**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, review of hospital paperwork, and review of facility polices, the facility failed to implement an adequate and effective pressure ulcer prevention program for Resident #168. This affected one Resident #168 of two residents reviewed for pressure ulcers. The facility census was 68. Actual Harm occurred on 02/03/25 when Resident #168 developed an in-house acquired Stage IV pressure ulcer (Full thickness tissue loss with exposed bone, tendon or muscle. Slough may be present on some parts of the wound bed. Often include undermining and tunneling.) to the right leg from an Ace wrap and immobilizer brace. Resident #168 was admitted to the facility from the hospital on [DATE] with an Ace wrap and a knee immobilizer brace on his right leg. There were no orders on admission to manage the right knee immobilizer brace and/or the Ace wrap. The admitting nurse documented that the unit manager was to clarify the order with the orthopedic physician on 01/24/25, and no orders were obtained. There was no documented evidence that the orthopedic physician was called for orders during Resident #168's 12-day stay at the facility. The Ace wrap and leg brace were never removed from Resident #168's leg from admission on [DATE]. Resident #168 was sent to the emergency room on [DATE] with red and yellow drainage draining from his right leg under the Ace wrap and right knee immobilizer brace and was diagnosed with an infected Stage IV pressure ulcer at the hospital. Findings include: Review of the medical record for Resident #168 revealed an admission date of 01/23/25 and a discharge date of 02/03/25. Diagnoses included spontaneous rupture of extensor tendons of the right thigh, chronic kidney disease, type two diabetes mellitus, and congestive heart failure. Review of the orthopedic note from his hospital stay dated 01/22/25 revealed Resident #168 had a spontaneous rupture of his right thigh tendons. Due to Resident #168's age and comorbidities an Ace wrap and knee brace were ordered for his right leg as well as rehabilitation. Review of the after-visit summary from Resident #168's hospital discharge date d 01/23/25 revealed the resident was to be admitted to the facility for rehabilitation. No orders to maintain his right leg knee brace and Ace wrap were included. Review of the admission assessment dated [DATE] revealed Resident #168 had multiple ecchymotic (bruises) areas on his bilateral arms and legs. The nurse was unable to fully assess Resident #168 due to an Ace wrap and brace intact to his right leg. Review of the pressure ulcer risk scale completed on admission revealed Resident #168 was at risk for developing pressure ulcers. Review of the physician's order dated 01/23/25 and discontinued on 01/24/25 revealed Ace wrap and immobilizer brace to remain on right leg until orders clarified with the orthopedic doctor by the unit manager. Review of further orders revealed no clarification order and/or orders for monitoring Resident #186's skin for pressure from the Ace wrap and immobilizer brace to the right leg. Review of the baseline care plan and care plan dated 01/23/25 revealed no skin focus areas and no skin interventions and no baseline care plan related to the use of the Ace wrap and immobilizer brace to the right leg. Review of the wound physician note from 01/29/25 revealed Resident #168 had bilateral heel blisters and treatments were put into place for both heels to be cleansed with Dakin's solution (topical antiseptic), apply Skin Prep (forms a film to reduce friction) to the border, apply hydrogel (promote healing by providing moisture), and covered with bordered gauze daily and as needed. During that visit Resident #168 refused to have the wound physician remove his ace wrap and immobilizer brace. There was no follow-up after that encounter. Review of the five-day Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #168 had moderate cognitive impairment. Resident #168 had lived independently prior to his hospitalization and now required set-up to moderate assistance for all activities of daily living. Resident #168 was at risk for developing pressure ulcers but did not have one at the time of the assessment. Review of the medical record and therapy notes, revealed no documented evidence in the medical record during Resident #168's 12-day stay that staff monitored the resident's skin, checked pedal pulses, monitored for edema, and monitored for pain related to the right knee immobilizer brace and Ace wrap to the right leg. There was also no documented evidence staff attempted to call the orthopedic physician at any time to get orders for the right knee immobilizer brace and Ace wrap to the right leg that Resident #168 was admitted to the facility with. Review of the nurse's note dated 02/03/25 at 1:10 P.M. revealed therapy notified the nurse that Resident #168 was bleeding from his right leg under his surgical dressing. No orders had been given to change the dressing. The physician and family were notified, and Resident #168 was sent to the emergency room. Review of the nurse's note dated 02/03/25 at 6:01 P.M. revealed Resident #168 was still in the emergency room and being admitted with a diagnosis of wound infection. Review of the emergency room paperwork dated 02/03/25 revealed Resident #168 presented to the emergency room from a nursing home where Resident #168 was said to have pus coming from a surgical wound. Resident #168 denied ever having surgery recently and stated he realized he had a wound. He was diagnosed with chronic decubitus ulcers on bilateral heels, large ulcer on right anterior knee, and large ulcers on the posterior calf. The paperwork stated to see pictures. Review of the picture of the anterior right knee wound revealed edges dry, base had slough and eschar with visible tendon and bone. The right posterior knee wound was macerated with full skin thickness loss. Resident #168 was admitted to the hospital with a diagnosis of wound infection and had to receive intravenous antibiotics and wound care. Interview on 04/01/25 at 5:10 P.M. with the Director of Nursing (DON) confirmed when Resident #168 was admitted , the admitting nurse placed an order for the unit manager to clarify whether the right knee immobilizer brace and Ace wrap could be removed in the morning. The unit manager never clarified the order, and Resident #168's right knee immobilizer brace and Ace wrap was never removed during his 12-day stay. The DON reported when Resident #168 began bleeding from his right leg where the immobilizer brace and Ace wrap were intact, he had developed a pressure ulcer (Stage IV) from the brace that had become infected, and he was admitted to the hospital. The DON also confirmed Resident #168's family did not send him back to the facility after the hospitalization. She verified that no staff attempted to clarify the orders with the orthopedic physician, and no staff assessed Resident #168's skin, pedal pulses, pain, and/or monitored for edema at any point during the 12-day stay. Review of the facility policy titled Prevention of Pressure Injuries, revised September 2022, revealed that medical devices will be monitored regularly for comfort and signs of pressure related injuries and for prevention measures associated with specific devices, consult clinical practice guidelines. This deficiency represents noncompliance investigated under Complaint Numbers OH00162679 and OH00162590.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 14. Review of Resident #18's medical record revealed an admission date of 06/29/19. Diagnoses included dementia, protein-calorie malnutrition, repeated falls, osteoarthritis of both hands, and Parkinson's disease. An OT evaluation dated 07/01/19 revealed ROM in the upper arms/hands and lower legs/feet were within normal limits. A QOL Program Recommendation Referral dated 08/12/19 indicated Resident #18 had recommendations for an ambulation program and recommendations for upper extremity ROM doing balloon volley and using a two pound dowel for the left upper extremity and ROM to both lower extremities using two pound dowels and three sets of repetitions in all planes. There was no recommendation as to the frequency the ROM exercises should be provided. Review of a task list report indicated LSTNAs who were to provide QOL programs were to incorporate ROM of both lower extremities and the left upper extremity into Resident #18's routine weekly. The list was silent as to the number of times the exercises were to be completed. Review of the task list documentation revealed staff documented the ROM in both lower extremities in all planes (may use 2 pound dowel) was worked into Resident #18's weekly routine, once a week. A PT evaluation dated 09/19/19 indicated Resident #18 had impaired range of motion to the right lower extremity (knee extension 20 degrees), which was a decline from the OT evaluation on 07/01/19 when no ROM deficits were identified. The left lower extremity range of motion remained within functional limits. On 12/06/19 between 8:20 A.M. and 12:00 P.M., LPTA #642 stated therapy made recommendations when residents were discharged from therapy and then it was nursing's decision whether to or how to implement the recommendations. Resident #18 had some declines in range of motion in the right knee between discharge from therapy on 08/14/19 and a therapy evaluation completed 09/19/19. LPTA #642 indicated the decline could also be related to the resident's osteoarthritis. Review of the QOL program policy, dated 10/04/18, revealed the program was to attain or maintain each resident's highest practicable physical, mental and psychosocial well-being, consistent with the resident's comprehensive assessment or MDS assessment and plan of care. The program was to be person-centered and the focus was to provide interventions the resident desired that gave the resident a sense of satisfaction with their self, the environment and control over their life. The procedure included to ensure the MDS was completed as required which would direct the specific needs of the resident. Interventions and goals were to be focused on what the resident desired and felt provided a QOL for them. The goals were to be documented on the plan of care (POC). The interventions were to be added to the point of care (the system the STNA documented tasks). Identified improvement/decline would be assessed on a subsequent MDS assessment and the POC would be adjusted as appropriate. If a decline in function was noted, new interventions would be implemented including referral to skilled therapy. Any changes would be reported to the unit manager. The LSTNA would assist residents in completing the interventions and recommendations made by skilled therapy evaluations and referrals. The LSTNA would document completion of the programs in the point of care. Review of the QOL list of programs offered revealed all programs were to be completed by the LSTNA. The programs were not specific or measurable but only said staff would walk me