**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility reported a census of 46 residents with four residents selected for review, including three residents reviewed for skin conditions. Based on observation, interview, and record review, the facility failed to ensure one of the three residents, Resident (R)1, had clean and dry dressings to his lower extremities. On 06/17/24, at an appointment, Consultant Staff GG discovered two maggots on R1's right lower extremity while removing urine and fluid-soaked dressings due to weeping from his right lower extremity. The dressings removed were dated 06/13/24, four days prior, when Consultant Staff GG applied the lymphedema wraps (compression wraps used to try and reduce swelling caused by accumulation of lymph). R1 reported concerns about his wraps to Licensed Nurse (LN) I on 06/16/24 between 10:00 PM to 11:00 PM, and LN I told R1 his wound appointment was scheduled for the next morning. R1's dressings remained in place until his appointment time on 06/17/24 at 01:00 PM, 14-15 hours after R1 voiced his concerns about his dressings. R1 lacked any additional orders to instruct the staff what to do should his dressings become soiled, wet, or loose. Findings included: - The Medical Diagnosis tab for R1 included diagnosis of lymphedema (swelling caused by accumulation of lymph), venous insufficiency (poor circulation), and cellulitis (skin infection caused by bacteria) of the right lower extremity. The admission Minimum Data Set dated 03/18/24, assessed R1 with a Brief Interview of Mental Status score of 15, which indicated he had intact cognition. R1 did not reject cares and was continent of urine. R1 had an infection of his foot, moisture associated skin damage (MASD). R1 had dressings applied to his feet, nonsurgical dressing applied other than to feet, and ointments/medications applied other than to feet. The Functional Abilities Care Area Assessment dated 03/25/24, revealed R1 required assistance with his activities of daily living (ADL's), had increased weakness, and was at risk for skin breakdown, incontinence, and further ADL decline. The Dehydration/Fluid Maintenance CAA dated 03/25/24, revealed R1 admitted to the facility with cellulitis and prescribed two antibiotics to treat the cellulitis. R1 had a chronic wound on his right leg with Ace wraps (elastic bandage) daily and wound treatments to his wound. R1 had risk factors of impaired fluid balance and impaired skin integrity. The Pressure Ulcer/Injury CAA dated 03/25/24, revealed the staff were to notify R1's physician of any abnormal findings and treatment orders. The Care Plan dated 04/11/24 revealed R1 had cellulitis to his right lower extremity and the infection would resolve without complication. R1 was to have elastic bandage wraps applied to bilateral (both) lower extremities in the am and taken off at hour of sleep. The staff were to administer antibiotics as ordered and follow wound treatment orders. The Skin and Wound Evaluation revealed on 06/11/24, R1 had a blister to his front left lower leg and had areas of weeping to his right calf in three different areas that were not open. On 06/19/24, R1 had a new blister to his left calf. The Physician Orders tab included an order for R1, dated 06/14/24 to keep lymphedema wraps to his bilateral lower extremities clean, dry, and intact. Outpatient therapy were to change the dressings on Monday, Wednesday, and Friday. Staff were to monitor the wraps twice daily during the 06:00 AM to 06:00 PM shift and the 06:00 PM and the 06:00 AM shift. The Treatment Administration Record (TAR) dated June 2024, revealed the resident's wraps were clean, dry, and intact on 06/14/24 for the 06:00 PM shift, 06/15/24 for the 06:00 AM and PM shift, and on 06/16/24 for the PM shift. On 06/16/24 for the 06:00 AM shift, the staff documented a 7 indicating to Other/See Progress Note. The Progress Note dated 06/13/24 at 09:42 AM, revealed R1 returned from his appointment at the outpatient clinic with new orders, and his next appointment was on 06/17/24 at 01:00 PM. The Progress Note dated 06/16/24 at 10:42 AM, an order administration note for R1, lacked documentation for the reason on the TAR to be charted as Other/See Progress Notes as to why the wraps may not be clean/dry/intact. The Progress Note dated 06/17/24 at 01:11 PM, revealed R1 left the facility for his appointment at the wound clinic. The Progress Note dated 06/17/24 at 02:02 PM, revealed R1 returned from his appointment at the wound clinic with no new orders. The note lacked documentation regarding maggots. The Progress Note dated 06/22/24 at 01:39 PM, revealed R1 removed his wraps this morning due to them being soaked with urine, which was a frequent occurrence with him, saturating his wraps and pants with urine. On 06/24/24 at 07:55 AM, observed R1 in his room in a recliner. His feet rested on a folded-up towel which was directly on the floor. A tied-up plastic bag sat on the floor, and next to the towel, his feet were on a pile of wraps and gauze. R1's left leg had gauze wrapped around it from above his ankle to below his knee and his right leg had gauze wrapped from the base of his toes to below his knee and was loose at the top with abdominal gauze pads (ABD pads - highly absorbent dressing) in place. The gauze wraps on the right lower leg were almost entirely yellow in color from drainage. R1 had a flyswatter in his room and killed one live fly and two others were observed in the room and landed on the dressings piled directly on the floor. There was a prominent foul odor in his room. On 06/24/24 at 07:57 AM, R1 stated he was told by LN H not to leave wet soiled wrappings on his leg and R 1 removed them at 06:00 AM. He informed the off-going CNA M and CNA N, and CNA N placed a towel on the floor for R1 to rest his feet on. R1 stated while at the (outpatient clinic for wound management), two maggots were found under his dressing. R1 stated staff were to change his dressing daily, but the dressing did not get changed yesterday. R1 stated he wished LN H would have changed them yesterday and further stated he had staff ask her about it but she had already gone home. R1 stated last week there were four days the dressings did not get changed as Administrative Nurse D said not to change or touch the wraps. R1 stated he was finally able to get staff to remove the plastic thing off of the toilet (referred to device in bathroom with elevated seat and handles that sits over the toilet) as it was causing urine to run down and get in his wraps. On 06/24/24 at 08:20 AM, LN G stated she did not think she had to do anything with R1's wraps, as he was scheduled to go today to the wound clinic, and she had not seen his legs yet today for her shift. LN G stated in shift change report, she was told R1's wraps were getting changed at there (outpatient clinic for wound care), and she was not able to change those due to lack of certification to apply the lymphedema wraps. LN G stated the wraps were to be changed on Monday, Wednesday, and Friday by outpatient therapy and prior to that, the facility nurses changed the dressings daily. LN G stated R1 removed the wraps a lot because they would get wet. LN G looked at the pile of wraps on the floor and they were dated for 06/22/24 and initialed by LN H. LN G left the pile of wraps and gauze on the floor and exited the room. On 06/24/24 at 08:54 AM, LN G asked Administrative Nurse D what to do with R1's legs. Administrative Nurse D stated she needed to find R1's order sheet, as she thought the outpatient therapy center sent