**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to consistently implement interventions to maintain or improve range of motion (ROM) and/or mobility, affecting three residents (R6, R22, and R77), resulting in the potential for further functional decline in joint motion and mobility. Findings include: Resident #6 (R6) On 6/26/23 at 9:31 AM, R6 was observed lying in bed. R6 did not respond to inquiry and was unable to be interviewed. On 6/26/23 at 2:36 PM, R6 was observed to still be lying in bed. A review of R6's record and Minimum Data Set (MDS) assessment dated [DATE] revealed that the resident was admitted into the facility on 7/2/20, most recently re-admitted on [DATE], and is severely cognitively impaired. Further review revealed that the resident requires total assistance from one to two staff for activities of daily living (ADLs), mobility, and transfers. R6's medical diagnoses include Hemiplegia and Hemiparesis Following Cerebral Infarction, Generalized Muscle Weakness, Dysphagia, Adjustment Disorder With Mixed Anxiety and Depressed Mood, Aphasia Following Cerebral Infarction, Vascular Dementia, Unspecified Severity with Other Behavioral Disturbance, and History of Pneumonia. On 6/26/23 at 1:45 PM, Confidential Witness V was interviewed regarding any concerns with R6's care at the facility. Witness V indicated that they felt the resident had experienced a decline in their ability to perform ADLs. Witness V stated that the resident did have behaviors and was resistant to care in the past but had previously been able to be up and out of bed. Witness V then stated, Now (R6) just doesn't get out of the bed at all. Witness V had concerns related to ensuring that R6 received services to maintain mobility. A review of R6's most recent therapy discharge summaries revealed that the resident was discharged from Physical Therapy (PT) on 5/20/23 and Occupational Therapy (OT) on 5/22/23 with recommendations for restorative services (range of motion and bed mobility specifically). Both PT and OT determined that R6's prognosis to maintain current level of functioning was, Good with consistent staff follow-though (of restorative services). Further review of R6's record revealed the following physician order: RNP (restorative nursing program) .Active .6/1/2023. A review of R6's task documentation revealed the following: -Task: Nursing Rehab: rolling on alternating sides every 2 hours. Not Applicable, was documented for the above task on 6/1/23, 6/7/23, 6/8/23, 6/14/23, and 6/21/23. -Task: Nursing Rehab: Passive ROM (range of motion) to BUEs and BLEs (bilateral upper extremities and bilateral lower extremities) in suppose position in all possible planes. Not Applicable, was documented for the above task on 6/1/23, 6/5/23, 6/8/23, 6/14/23, 6/21/23, and 0 minutes spent providing the above task was documented on 6/12/23. Six documented refusals were noted since 6/1/23. On 6/27/23 at 8:27 AM, R6 was observed sitting upright in bed with their head down. R6 appeared to be sleeping. On 6/27/23 at 10:46 AM, R6 was observed lying in bed and appeared to be sleeping. Resident #22 (R22) A review of R22's record and MDS assessment dated [DATE] revealed that the resident was admitted into the facility on 6/8/21 and is mildly cognitively impaired. Further review revealed that the resident requires extensive assistance from staff for toileting, dressing, and bed mobility, total assistance for transfers, and limited assistance for personal hygiene. R22's medical diagnoses include Hemiplegia and Hemiparesis Following Cerebral Infarction, Dysarthria and Dysphagia Following Cerebral Infarction, Generalized Muscle Weakness, Chronic Pain Syndrome, Contracture, Diabetes, Polyneuropathy, Anxiety Disorder, Adjustment Disorder with Depressed Mood, and Obesity. Further review of R22's hospital records upon initial admission into the facility did not indicate that the resident was admitted with contractures. On 6/26/23 at 8:35 AM, during the initial tour, R22 was observed in bed, lying on their back at approximately 45 degrees. An adaptive walker with forearm support was noted in the corner of the resident's room. R22's left leg was bent up and lying on a pillow. R22 was observed without any supportive devices on, such as a splint or brace. When queried regarding therapy or restorative services, the resident stated they were not receiving any. R22 was asked how often they are moved in bed to which the resident responded, Never. Only when I have a bowel movement and they have to come change me. That's the only time they move me. R22's bed was observed without assist bars. On 6/26/23 at 10:05 AM, R22 was observed lying in bed and appeared to be sleeping. R22 was observed without any braces/orthotic support devices on and their left leg remained bent up on a pillow. On 6/26/23 at 11:02 AM, R22 remained in bed and appeared to still be sleeping. Two blue orthotic support devices (braces) were noted on the floor near the resident's bedside dresser. R22 was