to the bathroom, provide range of motion (ROM) when I am getting dressed, assist me with the NuStep (a bike machine), seat me for meals at the table where I can be cued and fed and put on my splint according to my care card. Based on observation, record review and interview the facility failed to ensure range of motion (ROM) programs and/or splinting programs were provided as planned for Resident #2, #3, #9, #15, #18, #20, #22, #31, #32, #39, #40, #41, #48 and #54. This resulted in actual harm for Residents #2, #32, and #54 who experienced a decline in ROM and/or contractures (the shortening and hardening of muscles, tendons or other tissue often leading to deformity and rigidity of joints). This affected 14 of 14 residents reviewed for restorative nursing services. The facility census was 57. Findings include: 1. Resident #32 was admitted to the facility on [DATE] with diagnoses including cerebral vascular accident (CVA/stroke), with left sided hemiplegia (paralysis on one side of the body), kyphosis (curvature of the spine or hunch back), neuropathy (painful numbness and tingling usually at the extremities including the hands, feet and/or lower legs), and osteoporosis (brittle bones). Record review revealed on 07/16/18 Resident #32 developed a contracture to her left hand and developed contractures to her left knee and ankle on 10/04/18. Review of the Quality of Life (QOL) program, which was the facility's form of restorative/maintenance program, revealed a program was started on 08/02/18. The Lead State Tested Nurse Aide (LSTNA) task information revealed staff were to apply warm compresses and provide gentle hand massage to the resident's left hand then proceed to her fingers and wrist. There was no documentation the QOL program was ever provided to Resident #32. Review of the current care plan for ROM, initiated on 07/19/15, revealed Resident #32 had osteoarthritis and buckling knees due to her CVA. The resident had left foot inward rotation and required staff to reposition her foot. Resident #32 had a contracture of her left hand, ankle and knee. Interventions initiated on 10/22/18 included wear a left pressure relieving ankle and foot orthotic (PRAFO) at all times and a left knee extension splint every evening and night shift up to eight hours while in bed. In addition, staff were to provide ROM to both of the resident's lower legs/feet. Review of the current activities of daily living (ADL) care plan, initiated 10/19/18, revealed Resident #32 was to wear the left hand splint according to the physician orders. The care plan was updated on 03/11/19 and directed staff to follow the QOL tasks as assigned. Review of the current resident care card (a quick guide to each resident's individual needs which was hung in the residents room for STNA reference) revealed the resident was to have a carrot (orthotic device) placed in the palm of her hand (to position the fingers away from the palm). The orthotic had measurements for specific placement used to improve contractures in her left hand at all times. Staff were directed to slowly remove the carrot only for hygiene. The resident was to wear a left knee brace in the evening and throughout night. There was no indication for wearing the PRAFO boot. Review of the physician's orders dated 10/22/18 revealed Resident #32 was to wear the left PRAFO boot at all times to the resident's comfort with the kickstand down when in bed. The left knee extension splint was to be worn every evening and night shift up to eight hours at night in bed due to her left knee contracture. Review of the QOL STNA task information dated 11/13/18 revealed staff were to provide passive range of motion (PROM) to the left knee and ankle and to her right lower leg/foot two to three times a week. Weights may be used for strengthening. Review of the task documentation for completion revealed no documentation or evidence the QOL programs were ever provided or implemented. Review of the OT evaluation dated 01/21/19 revealed Resident #32 was seen for contracture and pain of her left hand and muscle weakness. Therapy goals included to increase wrist flexion and extension from five to 10, to increase the use of her left wrist and to prevent further contractures. The resident would tolerate a small hand roll in her left hand while wearing a palmar guard (an orthotic used as a barrier between the fingers and palm to prevent injury to the palm from severe finger flexion contractures) for one hour without complaints of pain, increase extension of the fingers/digits and thumb to five degrees in order to increase ability to put on and take off the orthotic and to increase ROM so the resident could perform hygiene and grooming. The resident was able to tolerate a massage to the hand for 10 minutes without complaints of pain to assist in increasing ROM of the hand joints. The resident wanted her fingers to be straighter and stronger for use. The resident tolerated active range of motion (AROM) to her left shoulder contracture (flexion was at 85 degrees). Review of the OT Discharge summary dated [DATE] revealed the resident met the goals including digit and thumb extensions from five to 10, wearing of the palmar guard with roll without pain, and increased her AROM to the left shoulder from 85 to 120 degrees. The wrist showed an improvement from 20 degrees flexion to 55 degrees and 20 degrees extension to 50 degrees. The resident was not able to tolerate the palmar guard as previously ordered and the orthotic was changed to a carrot. The resident was referred to the QOL program for ROM to her upper arms/hands, massages and application of the carrot orthotic. Review of the PT Discharge summary dated [DATE] revealed the resident had a reduction in pain to her left lower leg/foot, down to a four on the pain scale. The resident's knee showed an improvement from lacking knee extension from 35 degrees to 20 degrees and the ankle improved from lacking 35 degrees to 25 degrees. The resident demonstrated improvements in her ability to wear the orthotics. The resident was referred to the QOL or restorative/maintenance program for splinting/orthotic application in order to facilitate increased opportunities for functional task participation, ROM and exercises. Review of the PT evaluation dated 06/27/19 revealed Resident #32 was seen again by therapy because her therapy screen indicated she had a functional decline in standing and endurance in standing due to increased pain in the left knee and ankle. The resident had a reduction in ROM from the previous evaluation. Review of the PT Discharge summary dated [DATE] revealed the resident showed a reduction in pain to the left knee and ankle with an increase in ROM to the left ankle and knee and an increase in strength for transfers. The resident was referred to the QOL program to maintain the current level of performance and prevent decline for AROM, PROM and transfers. Review of the QOL referral dated 08/02/19 revealed staff were to provide stretches to both lower legs/feet with ROM and to ensure proper fit of the knee brace. Review of the QOL STNA task initiated 08/09/19 revealed staff were to do stretches for both lower legs/feet and ensure proper fit of the knee brace. Review of the participation documentation from 08/09/19 to the present revealed no documentation or evidence the program was ever implemented. Review of the OT evaluation dated 10/16/19 revealed the resident was seen again because she was not able to tolerate the left hand orthotic (carrot) and had a decrease in ROM from the previous evaluation. The resident not able to keep the carrot in place as planned. The resident indicated the staff had lost the carrot weeks ago and no devices were being put into her hand. Review of the OT Discharge summary dated [DATE] revealed the resident was to have a modified orthotic to the left hand and staff were educated on implementation. The resident was referred to the QOL program for ROM and monitoring/application of the modified orthotic. Review of the modification of the quarterly minimum data set (MDS) assessment dated [DATE] revealed the resident was cognitively intact and had limited ROM on one side of her body for her upper arm/hand and lower leg/foot. The assessment revealed Resident #32 was alert and oriented to all spheres and was cognitively intact for daily decision making abilities. Review of the STNA task implementation for the last 30 days revealed the following: a. resident's left knee extension splint was to be worn at night. The STNA documentation was marked as not applicable or that the splint was on during the day. On 12/02/19 at 10:14 A.M. and on 12/03/19 at 9:56 A.M. the documentation indicated the splint was in place. b. PROM to the left knee and ankle and AROM/PROM to the right leg/foot was to be done two to three times a week which may be done with two pound weights. There was no evidence this was completed. c. Incorporate stretching to both lower legs/feet and ensure proper fit of the brace in her routine. There was no evidence this was completed. d. Apply warm compresses and provide gentle hand massage to the left hand then proceed to the fingers, hand and wrist. Then apply the carrot orthotic. There was no evidence these were completed. e. The left ankle PRAFO was to be worn 24 hours a day/seven days a week. The documentation revealed staff frequently recorded it was not applicable. On 12/02/19 at 10:13 A.M. and on 12/03/19 at 9:56 A.M. the documentation indicated the PRAFO boot was in place. Review of the December 2019 treatment administration record (TAR) revealed the resident had the left knee extension splint in place during the evening and night shift on 12/02/19. Further review revealed the resident had the left ankle PRAFO in place during the afternoon shift on 12/02/19 and during the day and afternoon shifts on 12/03/19. On 12/02/19 at 10:00 A.M. and 12:34 P.M., the resident was observed in her wheelchair without any orthotics in her left hand or on her left leg or foot. On 12/02/19 at 12:35 P.M., interview with the resident revealed she was in a lot of pain. She stated the staff did not have any orthotics for her hands. She said she used to have a carrot but did not know where it was. She stated it had been a while since any one put on her PRAFO boot. She stated the staff put on her left knee extension brace sometimes during the day and did not know it was supposed to be put on at night. She stated she would wear all the orthotics because therapy said it would help with her pain. She stated staff did not always apply the devices as ordered. On 12/02/19 at 3:00 P.M. and 5:00 P.M., Resident #32 was observed in her wheelchair without any orthotics in her left hand or on her left leg. On 12/02/19 at 5:03 P.M., interview with STNA #592 verified the resident did not have any orthotics in place and she was not aware the resident was supposed to be wearing any. She stated there was a paper hanging in each resident's room as to their specific needs but said she had not reviewed it. STNA #592 proceeded to ask the