation indicated Resident 43 had a contracture in the left hand, limiting Resident 43's ability to grasp and release. During a review of Resident 43's PT Evaluation and Plan of Treatment, dated 4/14/2024, the PT Evaluation indicated Resident 43 had WFL ROM in both legs. During a review of Resident 43's MDS, dated [DATE], the MDS indicated Resident 43 had functional ROM impairments in one arm and one leg (unspecified side). During a review of Resident 43's OT Discharge summary, dated [DATE], the OT Discharge Summary indicated Resident 43 required maximum assistance (required 41 to 75% physical assistance to perform the task) for hygiene, grooming, and self-feeding. The OT Discharge Summary indicated Resident 43 achieved an OT goal of safely wearing a left WHO for 8 hours without any redness, swelling, discomfort and pain. The OT Discharge Summary recommendations included RNA program to provide Resident 43 with PROM to both arms and legs and to apply the left WHO. During a review of Resident 43's PT Discharge summary, dated [DATE], the PT Discharge Summary indicated Resident 43 required maximum assistance for bed mobility and dependent for transfers. The PT Discharge Summary recommendations included RNA to provide Resident 43 with PROM to both legs. During a review of Resident 43's Documentation Survey Report, dated 8/2024, the Documentation Survey Report indicated Resident 43 received RNA for PROM to the left arm and both legs and application of the left WHO on 8/7/2024 (14 days after PT and OT recommendations). During a review of Resident 43's care plan titled, Restorative Nursing Program, initiated 9/19/2023 and revised on 8/7/2024, the care plan interventions included for RNA to provide PROM to the left arm, PROM of both legs, and application of the left WHO for up to six hours, five times per week. During a review of Resident 43's MDS, dated [DATE], the MDS indicated Resident 43 had clear speech, understood verbal content, and had severely impaired cognition (ability to think, understand, learn, and remember). The MDS indicated Resident 43 required substantial/maximal assistance (helper does more than half the effort) for eating and rolling to either side while lying in bed and dependent for hygiene, dressing, bathing, and chair/bed-to-chair transfers. The MDS indicated Resident 43 had functional ROM impairments in one arm and one leg (unspecified side). During a concurrent observation and interview on 9/30/2024 at 11:04 a.m. in Resident 43's bedroom, Resident 43 was observed lying awake in bed and unable to move the left arm. Resident 43 stated she required physical assistance from someone to move her left arm. During an interview on 9/30/2024 at 11:23 a.m. with the Director of Rehabilitation (DOR), the DOR stated the therapists (PT and OT) complete a JMA on each resident upon admission and annually. The DOR stated the purpose of the RNA program was to maintain the residents' function to prevent decline in mobility. The DOR stated the RNA program included providing mobility, including walking and transfers, ROM exercises, and application of orthoses (also known as 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 ROM exercises (in general) included to maintain a resident's joint flexibility to prevent stiffness. The DOR stated the purpose of orthoses (in general) included to maintain ROM and prevent the development of contractures, which can cause pain and lead to skin breakdown (tissue damage caused by friction [surfaces rubbing against each other], shear [strain produced by pressure], moisture, or pressure). During a concurrent observation and interview on 9/30/2024 at 12:05 p.m. in Resident 43's bedroom, Resident 43 was observed lying awake in bed and stated she fell from the bed at home, which caused bleeding in the brain. Resident 43 was observed moving the right arm normally at each joint but was unable to move the left arm. Resident 43 stated the nurse (unknown) did exercises (unspecified) on 9/30/2024 morning. Resident 43's left elbow was bent at 90 degrees with the left hand resting on Resident 43's abdomen. Resident 43's left hand was positioned in a closed fist and did not have an orthosis (WHO) applied. Resident 43 stated she received exercises once per week. During a concurrent observation and interview on 10/1/2024 at 10:27 a.m. in Resident 43's bedroom, Resident 43 was observed sleepy but agreeable to receive RNA services. RNA 1 was observed standing on the right side of Resident 43's bed while RNA 2 was standing on the left side of Resident 43's bed. RNA 1 performed exercises on