observed without any brace/devices on and their left leg remained bent up on a pillow. On 6/26/23 at 12:25 PM, R22 was observed lying in bed. R22 used the bed remote to lift the head of their bed up so they could eat, however, the resident was unable to further adjust themselves in bed on their own. R22 continued to have no braces/orthotic support devices on and their left leg remained bent up on a pillow. On 6/26/23 at 2:36 PM, R22 was observed to still be lying in bed. R22 was again interviewed at this time and stated staff hadn't moved them all day. R22 was asked if staff attempted to put any braces, splints, or orthotic devices on their extremities. R22 replied, No, and added that they had, Waited all day yesterday for someone to move (them) and no one did anything. On 6/26/23 at 3:54 PM, Certified Nursing Assistant (CNA) I and CNA J were preparing to provide incontinence care to R22. CNA I indicated that she had worked midnight shift (leaving around 7 AM this morning) and had come back to work afternoon shift. R22 stated they had not been changed since they last saw CNA I this morning. R22 repeatedly denied that they had been changed on day shift. CNA J told R22 and this surveyor that she believed what the resident was claiming. R22 became tearful and stated, You see? They don't get me up, they don't walk me, nothing. R22 continued to have no splint/braces/orthotic support devices on and their left leg remained bent up on a pillow. The staff were queried regarding assist bars on R22's bed. CNA I stated that to her knowledge, R22 has not had assist bars on their bed any time recently. R22 was observed to need the assistance of both CNA I and CNA J to turn in bed and receive incontinence care. The staff were then queried regarding knowledge of R22's mobility history and capabilities. CNA J indicated she was familiar with R22 because the resident had been on C wing in the past, where CNA J normally works. CNA J stated that R22 had been, better, when they were on C wing. CNA J elaborated that R22 had been up out of bed at that time and able to do some things for themselves. CNA J commented that R22 hasn't been doing those things now that they are on the A wing. R22's left leg remained bent up. When this surveyor attempted to inquire about R22's left leg, the resident became very tearful and upset. R22 stated that it is painful when staff stretch their leg out. CNA I carefully placed a pillow underneath R22's left leg. When queried regarding when the pain in their left leg started, R22 indicated the pain had started worsening approximately one year ago and stated, When I came over here (to A wing), because they wouldn't get me up and wouldn't walk with me. R22 became tearful again. R22's left arm and hand appeared bent, but the resident indicated that they still have some mobility in their left arm/hand because they try to, work on it themselves. On 6/27/23 at 8:23 AM, R22 was observed lying in bed, eating breakfast. R22 was unable to effectively use their left arm/hand. R22 was observed without any braces/orthotic support devices on and their left leg was bent up and resting on a pillow. R22 stated, They still didn't put my brace on. On 6/27/23 at 9:50 AM, R22 was observed lying in bed and appeared to be sleeping. R22 was observed without any braces/orthotic support devices on and their left leg was bent up and resting on a pillow. On 6/27/23 at 10:25 AM, R22 remained in bed and expressed frustration that, They just leave me in bed all day. The two blue orthotic support devices (braces) remained on the floor near the resident's bedside dresser. R22 was observed without any brace/devices on and their left leg remained bent up on a pillow. R22 was asked if staff applied their braces or did any restorative/range of motion with them yesterday to which the resident replied, No. On 6/27/23 at 10:29 AM, the Regional Clinical Director (RCD) was interviewed and stated that staffing doesn't allow for designated restorative staff, and it is a program that was recently reviewed across the board. On 6/27/23 at 11:43 AM, R22 was observed lying in bed and appeared to be sleeping. R22 was observed without any braces/orthotic support devices on. The two blue orthotic support devices (braces) near the resident's bedside dresser. On 6/27/23 at 12:26 PM, R22 was observed to still be lying in bed. R22 was again interviewed at this time and stated that staff had not attempted to put any braces, splints, or orthotic devices on their extremities. R22 added that they had only been changed one time this morning. On 6/28/23 at 9:09 AM, Licensed Practical Nurse (LPN) L was interviewed and indicated she was R22's assigned nurse today. LPN L was queried regarding if R22 experiences pain. LPN L indicated that the resident does have pain and has multiple medications ordered to manage it. LPN L was then queried if she ever sees R22 be active or get up out of bed. LPN L stated they had not worked on the unit in a while but could not recall recently seeing