**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 mobility (ability to move) for one of four sampled residents (Resident 53) with limited range of motion [(ROM) full movement potential of a joint (where two bones meet)] and mobility by failing to: 1. Monitor Resident 53's ROM in each joint of both arms and legs upon admission, quarterly, and annually in accordance with the facility's policies and procedures (P&P) titled, Resident Mobility and Range of Motion, which indicated the resident's comprehensive assessment will identify a resident's current range of motion of his or her joints. 2. Provide Resident 53 with active assistive range of motion ([AAROM] use of muscles surrounding the joint to perform the exercise but required some help from a person or equipment) exercises from 12/23/2022 (admission assessment) to 5/1/2023 (more than four months) in accordance Resident 53's admission Rehab Screening Form (brief assessment of a resident's abilities) recommendations, dated 12/23/2022. 3. Provide Resident 53 with passive range of motion ([PROM] movement of joint through the ROM with no effort from the person) of the ankles in accordance with physician orders, dated 3/25/2024. 4. Assess and monitor Resident 3, 56, and 61's ROM in each joint of both arms and both legs upon admission, quarterly, and annually in accordance with the facility's policies and procedures (P&P) titled, Resident Mobility and Range of Motion. 5. Provide Resident 3 with PROM of both elbows, wrists, hands, knees, and the left ankle in accordance with physician orders, dated 11/27/2023. 6. Provide Resident 56 with active range of motion (AROM, performance of ROM of a joint without any assistance or effort of another person) of the right wrist and hand in accordance with physician orders, dated 4/7/2023. These deficient practices resulted in Resident 53 requiring full physical assistance to perform exercises of both arms and legs and Resident 53's development of both ankle contractures (condition of shortening and hardening of muscles, tendons, or other tissue, often leading to joint stiffness). These deficient practices also had the potential for Resident 3, 56, and 61 to experience an undetected decline in ROM and the development of contractures. Cross reference F580, F656, F677, F726, and F825 Findings: a. A review of Resident 53's general acute care hospital (GACH) Neurology (branch of medicine concerned with the study and treatment of disorders involving the brain, spinal cord, and nerves) Progress Note, dated 12/18/2022, indicated Resident 53 was fully awake, alert, and followed simple commands. The Neurology Progress Note also included a physical examination, which indicated Resident 53 held the arms and legs against gravity (active movement). A review of Resident 53's admission Record indicated Resident 53 was originally admitted to the facility on [DATE] and readmitted on [DATE]. The admission Record indicated Resident 53's diagnoses included psychosis (severe mental disorder in which thought and emotions are so impaired that contact is lost with external reality), major depressive disorders (depression, a mood disorder that causes a persistent feeling of sadness and loss of interest and can interfere with your daily functioning), seizures (burst of uncontrolled electrical activity between brain cells that causes temporary abnormalities in muscle tone or movements like stiffness, twitching or limpness), starvation (suffering caused by hunger), and attention to gastrostomy (G-tube, tube placed directly into the stomach for long-term feeding). A review of Resident 53's Minimum Data Set ([MDS] a comprehensive assessment and care planning tool), dated 4/2/2024, indicated Resident 53 had severely impaired cognition (ability to think, understand, learn, and remember). The MDS indicated Resident 53 did not have any ROM impairments to both arms and legs. The MDS indicated Resident 53 was dependent (helper does all the effort or the assistance of two or more helpers is required for the resident to complete the activity) for rolling to either side, transferring from sit to lying, chair/bed-to-chair transfers, oral hygiene (cleaning teeth), showering/bathing, and dressing. A review of Resident 53's Progress Note, dated 12/22/2022 timed at 3:00 p.m., indicated Resident 53 was found in the middle of the bed with both legs dangling outside of the bed. The Progress Note indicated Resident 53 was assisted back to bed and repositioned. The Progress Note indicated Resident 53's physician was informed, and a physician order was carried out to place the bed in the lowest position and floor mat. A review of Resident 53's admission Rehab Screening Form, dated 12/23/2022, indicated Resident 53 did not have any contractures or ROM impairments in both arms, but had a ROM impairment in one leg. The Rehabilitation Screening Form indicated Resident 53's left leg was within functional limits ([WFL] sufficient movement without significant limitation) and the right leg (hip) had tightness into flexion (bending the leg at the hip joint toward the body) and abduction (moving the leg away from the body). The Rehab Screening Form indicated to provide Resident 53 with Restorative Nursing Aide ([RNA] Certified Nursing Aide program that help residents to maintain their function and joint mobility) for AAROM exercises on both arms and legs, three to five times per week (3-5x/week) as tolerated. A review of Resident 53's Restorative Flow Sheets (record of RNA sessions) for 12/2022, 1/2023, 2/2023, 3/2023, and 4/2023 indicated AAROM exercises on both arms and legs were not included. A review of Resident 53's quarterly Rehab Screening Form, dated 4/9/2023, indicated Resident 53 did not have any contractures or ROM impairments in both arms. The Screening Form indicated Resident 53 had a ROM impairment in one leg. The Rehab Screening Form indicated Resident 53 had the same level of function without significant decline and to continue the RNA ROM exercise program. A review of Resident 53's physician orders, dated 5/1/2023, indicated for the RNA to provide Resident 53 with PROM on both arms and legs, 3-5x/week with one person assist as tolerated. A review of Resident 53's quarterly Rehab Screening Forms, dated 7/9/2023 and 10/10/2023, indicated Resident 53 did not have any contractures or ROM impairments in both arms. The Screening Form indicated Resident 53 had a ROM impairment in one leg. The Rehab Screening Forms indicated Resident 53 had the same level of function without significant decline and to continue the RNA ROM exercise program. A review of Resident 53's annual Rehab Screening Form, dated 1/9/2024, indicated Resident 53 did not have any contractures and did not have any ROM impairments in both arms. The Screening Form indicated Resident 53 had a ROM impairment in one leg. The Rehab Screening Form indicated Resident 53 had the same level of function without significant decline and to continue the RNA ROM exercise program. A review of Resident 53's physician orders, dated 3/25/2024, indicated for RNA to provide PROM on both arms and legs, followed by the application of both elbow splints (material used to restrict, protect, or immobilize a part of the body to support function, assist and/or increase range of motion) for four to six hours (4-6 hours), 3-5x/week. A review of Resident 53's quarterly Rehab Screening Form, dated 4/9/2024, indicated Resident 53 did not have any contractures or ROM impairments in both arms. The Rehab Screening Form indicated Resident 53 had a ROM impairment in one leg. The Rehab Screening Form indicated Resident 53 had the same level of function without significant decline and to continue the RNA ROM exercise program. During a concurrent interview and record review on 5/28/2024 at 10:48 a.m. with the Director of Rehabilitation (DOR), the facility's Rehab Screening Form was reviewed. The DOR stated the Rehab Screening Form was completed upon a resident's admission, quarterly, change of condition, and annually. The DOR stated ROM was assessed as either having no