Resident 43's right leg, including hip flexion (bending the leg at the hip joint toward the body) with the knee extended (straight), hip flexion with knee flexion (bending), hip abduction (moving the leg away from the body), hip rotation (circular motion) in clockwise (in the direction in which the hands of a clock turn) and counterclockwise (opposite direction in which the hands of a clock turn) directions, ankle rotation in clockwise and counterclockwise directions, and rotation of each toe of the right foot. RNA 1 left the room to assist another staff member. RNA 2 performed exercises on Resident 43's left leg, including hip flexion with the knee extended, hip flexion with knee flexion, hip rotation in clockwise and counterclockwise directions, ankle rotation in clockwise and counterclockwise directions, and ankle dorsiflexion (bending the ankle toward the body). Resident 43's left elbow was observed being bent to 90 degrees and the left hand was observed positioned in a closed fist. RNA 2 was observed performing PROM to Resident 43's left arm, including shoulder abduction (lifting the arm up and away from the body), shoulder rotation in clockwise and counterclockwise directions, wrist rotation in clockwise and counterclockwise directions, thumb rotation, and attempted to extend Resident 43's left-hand fingers. RNA 2 was observed being unable to fully extend Resident 43's fingers, which remained in a bent position. RNA 2 did not perform any PROM to Resident 43's left elbow. RNA 2 attempted to apply Resident 43's left WHO. The portion of the left WHO for Resident 43's fingers was bent completely downward to accommodate Resident 43's fingers. RNA 2 had difficulty extending Resident 43's fingers to apply the left WHO and stated he needed another person's assistance. The Physical Therapy Assistant (PTA 1) came into the room and assisted with extending Resident 43's left-hand fingers while RNA 2 applied the left WHO. Resident 43 complained of pain while RNA 2 and PTA 1 applied the left WHO. Resident 43 stated the WHO has not been applied to her left hand in two months. During an interview on 10/1/2024 at 10:59 a.m., RNA 1 and RNA 2, RNA 1 stated Resident 43 received PROM exercises to the left arm and both legs. RNA 2 stated he could not extend Resident 43's left-hand fingers and required two people to apply the left WHO. RNA 2 stated he forgot to perform the left elbow PROM exercises on 10/1/2024 at 10:27 a.m. During an observation on 10/1/2024 at 11:09 a.m. in Resident 43's bedroom, RNA 2 performed PROM exercises to Resident 43's left elbow into flexion and extension. RNA 2 was unable to fully extend Resident 43's left elbow, which continued to have a bent position. During a concurrent interview and record review on 10/2/2024 at 1:50 p.m. with the DOR, Resident 43's OT Discharge summary, dated [DATE], was reviewed. The DOR stated the professional standard for therapists prior to providing a resident with an orthosis (in general) included the therapist determining the orthosis' fit, monitoring the skin, and determining the wear time. The DOR stated a resident (in general) could develop skin breakdown if a therapist (PT or OT) did not monitor and determine the orthosis wear time. The DOR stated Resident 43 was provided a left WHO without establishing an OT goal to determine Resident 43's wear tolerance. During an interview on 10/2/2024 at 4:03 p.m. the Regional Director of Rehabilitation (RDR) stated the therapists (PT and OT) should perform JMA on each resident upon admission, change of condition, and annually. During a concurrent interview and record review on 10/2/2024 at 4:40 p.m. with the DOR, Resident 43's clinical record (medical records -collection of documents that contain a resident's medical history and care) was reviewed for the JMA. The DOR was unable to locate Resident 43's JMA upon admission to the facility on 8/12/2023. During a concurrent interview and record review on 10/3/2024 at 12:19 p.m., with the Director of Medical Records (DMR), the DMR reviewed Resident 43's RNA tasks, dated 8/2024. The DMR stated Resident 43 did not receive RNA for PROM on the left arm and both legs and application of the left WHO until 8/7/2024 when the care plan, titled Restorative Nursing Program, was revised on 8/7/2024. During a concurrent observation and interview on 10/3/2024 at 2:00 p.m. with RNA 2 and Resident 43, in Resident 43's room, Resident 43 was observed lying in bed while RNA 2 removed the left WHO. RNA 2 stated the WHO was applied to Resident 43's left hand at 9:20 a.m. and tolerated wearing the left