the resident get up/be active. On 6/28/23 at 9:18 AM, CNA K was interviewed and indicated that she was R22's assigned aide today. CNA K was queried if she had been informed that floor CNAs were responsible for carrying our restorative nursing services. CNA K responded, Not really, kind of .We do it (range of motion) when we get [residents] dressed. CNA K indicated she would have to look at the charts to determine which residents need specialized restorative services. CNA K was then asked if she had received training in restorative services to which she replied, No .ROM and things like that are part of regular CNA training .but haven't gotten 1:1 training. CNA K was then queried specifically regarding R22 and their required restorative services. CNA K indicated that she believes the resident needs to have their left leg straightened multiple times a day. CNA K stated, It's bent, it is very uncomfortable for (R22). The resident usually screams. CNA K indicated that R22 never refused restorative services attempts to her knowledge. On 6/28/23 at 11:41 AM, the Director of Nursing (DON) was interviewed and queried regarding who is responsible for carrying out and documenting Restorative Nursing Program (RNP) tasks. The DON stated that CNAs working the floor are assigned those duties. The DON acknowledged that she has identified the RNP tasks as not being completed per order. The DON was asked if there would be any reason for Not Applicable to be documented for an ordered RNP task. The DON responded, No, and indicated that if the CNA's encountered any issues with RNP tasks, they should report to nursing. When asked, the DON was unsure if the facility had provided training for the RNP to nursing/CNA staff. A review of R22's record revealed the following orders: -Restorative Nursing. Active 3/3/2023. -Pt (patient) would benefit from bilateral assist bars to promote participation in bed mobility and ADLs (activities of daily living). Active 11/2/2021. -Patient to wear Left knee extension brace up to 4 hrs/ day while monitoring s/s (signs/symptoms) of redness or discomfort, pain as tolerated by patient. Active 5/19/2022. -Left hand and elbow brace be worn by patient up to 4 hours a day as tolerated. Active 5/19/2022. The facility was asked to provide restorative documentation for R22. The facility provided RNP documentation (left knee and elbow brace application) that began in May 2022 to present day (consistent with above orders). A review of the documentation revealed that for the majority of days in May 2022 through December 2022 and January 2023 through May 2023, Not Applicable, or no documentation was present at all to indicate that R22's left knee brace and left elbow brace were applied per order. Further review of the brace task documentation from June 2023 revealed that, Not Applicable was documented on 6/1/23, 6/13/23, 6/15/23, 6/19/23, 6/20/23, and 6/22/23 and 0 minutes spent providing the brace task was documented on 6/5/23, 6/6/23, 6/7/23, 6/10/23, 6/11/23, 6/21/23. No documentation was present for 6/24/23 nor 6/26/23. The RNP documentation was also noted to include range of motion documentation that was initiated in March 2023. A review of the range of motion documentation titled, LLE and LUE PROM (left lower extremity and left upper extremity passive range of motion) in supine position in all possible planes within pain free ROM: 10 REP, revealed that from March 2023 through May 2023, Not Applicable, or no documentation was present at all to indicate that range of motion was provided to R22. Further review of the range of motion task documentation from June 2023 revealed that, Not Applicable was documented on 6/2/23, 6/7/23, 6/13/23 through 6/17/23, and 6/23/23 and 0 minutes spent providing the ROM task was documented on 6/9/23, 6/11/23, 6/24/23, and 6/25/23. A review of R22's Physical Therapy (PT) Discharge summary dated [DATE] revealed: Diagnoses: .Contracture, left knee Onset 3/16/2022 . Assessment and Summary of Skilled Services: .PT sessison (sic) was focused on imprvoing (sic) PROM of Left knee extesion (sic) strength of RLE in all major muscles by performing supine and [NAME] (sic) position exercises with resistance using nakle (sic) wt (weight), improving core strength to faciliatte (sic) sittign (sic) tolerance and blance (sic) dynamic sittign (sic) balance improvement training while crossing midline and reaching in various planes, consulted orthotics to get knee extension brace on LLE assess for proper tolerance w/o any s/s of pain, redness or discomfort to preven (sic) development (sic) of further contractures, improving independence with rolling on each side, supine <> sit t the EOB, W/C (wheelchair) mobility training on level [NAME] (sic) to facilitate functional mobility . Patient made substantial functional gains in response to skilled interventions .continue with HEP, Knee extension brace on LLE for 4 hrs/day .Prognosis to Maintain CLOF (current level of functioning) = Good with consistent staff