impairment, impairment on one side, or impairment on both sides. The DOR stated the Rehab Screening Form did not include a ROM assessment for limitations in each joint of the arms (shoulders, elbows, wrists, and hands) and the legs (hips, knees, ankles). The DOR stated RNA services helped residents maintain their ROM and function. During an observation on 5/29/2024 at 8:13 a.m., in Resident 53's room, Resident 53 was lying awake in bed with the head-of-bed (HOB) elevated and a bed sheet covering Resident 53's legs. Resident 53 smiled but did not speak. Resident 53's body twitched (short, jerky sudden movements) intermittently (did not happen continuously) and both elbows were in a bent position. Resident 53's hips and knees were visibly rotated away from the body with the knees bent, resembling a frog-like leg position, despite the presence of the bed sheet over both legs. Resident 53's ankles and feet were not visible. Resident 53 was not wearing any splints on both arms and legs. During an observation on 5/29/2024 at 9:09 a.m., in Resident 53's room, Resident 53 was observed lying awake in bed with the HOB elevated. Resident 53's elbows were in a bent position. Restorative Nursing Aide (RNA) 3 performed ROM exercises on Resident 53's left arm, including shoulder abduction (lifting the arm away from the body) and adduction (returning the arm toward the body), shoulder rotation (circular motion) in clockwise and counterclockwise directions, shoulder flexion (lifting the arm upward) and extension (returning the arm downward), elbow flexion (bending) and extension (straightening), and then applied an elbow extension splint (splint that prevents the resident from bending at the elbow) on the left arm. RNA 3 performed ROM exercises on Resident 53's right arm, including shoulder abduction and adduction, shoulder rotation in clockwise and counterclockwise directions, shoulder flexion and extension, elbow flexion and extension, and then applied an elbow extension splint on the right arm. Resident 53's legs were rotated away from the body, both knees were bent, and both ankles were positioned in plantarflexion (ankles bent with toes pointing away from the body). RNA 3 performed ROM exercises on Resident 53's right leg, including hip abduction (moving the leg away from the body) and adduction (returning the leg toward the body), hip rotation clockwise and counterclockwise while the knee was extended, hip flexion (bending the leg at the hip joint toward the body) with knee flexion (bending the knee), and ankle rotation. RNA 3 did not move Resident 53's right ankle into dorsiflexion (ankle bent with toes pointing toward the body). RNA 3 performed ROM exercises on Resident 53's left leg, including hip abduction, hip rotation clockwise and counterclockwise with the knee extended, hip flexion with knee flexion, and ankle rotation. RNA 3 did not move Resident 53's left ankle into dorsiflexion. RNA 3 then performed exercises to the left-hand fingers into flexion and extension, left wrist rotation, left wrist flexion and extension, right-hand fingers into flexion and extension, right wrist rotation, and right wrist flexion and extension. During an interview on 5/29/2024 at 9:37 a.m. with RNA 3, RNA 3 stated she performed PROM on both of Resident 53's arms and legs and applied both elbow extension splints. During an interview on 5/29/2024 at 11:36 a.m. with Physical Therapist (PT, professional trained in the restoration, maintenance, and promotion of optimal physical function) 1, PT 1 stated the ROM exercises that the RNAs were expected to perform for each resident's legs included hip flexion and extension, hip abduction and adduction, knee flexion and extension, and ankle dorsiflexion and plantarflexion to prevent contractures. During a concurrent interview and record review on 5/29/2024 at 4:06 p.m. with the DOR, in the presence of the Assistant Director of Nursing (ADON) and the MDS Coordinator (MDS 1), the facility's Rehabilitation electronic documentation (clinical therapy records) for PT, Occupational Therapy [(OT) profession aimed to increase or maintain a person's capability of participating in everyday life activities (occupations)], and Speech Therapy ([ST or SLP] profession aimed in the prevention, assessment, and treatment of speech, language, communicative, and swallowing disorders) was reviewed. The DOR stated Resident 53 never received any PT, OT, or SLP services while residing in the facility. During a concurrent interview and record review on 5/29/2024 at 4:23 p.m. with the DOR, Resident 53's Rehab Screening Form, dated 12/23/2022, was reviewed. The DOR stated Resident 53 had ROM impairments in the right leg due to tightness in the hip. The DOR stated Resident 53 did not have any contractures in both legs upon admission to the facility. During a concurrent observation and interview on 5/29/2024 at 4:38 p.m., with Resident 53, in the presence of the DOR, ADON, and MDS 1, in Resident 53's room, Resident 53 was observed lying in bed with a bed sheet covering both legs. The DOR lifted the bed sheet to view both legs. Resident 53 did not have any splints on both legs. Resident 53's ankles were positioned in plantarflexion. The DOR attempted to provide ROM to Resident 53's ankles into dorsiflexion, but Resident 53's ankles remained in plantarflexion. During an interview on 5/29/2024 at 4:43 p.m. with the DOR, ADON, and MDS 1, the DOR, ADON, and MDS 1 stated Resident 53 had plantarflexion contractures of both ankles. MDS 1 stated the ROM assessment in a resident's MDS indicated whether a resident had any ROM limitations but did not indicate which joint had a ROM limitation. The DOR stated the Rehab Screening Form did not include any assessment of a resident's ROM at each joint and the facility was not monitoring each resident's ROM. The ADON stated ROM exercises, movement, proper positioning, and splints assisted in preventing contractures. The ADON stated Resident 53 did not have any splints on both legs. The ADON and MDS 1 stated the facility did not know Resident 53 had both ankle plantarflexion contractures, and therefore, did not know when Resident 53's contractures developed. The ADON stated contractures increased a resident's risk of developing skin breakdown (tissue damage caused by friction, shear, moisture, or pressure) and fractures (break in the bone). The ADON and MDS 1 stated Resident 53's plantarflexion contractures in both ankles were preventable. During an interview on 5/30/2024 at 11:11 a.m. with PT 1, PT 1 stated contractures were a fixed positioning of a joint. PT 1 stated contractures were not reversible but could be surgically released. PT 1 stated contractures could be delayed with ROM exercises, proper positioning, and the application of splints. During a concurrent interview and record review on 5/30/2024 at 11:46 a.m. with the DOR, Resident 53's Rehab Screening Forms, dated 12/23/2022 and 4/9/2023, and physician orders dated, 5/1/2023, for RNA were reviewed. The DOR stated the Rehab Screening Form, dated 12/23/2022, included a recommendation for RNA to perform AAROM exercises to both arms and legs. The DOR stated Resident 53 did not receive RNA until the physician orders, dated 5/1/2023, which indicated for the RNA to perform PROM to both arms and legs. The DOR stated Resident 53 did not receive RNA for AAROM exercises from 12/23/2022 to 5/1/2023. The DOR stated the Rehab Screening Form, dated 4/9/2023, indicated to continue the RNA ROM exercise program but the DOR did not verify if Resident 53 was received RNA services. The DOR stated the facility's Rehab Screening Form did not monitor Resident 53's ROM. During an interview on 5/30/2024 at 3:44 p.m. with the DOR, the DOR stated AAROM meant a resident moved as much as possible but required additional help from another person. The DOR stated PROM meant the resident required full physical assistance. During a concurrent interview and record review on 5/31/2024 at 10:28 a.m. with the ADON and MDS 1, Resident 53's Rehab Screening Form, dated 12/23/2022, the Restorative Flow Sheets, and