WHO for more than four hours. Resident 43 stated the facility did not provide exercises and apply the left WHO that often (unspecified amount of time) prior to this week. During a concurrent interview and record review on 10/3/2024 at 4:20 p.m. with the DOR and the MDS Coordinator (MDSC), Resident 43's clinical record was reviewed, including Resident 43 MDS, PT Evaluation dated 8/13/2023, and OT Evaluation dated 8/14/2023. The DOR and MDSC were unable to locate Resident 43's JMA upon admission to the facility on 8/12/2023 in the electronic and physical clinical records. The DOR and MDSC reviewed Resident 43's PT Evaluation, dated 8/13/2023, which indicated Resident 43 had WFL ROM in both legs. The DOR and MDSC reviewed Resident 43's OT Evaluation, dated 8/14/2023, which indicated Resident 43 had WFL ROM in the right arm, left wrist, and left hand and impaired ROM in the left shoulder and elbow. The MDSC stated the OT Evaluation did not indicate any measurement of Resident 43's ROM impairments in the left shoulder and elbow. The MDSC reviewed Resident 43's MDS, dated [DATE], which indicated Resident 43 had ROM impairments in one arm and one leg. The MDSC stated the MDS did not indicate which arm and leg were impaired, did not indicate which joints in the arm and leg were impaired, and did not indicate ROM measurements of the impairments. The DOR stated the facility did not have a baseline ROM assessment for Resident 43's left arm impairments. During the same concurrent interview and record review on 10/3/2024 at 4:20 p.m. with the DOR and the MDSC, Resident 43's OT Treatment Notes from 8/14/2023 to 9/10/2023, OT Discharge summary, dated [DATE], PT Discharge summary, dated [DATE], and RNA tasks for 9/2023 were reviewed. The DOR and MDSC reviewed Resident 43's OT Discharge summary, dated [DATE], which indicated recommendations for the RNA to perform PROM exercises to both arms and to apply the left WHO. The DOR stated Resident 43's PT Discharge recommendation included for the RNA to perform PROM exercises to both legs. The MDSC reviewed Resident 43's RNA tasks and stated the DOR inputted the RNA tasks to provide PROM to both arms and legs and to apply the left WHO for up to 8 hours in Resident 43's clinical record on 9/20/2023 (10 days after discharge). The DOR reviewed all OT treatment notes and stated the OT documentation did not include any assessment of Resident 43's left WHO for fit and 8-hour wear tolerance prior to discharge on [DATE]. The MDSC stated Resident 43 did not receive RNA program from 9/11/2023 to 9/20/2023. During a concurrent interview on 10/3/2024 at 4:20 p.m. with the DOR and the MDSC, Resident 43's RNA tasks note from 10/2023 to 12/2023 were reviewed. The MDSC stated Resident 43's RNA tasks were cancelled on 10/19/2023 due to Resident 43's hospitalization on 10/19/2023 for a PermaCath replacement. The MDSC stated Resident 43 returned to the facility on [DATE]. The MDSC stated Resident 43's RNA tasks for PROM exercises to both arms and legs and application of the left WHO were not inputted into Resident 43's electronic clinical records until 11/30/2023 (more than one month after readmission to the facility). The MDSC stated Resident 43 did not receive RNA for PROM to both arms and legs and the application of the left WHO from 10/20/2023 to 11/30/2023. During a concurrent interview and record review on 10/3/2024 at 4:20 p.m. with the DOR and the MDSC, Resident 43's Nurses Progress Notes and JMA, dated 4/12/2024, were reviewed. The MDSC reviewed the Nurses Progress Notes, dated 4/8/2024, which indicated Resident 43 was transferred to the hospital for vomiting related to missing dialysis. The MDSC stated the facility readmitted Resident 43 on 4/12/2024. The MDSC and DOR reviewed the JMA, dated 4/12/2024, which indicated Resident 43's had minimal ROM limitations in the left wrist, moderate ROM limitations in the left elbow, and severe ROM limitations in the left shoulder and hand. The DOR stated Resident 43's hand experienced a three step (WFL, minimal, moderate, severe) ROM decline from WFL on 8/14/2023 to severe ROM impairment on 4/12/2024. During the same concurrent interview with the DOR and the MDSC on 10/3/2024 at 4:20 p.m., Resident 43's quarterly MDS assessments since 8/16/2023 (admission) and RNA meetings notes were reviewed. The DOR stated the facility relied on RNA report and the MDS to monitor Resident 43's ROM since it was the facility's policy to perform the JMA upon admission and annually. The MDSC and DOR were unable to locate any RNA meetings notes for any resident with RNA