resident if she wanted the orthotics on and she said she did and Licensed Practical Nurse (LPN) #585 told her she should always be wearing them. On 12/02/19 at 6:05 P.M., Resident #32 was observed without any orthotics in place. On 12/03/19 at 8:50 A.M., Resident #32 was observed without any orthotics in her hand. On 12/03/19 at 12:05 P.M., Resident #32 was observed to be holding the carrot orthotic, but it was almost out of her palm and only the tip of the carrot was in her palm. On 12/03/19 at 12:06 P.M., interview with the resident revealed someone found her carrot because it was lost and put it in her hand. She said it hurt and kept sliding out. The resident stated she was not able to put the carrot back in her palm herself and needed staff to do it. On 12/03/19 at 12:07 P.M., LPN #585 observed the carrot out of place but did not attempt to readjust the carrot to the proper position. On 12/03/19 at 2:55 P.M., 4:00 P.M., 4:55 P.M., and 6:05 P.M., Resident #32 observed without the carrot in her palm. On 12/03/19 at 6:06 P.M., interview with the resident revealed she was in a lot of pain, she said the staff removed her carrot and put it in her bag earlier but she could not reach the bag on the back of her wheelchair. On 12/04/19 at 8:45 A.M., the resident was observed without her carrot in her palm. On 12/04/19 at 8:46 A.M., interview with the resident revealed she was in too much pain to eat and her carrot was still in her bag from yesterday. On 12/04/19 at 10:15 A.M., interview with STNA #596 revealed she was not sure what orthotics the resident needed because night shift got the resident up and dressed and they were responsible for putting on all the residents interventions including orthotics. On 12/04/19 at 11:00 A.M., interview with Registered Nurse (RN) #701 verified the above concerns. On 12/04/19 at 1:15 P.M. , interview with LPN #585 revealed the orthotics help with the resident's chronic pain and he was not aware of her refusing to wear them. LPN #585 stated the carrot helps with pain but when it falls out or is removed it hurts to put it back in her hand. On 12/04/19 at 5:15 P.M., interview with RN #572, with RN #701 present, revealed she was in charge of the QOL program which replaced the restorative nursing program. RN #572 verified the QOL program did not include completing any resident assessments, did not include the development of measurable goals, monitoring progress or implementation of the programs according to skilled therapy recommendations when residents were discharged . She said the QOL program included herself and two Lead State Tested Nurse Aides (LSTNAs), LSTNA #542 and LSTNA #501. LSTNA #501 was supposed to work on the QOL programs two to three days a week and LSTNA #542 only worked weekends. RN #572 verified these LSTNAs were frequently pulled from doing the QOL programs to work the floor as STNAs as there were not enough STNAs to provide daily care for the residents. RN #572 verified there were no actual assessments completed because it was not a true restorative program. She said the facility discontinued their restorative program in October 2018 and replaced it with the QOL program. The goal of the QOL program was to improve the resident's overall QOL. RN #532 and RN #701 verified the QOL program was not implemented to maintain Resident #32's level of function when she was discharged from skilled therapy services. This resulted in the avoidable declines in ROM and function. On 12/04/19 at 6:45 P.M., interview with STNA #587 revealed she was not aware the resident was to have a hand roll in place in her contracted hand nor did she complete ROM. She said she just lifted her arms up when she was dressing her. On 12/05/19 at 9:25 A.M., interview with Physical Therapy Assistant (PTA) #642 revealed the resident's left knee extension brace was meant to be worn at night because it was an extension brace to help straighten the leg and did not help when the resident was in the wheelchair or when the resident's leg was bent. The PRAFO boot should be on during the day to stretch out the resident's foot and help with her pain. PTA #642 said she could wear it at night but she has a lot of neuropathy pain especially, at night, and she has Biofreeze cream for that. PTA #642 said Resident #32 does come to them at times, even when she is not in therapy, to ask about different things to try for her hand pain. In addition, stretching was very important to relieve the tightness in her hand before applying any orthotic. PTA #642 said they had tried different devices with her, including custom fabricated cone splints, a carrot splint and now most recently a towel roll. PTA #642 said they had picked her back up for therapy several times due to declines in ROM and worsening of her contractures. PTA #642 stated the January evaluation showed a decline in her ankle, knee and hand including her thumb ROM. The staff were not able to get her to stand up straight enough to use the sit to stand mechanical lift due to her worsening knee contracture. PTA #642 indicated the resident was also started on a hand roll with a [NAME] guard over it because she had lost all ROM in her thumb. Resident #32 was only able to open her palm 3.0 centimeters (cm). On discharge, PTA #642 said they were able to get her to wear the carrot (which needed a greater ROM) and she was able to open her palm up to 8.0 cm. They saw her again in June 2019 for a decline in AROM and PROM to the left extremities. On 08/02/19 at discharge Resident #32 was able to gain back some knee extension to be able to use the sit to stand lift but not back to her previous level. The resident has chronic pain including neuropathy in her feet and at times she can't even handle a blanket touching her toes. The resident was again referred to the QOL program. Then they picked her back up in October 2019 because the resident again had a decline in ROM of the left extremities and the carrot was not able to be maintained in position due to an increase in tightness/contracture of the palm. On discharge they were not able to open the palm enough for the carrot and had to change to a towel roll in her hand. They picked her up again just this week because the resident came to us and said she found her carrot and wanted to wear it. PTA #642 verified the declines could have been caused from not wearing the orthotics as planned. On 12/05/19 at 2:57 P.M., interview with LSTNA #501 revealed she started in this position in August 2019. Her role was to interact with the residents, do group exercises, take the residents outside when it was warm, provide them with snacks and talk to them. She said the difference in her role as a LSTNA versus working the floor as a STNA was she was to do group activities, puzzles, fold items and talk with the residents. When working as a LSTNA they did not provide personal care. LSTNA #501 verified she mostly worked in the secured dementia unit, both as a LSTNA and a floor STNA. She verified she did not get to work as a LSTNA very much, maybe one to two days in each two week period because she was usually pulled to work the floor as an STNA. She verified she rarely was able to complete ROM or ambulation programs, but if she did she documented under the LSTNA tasks in the computer. She stated the floor STNAs were responsible for applying splints. She said she works every other weekend as a floor STNA. The LSTNA said the other LSTNA, LSTNA #542, only worked weekends. She said he is also usually pulled to work the floor on the weekends she works. LSTNA #501 stated when she was asked to do the LSTNA position for the QOL programs she was told she could do what she wanted to and it was her program to do group activities mostly on the secured dementia unit. She said there were no other activity staff working in the secured dementia unit other than herself. On 12/07/19 at 12:55 P.M., phone interview with LSTNA #542 reveled he only worked weekends as an LSTNA but frequently got pulled to work the floor as they did not have enough staff to provide the care to the residents especially since October 2019. He said the facility changed the name of the restorative nursing program to the QOL program. The QOL program was less structured and there were no specific goals for residents to reach such as distance for ambulation. He said he did not do ROM programs and stated the floor staff were assigned ROM programs. He indicated he was responsible for ensuring residents had on their splints. He was also responsible for doing group exercise activities with residents. 2. Resident #54 was admitted to the facility on [DATE] with diagnosis including dementia. On 10/30/19 a diagnosis of contractures of the right knee and left elbow was added. Review of the current resident care card revealed Resident #54 was to have a right knee brace in place at all times except for hygiene, a sling to the right arm when out of bed, and a [NAME] guard was to be in his left hand at all times. Review of the PT evaluation dated 02/24/19 revealed the resident had impaired ROM of his right lower leg/foot. On discharge from PT on 04/25/19 the resident had regained his ROM. The resident was referred to the QOL program for AROM and PROM to both legs/feet. Review of the OT evaluation dated 02/25/19 revealed the resident had a contracture to the left hand and needed a resting hand splint to prevent further contractures or worsening of contractures. On discharge from OT on 05/10/19 the resident was to wear a palmar guard to the left hand at all times. The resident was referred to the QOL program for implementation of the splinting and ROM to the left arm/hand. Review of the current care plan revealed the resident had contractures to the right knee and left hand. Interventions included for him to wear the sling to the right arm when out of bed and [NAME] guards at all times for comfort according to OT recommendations. A right knee splint was to be worn according to PT recommendations. Review of the current physician order initiated 03/07/19 revealed Resident #54 was to wear the sling on the right arm when out of bed. Review of the current physician order initiated 03/22/19 revealed Resident #54 was to wear palmar guards at all times. Review of the significant change MDS 3.0 assessment dated [DATE] revealed Resident #54 was severely cognitively impaired and had limited ROM to one side for his upper arm/hand and lower leg/foot. Review of the PT evaluation dated 06/04/19 revealed Resident #54 had a decline in ROM of his right and left knees. With therapy and upon discharge on [DATE], the resident had improvement in ROM of his right and left knees with splinting to the right knee at all times. The resident was referred to the QOL program for AROM, PROM and splinting. Review of the OT evaluation dated 06/10/19 revealed Resident #54 was seen for a decrease in ROM to his left hand. The resident was not able to tolerate PROM and grimaced with three attempts. The resident was no longer able to tolerate the palmar guards. After additional therapy and upon discharge on [DATE] the resident was to have a rolled wash cloth in his palm at all times as tolerated. The resident was referred to the QOL program for ROM and splinting. Review of the current physician order, initiated 08/08/19, revealed Resident #54 was to wear the right knee splint at all times except for hygiene and bathing. Review of December 2019 TAR revealed the palmar guards, right sling and right knee splint where in place on all three shifts on 12/02/19 and 12/03/19. Review of the STNA documentation revealed the right knee splint and left hand rolled wash cloth were in place for the last 30 days, including 12/02/19 and 12/03/19. Further review revealed PROM was only performed on six of the last 30 days. On 12/02/19 at 10:05 A.M., 12:15 P.M., 3:30 P.M. and 4:22 P.M., Resident #54 was observed without any orthotics in either of his hands or to his legs. He had no sling to his right arm. His right knee was bent up and his left ankle was bent inward. On 12/02/19 at 4:25 P.M., interview with LPN #567 verified the resident did not have any of the ordered orthotics in place to either hand or leg and did not have the sling in place. LPN #567 indicated they were not aware the resident was to have these in place. On 12/02/19 at 5:40 P.M. and 6:55 P.M., Resident #54 was observed without any orthotics in place to the hands or legs and no sling was observed to the right arm. His right knee was bent up and his left ankle was bent inward. On 12/02/19 at 6:56 P.M., interview with STNA #540 verified the resident did not have on his knee brace and the STNA was not aware the resident was to wear [NAME] guards or a right arm sling. On 12/03/19 at 8:45 A.M., 12:10 P.M., 1:00 P.M., 2:53 P.M., 3:55 P.M., 4:54 P.M. and 6:10 P.M., the resident was observed without any orthotics on his hands or legs and the right arm sling was not observed on his right arm. His right knee was bent up and his left ankle was bent inward. On 12/04/19 at 8:42 A.M., Resident #54 was observed without any orthotics in either of his hands or legs and no sling was observed to his right arm. His right knee was bent up and his left ankle was bent inward. On 12/04/19 at 9:40 A.M., Resident #54 was observed with his right knee brace on but no hand orthotic or sling. On 12/04/19 at 9:51 A.M., interview with STNA #532 verified Resident #54 did not have on [NAME] guards or a sling and did not know the resident was supposed to wear them. On 12/04/19 at 9:57 A.M., interview with RN #559 verified Resident #54 did not have on the [NAME] guards or the sling. RN #559 said Resident #54 says ouch when applying the knee brace and [NAME] guards but thought it was just a behavior of his. On 12/04/19 at 11:00 A.M., interview with RN #701 verified the above concerns. On 12/04/19 at 5:15 P.M., interview with RN #572, with RN #701 present, revealed she was in charge of the QOL program which replaced the restorative nursing program. RN #572 verified the QOL program did not include completing any resident assessments, did not include the development of measurable goals, monitoring progress or implementation of the programs according to skilled therapy recommendations when residents were discharged . She said the QOL program included herself and two Lead State Tested Nurse Aides (LSTNAs), LSTNA #542 and LSTNA #501. LSTNA #501 was supposed to work on the QOL programs two to three days a week and LSTNA #542 only worked weekends. RN #572 verified these LSTNA's were frequently pulled from doing the QOL programs to work the floor as STNA's due to not having enough STNA's to provide care to the residents. RN #572 verified there were no actual assessments completed because it was not a true restorative program. She said the facility discontinued their restorative program in October 2018 and replaced it with the QOL program. The goal of the QOL program was to improve the resident's overall QOL. RN #532 and RN #701 verified the QOL program was not implemented to maintain Resident #54's current level of function when he was discharged from skilled therapy, resulting in an avoidable declines in ROM. On 12/04/19 at 6:45 P.M., interview with STNA #587 revealed she was not aware the resident was to have a hand roll in place in his contracted hand or a splint for his knee. She said she did not complete ROM with him she just lifted his arms when she was dressing him. She said she was not aware the resident was to use a sling for his right arm. On 12/05/19 at 10:05 A.M., interview with Certified Occupational Therapy Assistant (COTA) #702 and PTA #642 revealed the resident had displayed an increase in pain in his hand but he let them put on his orthotic. They said they were informed by STNA #540 she could not get a towel in the resident's hand and no one was able to find the [NAME] guard. They said Resident #54's son informed them he noticed an increase in the clenching of his hand in the last several days. PTA #642 stated she worked 11/30/19 and the resident did not have his knee brace or [NAME] guards in place. She said she was told they were soiled. COTA #702 stated she had to ask for them and did not receive them until 12/03/19. They said when they initially saw him, he had a resting hand splint over his hand and wrist and was bent for ROM in his fingers, with a small opening of his hand. They said he was not able to tolerate this and they had to change to a [NAME] guard for his left hand but it was not holding up his thumb, so on discharge he was to have a towel roll. The resident was seen again on 12/03/19 and he had some ROM in his index finger but the other fingers had minimum ROM. They said they were not able to try anything inside his palm because of the tightness. They said the therapist was able to stick her fingers into his palm and the resident's hand was so tight it took her 10 minutes to remove her fingers from his contracture. The resident's left hip was externally rotated and his left knee was flexed with internal tibia torsion, which causes his ankle to bend in, its the knee bending in so ankle does not need treatment at that time. The resident did express pain and AROM was not able to be performed to the left leg. On 12/05/19 at 10:28 A.M., interview with PT #703 revealed at d[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure effective management of chronic pain for one resident ( Resident #32). This resulted in actual harm when Resident #32 was unable to participate in her activities of daily living (ADLs) due to severe pain. This affected one of three residents reviewed for pain. The facility census was 57. Findings include: Resident #32 was admitted to the facility on [DATE] with diagnoses including cerebral vascular accident (CVA/stroke) with left sided hemiplegia (paralysis on one side of the body), kyphosis (curvature of the spine or hunch back), neuropathy (painful numbness and tingling usually at the extremities including the hands, feet and/or lower legs), and osteoporosis (brittle bones). On 07/16/18 Resident #32 developed a contracture (the shortening and hardening of muscles, tendons or other tissue often leading to deformity and rigidity of joints) to her left hand and on 10/04/18 she developed contractures to her left knee and ankle. Review of the modified quarterly Minimum Data Set assessment 3.0 (MDS) dated [DATE] revealed Resident #32 was alert and oriented to all spheres and was cognitively intact for daily decision making abilities. Review of the current pain care plan initiated 10/08/14 revealed Resident #32 had pain mainly in her left ankle, left leg, shoulders, and hips. The care plan indicated she also had neuropathy pain and had complaints of pain all over due to her kyphosis. The interventions included monitor for pain medication efficacy and have the resident rate her pain on a scale from zero to 10, with zero being no pain and 10 being the most pain ever. Nursing staff were to update the physician if pain persisted without effective relief. Additional interventions initiated on 07/15/18 included Resident #32 wear the left pressure relieving ankle and foot orthotic (PRAFO) according to the physician orders and on 10/19/18 wear the left knee extension splint according to physician orders. Review of Resident #32's current physician's orders revealed on 02/16/16 an order was written for Norco, an opioid pain medication containing Hydrocodone and acetaminophen (Tylenol), 5 milligrams (mg)-325 milligrams (mg) to be given every four hours only when needed for pain. It was not administered on a regular schedule. On 02/26/16, the physician ordered acetaminophen, 325 mg, two tablets every four hours only when needed for pain. On 01/08/17, a physician order was written for Norco, 5 mg-325 mg (the lowest dose), to be administered twice a day on a regular schedule for bone pain. On 04/23/18, a physician order for the topical analgesic, Biofreeze, was ordered to be rubbed on her shoulders every shift and to her left hip and foot every shift. On 10/21/18, the physician ordered Cymbalta, an antidepressant medication, 60 mg twice a day for leg pain, back pain and depression. Review of the physical therapy (PT) evaluation dated 01/18/19 revealed the resident was seen for spastic hemiplegia with affected her left side, muscle wasting and atrophy (muscle wasting) in multiple sites. The goals of therapy included to increase pain free range of motion (ROM) on Resident #32's left lower leg or extremity (LLE) to improve her ability to perform transfers. This evaluation indicated pain was limiting the resident's functional activities of daily living. The clinical impression revealed Resident #32 had increased left sided pain and weakness limiting the ability to perform sit to stand transfers and balance tasks. A physician order dated 06/20/19 revealed the Norco pain medication was increased from twice a day to three times a day at 5 mg-325 mg for pain management. Review of the physical therapy (PT) treatment session records between 06/27/19 and 08/02/19 revealed moist heat prior to manual stretching and massaging helped reduce Resident #32's pain. Review of the physical therapy daily notes from 06/26/19, 07/02/19, 07/03/19, 07/04/19, 07/05/19, 07/08/19, 07/11/19, 07/19/19, 07/25/19, 07/30/19 and 08/02/18 revealed the resident had pain that was relieved by therapy interventions including stretching and moist heat. Review of the pain evaluation dated 07/25/19 revealed the resident constantly had severe pain daily that affected her activities of daily living (ADL's). The assessment was incomplete and her pain level was not scored using there numeric scale. It only indicated the pain was severe. The plan section of this evaluation was to continue the current interventions for pain control. No new interventions were implemented for pain control. On 08/02/19 Resident #32 was discharged from PT and referred to the Quality of Life (QOL) program. Review of the QOL program referral dated 08/02/19 revealed nursing staff were to provide gentle massages prior to putting on her splints each day. Review of the task documentation records revealed the program was