physician orders dated, 5/1/2023, for RNA were reviewed. The ADON stated the Rehab Screening Form, dated 12/23/2022, indicated a recommendation for RNA to provide AAROM exercises to both arms and legs. The ADON stated Resident 53 had some movement in both arms and both legs if the recommendation was for AAROM. The ADON and MDS 1 reviewed the Restorative Flow Sheets from 12/2022 to 4/2022 and stated Resident 53 did not receive RNA for AAROM exercises for four months. MDS 1 stated Resident 53 started receiving RNA for PROM exercises to both arms and legs in accordance with the physician order, dated 5/1/2023. MDS 1 stated the physician orders changed from AAROM to PROM which indicated Resident 53 could have declined in the ability to move. The ADON stated the Rehab Screening Form should have indicated Resident 53 was monitored for ROM (at each joint) since the RNAs were not trained to observe ROM. The ADON stated Resident 53's ROM limitations were preventable. b. A review of Resident 3's admission Record, indicated Resident 3 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 3's diagnoses included type 2 diabetes mellitus (high blood sugar), myocardial infarction (heart attack), hemiplegia or hemiparesis (weakness or inability to move one side of the body) following cerebral infarction (stroke, brain damage due to a loss of oxygen to the area) affecting the right dominant (used most often) side, dysphagia (difficulty swallowing), acquired absence of the left toes, and acquired absence of the right leg below the knee. A review of Resident 3's annual Rehab Screening Form, dated 11/6/2023, indicated Resident 3 had a ROM impairment in one arm and a ROM impairment in one leg. The Rehab Screening Form did not indicate which arm and which leg had ROM impairments. The Rehab Screening Form indicated Resident 3 had the same level of function without decline and to continue the Restorative Nursing Aide ([RNA] certified nursing aide program that helps residents to maintain their function and joint mobility) program. A review of Resident 3's physician orders, dated 11/27/2023, indicated for the RNA to provide PROM on both upper extremities and both lower extremities, 3-5x/week with one person assist as tolerated. A review of Resident 3's quarterly Rehab Screening Form, dated 2/6/2024, indicated Resident 3 had a ROM impairment in one arm and a ROM impairment in one leg. The Rehab Screening Form did not indicate which arm and which leg had ROM impairments. The Rehab Screening Form indicated Resident 3 had the same level of function without decline and to continue the RNA program. A review of Resident 3 MDS, dated [DATE], indicated Resident 3 had severely impaired cognition, had ROM impairments to one arm and one leg, and was dependent for rolling to either side, transferring from sit to lying, chair/bed-to-chair transfers, oral hygiene, showering/bathing, and dressing. A review of Resident 3's quarterly Rehab Screening Form, dated 5/7/2024, indicated Resident 3 had a ROM impairment in one arm and a ROM impairment in one leg. The Rehab Screening Form did not indicate which arm and which leg had ROM impairments. The Rehab Screening Form indicated Resident 3 had the same level of function without decline and to continue the RNA program. During a concurrent interview and record review on 5/28/2024 at 10:48 a.m. with the DOR, the facility's Rehab Screening Form was reviewed. The DOR stated the Rehab Screening Form was completed upon a resident's admission, quarterly, change of condition, and annually. The DOR stated ROM was assessed as either having no impairment, impairment on one side, or impairment on both sides. The DOR stated the Rehab Screening Form did not include a ROM assessment for limitations in each joint of the arms (shoulders, elbows, wrists, and hands) and the legs (hips, knees, ankles). The DOR stated RNA services helped residents (in general) maintain their ROM and function. During an observation on 5/28/2024 at 11:30 a.m., in Resident 3's room, Resident 3 was observed asleep while lying in bed with the HOB elevated and receiving liquid feeding through the G-tube. Resident 3 woke up easily to sound but did not speak. Resident 3 attempted to move the left hand to reach forward but no other active movement was observed in both arms and both legs. During an observation on 5/29/2024 at 8:47 a.m., in Resident 3's room, Resident 3 was observed lying in bed with the HOB elevated receiving liquid feeding through the G-tube. During an observation on 5/29/2024 at 8:53 a.m., in Resident 3's room, the ADON came into Resident 3's room to disconnect the G-tube from the liquid feeding machine. RNA 2 stood on the left side of Resident 3's bed and performed exercises on Resident 3's left arm, including shoulder flexion (lifting the arm upward) and extension (returning the arm downward), shoulder horizontal abduction (lifting the arm from shoulder level in front of the body toward the side and away from the body) and horizontal adduction (lifting the arm from shoulder level on side of the body toward the front of the body), and shoulder rotation (circular motion). RNA 2 did not perform any exercises on the left elbow, wrist, or fingers. RNA 2 walked to the right side of Resident 3's bed and performed exercises on Resident 3's right arm including, shoulder flexion and extension, shoulder horizontal abduction and adduction, and shoulder rotation. RNA 2 did not perform any exercises to Resident 3's right elbow, wrist, and hand. RNA 2 removed the bed sheet over Resident 3's legs. Resident 3 was observed to have the absence of the right lower leg below the knee and a cushioned boot underneath the left foot. RNA 2 performed exercises to the right leg, including hip flexion (bending the leg at the hip joint toward the body) and extension (returning the leg down away from the body), hip abduction (moving the leg away from the body) and adduction (returning the leg toward the body), and hip rotation. RNA did not perform any exercises to the right knee. RNA 2 removed the cushioned boot from the left foot, and Resident 3 was observed with the absence of toes. RNA 2 performed exercises to the left leg, including hip flexion and extension, hip abduction and adduction, and hip rotation. RNA 2 did not perform any PROM to the left knee and left ankle. During an interview on 5/29/2024 at 9:04 a.m. with RNA 2, RNA 2 stated she performed PROM exercises to both arms and both legs. RNA 2 described and demonstrated the ROM exercises performed to Resident 3's arms and legs. RNA 2 stated she moved both of Resident 3's arms at the shoulder joint upward and downward (shoulder flexion and extension), side to side (shoulder horizonal abduction and horizonal adduction), and circles (shoulder rotation). RNA 2 stated she moved both of Resident 3's legs at the hip joint upward and downward (hip flexion and extension), side to side (hip abduction and adduction), and circles (hip rotation). During an interview on 5/29/2024 at 11:24 a.m. with the DOR, the DOR stated the ROM exercises that the RNAs were expected to perform for each resident's arms included shoulder flexion and extension, shoulder abduction (lifting the arm up and away from the body) and adduction (returning the arm downward to the side of the body), elbow flexion (bending the elbow) and extension (straightening the elbow), wrist flexion (bending the wrist downward) and extension (bending the wrist upward), and finger flexion (bending the fingers toward the palm) and extension (straightening out the fingers). The DOR stated it was important to perform ROM exercises to each joint to improve circulation and prevent stiffness. During an interview on 5/29/2024 at 11:36 a.m. with PT 1, PT 1 stated the ROM exercises that the RNAs were expected to perform for each resident's legs included hip flexion and extension, hip abduction and adduction, knee flexion (bending the knee) and extension (straightening out the knee), and ankle dorsiflexion (bending the ankle toward the body) and plantarflexion (bending the ankle away from the body) to prevent