services, including Resident 43, from 9/2023 to 4/2024. The MDSC stated Resident 43's MDS assessments were performed quarterly but the MDS did not indicate which arm and leg had ROM impairments, the joint location of the ROM impairment, and the severity of the ROM impairment. The MDSC stated Resident 43's quarterly MDS assessments did not reflect any changes in ROM. During an interview on 10/3/2024 at 6:08 p.m. with the Director of Nursing (DON), DOR, and MDSC, the DON stated the facility's process for monitoring each resident's ROM included RNA meetings and the MDS assessments. The DON stated there was a potential for a resident (in general) to experience a decline in ROM without the application of an orthosis and provision of ROM exercises. The DON stated the measuring and monitoring ROM was not in the RNA's scope of practice. The DON stated quarterly assessments completed for each resident included smoking, risk for developing skin breakdown, and falls. The DON stated the facility did not perform any quarterly assessments to monitor residents (in general) for ROM. The DOR stated Resident 43's medical condition caused Resident 43 to develop hypertonicity (increased muscle stiffness or tightness) in the left arm. The DOR stated Resident 43's hypertonicity in the left arm should be monitored since the hypertonicity increased Resident 43's risk for ROM decline. The DOR was unable to provide any documentation Resident 43's left arm ROM was monitored due to hypertonicity from 9/2023 to 4/2024. During a concurrent interview and record review on 10/4/2024 at 7:54 a.m. with the DOR, the DOR reviewed Resident 43's OT Evaluation, dated 8/13/2023, Treatment Notes from 8/13/2023 to 9/10/2023, and OT Discharge summary, dated [DATE]. The DOR stated Resident 43's baseline ROM of the left hand was WFL. The DOR stated the typical position of the WHO included the fingers positioned in extension. The DOR reviewed Resident 43's OT Treatment Notes and Discharge Summary and stated the OT documentation did not indicate Resident 43's left WHO was adjusted from the typical position upon discharge on [DATE]. During a review of a textbook titled, Occupational Therapy for Physical Dysfunction, (Fifth edition, 2002, page 316), the textbook indicated the OT's Role is to evaluate the need for a splint clinically and functionally; to select the most appropriate splint; to provide or fabricate (make) the splint; to assess the fit of the splint; to teach the patient and caregivers the purpose, care, and use of the splint. The Occupational Therapy for Physical Dysfunction textbook, page 316, indicated the OT must consider, carefully monitor, and teach the patient and caregiver to report any of these problems related to orthotic use, including impaired skin integrity (skin health), pain, and swelling. b. During a review of Resident 5's admission Record, the admission Record indicated Resident 5 was admitted to the facility on [DATE] with diagnoses including hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (weakness of the arm, leg, and trunk on the same side of the body) following a cerebral infarction (brain damage due to a loss of oxygen to the area) affecting the right side and facial weakness following a cerebral infarction. During a review of Resident 5's MDS, dated [DATE], the MDS indicated Resident 5 expressed ideas and wants, clearly understood verbal content, and had intact cognition. The MDS indicated Resident 5 had functional ROM limitations in one arm and one leg. During a review of Resident 5's care plan titled, Restorative Nursing Program, initiated on 10/5/2023, the care plan interventions included for the RNA to perform PROM to both resident's arms and legs and apply a right-hand palm guard (material used as a barrier between fingers and palmar skin to prevent injury to the palm from severe finger flexion contracture). During a review of Resident 5's PT Evaluation, dated 10/26/2023, the PT Evaluation indicated Resident 5's ROM in both hips and knees were within functional limits ([WFL] sufficient movement without significant limitation). The PT Evaluation indicated Resident 5's ROM in both ankles were impaired (unspecified). During a review of Resident 5's PT Discharge summary, dated [DATE], the PT Discharge Summary recommendations indicated for the RNA to provide PROM to both legs. During a review of Resident 5's OT Evaluation, dated 10/27/2023, the OT Evaluation indicated Resident 5's ROM in the left arm and right elbow were WFL. The OT Evaluation indicated Resident 5's ROM in the right shoulder, right wrist, and