back instructions on what to do. The Progress Note dated 06/24/24 at 09:01 AM, revealed Administrative Nurse D spoke with outpatient therapy on what treatment needed done when R1's wraps became soiled and the staff stated, Leave them off today and we will talk to him about removing them himself and will send orders back for what to replace wraps with when they become soiled. The note revealed nursing staff were notified. On 06/24/24 at 09:09 AM, LN G picked up the wraps and dressings off the floor in R1's room and removed part of the gauze wraps from his legs then exited the room. On 06/24/24 at 09:11 AM, LN G stated there was not an order for R1 if his wraps were not clean/dry/intact and Administrative Nurse D was going to request one. LN G stated what had been on R1's legs on 06/22/24 was the treatment that was being done before, and R1 should have an order on what to do in between times if the wraps were not clean/dry/intact. LN G stated she would clean R1's legs after he finished eating, and she left the current drainage covered gauze wraps in place to his right lower extremity and the gauze wraps remained on his left lower extremity. On 06/24/24 at 10:16 AM, LN G stated she did not have a treatment order for R1's legs yet. On 06/24/24 at 10:34 AM, LN G stated she was going to take the rest of the wraps off of R1's legs and clean them and did not have an order yet for any dressings. R1 was sitting in his recliner in his room. LN G placed the packaged gauze directly on the nightstand along with tape cut in pieces to secure the gauze. After removing the dressings, LN G began to clean R1's legs with the same contaminated gloves used to remove the soiled dressings. When the surveyor questioned if a new pair of gloves should be in place, LN G stated, It's dirty too and removed the gloves and applied a new pair without performing hand hygiene. Then, LN G placed four by four-inch gauze pads directly on R1's overbed table and used a gloved hand to open the nightstand drawer and removed more four -inch gauze pads out of the drawer and placed them directly on the overbed table. These treatment supplies were used to wipe R1's legs after LN G sprayed them with wound cleanser. R1 had an ABD pad which was stuck to his left lower extremity and required LN G to spray wound cleanser on to loosen the ABD pad from his leg. There was a live fly observed in R1's room during the process. LN G stated she was going to check with Administrative Nurse E to see if she wanted to take pictures of R1's legs and exited the room. R1's legs were noted to have redness, scaling, and edema. The left leg had a small scab to shin area and was not able to visualize the back of his legs. On 06/24/24 at 10:55 AM, LN G stated Administrative Nurse E wanted to take pictures of R1's legs but was assisting another resident at the time. LN G stated Administrative E told her to wrap his legs with Kerlix (gauze rolls which can be used to absorb wound drainage and hold dressings in place) because they were weeping. On 06/24/24 at 11:24 AM, entered R1's room with LN G and observed an area of fluid on the floor next to the towel R1 had his feet on. LN G stated that was from R1's legs it just runs. LN G retrieved a roll of gauze from the drawer in R1's nightstand, not packaged, sprayed R1's legs with a wound cleanser, and used the gauze wrap to wipe R1's legs. LN G then removed her gloves and applied a new pair without performing hand hygiene. LN G moved the packaged gauze wraps and strips of tape to R1's bed along with scissors without a barrier. LN G moved a trash can on its side and used the towel under R1's feet that was on the floor and placed it on the trash can, then R1's right foot on top of the towel that had been on the floor. LN G then began using gauze rolls to wrap R1's legs and during that time drips of fluid were coming from the back of his right leg. Once LN G finished wrapping the right leg, she placed his left foot directly on the trash can and removed her gloves. LN G stated she would be right back she needed to get more gauze. LN G returned and applied gloves then stated she forgot to grab socks, so she exited R1's room while removing the gloves at 11:36 AM without disposing gloves or performing hand hygiene before exiting the room On 06/24/24 at 11:38 AM, LN G returned to R1's room with socks, applied gloves, and placed a sock on R1's right foot. LN G stated, It is leaking already and applied another layer of gauze to R1's right leg. LN G placed R1's left heel back on the trash can and applied one roll of gauze. While she went to grab another roll, the end of the applied roll fell down and touched the surface of the trash can. LN G reapplied the end of the gauze roll that touched the trash can and began wrapping R1's left leg with the second roll. After securing with gauze with tape and after she applied a sock to his left foot, LN G exited the room at 11:47 AM with her gloved hands, tied up the trash and the linen bag, scissors, wound cleanser, and the stool she [NAME] in to sit on while she performed dressing cares. On 06/24/24 at 12:36 PM, Housekeeping Staff U stated the only issues with flies she had seen in the facility was in R1's room, which she thought was due to his legs that leaked fluids which smelled like rotten eggs. Housekeeping Staff U stated when she was in there yesterday his bandages were soaked through. When asked what was done about the flies in R1's room Housekeeping Staff U stated, I don't have a fly swatter and she had not killed any in his room. On 06/24/24 at 12:46 PM, LN G stated she had not seen any maggots on R1's skin or dressings but received in report one day they were found at the center where his wraps were done. On 06/24/24 at 12:54 PM, LN H stated she heard R1 had maggots in his leg dressings from R1 and LN J on one of the days he went to the clinic. LN H stated on 06/22/25, R1 removed his wraps, and his legs were weeping fluid all over the floor, so she applied wraps. LN H stated R1 told her the clinic said to remove the wraps when they became soaking wet. LN H stated she re-wrapped his legs because they were open to air and fluid leaked all over the floor. LN H stated she was not aware of what the clinic advised as there was not any paperwork received from them. LN H stated on 06/23/24, R1 had some wetness by the ankle and up a little bit and did not do anything with the dressings and left them in place through the end of her shift at 06:00 PM. On 06/24/24 at 01:06 PM, LN J stated R1 told her that last week when returning from the clinic they (clinic staff) found maggots. She verified there have been flies in his room, and thought he had a fly swatter in his room. LN J stated she had not killed any flies in his room and seemed like that was the only room that had them. LN J stated the clinic (where wraps are done) usually does not send paperwork back from his appointments. LN J stated Administrative Nurse D kept tracks of resident wounds. On 06/24/21 at 01:11 PM, Administrative Nurse E stated R1 returned from the center where his wraps are done and reported maggots were found, so she called the center to clarify what he had said. Administrative Nurse E stated she was told by Consultant Staff GG on 06/17/24 of two maggots found and had not seen any on 06/14/24. Administrative Nurse E stated hand hygiene should be performed during dressing changes and before going in a resident's room, gloves should be removed after taking off dressings and hand hygiene should be performed before applying new gloves. Administrative Nurse E stated