contractures (condition of shortening and hardening of muscles, tendons, or other tissue, often leading to joint stiffness). During a concurrent interview and record review on 5/29/2024 at 12:36 p.m. with the DOR, Resident 3's Rehab Screening Forms were reviewed. The DOR stated Resident 3's Rehab Screening Forms, dated 11/6/2023, 2/6/2024, and 5/7/2024, indicated Resident 3 had a ROM impairment in one arm and ROM impairment in one leg due to Resident 3's hemiplegia affecting the right side of the body. During an interview on 5/29/2024 at 2:36 p.m. with RNA 2, RNA 2 stated she did not perform ROM exercises to both of Resident 3's elbows, wrists, and hands because the physician orders indicated to perform exercises to Resident 3's upper extremity. During an interview on 5/29/2024 at 4:43 p.m. with the DOR, ADON, and MDS 1, MDS 1 stated the ROM assessment in a resident's MDS indicated whether a resident had any ROM limitations but did not indicate which joint had a ROM limitation. The DOR stated the Rehab Screening Form did not include any assessment of a resident's ROM at each joint and stated the facility was not monitoring each resident's ROM. During an interview on 5/31/2024 at 10:28 a.m., with the ADON, the ADON stated the Rehab Screening Form should have monitored a resident's ROM since the RNAs were not trained to observe ROM. c. A review of Resident 56's admission Record, indicated Resident 56 was admitted to the facility on [DATE] with diagnoses including diabetes mellitus (high blood sugar), hemiplegia or hemiparesis following a cerebrovascular disease affecting the left dominant side, aphasia (loss of ability to understand or express speech as a result of brain damage), and dysphagia (difficulty swallowing). A review of Resident 56's physician orders, dated 4/7/2023, indicated for the RNA to provide AROM on the right arm and right leg and PROM on the left leg, three to five times per week, with one person assist. A review of Resident 56's RNA Referral, dated 4/7/2023, indicated Resident 56 had increased stiffness on the left side of the body and refused to have the left arm touched. A review of Resident 56's quarterly Rehab Screening Forms, dated 6/22/2023, 9/24/2023, and 12/24/2023, indicated Resident 56 had ROM impairments in both arms and both legs. The Rehab Screening Form indicated Resident 56 had the same level of function without decline and to continue the RNA program. A review of Resident 56's MDS, dated [DATE], indicated Resident 56 had moderately impaired cognition and had ROM impairments to one arm and one leg. The MDS also indicated Resident 56 required substantial/maximal assistance (helper does more than half the effort) for rolling to either side, oral hygiene, showering/bathing, and upper body dressing, and was dependent for chair/bed-to-chair transfers and lower body dressing. A review of Resident 56's annual Rehab Screening Form, dated 3/24/2024, indicated Resident 56 had ROM impairments in both arms and both legs. The Rehab Screening Form indicated Resident 56 had the same level of function without decline and to continue the RNA program. During a concurrent observation and interview on 5/28/2024 at 10:05 a.m., with Resident 56, in Resident 56's room, Resident 56 was observed awake while lying in bed. Resident 56 moved the right arm and right leg without any physical assistance. Resident 56's left arm was positioned with the left shoulder rotated toward the body, the elbow was bent and touching Resident 56's chest, the wrist was bent downward, and the knuckles of each finger were bent toward the palm. Resident 56's left leg was resting on the bed. Resident 56 stated he was unable to move the left side of the body and stated someone (unknown) performed exercises with Resident 56 at least once per day. During a concurrent interview and record review on 5/28/2024 at 10:48 a.m. with the DOR, the facility's Rehab Screening Form was reviewed. The DOR stated the Rehab Screening Form was completed upon a resident's admission, quarterly, change of condition, and annually. The DOR stated ROM was assessed as either having no impairment, impairment on one side, or impairment on both sides. The DOR stated the Rehab Screening Form did not include a ROM assessment for limitations in each joint of the arms (shoulders, elbows, wrists, and hands) and the legs (hips, knees, ankles). The DOR stated RNA services helped residents maintain their ROM and function. During an observation on 5/29/2024 at 10:02 a.m., in Resident 56's room, Resident 56 was observed awake while lying in bed and performed exercises with RNA 1. Resident 56 performed AROM at the shoulder joint to lift the right arm upward (shoulder flexion) to shoulder level and downward (shoulder extension) without any physical assistance. Resident 56 required some physical assistance to perform right shoulder rotation (circular motion) and right elbow flexion (bending) and extension (straightening). Resident 56 did not perform any ROM exercises of the wrist and the hand. Resident 56 required some physical assistance to perform right hip and knee exercises. Resident 56 did not perform any right ankle exercises. RNA 1 performed PROM exercises to Resident 56's left leg, including hip flexion (bending the leg at the hip joint toward the body) and extension (returning the leg down away from the body). RNA did not perform PROM of the left knee and ankle. RNA 1 stated Resident 56 did not have physician orders to perform ROM exercises to the left arm because Resident 56 did not want anyone to touch it. During an interview on 5/29/2024 at 10:10 a.m. with RNA 1, RNA 1 described and demonstrated the ROM exercises performed with Resident 56. RNA 1 stated Resident 56 performed ROM exercises on the right arm, including moving the shoulder joint upward and downward (shoulder flexion and extension) and rotation. RNA 1 stated Resident 56 required some physical assistance to perform some right arm and right leg exercises and could only tolerate left hip flexion exercises due to pain. During an interview on 5/29/2024 at 11:24 a.m. with the DOR, the DOR stated the ROM exercises that the RNAs were expected to perform for each resident's arms included shoulder flexion and extension, shoulder abduction and adduction, elbow flexion and extension, wrist flexion (bending the wrist downward) and extension (bending the wrist upward), and finger flexion (bending the fingers toward the palm) and extension (straightening out the fingers). The DOR stated it was important to perform ROM exercises to each joint to improve circulation and prevent stiffness. During an interview on 5/29/2024 at 2:32 p.m. with RNA 1, RNA 1 stated Resident 56 did not perform any ROM exercises on the right wrist and hand because Resident 56 already used the right hand constantly to eat and reposition the body. RNA 1 stated Resident 56 did not perform any ROM exercises to the right ankle because Resident 56 was starting to have pain in the right leg. During an interview on 5/29/2024 at 4:43 p.m. with the DOR, ADON, and MDS 1, MDS 1 stated the ROM assessment in a resident's MDS indicated whether a resident had any ROM limitations but did not indicate which joint had a ROM limitation. The DOR stated the Rehab Screening Form did not include any assessment of a resident's ROM at each joint and stated the facility was not monitoring each resident's ROM. During a concurrent interview and record review on 5/30/2024 at 1:15 p.m. with the DOR, Resident 56's Rehab Screening Forms, dated 4/7/2023, 6/22/2023, 9/24/2023, 12/24/2024, and 3/24/2024, were reviewed. The DOR stated Resident 56's Rehab Screening Forms did not include any assessment of Resident 56's ROM at each joint. During an interview on 5/31/2024 at 10:28 a.m., with the ADON, the ADON stated [TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide Occupational Therapy ([OT] profession aimed to increase or maintain a person's capability of participating in everyday life activities [occupations]), Physical Therapy ([PT] profession aimed in the restoration, maintenance, and promotion of optimal physical function), and Speech Therapy ([ST or SLP] profession aimed in the prevention, assessment, and treatment of speech, language, communicative, and swallowing disorders) to one of four sampled residents (Resident 53), who had range of motion (ROM, full movement potential of a joint [where two bones meet]) mobility (ability to move) and swallowing problems. The facility failed to: 1. Provide Resident 53 with PT and OT evaluations upon admission to the facility in accordance with physician orders, dated 12/21/2022. 