right hand were impaired (unspecified). The OT Evaluation indicated Resident 5 had a contracture in the right hand, limiting Resident 5's ability to grasp and release. During a review of Resident 5's OT Discharge summary, dated [DATE], the OT Discharge Summary indicated recommendations for the RNA to provide PROM to both arms and apply a right-hand palm guard. During a review of Resident 5's MDS, dated [DATE], 1/24/2024, 4/19/2024, and 7/23/2024, the MDS indicated Resident 5 expressed ideas and wants, clearly understood verbal content, and had intact cognition. Each MDS indicated Resident 5 had ROM limitations in one arm and one leg (unspecified side). During a review of Resident 5's JMA, dated 7/23/2024, the JMA indicated Resident 5's ROM was WNL in the left shoulder, both elbows, left wrist, left hand, both hips, and both knees. The JMA indicated Resident 5's ROM was severely impaired (less than 25 percent [%] available range for that joint) in the right shoulder, right wrist, right hand, and both ankles. During an interview on 9/30/2024 at 11:23 a.m. with the Director of Rehabilitation (DOR), the DOR stated the therapists (PT and OT) complete a JMA on each resident upon admission and annually. During an observation on 9/30/2024 at 12:43 p.m. in the dining room, Resident 5 was observed sitting in a Geri chair (reclining chair that allows someone to get out of bed and sit comfortably in different positions while fully supported) eating lunch while watching a movie. Resident 5 moved the left arm actively at all joints to scoop food from the plate and hold a cup to drink liquids. Resident 5's moved the right arm at the elbow and shoulder joints, but Resident 5's right hand was observed positioned in a closed fist without a palm guard. During a concurrent observation and interview on 9/30/2024 at 2:00 p.m. with Resident 5, in the facility lobby, Resident 5 was observed awake, alert, and sitting upright in a Geri chair. Resident 5 used gestures and the left hand to write responses to questions. Resident 5 wrote and gestured that the RNAs does not apply the palm guard to the right hand every day. During an observation on 10/1/2024 at 9:15 a.m., in Resident 5's bedroom, Resident 5 was observed awake and lying flat in bed. Resident 5 was already wearing a right-hand palm guard, which was lined with sheepskin, and both ankles were positioned in plantar flexion (ankle bent with toes pointing away from the body). RNA 1 was observed standing on the right side of Resident 5's bed and RNA 2 was standing on the left side. RNA 1 was observed performing PROM on Resident 5's right leg into hip flexion (bending the leg at the hip joint toward the body) and hip abduction (moving the leg away from the body). RNA 1 attempted to perform right knee flexion (bending the knee) but Resident 5 refused additional exercises on the right [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, who underwent an open reduction internal fixation ([ORIF] a surgical procedure that puts pieces of a broken bone into place using screws, plates, sutures, or rods) surgery of the right ankle fracture (break in the bone), did not have the surgical wound infected with exposed surgical hardware (pins, plates, or screws used to help fix a broken bone, torn tendon, or to correct an abnormality in a bone) for one of three sampled residents (Resident 1). The facility failed to: 1. Ensure treatment nurses (TN 1 and TN 2) followed Resident 1's orthopedic surgeon's treatment orders to stop using an antibiotic ointment (a substance used on the skin to soothe or heal wounds) on Resident 1's right medical ankle and to use a Betadine (a solution used to prevent infection in minor cuts, scrapes, and burns) soaked gauze treatment to Resident 1's right ankle starting on 2/7/2024. TN 1 and TN 2 continued to apply ointment to Resident 1's surgical wound from 2/7/2024 to 2/10/2024 (three days). 2. Ensure TN 1 and TN 2 followed Resident 1's Care Plan dated 1/19/2024 and 2/1/2024 to notify Resident 1's physician and/or Resident 1's orthopedic surgeon when Resident 1's surgical hardware was observed being exposed through Resident 1's right ankle surgical site on 2/10/2024. 3. Ensure TN 1 documented a Change of Condition (COC-communication tool use to share information about resident) when she identified for the first time Resident 1's surgical hardware was visible through the resident's right ankle surgical incision (a cut that is made in skin during a surgery) on 2/10/2024. 