follow-through . R77 On 6/26/23 at 10:03 AM,. during an initial tour of the facility R77 was observed to have contracted fingers on their right hand. R77 was interviewed and asked if they received therapy and/or restorative therapy related to their contracture. R77 indicated that they did not receive any therapy at the current time and indicated that they would like to receive restorative therapy. On 6/27/23 at 10:27 AM, An observation was made of R77 continuing to have contracted fingers on their right hand. R77 denied having any pain. On 6/28/23 at 9:20 AM, the Acting Therapy Program Director (TPD) B was interviewed regarding R77's contracted fingers and asked if R77 was involved in any therapy and/or a restorative program related to their contracture. TPD B indicated that R77 was able to partially straighten their fingers and stated, It takes them some time. TPD B further indicated that R77 was supposed to be receiving Passive range of motion (ROM) exercises to their fingers, hands, and upper body, for maintenance. TPD B indicated that staff should be documenting ROM exercises when offered and/or completed with R77. TPD B reviewed R77's most recent Occupational Therapy (OT) Discharge Summary dated 5/31/23 which indicated the following, Discharge Recommendation: RNP (Restorative Nursing Program). TPD indicated that there should be a goal and interventions on R77's care plan regarding restorative care. On 6/28/23 at 9:24 AM, a review of R77's electronic medical record (EMR) revealed no care plan goal/interventions regarding restorative care and no documentation in R77's EMR of them having received/being offered ROM exercises. On 6/28/23 at 9:26 AM, further review of R77's EMR revealed that R77 was most recently admitted to the facility on [DATE] with diagnoses that included Cerebral infraction (Stroke) and Chronic respiratory failure. R77's most recent annual minimum data set assessment (MDS) dated [DATE] revealed that R77 had an intact cognition and required one to two persons, total dependence to extensive assistance, for all activities of daily living (ADLs) other than eating. On 6/28/23 at 9:29 AM, the Director of Nursing (DON) was interviewed regarding the provision of restorative care for R77 and indicated that a restorative care goal should be documented on the resident's care plan and ROM documentation should be documented under the Task section in R77's EMR. The DON stated, If it's not documented, it didn't happen. On 6/28/23 at 3:38 PM, a facility policy titled Restorative Program Revision: 2/21/2018 was reviewed and stated the following, Purpose and Policy Statement: Based on the comprehensive assessment of a resident and consistent with the resident's needs and choices, the facility will provide the necessary care and services to ensure that a resident's abilities in activities of daily living do not diminish .Process: Candidates for the restorative nursing program may be identified in the following ways: After discharge from a skilled therapy service .1. Following identification of need the interdisciplinary team will put a plan in place that identifies the restorative approaches that will support the resident .2. The applicable restorative interventions will be assigned which may include .ROM .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation refers to Intake number MI00132714. Based on interview and record review the facility failed to ensure a resident did not develop a pressure ulcer for one sampled resident (R905) of three resident reviewed for skin management, resulting in the development of a pressure ulcer and subsequent infection of the pressure ulcer and hospitalization. Findings include: On 12/28/22 at 09:25 AM, Family Member A was called to discuss the complaint related to their family member. Family Member A said that they visited R#905 on September 4, 2022, and that the nurse said R#905 had a bad wound infection. Family Member A stated they didn't know about the wound. A review of the electronic medical record noted R#905 was initially admitted to the facility on [DATE] and readmitted on [DATE] with the diagnoses of Heart Failure, Dementia, Cardiomyopathy, Osteoarthritis, and Stroke. A review of the Minimum Data Set (MDS) assessment dated [DATE] revealed R#905 was Moderate cognitively impaired and required extensive assistance to perform Activities of Daily Living (ADLs). A medical record review of the Skin & Wound - Total Body Skin Assessment noted 6/11/22 zero new wounds. A medical record review of the Skin & Wound - Total Body Skin Assessment noted 6/25/22 zero new wounds. A medical record review of the Skin & Wound - Total Body Skin Assessment noted 7/2/22 zero new wounds. A medical record review of the Skin & Wound - Total Body Skin Assessment noted 7/9/22 zero new wounds. A medical record review of the Skin & Wound - Total Body Skin Assessment noted 7/16/22 zero new wounds. A medical record review of the Skin & Wound - Total Body Skin Assessment noted 7/23/22 zero new wounds. A medical