2. Provide Resident 53 with PT and OT evaluations upon admission to the facility in accordance admission notes, dated 12/22/2022. 3. Provide Resident 53, who received gastrostomy (G-tube- tube placed directly into the stomach for feeding and medication administration) feedings with a SLP evaluation in accordance with the physician orders, dated 12/27/2022. 4. Provide PT, OT, and SLP services consistent with the facility's job descriptions and the facility's policy and procedure (P&P) titled, Skilled Nursing Rehabilitation Services. 5. Provide Resident 3 PT and OT evaluations in accordance with the physician orders, dated 9/5/2022 and 10/23/2023, the facility's job descriptions for PT and OT, and the facility's P&P titled, Skilled Nursing Rehabilitation Services. These deficient practices resulted in Resident 53 not receiving any interventions to improve speech, cognition (ability to think, understand, learn, and remember), the ability to eat by mouth, mobility, and activities of daily living (ADLs), resulting in Resident 53's dependence on staff for mobility and ADLs and a decline in the resident's physical and psychosocial well-being. These failures also had the potential to prevent Resident 3 from improving mobility, ADLs, and overall physical and psychosocial well-being. Cross reference F677, F684, and F688. Findings: a. A review of Resident 53's GACH Neurology (branch of medicine concerned with the a. study and treatment of disorders involving the brain, spinal cord, and nerves) Progress Note, dated 12/18/2022, indicated Resident 53's overall mental status appeared to be improving. The Neurology Progress Note indicated Resident 53 was fully awake, alert, followed simple commands, and held the arms and legs against gravity (active movement). A review of Resident 53's admission Record, indicated Resident 53 was originally admitted to the facility on [DATE] and readmitted on [DATE]. The admission Record indicated Resident 53's diagnoses included psychosis (severe mental disorder in which thought and emotions are so impaired that contact is lost with external reality), major depressive disorders (depression, a mood disorder that causes a persistent feeling of sadness and loss of interest and can interfere with daily functioning), seizures (burst of uncontrolled electrical activity between brain cells that causes temporary abnormalities in muscle tone or movements like stiffness, twitching or limpness), starvation (suffering caused by hunger), and attention to gastrostomy (G-tube, tube placed directly into the stomach for long-term feeding). A review of Resident 53's physician orders, dated 12/21/2022 timed at 11:41 p.m., indicated to provide PT and OT evaluation/consult as needed. A review of Resident 53's admission Progress Note, dated 12/22/2022 timed at 1:02 a.m., indicated Resident 53 was admitted to the facility on [DATE] at 11:25 p.m. under skilled level of care, for PT and OT evaluation. The admission Progress Note indicated Resident 53 was alert with episodes of confusion, able to make needs known, was striking out at staff, resisted care while cleaning and changing, and kept moving the arm (unspecified). A review of Resident 53's Progress Note, dated 12/22/2022 timed at 3:00 p.m., indicated Resident 53 was found in the middle of the bed with both legs dangling outside of the bed. The Progress Note indicated Resident 53 was assisted back to bed and repositioned. The Progress Note indicated Resident 53's physician was informed, and a physician order was carried out to place the bed in the lowest position and floor mats. A review of Resident 53's physician orders, dated 12/27/2022 timed at 2:20 p.m., indicated to provide a SLP evaluation and treatment as indicated. A review of Resident 53's physician orders, dated 12/29/2022 timed at 4:32 p.m., indicated PT and OT evaluation/consult as needed was discontinued. A review of Resident 53's physician orders, dated 2/22/2023 timed at 4:44 p.m., indicated discontinue speech therapy evaluation and treatment as indicated. A review of Resident 53's physician orders, dated 3/25/2024, indicated for Restorative Nursing Aide ([RNA] Certified Nursing Aide program that helps residents to maintain their function and joint mobility) to provide passive range of motion ([PROM] movement of joint through the ROM with no effort from the person) on both arms and both legs, followed by the application of both elbow splints (material used to restrict, protect, or immobilize a part of the body to support function, assist and/or increase range of motion) for four to six hours, three to five times per week. A review of Resident 53's Minimum Data Set ([MDS] a comprehensive assessment and care planning tool), dated 4/2/2024, indicated Resident 53 had severely impaired cognition. The MDS indicated Resident 53 did not have any ROM impairments to both arms and legs. The MDS indicated Resident 53 was dependent (helper does all the effort or the assistance of two or more helpers is required for the resident to complete the activity) for rolling to either side, transferring from sit to lying, chair/bed-to-chair transfers, oral hygiene (cleaning teeth), showering/bathing, and dressing. During an interview on 5/28/2024 at 10:48 a.m. with the Director of Rehabilitation (DOR), the DOR stated therapy services helped residents regain ability and function. During an observation on 5/29/2024 at 8:13 a.m., in Resident 53's room, Resident 53 was observed lying in bed, awake, with the head-of-bed (HOB) elevated and a bed sheet covered Resident 53's legs. Resident 53 smiled but did not speak and was receiving feeding through a G-tube. Resident 53 did not actively move either arms or legs upon request. Resident 53's body twitched (short, jerky sudden movements) intermittently (did not happen continuously) and both elbows were in a bent position. Resident 53's hips and knees were visibly rotated away from the body with the knees bent, resembling a frog-like leg position, despite the presence of the bed sheet over both legs. Resident 53's ankles and feet were not visible. During an observation on 5/29/2024 at 9:09 a.m., in Resident 53's room, Resident 53 was observed lying in bed, alert, with the HOB elevated. Resident 53's elbows were in a bent position. Restorative Nursing Aide (RNA) 3 performed ROM exercises on Resident 53's left arm and then applied an elbow extension splint (splint that prevents bending at the elbow) on the left arm. RNA 3 performed ROM exercises on Resident 53's right arm and then applied an elbow extension splint on the right arm. Resident 53's legs were rotated away from the body, both knees were bent, and both ankles were positioned in plantarflexion (ankles bent with toes pointing away from the body). RNA 3 performed ROM exercises on both of Resident 53's legs. During an interview on 5/29/2024 at 9:37 a.m. with RNA 3, RNA 3 stated she performed PROM on both of Resident 53's arms and legs and applied elbow extension splints on the resident's elbows. During a concurrent interview and record review on 5/29/2024 at 4:06 p.m. with the DOR in the presence of the Assistant Director of Nursing (ADON) and the MDS Coordinator (MDS 1), the DOR reviewed the facility's Rehabilitation electronic documentation system (clinical therapy records) and stated Resident 53 never received any PT, OT, or SLP services while residing in the facility. During a telephone interview on 5/30/2024 at 9:36 a.m. with Resident 53's family member (FM) 1, FM 1 stated Resident 53 used to walk, dress, and do everything without