4. Ensure TN 1 notified Resident 1's physician and orthopedic surgeon (a doctor who specializes in the prevention, diagnosis, and treatment of disorders of the bones, joints, ligaments, tendons, and muscles) when identified Resident 1's surgical hardware became visibly exposed through the resident's surgical incision on a right ankle on 2/10/2024. 5. Ensure TN 2 notified Resident 1's physician and orthopedic surgeon when first noted Resident 1's surgical hardware became visibly exposed through the resident's surgical incision on a right ankle on 2/20/2024. These deficient practices resulted in Resident 1's right ankle surgical incision becoming infected and Resident 1's transfer to a General Acute Care Hospital (GACH 1) where Resident 1 underwent a surgical procedure to remove infected hardware with irrigation and debridement (washout and removal of dead, infected, or contaminated tissue) of the infected wound and placement of a wound vacuum (a vacuum device that promotes healing by gently pulling fluid from the wound over time, reducing swelling, cleaning the wound and removing bacteria). Findings: During a review of Resident 1's Change in Condition (COC) dated 12/08/2024, the COC indicated Resident 1 used a shower chair to climb out of a bathroom window and was found sitting on the ground outside of the facility under the window holding her right ankle and grimacing from pain. The COC indicated Resident 1's physician was notified, and the physician ordered for Resident 1 to be transferred to GACH 2 for further evaluation. During a review of GACH 2's Face Sheet, the Face Sheet indicated Resident 1 was admitted to the GACH 2 on 12/08/2024 with a diagnosis of a right tibia (the inner and typically larger of the two bones between the knee and the ankle) and fibula (the outer and usually smaller of the two bones between the knee and the ankle) fracture. During a review of Resident 1's Discharge Summary from GACH 2 dated 1/18/2024, the Discharge Summary indicated on 12/9/2023 Resident 1 ORIF surgery of the right ankle. The Discharge Summary indicated Resident 1 was discharged from GACH 2 on 1/18/2024. During a review of Resident 1's admission Record (Face Sheet) to the facility, the Face Sheet indicated Resident 1 was initially admitted to the facility on [DATE] and was readmitted on [DATE] with the diagnoses including a history of falling and a displaced comminuted (type of broken bone where the bone snaps into two or more parts and moves so that the two ends are not lined up straight) fracture of the shaft of the right fibula and right tibia. During a review of Resident 1's Minimum Data Set ([MDS] a standardized assessment and care screening tool) dated 1/22/2024, the MDS indicated Resident 1's cognitive (thinking and reasoning) skills for daily decision-making were moderately impaired. The MDS indicated Resident 1 required moderate to maximum assistance from staff to complete most activities of daily living ([ADLs] eating, drinking, toileting, and dressing). During a review of Resident 1's Physician's Order dated 1/19/2024, the Physician's Order indicated to cleanse Resident 1's right medial (toward the middle or center) ankle with normal saline ([NS] a non-toxic solution that does not damage healing tissues), pat dry, apply betadine then cover with a dry island dressing (a dressing that is ideal for the treatment of wounds with light drainage) daily and as needed. During a review of Resident 1's Care Plan dated 1/19/2024, the Care Plan indicated Resident 1 had a potential/actual impairment of the skin integrity to the surgical site on her right medial ankle. The Care Plan indicated Resident 1 had sutures (row of stitches holding together the edges of a wound or surgical incision) to her right medial ankle and was at continued risk for skin breakdown related to her fragile skin and infection. Under this Care Plan a goal was for Resident 1 to have no complications through the next review date (1/27/2024). The Care Plan's interventions included reporting declines in skin integrity to Resident 1's physician. During a review of Resident 1's COC note dated 2/1/2024, the COC note indicated Resident 1's surgical wound on the medial ankle had a moderate amount of pus (thick yellowish or greenish liquid produced from an infected tissue), redness, swelling and warmth. The COC note indicated Resident 1's surgical wound was cleansed with NS, following application of Betadine (a solution that kills germs to prevent infection) and Mupirocin ointment (an antibiotic ointment used to treat bacterial skin infections) according to the wound physician's recommendation. The COC note indicated Resident 1's primary physician