staff should place a barrier between the dressing supplies and the surface placed on. Administrative Nurse E stated a trash can should not be used to prop his foot/leg up on for the dressing change and if any part of the dressing touched the trash can surface, it should be disposed of. Administrative Nurse E stated if the dressings are loose, the nursing staff should address that as soon as they see it and should use a clean towel under his feet before doing his dressing changes. Gloved hands should not be used to gather supplies from the nightstand drawer. If R1's dressings were leaking, then the nursing staff should try to address it even if just reinforcing them and should call the doctor at any time to get an order, as he was the one that ordered the wraps. Administrative Staff A stated the staff should clean/sanitize the floor where the wraps were in contact with. On 06/24/24 at 02:00 PM, LN G stated during the weekend of 06/15/24 and 06/16/24, during her day shift (06:00 AM to 06:00 PM) R1's legs were not leaking, and she did not do any treatments to R1's legs. On 06/24/24 at 02:37 PM, Consultant Staff GG stated she had been doing the lymphedema wraps and when R 1 came in on 06/13/24, his wraps were soiled. When R1 came in on 06/17/24 his wraps were soiled with urine and his legs weep a lot. The dressings in place were dated 06/13/24 and were the ones she had placed on that day when she evaluated him. When she was unwrapping R1's right leg on 06/17/24, she observed a maggot toward the top of his leg and one on his ankle. Consultant Staff GG stated she told R1 to keep the bandages on unless soiled then to take them off. Consultant GG stated she did not call the facility right away regarding the maggots as she had another patient and Administrative Nurse E had called her and she gave Administrative Nurse E instructions on keeping the wraps on and clean unless they became soiled. Consultant Staff GG stated she would have expected R1 to arrive with cleaner dressings on than he did on 06/17/24 and not the ones from 06/13/24. Consultant Staff GG stated she had made contact with the facility almost every visit she had seen R1. On 06/24/24 at 02:59 PM, Administrative Nurse D stated R1 went for an evaluation on 06/13/24 and they received the treatment orders on 06/14/24 from the clinic. Administrative Nurse D stated the nurse should call if wraps were soiled to get a treatment order. On 06/24/24 at 04:17 PM, LN I stated he took care of R1 on 06/14/24, 06/15/24, and 06/16/24 during the 06:00 PM to 06:00 AM shift and R1 had an order for lymphedema wraps on Monday, Wednesday, and Friday for therapy to perform the dressing changes. LN I stated he was told not to apply new wraps as he was not trained to change the wraps. LN I stated he looked at the wraps and on 06/16/24 they were not clean/dry/intact. LN I stated R1 had brought that to his attention around 10:00 PM or 11:00 PM and LN I told R1 the wraps would get changed in the morning. LN I stated he was not aware of any other orders in place when not clean/dry/intact. On 06/24/24 at 04:56 PM, Administrative Staff A stated, when asked what the facility had done to address the issue of maggots being found on R1's skin, he stated he was not aware of maggots being found until today (06/24/24) from one of the nurses after the surveyor's arrival on site. The facility's policy for Hand Hygiene Audit undated, revealed hand washing should be done every time staff remove gloves, before and after each resident contact, every time moving from a dirty to a clean area, and sanitizer could be used instead of soap and water when hands are lightly soiled without visible debris on hand. The facility's undated policy for Clean Dressing Change revealed to create a clean field using a towel or paper towels, open dressings, and place on first pair of gloves, remove soiled dressing, dispose of gloves, wash hands, apply a second pair of gloves, cleanse wound, remove gloves, wash hands/sanitize, and re-glove. After applying prescribed medication/dressing secure per order, remove gloves, and wash hands. The facility's policy for Notification of Patient/Resident Change dated 11/01/16, revealed the facility will consult the resident's physician, nurse practitioner or physician assistant when there is a need to alter treatment significantly (i.e., need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment). The facility failed to ensure R1 had clean/dry/intact dressings/wraps to his lower extremities and failed to contact the physician for orders when dressing were wet/soiled, which resulted in R1 going 14 - 15 hours from 06/16/24 to 06/17/24 when he had his appointment with outpatient therapy for his lymphedema wraps. On 06/17/24 at outpatient therapy, maggots were found on R1's skin when therapy staff removed his wet and soiled wraps dated 06/13/24. Additionally, the facility failed to ensure wraps were clean/dry/intact on 06/24/24 when R1 alerted staff regarding their condition at 06:00 AM. The staff removed the rest of the soiled dressings from his legs on 06/24/24 at 10:34 AM, more than four hours later. The facility failed to ensure R1 had an order in place for treatment to R1's legs if the wraps were not clean/dry/intact, placing R1 at risk for further skin impairment and further presence of maggots to areas requiring treatment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility reported a census of 54 residents with 17 residents sampled, including one resident reviewed for pressure ulcers (PU). Based on record review, interview, and observations, the facility failed to ensure appropriate treatment and services for the one Resident (R)4, with the failure to prevent the development of one unstageable (full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed) PU. Findings included: - Review of Resident (R)4's electronic medical record (EMR), under the Med Diag[nosis] tab, included diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion) and type I diabetes mellitus (DM,autoimmune destruction of insulin-producing beta cells in the islets of the pancreas). The admission Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of eight, indicating moderate cognitive impairment. The resident had no rejection of care. He required extensive assistance of two staff for bed mobility, transfers, dressing, and toilet use. He needed extensive assistance of one staff for locomotion on the unit. He had no functional limitations in range of motion (ROM). He was at risk for the development of pressure ulcers (PU), with no unhealed PUs at the time of the assessment. He had a pressure reducing device for his bed and chair and was on a turning and repositioning schedule. The Cognitive Loss/Dementia Care Area Assessment (CAA), dated 02/24/22, documented the resident had a diagnosis of dementia. He was able to make his needs and wants known at times. Staff were to monitor his need for cueing and reorientation. The Activities (ADL) Functional/Rehabilitation Potential CAA, dated 02/24/22, documented the resident transferred with a sit to stand lift (mechanical device designed to help residents who lack the specific strength or muscle control to rise to a standing position and quickly transfer) and required extensive assistance for most of his ADLs. The Pressure Ulcer CAA, dated 02/24/22, documented the resident required extensive assistance with bed mobility and transfers. The Baseline Care Plan, dated 02/18/22, stated the initial skin goal was to maintain the resident's skin integrity. Staff were to turn and reposition the resident. The