assistance but had mental health problems. FM 1 stated Resident 53 had gotten worse while residing at the facility since Resident 53 could no longer move and talk. During an interview on 5/30/2024 at 11:32 a.m. with Speech Therapist (SLP) 1, SLP 1 stated a resident with a G-tube did not mean the resident could not chew or swallow. SLP 1 stated a Speech Therapist was the best person to determine whether a resident could swallow. SLP 1 stated the purpose of Speech Therapy included interventions for speech, swallowing, language, and cognition. During a concurrent interview and record review on 5/30/2024 at 11:56 a.m. with the DOR, Resident 53's physician orders for PT and OT evaluation, dated 12/21/2022, admission Progress Note, dated 12/22/2022, and physician orders for SLP evaluation, dated 12/27/2022, were reviewed. The DOR stated Resident 53's admission Progress Note, dated 12/22/2022, indicated Resident 53 was admitted for skilled level of care, including PT and OT evaluations. The DOR stated the physician orders for PT and OT evaluation were not completed and were discontinued on 12/29/2022 for an unknown reason. The DOR reviewed Resident 53's physician orders, dated 12/27/2022, for a SLP evaluation and treatment. The DOR stated the SLP evaluation was not completed and the SLP evaluation was discontinued on 2/22/2023. The DOR stated the resident's payor source (person, organization, or entity that pays for the care services administered by a health provider) had to be verified prior to evaluating a resident for therapy. The DOR stated the facility did not complete the PT, OT, and SLP evaluations on Resident 53 in accordance with the physician orders. During an interview on 5/30/2024 at 3:44 p.m., the DOR stated the purpose of PT, OT, and SLP were to improve the resident's strength and attempt to return the resident to his/her prior level of function (ability prior to admission to the facility). The DOR stated PT interventions were for the resident's legs, mobility, standing, transfers, and ambulation (the act of walking). The DOR stated OT interventions included interventions to the resident's arms, self-care, and ADLs. During a concurrent interview and record review on 5/31/2024 at 9:49 a.m. with the Assistant Director of Nursing (ADON) and MDS Coordinator (MDS 1), Resident 53's physician orders for PT and OT, dated 12/21/2022, admission Progress Notes dated, 12/22/2022, physician's orders for SLP, dated 12/27/2022, and job descriptions for PT, OT, and SLP were reviewed. The MDS 1 stated, the admission Progress Note indicated Resident 53 was admitted to the facility for skilled services, including PT and OT. MDS 1 stated Resident 53's physician orders, dated 12/21/2022, for PT and OT evaluation was discontinued on 12/29/2022. The ADON stated the standard of practice for discontinuing physician orders included contacting the physician for an order to discontinue treatment and then the designated staff would carry out the order. MDS 1 reviewed Resident 53's Progress Notes dated 12/2022 and stated there were no nursing notes indicating Resident 53's physician was contacted to discontinue the PT and OT evaluation order. MDS 1 reviewed Resident 53's physician orders, dated 12/27/2022, for SLP evaluation and stated the order was discontinued on 2/22/2023. MDS 1 stated, there were no nursing notes indicating Resident 53's physician was contacted to discontinue the SLP evaluation order. The ADON and MDS 1 stated they did not know the reason Resident 53 did not receive any therapy. The ADON stated Resident 53 should have received PT, OT, and SLP evaluations. The ADON stated the purpose of therapy was for mobility and to regain strength. The ADON and MDS 1 stated facility did not attempt to maintain Resident 53's ability since Resident 53 did not receive any therapy services. The ADON stated she did not know whether Resident 53's mobility, ADLs, speech, and swallow could have improved since Resident 53's physician orders for PT, OT, and SLP were never carried out. The ADON stated according to the facility's job descriptions for PT, OT, and SLP, the facility did not provide therapy to Resident 53 in accordance with the job descriptions. During an interview on 5/31/2024 at 12:45 p.m. with the Acting Administrator (AADM), the AADM stated the facility was responsible for a resident's care, including following the treatment plan and physician orders, upon accepting the resident's admission to the facility. A review of the facility's undated job description titled, Speech Pathologist, indicated the purpose for this position was to evaluate, treat, document and/or facilitate care for residents with impaired ability to swallow or communicate due to disease process. The SLP job description indicated the SLP was authorized to Evaluate resident's functional needs when referred by the resident's attending physician and Follow physician's orders, facility policies and procedures to evaluate and treat residents. A review of the facility's policy and procedure titled, Skilled Nursing Rehabilitation Services, indicated each resident with physician orders for therapy services will receive an assessment. b., A review of Resident 3's admission Record, indicated Resident 3 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 3's diagnoses included type 2 diabetes mellitus (high blood sugar), myocardial infarction (heart attack), hemiplegia or hemiparesis (weakness or inability to move one side of the body) following cerebral infarction (stroke, brain damage due to a loss of oxygen to the area) affecting the right dominant (used most often) side, dysphagia (difficulty swallowing), acquired absence of the left toes, and acquired absence of the right leg below the knee. A review of Resident 3's physician orders, dated 9/5/2022 timed at 4:57 p.m., indicated PT/OT evaluation as needed. A review of Resident 3's physician orders, dated 9/6/2022 timed at 4:53 p.m., indicated the physician orders for PT/OT evaluation as needed, dated 9/5/2022, was discontinued. A review of Resident 3's physician orders, dated 10/23/2023 timed at 8:33 p.m., indicated PT/OT evaluation as needed. A review of Resident 3's physician orders, dated 10/24/2023 timed at 12:43 p.m., indicated the physician orders for PT/OT evaluation as needed, dated 10/23/2023, was discontinued. A review of Resident 3's physician orders, dated 11/27/2023, indicated for the RNA to provide PROM on both arms and both legs, 3-5x/week with one person assist as tolerated. A review of Resident 3 MDS, dated [DATE], indicated Resident 3 had severely impaired cognition, had ROM impairments to one arm and one leg, and was dependent (helper does all of the effort or the assistance of two or more helpers is required for the resident to complete the activity) for rolling to either side, transferring from sit to lying, chair/bed-to-chair transfers, oral hygiene (cleaning teeth), showering/bathing, and dressing. During an interview on 5/28/2024 at 10:48 a.m. with the DOR, the DOR stated therapy services helped residents regain ability and function. During an observation on 5/28/2024 at 11:30 a.m., in Resident 3's room, Resident 3 was observed asleep while lying in bed with HOB elevated and receiving liquid feeding through the gastrostomy tube (G-tube, tube placed directly into the stomach for long-term feeding). Resident 3 woke up easily to sound but did not speak. Resident 3 attempted to move the left hand to reach forward but no other active movement was observed in both arms and both legs. During an observation on 5/29/2024 at 8:47 a.m., in Resident 3's room, Resident 3 was observed lying in bed with the HOB elevated and receiving liquid feeding through the G-tube. During an observation on 5/29/2024 at 8:53 a.m., in Resident 3's room, the ADON came into Resident 3's room to disconnect the G-tube from the liquid feeding machine. RNA 2 stood on the left side of Resident 3's bed and performed exercises on Resident 3's left shoulder. RNA 2 walked to the right side of Resident 3's bed and performed exercises on Resident 3's right