was notified of the COC. During a review of Resident 1's Care Plan dated 2/1/2024, the Care Plan indicated Resident 1 had drainage coming from the surgical wound site on the right ankle surgical site. Under this Care Plan the goal for Resident 1 was to be free from any complications related to the surgical site on the right ankle. The Care Plan's interventions included to notify the physician regarding any Resident 1's COC. During a review of Resident 1's Physician's Order dated 2/6/2024, the Physician's Order indicated to apply Mupirocin to Resident 1's right medial suture/wound every day shift, cleanse the wound with NS, pat dry, apply Bactroban (an antibiotic ointment used to treat skin infections) then cover with an abdominal ([ABD] a pad used to absorb discharges from the abdominal and other heavily draining wounds) pad dressing and wrap with a Kerlix (hypoallergenic gauze rolls that provides fast-wicking [quickly moving fluid to the fabric's outer surface] action, superior aeration (circulation of air), and excellent absorbency). During a review of Resident 1's orthopedic surgeon Progress Note dated 2/7/2024, the Progress Note indicated the orthopedic surgeon ordered a Betadine-soaked gauze, no ointment, to apply to Resident 1's right ankle medial incision, every two to three days. During a review of Resident 1's Nursing Progress Notes dated 2/10/2024 and timed at 9:17 a.m., the Nursing Progress Notes indicated a hardware was visible in Resident 1's right lower leg. During a review of Resident 1's Skin and Wound Evaluation dated 2/13/2024, the Skin and Wound Evaluation indicated the hardware was visible in Resident 1's wound bed on the right ankle and the section that indicated if Resident 1's physician was notified was left blank. During a review of the Wound Physician's Consult Note dated 2/13/2024, the Wound Physician's Consult Note indicated Bactroban, and a dry dressing were applied to Resident 1's surgical wound on a right ankle. The Physician's Wound Consult Note indicated there was exposed hardware at the distal (a part of the body that is farther away from the center of the body than another part) end of Resident 1's surgical wound on the right ankle. During a review of Resident 1's Treatment Record dated 2/2024, the Treatment Record indicated the following: 1. From 2/7/2024 - 2/10/2024 Mupirocin and Bactroban was applied to Resident 1's right ankle medial suture/wound daily (when order from orthopedic surgeon on 2/7/2024 indicated no ointment to be used). 2. There was no documentation that Resident 1's right ankle medial suture/wound was treated with a Betadine-soaked gauze every two to three days as ordered on 2/7/2024. During a review of Resident 1's Physician Orders dated 2/7/2024, the Physician's Order indicated Resident 1 had a follow up appointment with the orthopedic surgeon on 2/21/2024 at 9:45 a.m. During a review of Resident 1's orthopedic surgeon Progress Note, dated 2/21/2024, the Progress Note indicated there was no wet to dry (Betadine-soaked gauze) dressing done at the facility, Resident 1's surgical incision was noted with drainage (fluid) and an exposed screw at the surgical incision site on a right ankle. The orthopedic surgeon Progress Note indicated Resident 1 was referred to the emergency room for intravenous ([IV] in the vein) antibiotics and a Wound Care Consult for an exposed screw. During a review of Resident 1's Nursing Progress Notes dated 2/21/2024 and timed at 1:22 p.m., the notes indicated Resident 1 went to orthopedic surgeon appointment and returned with a new order to transfer Resident 1 to the emergency room (ER) due to infected right tibia with exposed hardware. During a review of Resident 1's Physician's Order, dated 2/21/2024 the Physician's Order indicated to transfer Resident 1 to a GACH due to an infected right tibia with exposed hardware. During a review of GACH 1's Face Sheet, the Face Sheet indicated Resident 1 was admitted to GACH 1 on 2/22/2024 with diagnoses including a right ankle surgical wound infection with exposed orthopedic hardware. During a review of GACH 1's History and Physical (H&P) dated 2/22/2024, the H&P indicated during the physical exam of Resident 1's right ankle, there was a two centimeter ([cm] a unit of measurement) wound in length with an exposed screw (part of the hardware) on Resident 1's right medial malleolus (the inside of the ankle formed by the tibia). During a review of Resident 1's Orthopedic Medicine Progress Note dated 2/24/2024, the Orthopedic Medicine Progress Note indicated Resident 1's right lower extremity