base line care plan lacked staff instruction on the frequency of turning and repositioning the resident. The Cognition Care Plan, dated 02/28/22, instructed staff to cue and reorient the resident due to a diagnosis of dementia. The ADL Care Plan, dated 02/28/22, instructed staff the resident required extensive assistance of two staff for bed mobility, dressing, and toileting. The PU Care Plan, dated 02/28/22, instructed staff the resident was at risk for the development of PUs. The revised Care Plan, dated 03/15/22, instructed staff the resident had a deep tissue pressure injury (persistent non-blanchable deep red, purple or maroon areas of intact skin, non-intact skin or blood-filled blisters caused by damage to the underlying soft tissues, caused by pressure) to his right heel. Staff were to off load the resident's bilateral lower extremities (LE) and paint the right heel with an iodine swab (antiseptic used to clean wounds) twice daily (BID), until healed. Staff were to ensure the resident had a pressure reducing mattress on his bed and a pressure reducing cushion in his wheelchair. The revised Care Plan, dated 05/24/22, instructed staff the resident had an unstageable PU to his right heel. Review of the resident's EMR, under the Evaluations tab, included a Clinical Health Status Evaluation, dated 02/18/22, which documented the resident required assistance with bed mobility, dressing, and personal hygiene. The resident had no history of foot ulcers or deformities. Review of the resident's EMR, under the Evaluations tab, included a Braden Assessment (determines the risk of developing pressure ulcers), dated 02/18/22, which placed the resident at risk of developing a pressure ulcer. The EMR lacked any other Braden Assessments. Review of the resident's EMR, under the Evaluations tab, revealed Skin & Wound Evaluations, which included: On 03/15/22 the resident had a facility acquired PU DTI (deep tissue injury) to his right heel, which measured 4.3 cm (centimeters) in length (L) by 4.1 cm in width (W). The wound had no tunneling (a wound that goes deep in the body and snakes through layers of tissue), depth or undermining (occurs when the tissue under the wound edges becomes eroded). Documentation lacked further description of the wound bed. The wound showed no signs of infection and no exudate. The peri-wound (skin surrounding the wound) was normal in color for the resident. Additional care included a cushion, foam mattress, and heel suspension protective boots (boots designed to keep pressure off of the heels). The staff notified the resident's physician, responsible party, Registered Dietician (RD), and therapy of the new wound. Review of the resident's EMR, under the Orders tab, included liquid protein supplement (a dietary supplement which provides increased protein), 30 milliliters (ml) three times a day (TID), dated 03/22/22. The order lacked documentation of a diagnosis. Staff were to ensure the resident wore off-loading boots (boots to keep pressure off) to his bilateral LEs at all times, to maintain skin integrity, dated 03/15/22, and paint the wound with an iodine swab twice daily (BID) for wound care, dated 03/15/22. Review of the resident's EMR, under the Evaluations tab, revealed Skin & Wound Evaluations, which included: On 03/22/22, the resident's wound measured 3.5 cm L by 3.4 cm W. The wound assessment lacked further description of the wound bed, peri-wound and surrounding skin. The wound was stable, but slow to heal. On 03/29/22, the resident's wound measured 4.6 cm L by 3.5 cm W. The wound assessment lacked further description of the wound bed. The wound was improving and was slow to heal. On 04/05/22, the resident's wound measured 4.8 cm L by 3.0 cm W. The wound assessment lacked further description of the wound bed. The wound was slow to heal. On 04/12/22, the resident's wound measured 2.4 cm L by 2.5 cm W. The assessment lacked further description of the wound bed. The wound was improving and was slow to heal. On 04/19/22, the resident's wound measured 2.5 cm L by 2.2 cm W. The wound assessment lacked further description of the wound bed. The wound was improving and was slow to heal. On 04/26/22, the resident's wound measured 3.5 cm L by 1.8 cm W. The wound bed had 100 percent (%) eschar, with no evidence of infection. On 05/03/22, the resident's wound measured 2.0 cm L by 2.6 cm W. The wound bed had 100% eschar, with no evidence of infection. On 05/10/22, the resident's wound measured 2.8 cm L by 1.0 cm W. The wound bed had 100% eschar, with no evidence of infection. On 05/17/22, the resident's record lacked an assessment for the wound. Review of the resident's EMR, under the Prog[[NAME]] Notes tab, on 05/17/22, included a nurses' note which documented the staff visually assessed the resident's wound during treatment. No changes were noted from the previous week. Documentation lacked measurements of the wound. On 05/23/22, the facility received a Physician's Order to cleanse the right heel with normal saline (NS a mixture of sodium chloride (salt) and water), apply skin prep (used for skin protection), and leave the wound open to air, every day and night shift. On 05/24/22, the resident's wound measured 3.2 cm L by 2.6 cm L. The wound bed had 10% slough (A layer or mass of dead tissue separated from surrounding living tissue, often yellow in color) and 80% eschar. The wound had evidence of infection with increased redness, inflammation, warmth, and a moderate amount of seropurulent (containing both serum and pus) exudate. On 05/24/22, the facility received a Physician's Order to culture the right heel wound, cleanse the right heel wound with NS, apply a thin layer of Santyl (an ointment used to help remove dead skin tissue and aid in wound healing), and cover with a clean, dry dressing every day shift for right heel wound. Review of the resident's EMR, under the Orders tab, revealed a physician's order to cleanse the resident's right heel with NS, apply skin prep, and leave open to air (OTA) every day and night shift. Review of the resident's EMR, under the Orders tab, revealed a physician's order to obtain a wound culture of the resident's right heel, ordered 05/24/22. Review of the resident's EMR under the Prog Notes, included: On 05/22/22, a Progress Note documented the wound bed had dark brown necrotic tissue with yellow edges. Documentation revealed staff notified Administrative Nurse D of the decline in the resident's wound. On 05/24/22, a Progress Note documented the right heel wound was extremely macerated (skin has been exposed to moisture for too long) and edematous (swollen) with an extremely foul odor and copious amounts of dark brown, dark yellow drainage. The wound bed was black in color with the right side of the wound noted to be yellow and white in color with raised edges. On 05/22/22 at 08:57 AM, the resident sat in his high back wheelchair with bilateral (both sides) air boots (boots made to off-load PUs on the heels) on. On 05/22/22 at 12:35 PM, Certified Medication Aide (CMA) S and Certified Nurse Aide (CNA) N used the mechanical lift (full body lift) to transfer the resident from his wheelchair to bed. Upon placing the resident in his bed, his heels rested directly on the mattress. On 05/23/22 at 10:11 AM, Licensed Nurse (LN) I entered the resident's room to perform care to the resident's right heel. The wound to the resident's right heel had black eschar, surrounded by maceration. The area was cleansed with normal saline (NS) and patted dry. LN I applied skin prep, covered the wound with a bordered