not implemented or provided since 08/02/19. Review of the physician's progress note dated 08/05/19 revealed Resident #32 had diffuse pain in multiples joints due to primary osteoarthritis. The resident had a lot of pain in the lower lumbar spine and neck pain with decreased range of motion to multiple joints. The resident also had a lot of pain in her cervical spine (neck area). The resident displayed abnormal reflex and muscle tone. The physician documented the resident received Norco three times a day at the lowest dose, which was 5 mg-325 mg. The resident had received Cymbalta, an antidepressant also used to relieve neuropathy pain, but it was discontinued by the psychiatrist on 07/31/19. The note indicated Resident #32 was medically stable and no changes in the plan of care were indicated. Review of the interdisciplinary team meeting notes dated 08/06/19, held with Resident #32 and her daughter, revealed the resident had chronic pain. There was no documentation or evidence they discussed options to address her ongoing, chronic pain although the pain evaluation from 07/25/19 indicated she had severe pain that limited her ability to do ADL's. Review of the physician's progress note dated 09/11/19 revealed the resident had diffuse multiple joint pain due to primary osteoarthritis. The note indicated the resident had a lot of pain in the lower lumbar spine and neck pain with decreased range of motion to multiple joints. The resident also had a lot of pain in her cervical spine. The resident displayed abnormal reflex and muscle tone. The resident received Norco three times a day. This progress note indicated Resident #32 was medically stable and no change in the plan of care was indicated. Review of the nurse's note dated 10/01/19 revealed the resident refused to take a shower because she was in so much pain. There was no evidence any addition as needed pain medication or any nonpharmacological pain relieving interventions were provided. The physician was not notified regarding pain which limited Resident #32's ADL ability. Review of the pain evaluation dated 10/07/19 revealed the resident constantly had pain daily that affected her activities of daily living. On a scale of zero to 10, with zero being no pain and 10 being the most pain, the resident scored her pain an eight. The plan section of this evaluation indicated they would continue the current interventions. There were no new interventions put into place and evidence the physician was notified in order to address her unrelieved pain. Review of the physician's progress note dated 10/09/19 revealed the same information as previous notes. Resident #32 had diffuse and multiple joint pain due to primary osteoarthritis. The resident had a lot of pain in the lower lumbar spine and neck pain with decreased range of motion to multiple joints. The resident also had a lot of pain in her cervical spine. The resident displayed abnormal reflex and muscle tone. The resident received Norco three times a day. The physician indicated they would continue with the current plan of care. Review of the occupational therapy (OT) treatment session records between 10/16/19 and 11/22/19 revealed Resident #32's pain was decreased with the provision of range of motion, gentle massage and warm moist heat. Review of the nurse's note dated 10/25/19 revealed Resident #32 complained of pain in the right anterior axilla (front shoulder area). There was no documentation of her pain level, location or that any interventions to relieve were attempted. There was no evidence any as needed pain medications were administered or that any non-pharmacological pain relieving interventions were attempted. Review of the interdisciplinary team meeting notes dated 10/29/19 with Resident #32 and her daughter revealed the resident had chronic pain. There was no documentation or evidence of discussion of any other options to address her unrelieved pain. Review of the pain evaluation dated 11/01/19 revealed Resident #32 constantly had pain, on a daily basis, that affected her activities of daily living. The resident's pain was rated as a 10 out of 10. The plan was to continue the current interventions. There were no new interventions planned or implemented to attempt to reduce her pain. Review of the physician's progress note dated 11/08/19 continued to document the same information. It indicated Resident #32 had diffuse multiple joint pain due to primary osteoarthritis. The resident had a lot of pain in the lower lumbar spine and neck pain with decreased range of motion to multiple joints. The resident also had a lot of pain in her cervical spine. The resident displayed abnormal reflex and muscle tone. The resident received Norco three times a day. The note indicated the resident was medically stable and no change in the plan of care was indicated. The resident was discharged from OT on 11/22/19 and referred to the QOL program. Review of the QOL program referral dated 11/22/19 revealed nursing staff were to provide warm compresses and gentle massage to the left hand then proceed to the fingers, hand and wrist prior to applying the orthotic. These modalities aided in pain relief during therapy. Review of the task documentation records revealed the program was not implemented or provided since 11/22/19. On 12/02/19 at 12:35 P.M., interview with Resident #32 revealed she was in terrible pain and wanted to talk to the doctor because she wanted a different or stronger medication for the pain. The resident stated she just wanted to die because she could not live with this much pain anymore. She said it had been going on for a long time and she said she tells the aides and nurses every day that she is in pain. Review of the 12/02/19 case management note (after surveyor intervention on 12/02/19) revealed RN #559 spoke to the resident who stated her pain was terrible and indicated her left leg, foot and buttock were hurting. The resident wanted the doctor to be called to see what could be done. The resident's left leg splint was not on her leg and the note indicate the resident requested it be put on because it helped with the pain. No other information was found to indicate the physician was contacted. On 12/02/19 at 5:03 P.M., interview with State Tested Nurse Aide (STNA) #592 revealed Resident #32 was always complaining of being in pain and she would inform the nurse daily. On 12/02/19 at 5:15 P.M., interview with Resident #32 revealed she was upset because she had previously asked Licensed Practical Nurse (LPN) #585 to call the doctor to get her more pain medication but he said there was nothing else they could do for her. She stated the pain was so bad in her left leg and foot. On 12/02/19 at 6:18 P.M., interview with Registered Nurse (RN) #559 revealed she was aware Resident #32 had chronic pain and said she was given her regularly ordered pain medication at 1:00 P.M. today. She also gets topical Biofreeze to her shoulder, knee, hip and foot daily. RN #559 verified she completed the pain assessments which indicated Resident #32 was always in significant pain. RN #559 verified there had not been any other pain relieving interventions implemented since 06/20/19 when the resident's Norco pain medication was increased from twice a day to three times a day. On 12/04/19 at 8:45 A.M., the resident was observed in the dining room and had not eaten any of her breakfast. Resident #32 said she was in too much pain to eat. She stated she told LPN #585 again today and he was going to see if the doctor would come in and see her. No other interventions were attempted. On 12/04/19 at 10:15 A.M., interview with STNA #596 revealed the resident was in pain daily, especially her feet, which hurt a lot at night and her left leg, foot and hand most of the time. She has been complaining of more pain more frequently and says it worse and she lets the nurse know daily. On 12/04/19 at 1:00 P.M., interview with RN #559 and Licensed Social Worker (LSW) #630 verified there was no evidence of any new pain control interventions since the increase in pain medication on 06/20/19. On 12/04/19 at 1:15 P.M., interview with LPN #585 verified the resident had chronic pain daily and she was receptive to suggestions. LPN #585 verified the resident complained of pain to him on 12/02/19 and 12/03/19 but there was no documentation in the medical record. LPN #585 verified he could not document every time the resident said she was in pain. He stated the pain medication was increased on 06/20/19 and verified there were no other interventions since then. LPN #585 said the resident did seem to be complaining of more pain and she had an increase in buttock pain. LPN #585 said she recently received a different wheelchair and thought it could be the cushion causing the increased pain but verified he had not attempted to try a different cushion. LPN #585 verified Resident #32's pain affected her everyday living including her not wanting to eat, not participating in activities and at times not wanting to get out of bed. He said the doctor was aware but he could not call the doctor every time the resident complained of pain because it was daily. On 12/04/19 at 5:15 P.M., interview with RN #532 and RN #701 verified the QOL programs recommended by PT and OT were not implemented to maintain the resident's current level of function and aid in pain relief. On 12/05/19 at 11:40 A.M., interview with Physician #704, with the Executive Director and RN #701 present, indicated they talked about Resident #32's pain monthly in the interdisciplinary team meetings (IDTs) but verified there was no documented evidence of this being discussed. He said the resident has and will always have chronic pain. He said he did not want to use opioids because they cause other problems. When asked about any non-pharmacological interventions attempted, he verified none were mentioned or attempted. He said the resident had severe kyphosis, neuropathy pain and other joint pain, neck pain, hand and leg pain. He said when the resident was in bed her feet hurt so bad and she felt better when she was up in the wheelchair. He said the psychiatrist stopped her Cymbalta which he was using to help with her neuropathy and he said it had helped. The physician had no answer when asked why he did not discuss this with the psychiatrist, restart the medication or try a different medication. He said he wouldn't put her on any stronger medications or increase the strength of her current Norco. The physician was made aware of the conversation when the resident stated she would rather be dead than to have to deal with all this pain. Physician #704 said there was nothing else they could do for the resident's chronic pain. He verified there was no documentation Resident #32 was involved in her own care and treatment related to her unrelieved pain. Review of the pain assessment and management policy, last reviewed 04/17/19, revealed the purpose was to help staff identify pain in residents and to develop interventions consistent with resident's goals and needs, including addressing the underlying causes of pain. The physician and staff would identify residents who had pain or who were at risk for having pain. Including review of the treatments the resident was currently receiving for pain both complimentary and non-pharmacologic treatments. The resident would be assessed on admission, quarterly, with a significant change and when there was an onset of new pain or worsening of existing pain. The staff would identify any situations or interventions when an increase in pain may be anticipated such as need for repositioning. The staff and physician would evaluate if the was affecting the resident's mood, activities of daily living, sleep and quality of life as well as how the pain may be contributing to social isolation, falls and range of motion issues. The physician would help identify the extent to which underlying causes of pain would be addressed or reversed. The physician would perform or order appropriate tests as needed to help clarify sources of pain. With input from the resident, the physician and staff would establish goals of pain treatment. The staff would evaluate effectiveness of the analgesic medications and document on the medication administration record. If the residents pain was complex or not responding to standard interventions, the attending physician may consider additional consultative support. If pain management was obtained, the attending physician would maintain an active role by reviewing the consults, recommendations and evaluating subsequent progress.