hardware was removed, the wound was irrigated and debrided (the process of removing dead skin and foreign material from a wound), closed and a wound vacuum was placed in the wound. During a review of GACH 1's Discharge Order, dated 2/26/2024, GACH 1's Discharge Orders indicated to leave the dressing to the right ankle in place until follow up appointment with orthopedic surgeon in one to two weeks. During an observation of Resident 1 on 2/29/2024 at 12:15 p.m., at the facility, Resident 1 was observed in her room with a small wound vacuum machine attached to the resident's right ankle with a cannister at the foot of her bed. During an interview on 2/29/2024 at 1:30 p.m., and a subsequent interview on the same day at 3:30 p.m., Treatment Nurse 2 (TN 2) stated Resident 1's right medial ankle surgical wound was treated with Mupirocin from 2/7/2024 until 2/10/2024. TN 2 stated when she (TN 2) was treating Resident 1's wound on 2/20/2024, she could see the top of a metal button that looked like the top of a screw, on Resident 1's right medial lower leg surgical incision. TN 2 stated she was not sure if the metal hardware was supposed to be visible through the incision site, but the incision did not look normal because there was no skin covering the hardware. TN 2 stated she did not notify Resident 1's physician or the orthopedic surgeon that the hardware was visible, and stated she did not create a COC form and could offer no explanation why. TN 2 stated if there was no skin covering Resident 1's wound to protect it, the wound could get infected. During an interview on 2/29/2024 at 2:35 p.m., and a subsequent interview on 3/1/2024 at 2:22 p.m., TN 1 stated on 2/10/2024 she noticed hardware was visible in Resident 1's right ankle surgical wound. TN 1 stated she reported to the wound doctor that the hardware in Resident 1's surgical incision was visible, and he (the wound doctor) did not provide any new orders for treatment of the visible hardware. TN 1 stated she did not notify the orthopedic surgeon on 2/10/2024 when she noticed the visible hardware because Resident 1 had a follow up appointment with the orthopedic surgeon in a few days on 2/21/2024, (11 days after the hardware was noticed in Resident 1's wound) and she thought the surgeon could evaluate it then. TN 1 stated she should have notified the orthopedic surgeon about the visible hardware in Resident 1's surgical wound incision on 2/10/2024 when she first noticed it and documented what she saw as a COC. TN 1 stated she overlooked treating Resident 1's wound with Betadine-soaked gauze and she should have stopped using the ointments (Mupirocin and Bactroban) on Resident 1's incision site, per the orthopedic surgeon's order on 2/7/2024. TN 1 stated the physician's orders should have been carried out as the orders were written and the resident's physician should be called if clarification of the order was needed. During an interview on 3/1/2024 at 4:11 p.m., the Director of Nursing (DON) stated if there was a COC to resident's skin, the nurse should have notified Resident 1's physician and documented that change on a COC form. The DON stated visible hardware was a COC, but she was not sure if Resident 1's physician or the orthopedic surgeon were notified. The DON stated if hardware was visible through Resident 1's incision, that meant the incision was open and there was a higher chance of infection to occur. The DON stated properly transcribing and implementing physician orders helps ensure residents receive proper treatment to promote healing and prevent an infection. During a review of the facility's policy and procedure (P/P) titled, Notification of Changes, dated 12/2022, the P/P indicated the facility must consult with the resident's physician when there is a significant change in the resident's physical condition which may include clinical complications, circumstances that require a need to alter treatment. During a review of the facility's P/P titled Provision of Physician Ordered Services, dated 12/2022, the P/P indicated qualified nursing personnel will administer therapeutic treatments as ordered by the physician. During a review of the facility's Job Description for a Treatment Nurse dated 2003, the Job Description indicated the job functions of the treatment nurse include examining the resident's records and charts and discriminate between normal and abnormal findings to refer the resident to a physician for evaluation and supervision. The treatment nurse's job function included providing assessments and diagnostic services to the residents.