dressing. No exudate noted at that time. On 05/23/22 at 01:30 PM, CMA S and CNA O transferred the resident from his wheelchair to his bed with the mechanical lift. CMA S cupped the resident's bilateral heels in her hands during the transfer, placing pressure directly onto the resident's heels through the air boots. On 05/24/22 at 07:47 AM, CMA T entered the resident's room to get him up for the day. The resident's heels, without air boots, rested directly on the mattress. There was a moderate amount of tannish, clear exudate (drainage) on the mattress beneath where the resident's heel rested. On 05/24/22 at 09:27 AM, the resident sat in the commons area. The air boot to his right heel moved slightly to one side, causing approximately 50% of the wound to be partially inside of the air boot, causing pressure to the wound. On 05/24/22 at 07:47 AM, the resident stated he was unable to move his legs much at all. On 05/23/22 at 01:30 PM, CNA O stated, the resident wore the boots due to a wound on his right heel. When staff put the resident to bed, they will prop his legs with a pillow in order to keep his heels off the bed. CNA O stated the resident was able to help staff with repositioning some, but was not able to keep his heels elevated on his own. On 05/24/22 at 07:47 AM, CMA T stated, the staff would elevate the resident's legs with a pillow to keep his heels off the bed. Staff turned and repositioned the resident every two hours. CMA T confirmed the resident's heels were resting directly on the mattress. On 05/24/22 at 07:50 AM, CNA Q stated, the resident's heels were to be elevated while in bed. CNA Q confirmed the resident's heels were resting directly on the mattress. On 05/24/22 at 07:50 AM, CNA O stated, the staff were to ensure the resident's heels were kept off the mattress. CNA O confirmed the resident's heels were resting directly on the mattress. CNA O confirmed there was a moderate amount of drainage on the sheet from the resident's right heel. On 05/24/22 at 02:58 PM, CNA M stated, staff needed to ensure the resident's heels were floating when he was in bed On 05/23/22 at 10:11 AM, Licensed Nurse (LN) I stated she had not seen the resident's wound in quite awhile. The last time she saw the resident's wound, it was closed, but the wound was now open. LN I stated she would notify Administrative Nurse D of the change in the resident's wound. On 05/24/22 at 12:30 PM, Administrative Nurse D stated, consultant staff HH had been consulted to see the resident, regarding the wound to his right heel. On 05/24/22 at 01:09 PM, consultant staff HH stated, she observed a photo of the resident's wound and ordered cultures and Santyl for the wound. Consultant staff HH stated she would look at the wound next week while doing rounds in the facility. On 05/25/22 at 03:30 PM, Administrative Nurse D stated, when the wound healing stalled on 05/03/22, the doctor should have been notified and a treatment change requested. The instrument used to measure the wound was not working on 05/17/22, so no measurements were taken. Administrative Nurse D stated she did not recall being notified of the decline in the wound of 05/22/22. Administrative Nurse D confirmed the area worsened and the wound nurse would not be able to see the wound until the following week, however, the wound nurse put in new orders. The facility policy for Skin Care Guideline, dated July 2018, included: The wound bed color and type of tissue will be documented weekly. If there was any deterioration of the wound status the staff would initiate comprehensive re-evaluation and notify the resident's physician and representative. The facility failed to ensure appropriate services to prevent the development and promote healing of this unstageable PU to this dependent R4's right heel.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** - The signed Physician Order Sheet for (R)19, dated 06/09/2020, documented the resident had the following diagnoses: chronic obstructive pulmonary disease (a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), anxiety (a mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), and pain. The Significant Change Minimum Data Set, dated 06/24/2020, documented R19's cognitive status as moderately impaired. She was independent with bed mobility and transfer, had occasional pain, and did not have pressure ulcers. The Pressure Ulcer/Injury Care Area Assessment, completed 06/29/2020, documented R19 was at risk for pressure injury. The pressure ulcer care plan, revised 08/26/2020, instructed staff to perform weekly pressure ulcer monitoring and measurement. A physician's order, dated 08/09/2020, instructed the nurse to clean R19's coccyx pressure ulcer, cover with a dressing, every three days, and verify the resident's coccyx dressing was in place, every day. The Treatment Administration Record, (TAR) dated 08/01/2020 to 08/31/2020, lacked documentation of treatment to R19's coccyx on 08/26/2020. The TAR lacked documentation regarding monitoring of the coccyx dressing. The Progress Notes documented staff monitored the coccyx dressing on 08/08/2020 and on 08/15/2020. (R)19's Skin & Wound Evaluation dated 08/30/2020, documented a dressing was in place however, lacked the location of the wound. On 08/27/2020 at 03:21 PM, Licensed Nurse (LN) H uncovered R19 to check on the coccyx pressure ulcer. The coccyx pressure ulcer lacked a dressing. At the surveyor's request, LN H obtained measurements. The pressure ulcer measured 3.5 by 3.0 centimeters (cm). The surrounding tissue was without irritation or redness. On 08/31/2020 at 01:14 PM, LN G removed R19's coccyx dressing, dated 08/27/2020. Staff measured the redness around the open pressure ulcer and the redness measured 5.4 cm long by 8.0 cm wide. The redness above the wound remained completely red when LN G pressed on the surrounding tissue. Administrative Nurse D observed the area at this time. On 08/31/2020 at 04:40 PM, Administrative Nurse D verified staff lacked monitoring of the pressure ulcer since 08/01/2020, and reported staff should monitor the resident's skin ulcer weekly. Furthermore, the physician's order, dated 08/20/2020, instructed staff to clean and apply a dressing on R19's left elbow pressure ulcer every three days. The Treatment Administration Record, dated 08/01/2020 to 08/31/2020, documented staff provided treatment to R19's left elbow pressure ulcer up through and including 08/26/2020. On 08/27/2020 at 03:35 PM, R19's left elbow's dressing dated 08/26/2020. LN H stated the pressure ulcer was healed and the dressing was a protective barrier. On 08/31/2020 at 01:20 PM, upon request, LN G removed the dressing on R19's left elbow, dated 08/26/2020 (a total of four days later). LN G, and Administrative D, verified they thought the area was Healed. LN G measured the left elbow pressure ulcer as 0.9 cm by 1.0 cm wide. On 08/31/2020 at 04:40 PM Administrative Nurse D verified the resident's left elbow pressure ulcer had not been measured since 08/21/2020. She verified staff failed to monitor R19's pressure ulcers weekly, for improvement or worsening of the pressure ulcers. The facility's policy titled, Skin Care Guideline, dated July 2018, instructed staff to assess pressure ulcers weekly. The facility failed to appropriately assess and treat the resident's pressure ulcers on her coccyx and left elbow, to promote healing, and prevent further pressure ulcer development. The facility reported a census of 50 residents with 17 residents sampled, including three residents reviewed for pressure ulcers (PU). Based