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure Resident's #2, #3, #5, #7, #9, #10, #15, #18, #20, #21, #24, #30, #31, #33, #39, #40, and #43 received restorative/maintenance programs to maintain function for activities of daily living (ADLs) and/or prevent decline in ADL's after being discharged from skilled therapy. This affected 17 of 17 sampled residents. Actual Harm occurred when skilled therapy recommendations were not followed/implemented by the quality of life (QOL) program resulting in an avoidable declines in ambulation for Resident's #10, #18, #21, and #33, an avoidable decline in ambulation and transfers for Resident #15, and avoidable declines in the ability to sit to stand for Resident #7 and Resident #20. Findings include: 1. Review of Resident #18's medical record revealed diagnoses including dementia, osteoarthritis of both knees and Parkinson's disease. A plan of care initiated 07/10/19 indicated Resident #18 had an activity of daily living (ADL) deficit related to dementia and needed staff assistance for ADLs. Interventions included obtaining a Physical Therapy (PT) evaluation and treating the resident as indicated per orders. Interventions also included providing QOL tasks as assigned. Resident #18 received physical therapy (PT) from 06/30/19 to 08/14/19. A QOL Program Recommendation Referral dated 08/12/19 revealed recommendations for Resident #18 to be ambulated 30 feet with a front wheeled walker with minimum assistance with a wheelchair following. A PT Discharge summary dated [DATE] indicated Resident #18 was able to ambulate up to 100 feet with a front wheeled walker needing minimum assist to contact guard assistance for safety, displaying a step to/through gait pattern needing visual cues to increase step length and cadence (voice inflection) with a wheelchair following. Resident #18's prognosis to maintain her level of function was good with consistent staff follow through. A Restorative Nursing Program/Functional Maintenance Program was completed with the Interdisciplinary team for ambulation. Review of the nursing assistant task list report, which is where specific programs were listed and where staff recorded provision of programs, revealed an entry to please ambulate Resident #18 short distances with a front wheeled walker, a gait belt and with a wheelchair to follow. Review of the documentation regarding ambulation on the task list between 08/14/19 and 09/19/19 revealed Resident #18 was ambulated three times. A PT evaluation dated 09/19/19 indicated Resident #18 was referred for PT services due to a decline in function. Resident #18 reported increased difficulty with transfers. Nursing had to downgrade the transfer device and Resident #18 declined as evidenced in increased staff assistance needed for mobility. Resident #18 needed maximum staff assistance to transfer and she was totally dependent on staff without attempts to initiate ambulation. Resident #18 did not take any steps during the PT evaluation. A QOL Program Recommendation referral form dated 10/31/19 indicated recommendations for Resident #18 to now use a sit to stand lift for transfers. A PT Discharge summary dated [DATE] indicated Resident #18 was able to ambulate 25 feet with moderate assistance. On 12/06/19 between 8:20 A.M. and 12:00 P.M., while interviewing Licensed Physical Therapy Assistant (LPTA) #642 about the quality of life program, she stated therapy made recommendations upon discharge but it was up to nursing to decide if the recommendations would be implemented. LPTA #642 verified Resident #18 had a decline after being discharged from PT on 08/14/19 resulting in PT needing to place Resident #18 back on caseload. On 12/06/19 at 2:10 P.M., State Tested Nursing Assistant (STNA) #690 stated Resident #18 transferred with a lift but she did not walk. STNA #690 stated she had never attempted to ambulate Resident #18. On 12/06/19 at 2:13 P.M., STNA #501, a QOL nursing assistant, known as a Lead State Tested Nursing Assistant (LSTNA), stated she had never ambulated Resident #18. On 12/06/19 at 3:30 P.M., Physical Therapist (PT) #643 verified when Resident #18 was discharged from PT on 08/14/19 she was able to ambulate 100 feet and a QOL program recommendation was made for nursing staff to continue to ambulate Resident #18. When Resident #18 was evaluated by therapy on 09/19/19 she was unable to ambulate. PT #643 verified inactivity and not following recommendations could result in decline in condition. Review of the QOL program policy, dated 10/04/18, revealed the program was to attain or maintain each resident's highest practicable physical, mental and psychosocial well-being, consistent with the resident's comprehensive assessment, the minimum data set (MDS), and plan of care. The program was person-centered and the focus was to provide interventions the resident desired that gave the resident a sense of satisfaction for overall well being of self, the environment and control over their life. Interventions and goals were focused on what the resident desired and felt provided a QOL. The goals were documented on the plan of care (POC). The interventions were added to the point of care (the computer system where the STNAs or LSTNA's documented task completion). Identifying improvement/decline would be assessed on a subsequent MDS assessment and the POC would be adjusted as appropriate. If a decline in function was noted a new intervention would be implemented including referral to skilled therapy. Any changes would be reported to the unit manager. The LSTNA would assist residents in completing there skilled therapy interventions and recommendations. The LSTNA would document in the point of care completion of the programs under their specific assigned tasks. Review of the QOL list of programs offered revealed all programs were to be completed by the LSTNA. The programs were not specific or measurable and only included statements such as, walk me to the bathroom, provide range of motion (ROM) when I am getting dressed, assist me with the NuStep (a bike machine), seat me for meals at the table where I am to be cued and fed and put on my splint according to my care card. 2. Review of Resident #33's medical record revealed diagnoses including myopathies, epilepsy, osteoarthritis of the hip, and repeated falls. A care plan initiated 09/12/19 revealed Resident #33 had noted declines in ADL's and required extensive assistance of one to two staff to total dependence for ADL's. Resident #33 was unable to stand and transfer unassisted. Resident #33 received PT services from 08/31/19 to 10/21/19. A Discharge summary dated [DATE] indicated Resident #33 was ambulating up to 100 feet with a front wheeled walker and minimum to moderate assistance. A QOL program recommendation referral indicated recommendations to ambulate Resident #33 50 to 75 feet with a front wheeled walker with minimal assistance of two with a wheelchair to follow. A nurse task list report revealed notations to please ambulate Resident #33 50-75 feet with a front wheeled walker with two assists. There was no indication how frequently Resident #33 was to be ambulated. Review of the nurse aide task list documentation from 10/21/19 to 11/25/19 revealed one refusal, one participation and all other entries indicated the ambulation was not applicable. A PT evaluation dated 11/25/19 revealed when PT screened Resident #33 a decline in transfers and gait were noted and he was referred for a PT evaluation and treatment. Resident #33 was totally dependent with attempts to initiate gait. On 12/06/19 between 8:30 A.M. and 12:00 P.M., Licensed Physical Therapy Assistant (LPTA) #642 was interviewed regarding the residents on the Quality of Life program. LPTA #642 verified when Resident #33 was discharged from PT on 10/21/19 he was ambulating 100 feet with minimum to moderate assistance. Resident #33 was readmitted to therapy 11/25/19 due to declines and required maximum assistance of two, was unsteady and only ambulated 25 feet. Resident #33 remained on therapy at this time. During the initial PT services, Resident #33's daughter was trained to assist with ambulation. Resident #33 was more comfortable when the daughter was present for the ambulation. However, two staff had the ability to ambulate Resident #33 without the daughter. On 12/06/19 at 3:36 P.M., Physical Therapist (PT) #643 verified therapy made recommendations for programs but it was up to nursing to determine the frequency. PT #643 verified there was no frequency set up for the ambulation. PT #643 verified Resident #33 had experienced a decline in ambulatory status between 10/21/19 and 11/25/19. On 12/06/19 at 4:05 P.M., Registered Nurse (RN) #549 verified Resident #33 was discharged from PT on 10/21/19 with recommendations for ambulation services. She said there was nobody to initiate the program and it was not started until 11/19/19. On 12/06/19 at 4:07 P.M., STNA #540 stated she had never ambulated Resident #33 or seen the LSTNAs for QOL ambulate him. STNA #540 verified she was unaware of an ambulatory program. On 12/06/19 at 4:10 P.M., Resident #33 stated he was at a rehabilitation hospital prior to his admission to the facility and was walking. He said when he was admitted to the facility he received therapy. After therapy ended, he said nobody from the nursing staff offered to ambulate him and he was back in therapy again. Resident #33 stated when he started therapy the second time he was weaker. Resident #33 stated although he would be nervous walking with nursing staff he would have participated. On 12/06/19 at 4:30 P.M., LSTNA #501 verified she had never ambulated Resident #33. Review of the QOL program policy, dated 10/04/18, revealed the program was to attain or maintain each resident's highest practicable physical, mental and psychosocial well-being, consistent with the resident's comprehensive assessment, the minimum data set (MDS), and plan of care. The program was person-centered and the focus was to provide interventions the resident desired that gave the resident a sense of satisfaction for overall well being of self, the environment and control over their life. Interventions and goals were focused on what the resident desired and felt provided a QOL. The goals were documented on POC. The interventions were added to the point of care. Identifying improvement/decline would be assessed on a subsequent MDS assessment and the POC would be adjusted as appropriate. If a decline in function was noted a new intervention would be implemented including referral to skilled therapy. Any changes would be reported to the unit manager. The LSTNA would assist residents in completing there skilled therapy interventions and recommendations. The LSTNA would document in the point of care completion of the programs under their specific assigned tasks. 