record review of the Skin & Wound - Total Body Skin Assessment noted 7/30/22 zero new wounds. A medical record review of the Skin & Wound - Total Body Skin Assessment noted 8/6/22 zero new wounds. A medical record review of the Skin & Wound - Total Body Skin Assessment noted 8/13/22 zero new wounds. A medical record review of the Skin & Wound - Total Body Skin Assessment noted 8/20/22 zero new wounds. A medical record review of the Skin & Wound - Total Body Skin Assessment noted 8/27/22 zero new wounds. A medical record review of the Skin & Wound - Total Body Skin Assessment noted 9/3/22 zero new wounds. A review of the medical record progress notes noted the following: -8/26/2022 23:30 (11:30 PM) . Nurses Note: CNA (Certified Nurse Aide) reported to nurse regarding a wound to residents (R#905) left side of (their) left foot. Observed round wound with redness and whitish and dark center. Cleansed with saf cleanse and applied aquacel foam dressing. Ordered wound consult. Placed in communications. Message in doctor's book. Report to oncoming nurse. Resident resting in bed. No c/o (complaint of) pain. Scheduled pain meds effective. -9/1/2022 12:56 (12:56 PM) .Nurses Note: Writer noted decline in resident condition, also wound to left foot has slight green discharge. Writer call MD (medical doctor) and log it in Dr (doctor) book. -9/2/2022 12:05 (12:05 PM) .Lab Results Note Text: Results reviewed with physician, new orders in place. Physician spoke with family, all parties agreeable to plan of care. -9/4/2022 15:33 (3:33 PM) .Nurses Note: (R#905) intake has decreased .Pt (patient) has had no urine this shift. It looks like she just had 1L 0.9 NS (1 Liter of Normal Saline intravenous-IV-solution) . -9/7/2022 09:03 (9:03 AM) Lab Results Note Text: Physician made aware of lab results. Upon physical exam resident was noted to be short of breath and hypoxic. VO (Verbal Order) to send (R#905) to (Emergency Room) for further evaluation and treatment . -9/7/2022 09:08 Nurses Note: Upon doing rounds writer noted resident had gurgling cough, rapid breathing and complaints of SOB (short of breath) .911 was initiated and resident was sent to hospital for further evaluation . -9/7/2022 18:56 (6:56 PM) Physician's Note Text: Transfer to hospital (R#905) secondary to hypoxia, sepsis . Patient started on antibiotics and IV (intravenous) fluid last week secondary to wound infection with dehydration. Noted to have very poor urine output. Order written to insert indwelling catheter and continue IV fluid, labs ordered. 9/1/2022 WBC (White Blood Count) 17 (The normal number of WBCs in the blood is 4,500 to 11,000). Chest x-ray was ordered due to hypoxia however breathing became labored and mentation worsened. Transferred to acute care hospital for evaluation, likely sepsis . -9/6/22, Lab Results Report noted WBC of 20. A review of the Braden Scale for Predicting Pressure Sore Risk dated 8/14/22 indicated a score of 14 (Moderate risk for skin breakdown). A review of the hospital notes dated 9/8/22 01:28 PM, noted the following: .Pressure ulcer noted on the left lateral foot with purulent discharge and surrounding erythema (redness and swelling) .Wound Care Progress Note Service Date/Time: 9/8/2022 10:06 (AM), Wound care consulted. Stg 4 PI (stage 4 pressure injury/ulcer-deep wound reaching into muscle and bone) to the left lateral foot . Stg 2 PI (Stage 2 pressure injury/ulcer-outer surface of the skin damaged) to the spine . On 12/28/22 at 2:28 PM, Wound Care Nurse E was interviewed and asked about R#905 wound, staging, and skin assessments. Wound Care Nurse E stated, I was off on a medical leave .the Director of Nursing (DON) is not hear .I'll get the Nurse Manager (Nurse Manger F). On 12/28/22 at 2:35 PM, Nurse Manager F was interviewed and queried about R#905's wound that was documented on 8/26/22 in the progress note. Nurse Manager F said that it was not documented in the wound assessment because they discussed it during the facility's morning meeting. On 12/28/22 at 4:37 PM, an interview was completed with the NHA (Nursing Home Administrator) and Corporate Nurse (covering for the DON) were queried in regards to the wounds for R#905. The Corporate Nurse stated, The wound care assessments should be completed. The Administrator did not provide and explanation in regard to R#905's wounds. Requested Total Body Skin Assessment from 6/1/22 to discharge (9/7/22) via email on 12/28/2022 2:52 PM, did not receive any staging of the foot wound or wound documentation related to the spine pressure ulcer. A review of the facility's wound care policy Wound Managment Program dated revised on 8/17/2017 noted the following: Complete the following documentation weekly, as applicable to type of wound/skin condition: Weekly Pressure Ulcer .Wound Documentation and picture.in wound rounds Weekly Non-Pressure Wound Documentation and picture in wound rounds Print off weekly documentation from wound rounds and scan it into (name of electronic medical record system.