on observation, interview, and record review, the facility failed to ensure appropriate treatment and services for two of the three sampled residents, including Residents (R)44, for failure to prevent the development of four stage II PUs, and R19 regarding the worsening of a PU. Findings included: - The Physician Order Sheet (POS), dated 08/13/20, documented the resident had a diagnosis of cerebrovascular accident (CVA, sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage). The Annual Minimum Data Set (MDS), dated [DATE], documented the staff assessment for cognition revealed the resident had severe cognitive impairment. She required total assistance of two staff for bed mobility. She was at risk for the development of pressure ulcers (PU), but had no unhealed PUs at the time of the assessment . She had a pressure reducing device for her chair and bed and was on a turning and repositioning program. She had limited range of motion (ROM) on both sides of her lower extremities. The Care Area Assessment for Pressure Ulcers, dated 01/24/20, documented the resident required total assistance with all cares and had a diagnosis of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure). Staff were to turn and reposition the resident every two hours and as needed (PRN). The Quarterly MDS, dated 08/13/20, documented the staff assessment for cognition revealed the resident had severe cognitive impairment. She required total assistance of two staff for bed mobility and personal hygiene. She was at risk for the development of PU, but had no unhealed PUs at the time of the assessment . She had a pressure reducing device for her chair and bed and was on a turning and repositioning program. She had limited range of motion (ROM) on both sides of her lower extremities. The Pressure Ulcer Care Plan, dated 08/25/20, instructed staff to have the resident wear the gray multi-podus boots (boots used to help prevent the development of PUs) while she was in the wheelchair and the air boots while she was in bed. Review of the Evaluations tab in Point Click Care (PCC), an electronic documentation system, revealed Braden assessments (assessments used to determine the risk of skin breakdown) which revealed assessments completed on 12/11/19, 03/11/20, and 04/12/20, which placed the resident at a high risk for skin breakdown and an assessment completed on 08/27/20, which placed the resident at a severe risk for skin breakdown. Review of Skin and Wound Evaluation in PCC included the following documentation: On 8/28/20, Stage II (partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed) PU to the second toe of the right foot, measured 1.3 cm (centimeters) in length (L) by 0.8 cm in width and acquired in-house. Documentation lacked description of the wound bed, exudate (drainage), odor, and periwound (surrounding wound tissue). On 09/01/20, documentation revealed the Stage II PU to the second toe of the right foot, which measured 1.86 cm by 1.29 cm. The form also identified another new Stage II PU to the third toe of the right foot, which measured 0.9 cm by 0.7 cm, and developed in-house. The area had no exudate or odor and the periwound was discolored black/blue. Documentation lacked description of the wound bed. On 09/01/20, documentation revealed the Stage II PU to the third toe of the right foot, measured 0.96 cm by 0.64 cm . The form identified another new area, Stage II PU to the fourth toe of the right foot, which measured 1.2 cm by 0.8 cm, and developed in-house. The wound had no exudate or odor. The periwound was blanchable (when a patient's skin loses redness with pressure). Documentation lacked description of the wound bed. On 09/01/20 documentation revealed the Stage II PU to the fourth toe of the right foot, measured 0.79 cm by 0.59 cm. Stage II PU to the fifth toe of the right foot, measured 0.9 cm by 0.4 cm, acquired in-house. No exudate or odor. Periwound discolored black/blue. Documentation lacked description of the wound bed. On 09/01/20 documentation revealed the Stage II PU to the fifth toe of the right foot, measured 0.99 X 0.54 cm . Treatment orders, dated 08/27/20, instructed staff to cleanse the areas to the toes on the right foot with normal saline (NS) and apply a generous amount of betadine (antiseptic)., Leave open to air twice daily (BID) and every one hour, as needed (PRN), for blisters. Staff were also to administer Proheal (medical food developed for the dietary management of wounds and conditions requiring supplemental protein) 30 ml (millimeters), by mouth (po), BID; Vitamin C 500 mg (milligrams), po every day (QD); Multivitamin po, QD; and Zinc 220 mg, po QD. On 08/27/20 at 11:25 AM, the resident rested in bed bare footed. The resident had four open areas to the tops of her 2nd, 3rd, 4th, and 5th toes of her right foot. The open areas were dry and dark red. Physician SS came into the room to see the resident and stated, The areas are certainly pressure . On 08/31/20 at 07:10 AM, the resident rested in bed on the air mattress. The resident had on bunny boots (pillow cushioning boot with toes open) to her bilateral feet. The resident's right foot was partially out of the boot with the open areas of her toes/feet pushing up against the foot area of the boot. On 08/31/20 at 02:57 PM, Licensed Nurse (LN) G entered the resident's room to do a treatment for the PUs on her toes. Staff G washed her hands with soap and water and applied gloves, cleaned the resident's wounds on the right foot with normal saline and patted dry with a guaze pad. Staff G then removed her gloves, washed her hands with soap and water, put on new gloves and then applied betadine to all four open areas, as ordered. On 08/31/20 at 04:30 PM, the resident rested in bed. The blankets covering the resident rested directly on the open areas of her toes. On 09/01/20 at 10:54 AM, Administrative Staff D, entered the resident's room to measure the areas on the resident's toes. The resident's right foot had come partially out of the boot with the open areas of her feet pushing up against the foot area of the boot . On 09/01/20 at 02:59 PM, the resident rested in bed. Her right foot was partially out of the boot with the open areas of her feet up against the foot area of the boot. On 08/31/20 at 007:13 AM, Certified Nurse Aide (CNA) M stated, staff attempted to keep the resident's toes open to air due to the pressure ulcers (PU) on her toes. The resident curled her toes so the boot did not stay in place on her foot and her toes would come to rest directly against the boot. On 08/31/20 at 02:03 PM, CNA O stated, the resident had PUs on her toes, but staff did not know how they occurred. She wore bunny boots while in bed with socks and the bed linens/blanket would rest directly on her toes. On 08/31/20 at 04:30 PM, CNA P stated she had been instructed to not put the resident's bunny boots or socks on her anymore while she was in bed. CNA P confirmed the blanket would rest directly on the open areas of the resident's toes. On 08/31/20 at 04:00 PM, LN G stated, the resident currently had four new PUs to the top sides of her toes. Staff were unsure of what caused the PUs to develop. On 09/01/20 at 10:15 AM, Administrative Nurse D stated, the resident had four new stage II PUs to her toes which developed on Thursday. Staff D stated the reason for the development of the PUs was due to the resident curling her toes when her socks were on. The intervention was to remove the resident's socks when she was in bed at night and the air boots were removed from the resident's room. Staff would continue to use the bunny boots while the resident was in bed. The facility planned to put a cradle (wire lifted device to keep bed linens/pressure off of the resident) on the resident's bed to prevent the blankets from touching the resident's toes, but therapy had not been notified about this yet . The facility policy for Skin Care Guidelines, dated July 2018, included: The facility will have a system for evaluation of skin to identify risk and identify individual interventions to address risk and a process for care in disruption of skin integrity. The facility failed to ensure appropriate services to prevent the development of four stage II PUs on the tops of this dependent resident's toes.