shoulder. RNA 2 removed the bed sheet over Resident 3's legs. Resident 3 was observed to have the absence of the right lower leg below the knee and the absence of toes on the left foot. RNA 2 performed exercises to the right hip and then performed exercises to the left hip. During an interview on 5/29/2024 at 9:04 a.m. with RNA 2, RNA 2 stated she performed PROM exercises to both arms and both legs since Resident 3 did not assist with the exercises. During an interview on 5/29/2024 at 11:36 a.m. with PT 1, PT 1 stated she had never seen Resident 3 for PT services. During a concurrent interview and record review on 5/29/2024 at 11:50 a.m. with the DOR, Resident 3's therapy documentation and physician orders were reviewed. The DOR stated Resident 3 received a PT evaluation on 4/14/2021 and had not received any PT services since 4/14/2021. The DOR stated Resident 3 had never received any OT services. The DOR reviewed Resident 3's physician orders, dated 9/5/2022, for PT/OT evaluation as needed which was discontinued on 9/6/2022. The DOR stated Resident 3 never received PT and OT evaluations in accordance with the physician orders, dated 9/5/2022. The DOR reviewed Resident 3's physician orders, dated 10/23/2023, for PT/OT evaluation as needed which was discontinued on 10/24/2024. The DOR stated never received the PT and OT evaluations in accordance with the physician orders, dated 10/23/2023, but received RNA services to continue to help Resident 3. The DOR stated the facility discontinued the physician orders for PT and OT without completing the evaluation if the PT and OT evaluation was not necessary. During an interview on 5/29/2024 at 3:18 p.m. with Certified Nursing Assistant (CNA) 7, CNA 7 stated Resident 3 used to have a leg prosthesis (device designed to replace a missing part of the body or to make a part of the body work better) and stood up with assistance to transfer to the chair despite weakness to one-side of the body. CNA 7 stated Resident 3's abilities changed about two to three years ago but did not know the reason for Resident 3's decline. CNA 7 stated Resident 3 currently had stiffness in both arms and required complete care. During an interview on 5/30/2024 at 11:56 a.m. with the DOR, the DOR stated the resident's payor source (person, organization, or entity that pays for the care services administered by a health provider) had to be verified prior to evaluating a resident for therapy. During an interview on 5/30/2024 at 8:46 a.m. with CNA 4, CNA 4 stated Resident 3's function has been the same for the past two years. CNA 4 stated Resident 3 did not speak, had leg amputations (loss or surgical removal of a body part), required G-tube feeding, and required two people for dressing due to difficulty lifting both arms. During an interview on 5/30/2024 at 9:02 a.m. with the MDS 1, MDS 1 stated Resident 3 used to sit up in a wheelchair, had conversational language, and would eat. MDS 1 stated Resident 3 went to the hospital (unknown date) for an unknown reason and returned to the facility (unknown date) requiring total dependence for ADLs and mobility. During an interview on 5/30/2024 at 3:44 p.m. with the DOR, the DOR stated the purpose of OT included intervention to a resident's arms, self-care, and ADLs. The DOR stated the purpose of PT included intervention to a resident's legs, mobility, standing, transfers, and ambulation (the act of walking). The DOR stated the purpose of therapy was to improve a resident's strength and attempt to return the resident to their prior level of function (ability prior to admission to the facility). During an interview on 5/31/2024 at 12:45 p.m. with the AADM, the AADM stated the facility was responsible for a resident's care, including following the treatment plan and physician orders, upon accepting the resident's admission to the facility. During an interview and record review on 5/31/2024 at 4:18 p.m. with Registered Nurse (RN) 1, Resident 3's nursing Progress Notes were reviewed. RN 1 stated the process of discontinuing a physician's order included calling the physician who will decide whether to discontinue the order. RN 1 reviewed Resident 3's nursing Progress Notes for the months of 9/2022 and 10/2023. RN 1 stated there were no nursing progress notes indicating the physician was called to discontinue PT and OT evaluations during the months of 9/2022 and 10/2023. A review of the facility's undated job description titled, Physical Therapist, indicated the purpose of this position was to evaluate, treat, document and/or facilitate care for residents with impaired ability to function at an independent level due to disease process. The PT job description indicated the PT was authorized to evaluate resident's functional needs when referred by the resident's attending physician and follow physician's orders, facility policies and procedures to evaluate and treat residents. A review of the facility's undated job description titled, Occupational Therapist, indicated the purpose of this position was to evaluate, treat, document and/or facilitate care for residents with impaired ability to perform activities of daily living at an independent level due to disease process. The OT job description indicated the OT was authorized to evaluate resident's functional needs when referred by the resident's attending physician and follow physician's orders, facility policies and procedures to evaluate and treat residents. A review of the facility's policy and procedure (P&P) titled, Skilled Nursing Rehabilitation Services, indicated each resident with physician orders for therapy services will receive an assessment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure Certified Nursing Assistant (CNA) 1 provided care and services to prevent an injury for one of three sampled residents (Resident 1) by failing to: 1. Ensure CNA 1 provided two-person physical assistance (help from two person) when using a Hoyer Lift (mechanical lift, a device used by staff to transfer residents from a bed to a chair or other similar places) to transfer Resident 1 from Resident 1 ' s bed to the wheelchair. 2. Ensure CNA 1 used the Hoyer lift according to the manufacturer ' s instructions, indicating to use a two-person assistance for transferring a person to a wheelchair with one assistant behind the chair and the other operating the patient lift, the assistant behind the chair will pull back on the grab handle or sides of the sling to seat the patient well into the back of the chair. As a result, CNA 1 transferred Resident 1 to the wheelchair on her own, without assistance, and the Hoyer lift hit Resident 1 in the left eye. Resident 1 was transferred to the general acute care hospital (GACH) due to the injury sustained to the left eye and was diagnosed with a corneal abrasion (a superficial scratch on the clear, protective window at the front of the eye [cornea]). Findings: During a review of Resident 1 ' s admission Record (face sheet), the face sheet indicated Resident 1 was originally admitted to the facility on [DATE], and was readmitted on [DATE], with diagnoses including glaucoma (a group of eye conditions that can cause blindness. The nerve connecting the eye to the brain is damaged, usually due to high eye pressure), type 2 diabetes mellitus (a long-term condition that impairs the way the body regulates and uses sugar as a fuel), difficulty in walking, and muscle weakness. During a review of Resident 1 ' s History and Physical (H&P), dated 10/29/2022, the H&P indicated Resident 1 had the capacity to understand and make decisions. During a review of Resident 1 ' s Minimum Data Set ([MDS], a standardized resident assessment and care screening tool), dated 2/3/2023, the MDS indicated Resident 1 had the capacity understand and be understood. The MDS indicated Resident 1 had total dependence for transfers out of bed and required two-person physical assistance. During a review of Resident 1 ' s Progress Note, dated 3/18/2023, at 10:12 a.m., the note indicated at 9:45 a.m., the Charge Nurse reported Resident 1 was hit by the Hoyer