3. Resident #21 was admitted to the facility on [DATE] with diagnoses which included dementia and joint disease in the right and left knees. Review of the current activities of daily living (ADL) care plan revealed staff were to follow the QOL tasks as assigned. Review of the physical therapy evaluation (PTE) dated 04/30/19 revealed Resident #21 was able to ambulate five feet with moderate assistance with the front wheeled walker (FWW). Further review of the discharge information, dated 06/03/19, indicated Resident #21 was able to ambulate 200 feet with contact guard (CG) assistance. The resident was referred to a restorative nursing program or the QOL to maintain and/or improve their current level and prevent decline in ambulation. Review of the QOL program referral form dated 06/03/19 revealed staff were to ambulate Resident #21 100 feet with a front wheeled walker and contact guard assistance. Review of the task list report revealed the ambulation program for the QOL LSTNA was not initiated until 08/07/19, over two months after the therapy referral. The task grids which is where the LSTNAs document implementation of the program revealed no documentation the ambulation program was ever provided to Resident #21. Review of the PTE dated 11/18/19 revealed Resident #21 was referred back to therapy due to increased weakness and difficulty with transfers. The resident was only able to ambulate 25 feet and needed more staff assistance. Review of the quarterly minimum data set (MDS) 3.0 assessment dated [DATE] revealed Resident #21 was severely impaired for cognition and had not walked at all during the seven day reference period. On 12/05/19 at 2:57 P.M., interview LSTNA #501 revealed she had not ambulated Resident #21 according to the QOL plan. On 12/04/19 at 5:15 P.M., interview with RN #572 and RN #701 verified the QOL program was not implemented as planned to ensure Resident #21 maintained the level of function at the time of discharge from therapy and to prevent an avoidable decline in ambulation. On 12/06/19 at 10:00 A.M., interview with LPTA #642 verified Resident #21 was unable to walk 100 feet on 12/05/19. LPTA #642 verified they had wanted the resident to walk 100 feet and it was up to nursing to determine the actual program based on their needs. LPTA #642 verified when she observed the staff occasionally walking the resident it was not to the goal of 100 feet. LPTA #642 verified the resident's decline in ambulation was avoidable if the resident had been ambulated as planned. PTA #642 revealed therapy made recommendations upon discharge but it was up to nursing to decide if the recommendations would be implemented. LPTA #642 verified Resident #21 had a decline after being discharged from PT on 06/03/19 resulting in PT needing to place the resident back on caseload on 11/18/19. On 12/06/19 at 3:25 P.M., interview with the resident revealed the nursing assistants don't walk her and the only time she was walked was when she was in therapy. She said she wanted to walk more and would not refuse if staff asked her to walk because she wanted to keep up her strength. 4. Resident #15 was admitted to the facility on [DATE] with diagnoses which included cerebral vascular accident (CVA/stroke) with left (dominant side) hemiplegia (paralysis on one side of the body). Review of the current fall and ADL care plans initiated 11/11/18 revealed staff were to follow the QOL tasks as assigned. Review of the PTE dated 11/11/18 revealed the resident could ambulate 20 feet with minimum assistance with a front wheeled walker, could transfer with minimum assistance, and could ascend five steps. Review of the therapy Discharge summary dated [DATE] revealed Resident #15 could ambulate 300 feet with stand by assistance using the front wheeled walker and only needed stand by assistance with transfers. Resident #15 showed an increase in strength in range of motion (ROM) in both lower extremities (legs/feet) and was able to ascend five steps per the goal. Resident #15 was referred to the QOL program for ambulation and transfers. Review of the task list report revealed exercises for Resident #15's legs were initiated on 12/14/18 for and were to be provided by the floor STNA's, not through the QOL program. There was no evidence transfers or ambulation programs were initiated as recommended by therapy to attempt maintain Resident #15's functional abilities. Review of the PTE dated 05/06/19 revealed Resident #15 was seen again for an increase in weakness, pain/tightness in both knees with a pain score of 9/10 to the right knee and difficulty with home visits with family with a decrease in ambulation and transfers. The resident was only able to walk 75 feet with minimum assistance and a rolling walker (RW). The resident needed moderate assistance with transfers and was only able to ascend two steps. Further review of the Discharge summary dated [DATE] revealed the resident was able to ambulate 200 feet with stand by assistance and a RW, was able to ascend eight steps and was a stand by assistance with transfers. The pain to the knees was decreased to a 2/10. The resident was referred to the QOL program for ambulation and transfers. Review of the QOL referral dated 06/03/19 revealed to ambulate the resident 150 to 250 feet with the RW and provide ROM to both lower extremities. Review of the task list report revealed there was no evidence of any added programs for ambulation or transfers. Review of the PTE dated 08/20/19 revealed the resident was seen by therapy due to a family request as Resident #15 had increased pain in both knees, had a decline in functional mobility, transfers and ambulation. Therapy indicated Resident #15 was able to ambulate 75 feet with a rolled walker, had knee pain of 6/10, had to rock herself to use momentum to get going and was unsteady for transfers requiring assistance. The resident was not able to ascend any steps. Review of the therapy Discharge summary dated [DATE] revealed Resident #15 improved and was able to ambulate 125 feet with contact guard asguard assistance and was able to ascend two steps. The resident was referred to the QOL program. Review of the QOL referral dated 09/09/19 revealed Resident #15 was to ambulate 150 to 250 feet with the rolled walker and contact guard assistance. Review of the task list report revealed on 09/18/19 Resident #15 was to ambulate with the rolled walker two to three times a week. Review of the participation grids revealed there was no documentation the ambulation program for Resident #15 was implemented. Review of the annual MDS 3.0 assessment dated [DATE] revealed Resident #15 was cognitively intact, was not walked during the seven day reference period and needed extensive assistance of one staff person for transfers. On 12/04/19 at 5:15 P.M., interview with RN #572 and RN #701 verified the QOL program was not implemented as planned to ensure Resident #15 maintained her level of function at the time of discharge from therapy and to prevent an avoidable decline. On 12/05/19 at 2:57 P.M., interview with LSTNA #501 revealed she was not able to ambulate the resident according the QOL plan. On 12/06/19 at 8:30 A.M., interview with LPTA #642 revealed Resident #15 had avoidable declines in ambulation and transfers due to nursing staff not implementing a restorative program or QOL program each time the resident was discharged from skilled therapy. LPTA #642 verified the resident's son called her, as he was a PT and informed her he was having increased difficulty when taking the resident to outings including ambulation, ascending steps, transfers and with ROM. LPTA #642 had an evaluation completed on 8/20/19 which again revealed the resident had a decline in ambulation, transfers, ascending steps and ROM since the last therapy discharge on [DATE]. On 12/06/19 at 3:20 P.M., interview with Resident #15 revealed the staff did not walk her. She said her son walked her wen he came to visit. She stated she would like to walk every day but staff did not have time. She said LSTNA #542 occasionally walked her down the halls but said it had been at least a month or so since that had been done. On 12/06/19 at 3:30 P.M., phone interview with Resident #15's son revealed he was a physical therapist and had concerns with the resident's declines. He said he talked to LPTA #642 about it and she was picked up in therapy due to the declines. He said his mother had improved with skilled therapy. He said he visited daily and walked his mother but said he did not see the staff performing any of the programs for her. 5. Resident #10 was admitted to the facility on [DATE] with diagnoses which included dementia and osteoarthritis. Review of the current ADL care plan revealed staff were to follow the QOL tasks as assigned. Review of the PTE dated 05/20/19 revealed Resident #10 was able to ambulate 75 feet with contact guard assistance. Review of the Discharge summary dated [DATE] revealed Resident #10 had improved and was able to ambulate 150 feet with stand by assistance. The resident was referred to the restorative or QOL program for ambulation. Review of the task list report dated 06/10/19 revealed Resident #10 was to ambulate with one person and the front wheeled walker. Review of the participation grids revealed there no documentation the ambulation program was implemented. Review of the PTE dated 09/17/19 revealed Resident #10 was referred back to skilled therapy due to a fall in the bathroom. The resident had declined from walking 100 feet with stand by assistance and could now ambulate 75 feet with contact guard assistance and the front wheeled walker. Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #10 was severely cognitively impaired, was unsteady with ambulation, and needed assistance of one person for ambulation. Review of the PT Discharge summary dated [DATE] revealed Resident #10 improved and was able to ambulate 150 feet with stand by assistance using the front wheeled walker. The resident was referred to the QOL program. Review of the QOL referral dated 10/29/19 revealed staff were to ambulate Resident #10 150 feet with the front wheeled walker and provide range of motion to both legs/feet. Review of the task list report revealed there was no documentation the ambulation program or the range of motion programs were implemented. On 12/04/19 at 5:15 P.M., interview with RN #572 and RN #701 verified the QOL program was not implemented as planned to ensure Resident #10 maintained their current level of function and prevent an avoidable decline. They verified Resident #10 was discharged from PT on 06/07/19 and referred to the QOL program for ambulation, which was not provided, resulting in a decline in ambulation and the need for additional PT on 09/17/19. On 12/05/19 at 2:57 P.M., interview with LSTNA #501 verified she was not able to ambulate Resident #10 according the QOL plan. 6. Resident #2 was admitted to the facility on [DATE] with diagnoses which included contracted right hand and dementia. Review of the current resident care card revealed all food was to be served in separate bowls and the resident needed extensive staff assistance with eating. Review of the current nutrition care plan initiated 04/01/19 revealed the resident could feed herself with cues from staff during meals. Review of the occupational therapy (OT) evaluation dated 08/15/19 revealed on 09/09/19 the resident required increased time to complete self-feeding and displayed increased difficulty in management of the utensil with a spillage rate of 30 percent. By 09/17/19, Resident #2 was able to self-feed with regular utensils with a spillage rate of five to 10 percent. Upon discharge on [DATE], Resident #2 was able to feed herself with stand by assistance. Resident #2 was referred to the QOL program to maintain her current level of function. Review of the STNA task documentation for the last 30 days for eating revealed Resident #2 was usually fed her meals by staff and she was not feeding herself. There was no QOL task listed to indicate Resident #2 was in a program to promote independent eating as recommended by OT. On 12/02/19 at 12:20 P.M., Resident #2 was observed being fed lunch by staff and was not encouraged or cued to feed herself. On 12/03/19 at 8:41 A.M., Resident #2 was observed being fed breakfast by staff and was not encouraged or cued to feed herself. On 12/04/19 at 5:15 P.M., interview with RN #572 and RN #701 verified the QOL program was not implemented as planned to ensure Resident #2 maintained her current level of function for eating meals herself. On 12/04/19 at 5:20 P.M., Resident #2 was observed being fed dinner by STNA #587. The resident was not encouraged or cued to feed herself. On 12/04/19 at 5:30 P.M., interview with STNA #587 verified she fed the resident and the resident did not make any attempts to feed herself. STNA #587 was not aware Resident #2 was able to feed herself with cueing and had not attempted to let the resident feed herself. On 12/05/19 at 9:00 A.M., interview with Certified Occupational Therapy Assistant (COTA) #702 and LPTA #642 verified Resident #2 was discharged from OT on 09/17/19 and was able to feed herself with cueing. The resident was referred to the QOL program to ensure the resident maintained her independence with eating. COTA #702 verified she was not aware the staff were feeding the resident versus encouraging her to feed herself. On 12/05/19 at 2:57 P.M., interview with LSTNA #501, the aide for the QOL program, revealed she was not involved with assisting Resident #2 with meals. 7. Resident #24 was admitted to the facility on [DATE] and diagnoses included dementia. Review of the admission MDS 3.0 assessment dated [DATE] revealed Resident #24 was severely cognitively impaired, was unsteady with walking and needed extensive assistance of one staff person for transfers. Review of the significant change MDS 3.0 assessment dated [DATE] revealed Resident #24 was severely cognitively impaired, did not walk and needed extensive assistance of two or more staff for transfers. Resident #24 was seen and treated in therapy. Review of the QOL referral form from therapy dated 11/15/19 revealed nursing staff were to ambulate Resident #24 50-75 feet with the assistance of one staff using a front wheeled walker. Review of the QOL task list report and the participation documentation revealed there was no evidence the program was ever implemented. On 12/04/19 at 5:15 P.M., interview with RN #572 and RN #701 verified the QOL program was not implemented as planned to ensure Resident #24 maintained their current level of function and/or to prevent any declines in functional abilities. On 12/05/19 at 2:57 P.M., interview with the QOL aide, LSTNA #501, revealed she was not able to ambulate the resident according the QOL plan. 8. Resident #7 was admitted to the facility on [DATE] with diagnoses which included dementia. Review of the task list report revealed a QOL program initiated on 03/25/19 for staff to do sit to stand with Resident #7 two to three times a week. Review of the task documentation revealed no evidence the program was implemented. Resident #7 was referred back to therapy for skilled services and referred back to the QOL program on 09/10/19. Review of the QOL referral from therapy dated 09/10/19 revealed staff were to provide the sit to stand program at the grab bar two to three times a week. Review of the participation grids revealed this program was not implemented or provided. Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #7 was severely cognitively impaired and was totally dependent on two or more staff for transfers using a mechanical lift and the resident did not walk in the seven day review period. On 12/04/19 at 5:15 P.M., interview with RN #572 and RN #701 verified the QOL program was not implemented as planned to ensure Resident #7 maintained their previous level of function and to prevent an avoidable decline. On 12/05/19 at 2:57 P.M., interview with LSTNA #501, the QOL aide, revealed she was not able to provide the QOL program for Resident #7 to sit to stand. 9. Resident #30 was admitted to the facility on [DATE] with diagnoses which included osteoarthritis. Review of the QOL referral from therapy dated 09/03/19 revealed LSTNAs were to provide ambulation with stand by assistance using a front wheeled walker for 150 feet. Review of the task list report for the QOL program revealed no evidence the program was ever initiated. Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #30 was alert, oriented and cognitively intact. This assessment indicated she needed extensive assistance with one staff person for ambulation and she was unsteady, needing staff support. Review of the QOL referral from therapy dated 11/12/19 revealed QOL staff were to provide ambulation with a front wheeled walker with contact guard assistance for 75 to 100 feet and a walk to dine program (staff are to walk the resident to eat meals in the dining room). Review of the task list report revealed there no evidence these programs were ever initiated for Resident #30. On 12/04/19 at 5:15 P.M., interview with RN #572 and RN #701 verified the QOL program was not implemented as planned to ensure Resident #30 maintained her current level of function. On 12/05/19 at 2:57 P.M., interview with LSTNA #501 revealed she was not able to ambulate Resident #30 according the QOL plan. On 12/07/19 at 1:25 P.M., interview with Resident #30 revealed she was only walked in therapy. She said she wanted to be walked more so she did not need the wheelchair. She wanted to walk with her walker like she did before. 10. Resident #40 was admitted to the facility on [DATE] with diagnoses which included dementia and osteoarthritis. Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #40 was alert, oriented, and cognitively intact, needed extensive assistance of two or more staff for transfers and was unsteady with ambulation needing extensive assistance of one staff person. Resident #40 was seen and treated by therapy. Review of the QOL referral from therapy dated 11/04/19 revealed QOL staff were to ambulate Resident #40 50-75 feet with the assistance of one staff person using the front wheeled walker. Review of the task list report for the QOL programs revealed no evidence the program was ever initiated for Resident #40. On 12/04/19 at 5:15 P.M., interview with RN #572 and RN #701 verified the QOL program was not implemented as planned for Resident #40. On 12/05/19 at 2:57 P.M., interview with LSTNA #501 revealed she was not able to ambulate Resident #40 according the QOL plan. 11. Resident #43 was admitted on [DATE] with diagnoses which included a hip fracture. Review of the PTE dated 08/31/19 revealed Resident #43 was admitted with a hip fracture and was treated by therapy. Review of the therapy Discharge summary dated [DATE] revealed Resident #43 was able to ambulate 100 feet. Review of the QOL referral form dated 10/24/19 revealed QOL staff were to ambulate Resident #43 50-100 feet with the front wheeled walker. Review of the participation grids revealed no evidence the program was ever implemented. Review of the significant change MDS 3.0 assessment dated [DATE] revealed the resident had mild cognitive impairment, was unsteady with ambulation and needed assistance of one person for ambulation. Review of the PTE dated 11/18/19 revealed Resident #43 was seen again by therapy because he began to scissor with his gait. The resident was currently receiving skilled therapy. On 12/04/19 at 5:15 P.M., interview with RN #572 and RN #701 verified the QOL program was not implemented as planned for Resident #43. On 12/05/19 at 2:57 P.M., interview with LSTNA #501, the QOL aide, revealed she was not able to ambulate Resident #43 according the QOL plan. 12. Resident #20 was admitted to the facility on [DATE] with diagnoses which included Alzheimer's disease and a recent hip fracture. Review of the PTE dated 10/04/19 revealed Resident #20 was seen, treated and discharged on 11/08/19 with a referral to the QOL program. Review of the QOL referral form from therapy dated 11/08/19 revealed QOL staff were to provide the sit to stand program with maximum assistance of two staff. Review of the task list report revealed the sit to stand program was initiated on 11/19/19. Review of the participation grids revealed there no evidence the program was ever provided to Resident #20. Review of the PTE dated 12/06/19 revealed Resident #20 was picked back up by therapy and was being seen for a decrease in the ability to sit to stand and for a decline in the ability to extend the right knee. On 12/04/19 at 5:15 P.M., interview with RN #572 and RN #701 verified the QOL program was not implemented as planned for Resident #20 to attempt to assist the resident to maintain their previous le[TRUNCATED]