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** - The signed Physician Order Sheet for Resident (R) 6, dated 08/23/2020, documented the following diagnoses: quadriplegia (paralysis [Loss of muscle function in one or more muscles] of the arms, legs and trunk of the body below the level of an associated injury to the spinal cord), autonomic dysreflexia (a neurological disorder that impaired the body's involuntary functions, including blood pressure, heart rate, bladder function, and digestion), muscle contracture, muscle wasting, and generalized edema (swelling resulting from an excessive accumulation of fluid in the body tissues). The annual Minimum Data Set, dated 06/05/2020, documented (R)6 was cognitively intact and had functional limitation in all his extremities. He required staff to feed, dress, toilet, transfer, and bathe him, as well as to perform his personal hygiene and move him in bed . The ADL (Activity of Daily Living) Functional /Rehabilitation Potential Care Area Assessment (CAA), dated 06/05/2020, revealed (R)6 was quadriplegic and required total dependence of staff for all his cares. The current Care Plan instructed staff to perform Passive Range of Motion (PROM [amount of motion at a given joint when the joint is moved by an external force] for his Restorative program. The care plan lacked guidance for the resident's individual range of motion program. A Progress Note, located in the electronic medical record (EMR), dated 04/22/2019, documented a Passive Range of Motion Program that required staff to exercise his arms and legs for 15 minutes a day, for three to six days, each week. On 08/31/2020 at 07:58 AM, Certified Nurse Aide (CNA)N reported the facility lacked a restorative aide since October 2019 ( a total of 10 months), related to the restorative aide was Pulled to work the floor as a CNA. On 09/01/2020 at 07:47 AM, Administrative Nurse E reported the facility lacked restorative services for the residents of the facility. There were programs in place previously, however nobody (staff) carried out the restorative programs. The restorative aide was unable to perform restorative as restorative staff were Needed to work on the floor as a CNA. On 09/01/2020 at 10:15 AM, Administrative Nurse D verified the facility failed to have residents participate in a restorative program. On 09/01/2020 at 01:53 PM Consultant NN explained that (R)6 required staff to perform exercises to his hips, knees, ankles, toes, shoulders, elbows, wrists, fingers, thumbs, and neck. (R)6 was unable to feel ort move himself due to his spinal cord injury, he was at risk for contractures (abnormal permanent fixation of a joint) and required the exercises to help with his blood flow as well as to maintain his skin integrity. The facility policy for Restorative Guidelines, dated 2019, included: Restorative services are used to assist the resident in reaching her highest level and then maintain the function. Measurable objectives and interventions must be documented in the care plan. The facility failed to provide appropriate restorative treatment and services to maintain range of motion, for this dependent resident who had no movement to his extremities, to prevent further contractures. - The signed Physician Order Sheet (POS), for Resident (R)32, dated 08/12/2020, documented the resident had the following diagnoses: injury to left rotator cuff of left shoulder, and pain. The Annual Minimum Data Set (MDS), dated [DATE], revealed R32 had a Brief Interview for Mental Status (BIMS) score of 15, indicating she had intact cognition. She had occasional mild pain. She used opioid (narcotic pain medication) four on the seven days on the look back period. The Pain Care Area Assessment, dated 12/19/12 did not trigger. The Quarterly MDS, dated [DATE], documented the resident had occasional mild pain and used opioid medication four days of the seven day look back period. The care plan, dated 08/19/2020, instructed staff that R32 was in the restorative nursing program for active range of motion to restore or maintain her level of function in both shoulders. Review of restorative electronic medical records revealed staff administered services for seven of the 31 days. On 08/26/2020 at 12:59 PM, the resident reported she had occasional pain in her shoulder and should have received exercises to help with the pain. It really gets stiff at times. I have not had anyone work on my shoulder for a long time. On 08/27/2020 at 08:06 AM, direct care staff QQ stated the resident does have stiffness in her shoulder. She verified staff failed to provide the resident exercise or restorative. On 09/01/2020 at 07:47 AM, Administrative Nurse E, stated there was no restorative services for the residents in the facility. There have been programs in place, but nobody is carrying out the plans currently. The restorative aide was not doing restorative as she was needed to work the floor as direct care staff. Administrative Nurse D are aware that there is no restorative services. On 09/01/2020 at 10:15 AM, Administrative Nurse D, stated the restorative aide is working the floor, instead of providing restorative services. The policy Restorative Guideline dated 2020, instructed restorative services was to assist the resident in reaching his/her highest level, and then maintain that function. Measurable, objectives and interventions must be documented in the care plan. The facility failed to provide appropriate restorative services to increase or maintain range of motion, for this resident who had shoulder pain, to prevent a decline in range of motion ability. The facility reported a census of 50 residents with 17 residents sampled, including three residents reviewed for restorative services. Based on observation, interview, and record review, the facility failed to provide restorative services for three sampled Residents (R)44, R 32 and R 6, to maintain or prevent decline in range of motion (ROM) ability. The facility failed to provide R44 with the planned restorative services for at least 10 months. R44's arms became tighter with contractures, with increased difficulty to dress, and the need for increased muscle relaxant medication from the physician. Findings included: - The Physician Order Sheet (POS), dated 08/13/20, documented Resident (R)44 had diagnoses which included: Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure) and cerebrovascular accident (CVA, sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage). The Annual Minimum Data Set (MDS), dated [DATE], documented the staff assessment for cognition revealed the resident had severe cognitive impairment. She required total assistance of two staff for dressing and total assistance of one staff for personal hygiene. She had no impairment in functional range of motion (ROM) of the upper extremities and bilateral impairment in ROM of the