lift and the resident was bleeding in the left eye. The note indicated Resident 1 was assessed and noted with a bloodshot left eye, with bloody tears coming out from it. The note indicated the facility's Medical Director was notified and ordered to transfer the resident to the hospital. During a review of CNA 1 ' s written statement, dated 3/18/2023, the statement indicated CNA 1 transferred Resident 1 to the wheelchair using the mechanical lift without the assistance of another staff member. During a review of CNA 1 ' s Disciplinary Action Notice, dated 3/18/2023, the notice indicated, During patient transfer, an injury occurred. Resident was supposed to be 2-person assist; however, the resident was transferred by the CNA alone/without assistance from another CNA. The disciplinary action notice was signed by CNA 1 on 3/18/2023. During a review of Resident 1 ' s Resident Transfer and Referral Record, dated 3/18/2023, the record indicated Resident 1 was transferred via ambulance to a general acute care hospital (GACH) on 3/18/2023 for an injury to the left eye. During a review of Resident 1 ' s GACH After Visits Summary, dated 3/18/2023, the summary indicated Resident 1 was diagnosed with a corneal abrasion and decreased vision. During a review of Resident 1 ' s Follow-Up Investigation Report, dated 3/20/2023, the report indicated on 3/18/2023, an eye patch was applied to Resident 1 ' s left eye. The report indicated Resident 1 arrived from the GACH with a diagnosis of corneal abrasion related to injury. The report indicated the following physician ' s orders: 1. Erythromycin Ophthalmic Ointment (used to treat bacterial infections of the eye) 5 milligrams per gram (mg/g, unit of measurement) instill 1 application in the left eye every 6 hours for 7 days. 2. Fluorometholone Ophthalmic Suspension 0.1% (used to treat eye conditions caused by inflammation [swelling]) instill 1 drop in the left eye every 4 hours for 10 days. 3. Follow-up appointment with ophthalmologist (eye doctor) on 3/21/2023 at 11 a.m. During an interview on 3/31/2023, at 11:51 a.m., with Registered Nurse (RN) 1, RN 1 stated she was the supervisor on 3/18/2023, day shift. RN 1 stated Licensed Vocational Nurse (LVN) 1 reported CNA 1 used the Hoyer lift to transfer Resident 1 to the wheelchair and when CNA 1 moved the Hoyer lift away from the resident, Resident 1 leaned forward, and the cradle part of the lift hit the resident in the left eye. RN 1 stated Resident 1 ' s left eye sclera (the white outer layer of the eyeball) was blood red and had blood-tinged tears. RN 1 stated 911 (emergency services) was called and Resident 1 was transferred to the GACH via ambulance. During an interview on 3/31/2023, at 12:02 p.m., with LVN 1, LVN 1 stated on 3/18/2023, the Hoyer lift hit Resident 1 in the left eye, when CNA 1 transferred Resident 1 to the wheelchair. LVN 1 stated it was required to have two-staff assistance when transferring a resident with the Hoyer lift. LVN 1 stated CNA 1 had not mentioned she had asked another staff for assistance when she transferred Resident 1 to the wheelchair. During an interview on 3/31/2023, at 12:44 p.m., with CNA 2, CNA 2 stated she was caring for Resident 1 today, 3/31/2023. CNA 2 stated when she transferred Resident 1 from the bed to the wheelchair, she requested two to three staff for assistance to transfer the resident using the Hoyer lift for safety. During an interview on 3/31/2023, at 1:22 p.m., with CNA 3, CNA 3 stated CNA 1 had not asked her for assistance to transfer Resident 1 to the wheelchair on 3/18/2023. CNA 3 stated when using the Hoyer lift, there should be at least two staff assisting for the safety of the resident and the staff. During an interview on 3/31/2023, at 1:40 p.m., with CNA 5, CNA 5 stated CNA 1 had not asked her for help to transfer Resident 1 to the wheelchair on 3/18/2023. CNA 5 stated a minimum of two staff must be used when using the Hoyer lift and three staff should assist if the resident was heavier. During an interview on 3/31/2023, at 2:07 p.m., with the Director of Staff Development (DSD), the DSD stated the Hoyer lift must be used with a minimum of two staff. The DSD stated one staff controlled the mechanical lift and the other staff was to guide the lift and ensure the resident was safe. The DSD stated she had interviewed CNA 1 over the telephone and stated the first thing CNA 1 said was that she knew she was supposed to have another staff assist her when she transferred Resident 1 using the Hoyer lift. The DSD stated CNA 1 had not mentioned that she had asked anyone for help when she transferred Resident 1 to the wheelchair. The DSD stated Resident 1 ' s accident was preventable because CNA 1 should have had another staff assist her when she transferred Resident 1 to the wheelchair using the Hoyer lift. During an interview on 3/31/2023, at 3 p.m., with Resident 1 in the hallway, Resident 1 stated CNA 1 had transferred her from the bed to the wheelchair using the Hoyer lift by herself. Resident 1 stated other staff had used the Hoyer lift and transferred her to the wheelchair by themselves, but this was the first time she got hurt. Resident 1 stated the Hoyer lift was not raised high enough and it moved and hit her in the left eye. Resident 1 stated it was very bad when the accident happened because the resident's eye was a very delicate area. Resident 1 stated she was very scared because her eye was all bloody and she was afraid she could lose her eye. During a telephone interview on 4/10/2023, at 12:10 p.m., with CNA 1, CNA 1 stated on 3/18/2023, she transferred Resident 1 to the wheelchair using the Hoyer lift by herself. CNA 1 stated when she was retracting the Hoyer lift, Resident 1 leaned forward while she adjusted her blouse, and the metal bar of the Hoyer lift grazed (slightly hit) the resident ' s left eye. CNA 1 stated Resident 1 ' s left eye was bleeding a little bit and she went to get the Charge Nurse and the Supervisor to assess the resident. CNA 1 stated she was trained to use the Hoyer lift and was instructed to always have two-person assistance when transferring a resident, but she had transferred Resident 1 on her own. CNA 1 stated she did not remember if she had asked someone for assistance, but at the end of the day it was her fault because she should have had another staff member assist her. CNA 1 stated she was not thinking when she transferred Resident 1 on her own. CNA 1 stated it was a mistake that would not happen again. During a review of the facility ' s assistive devices lesson plan, dated 3/20/2023, the plan indicated the sling lift/Hoyer lift must be used with two staff members. During a review of the manufacturer instructions for the battery powered patient lift user manual, dated 10/18/2018, the manual indicated manufacturer recommended two assistants be used for all lifting and transfers. The manual indicated for transferring to a wheelchair one assistant behind the chair and the other operating the patient lift, the assistant behind the chair will pull back on the grab handle or sides of the sling to seat the patient well into the back of the chair. This will maintain a good center of balance and prevent the chair from tipping forward. During a review of the facility ' s policy and procedure (P&P) titled, Mechanical Lift Use, undated, the P&P indicated, The mechanical lift shall be used according to the manufacturer ' s instruction booklet. During a review of the facility ' s P&P titled, Mechanical Lift (Hoyer Brand), dated 7/2012, the P&P indicated, It is the policy of this facility to move a resident who is totally dependent in transfer by a mechanical means for resident ' s safety. The P&P indicated the procedure must be performed by nursing assistants or licensed nurses who have been in-serviced on use of the device. The P&P indicated, as one person (First person) operates and maneuvers the lift, Move lift slowly away from bed. (Second person should guide the sling.) .First person to lower the patient down SLOWLY, and the second person guides the resident into the chair.