lower extremities. She received passive range of motion (PROM) one day of the assessment period. The Care Area Assessment for Activities of Daily Living (ADL), dated 01/24/20, did not trigger for further review. The Quarterly MDS, dated 08/13/20, documented the staff assessment for cognition revealed the resident had severe cognitive impairment. She required total assistance of two staff for dressing and personal hygiene. She had no impairment in functional range of motion (ROM) of the upper extremities and bilateral impairment in ROM of the lower extremities. She did not receive any restorative services during the assessment period. The Restorative Care Plan, dated 12/16/19 and revised 08/25/20, instructed the staff to perform PROM. Review of the resident's medical record revealed restorative services had not been done for at least 10 months. The facility lacked documentation evidence of restorative services completed. Review of the resident's medical record in Point Click Care (PCC), an electronic documentation system, under the Progress Notes tab, revealed the following nursing documentation, dated 08/19/20: The resident was found to have redness to her axillaries (arm pits) with a foul odor, redness, and moisture. Staff were unable to fully assess due to the resident's rigidity and limited ROM. Review of the resident's medical record in PCC under the Progress Notes tab, revealed the following nursing documentation, dated 08/20/20: Staff observed the resident as appearing to be tensed up and rigid mostly in her upper extremities. Staff reported her rigidity was causing difficulty with all activities of daily living (ADLS), especially dressing and undressing. It was also difficult for staff to get her blood pressure due to the resident being tense. Nurse updated the daughter regarding the resident's status and the daughter would like to have the resident evaluated for therapy. Message sent to the resident's physician inquiring about further orders. Currently awaiting response from the physician. Review of the resident's medical record chart, behind the Physician's Orders tab, dated 08/20/22, revealed faxed communication from the facility to the resident's physician, which included: The resident continuously tensed up and had rigid arms. Staff have difficulty dressing her and obtaining her blood pressure (BP). She was receiving Tizanidine (a muscle relaxer medication) 4 mg (milligrams) twice daily (BID), as needed (PRN), but this does not seem to help. The physician responded on 08/21/20 with a new order for Tizanidine 2 mg (milligrams) three times a day (TID), for rigidity and tight muscles. Review of the resident's medical record in PCC under the Progress Notes tab, revealed the following nursing documentation, dated 08/22/20: Contacted on call APRN (Advanced Practice Registered Nurse) and requested an order for Diflucan (an anti-fungal medication) due to a yeast infection under the resident's arms. The nystatin (an antibiotic used chiefly to treat fungal infections) was ineffective due to the areas being difficult to reach due to rigidity. APRN responded with a new order for Diflucan 150 mg, one time. On 08/26/20 at 08:51 AM, the resident sat in her geri-chair (high back specialized wheelchair). The resident's bilateral shoulders pulled up with her elbows and wrists contracted (abnormal permanent fixation of a joint). On 08/27/20 at 11:20 AM, Certified Nurse Aide (CNA) TT and CNA N positioned the resident in the bed. Staff have a difficult time straightening the resident's shirt due to her arms being held tightly against her torso and her elbows being difficult to open. On 08/31/20 at 07:13 AM, CNA M and Q dressed the resident for the day. Staff explained they have a difficult time getting the resident's shirt on due to her upper extremities being tight. On 08/31/20 at 09:53 AM, CNA M and Q lay the resident down following breakfast. Staff have a difficult time situating the resident's shirt due to her contracted upper extremities. On 08/31/20 at 07:13 AM, CNA M stated, the facility does not currently have a restorative aide. No restorative was being done with the residents. The resident had contractures in her shoulders and she had an odor in her arm pits. Staff were not able to get her arms moved out far enough to clean well in the resident's arm pits. The resident did not refuse cares. On 08/31/20 at 09:53 AM, CNA N stated the resident had contractures to her arms for a long time, however, her arms at the elbows have become much stiffer than they were before. Staff have a difficult time getting her shirt on and off and the resident had reddened areas in the crease of her elbow. The resident had become stiffer due to not receiving restorative care for at least 10 months, according to staff N. On 08/31/20 at 02:03 PM, CNA O stated, the resident has contractures which make it difficult for staff to get her shirts on and off. It takes two staff to get her dressed because of the contractures. Lately, she has been keeping her arms tucked in more tightly. Currently, no staff are doing restorative care. On 08/31/20 at 04:30 PM, CNA P stated, the resident was a lot stiffer lately in her arms and shoulders. It's difficult to get her arm pits and elbow areas clean. The resident did not refuse cares. On 09/01/20 at 07:30 AM, CNA Q stated, the resident's arms are tight which makes it difficult to get them pulled out far enough to get her shirt on. CNA Q stated she does not do ROM with the resident. On 09/01/20 at 02:55 PM, CNA MM stated, the resident was stiff and it was hard to get her clothes on and off. The resident did not refuse cares. On 08/31/20 at 04:00 PM, Licensed Nurse (LN) G stated she was not sure if restorative care was being done with residents or not. On 09/01/20 at 07:47 AM, Administrative Nurse E stated, currently there was no restorative taking place in the facility. Some residents have programs in place, including this resident, but nobody was working as a restorative aide at this time. Staff E was unsure of an exact date that restorative services were completed. On 09/01/20 at 01:53 PM, therapy staff NN stated, the resident received occupational therapy from 04/27/20 until 05/23/20 for bed and wheelchair positioning. When she came off of therapy, she was put onto a restorative program which was to include hip abduction, hip and knee flexion, ankle rotation, toe flexion and extension, hamstring stretch, finger and wrist flexion and extension, thumb flexion and extension, elbow flexion and extension, shoulder flexion and extension, neck rotation, and neck flexion. Staff were to complete these exercises at a minimum of three times a week by the restorative aide. On 09/01/20 at 10:15 AM, Administrative Nurse D stated, she did not believe the resident was becoming stiffer, but some of the staff thought she was getting stiffer. The facility had not had anybody doing restorative for at least 10 months. A message was left with the physician SS on 09/02/20, with no return call to date. The facility policy for Restorative Guidelines, dated 2019, included: Restorative services are used to assist the resident in reaching her highest level and then maintain the function. Measurable objectives and interventions must be documented in the care plan. The facility failed to provide restorative services as planned for at least 10 months for this dependent resident, causing her to decline in her range of motion ability, with increase difficulty in dressing, and the need for an increase in her muscle relaxant medication ordered from the physician.