**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of Resident #34's medical record revealed the resident was admitted to the facility on [DATE]. Her diagnoses included congestive heart failure, atrial fibrillation, peripheral vascular disease, generalized osteoarthritis, and obesity. Review of Resident #34's admission MDS assessment dated [DATE] revealed the resident had a functional limitation in her range of motion of her bilateral upper extremities. A wheelchair was one of the mobility devices being used. She was dependent on staff for transfers and ambulation had not occurred. She was assessed as being at risk for pressure ulcers, but did not have any unhealed pressure ulcers at that time. Review of Resident #34's nurses' progress notes revealed a nurse's note dated 04/10/25 at 8:00 P.M. that indicated the nurse was notified by a nursing assistant that the resident had a red area to her heel. Upon assessment, the nurse noted a non-blanchable red area to resident's left heel. The area measured 1 centimeter (cm) x 0.5 cm. Treatment was initiated and skin prep was applied and a pillow was placed under the resident's heels. Review of Resident #34's skin and wound evaluation dated 04/11/25 revealed the resident was assessed as having a pressure ulcer to her left heel that was staged as a deep tissue injury (persistent non-blanchable deep red, maroon or purple discoloration. It was indicated to be facility acquired with an onset date of 04/10/25. It measured 0.7 cm x 0.6 cm. An assessment of peri-wound area, presence of pain, and any additional care provided was not documented on the wound evaluation. The wound evaluation form used by the facility included a place for the nurse assessing the pressure ulcer to complete an assessment of those areas as part of the wounds overall assessment. The nurse assessing the wound left those areas of the assessment blank. Review of Resident #34's active care plans revealed she had a care plan in place for having an actual deep tissue injury on her left heel. The care plan was initiated on 04/16/25. The goal was for her pressure ulcer to show signs of healing and remain free from infection through the review date. The interventions included the need to have heel boots to her bilateral feet while up in her chair. They were also to assess her wound and record/ monitor the status of the wound weekly. They were to measure the wound, assess and document the status of the wound perimeter, wound bed, and healing progress. Review of Resident #34's physician's orders revealed an order was put in place for her to have a heel boot to her left foot while up in a chair every shift due to a pressure ulcer. The order was written on 05/05/25 at 2:53 P.M. The physician's orders were updated on 05/07/25 for the resident to use heel boots to her bilateral feet when up in her chair. Further review of Resident #34's weekly skin and wound evaluations completed after the initial wound evaluation on 04/11/25 revealed the nurses continued to not complete a comprehensive and thorough assessment of the resident's pressure ulcer to the left heel on a weekly basis. The skin and wound evaluation completed on 04/17/25 and 05/01/25 did not include an assessment of the peri-wound area, presence of any wound pain, and additional care provided to promote wound healing. The skin and wound evaluation completed on 04/24/25 did not identify the presence of any pain or additional care provided to promote wound healing. It included an assessment of the resident's wound bed, which indicated epithelial tissue was present, which could not have been present due to the wound bed being intact and epithelial tissue would only be present with the development of new skin. On 05/06/25 at 9:10 A.M., an observation of Resident #34 noted her to be sitting up in her wheelchair in her room. Her feet were edematous and she was wearing non-skid socks. She had her feet resting on the foot pedals of the wheelchair, but was not wearing any heel protectors at the time the observation was made. Ongoing observations on 05/06/25 at 12:15 P.M., and again on 05/07/25 at 8:32 A.M., noted Resident #34 to be up in her wheelchair, without her heel protector(s) on. It was not until 05/07/25 at 8:58 A.M. when the resident was observed for the first time in the past two days to have heel boot(s) on either of her feet while up in her wheelchair. On 05/07/25 at 9:01 A.M., an interview with the RN #500 confirmed Resident #34 just had her heel protectors put on her bilateral feet that were not previously in place, when an observation was made earlier that morning of the resident being up in her wheelchair without them. She was asked who applied the heel protectors on the resident's feet. She reported the facility's Administrator was just in there and had applied them to the resident's feet. She was informed the resident was observed on 05/05/25, 05/06/25, and again on 05/07/25, without heel protectors on either feet while the resident was up in her wheelchair. She claimed she had seen the resident with them on the day before, but that was while the resident was in bed. She acknowledged the use of heel protectors on the resident's feet while up in her chair was one of the interventions added to promote wound healing of her existing pressure ulcer to the left heel and to prevent any additional areas from developing. On 05/07/25 at 9:05 A.M., an interview with Resident #34 revealed she just had her heel protectors put on that morning. She denied that she had one on her left foot when she was up in her wheelchair the prior two days (05/05/25, 05/06/25) and did not have any on her feet while up in her chair earlier that morning, until the Administrator put them on her around 8:58 A.m. that morning. She reported her heel felt better when her heel boot was on compared to when she sat in the wheelchair without them. On 05/08/25 at 8:50 A.M., an interview with RN #500 revealed she was the facility's nurse that completed the weekly wound assessments for pressure ulcers. She stated she completed her assessments every Thursday. She denied the facility had a visiting wound physician or a nurse practitioner that came to the facility to assess wounds. If the resident would need to be seen by a wound doctor they sent them out to the local wound clinic. She confirmed the weekly wound assessments were not comprehensive, as not all areas on the assessments were being completed. She acknowledged there were missing assessments of the peri-wound area, presence of any pain, and additional care being provided to promote wound healing. She further acknowledged a couple of the assessments had the wound bed having epithelial tissue, which was not accurate as there would not have been the presence of any new skin if the wound had always been intact. She stated she did not complete the assessments that showed epithelial tissue being present in the wound bed and those assessments had been completed by another nurse in her absence. Review of the facility's procedure on Prevention of Pressure Injuries from Nursing Services Policy and Procedure Manual for Long-Term Care copyrighted in 2001 by Med_Pass Inc. revealed the purpose of the the procedure was to provide information regarding identification of pressure injury risk factors and interventions for specific risk factors. They were to review the resident's care plan and identify the risk factors as well as the interventions designed to reduce or eliminate those considered modifiable. Under mobility/ repositioning, they were to reposition all residents with or at risk of pressure ulcers on an individualized schedule, as determined by the interdisciplinary care team. They were to provide support devices and assistance as needed. Based on observation, record review, review of wound notes, facility policy review review and interview, the facility failed to assess, develop, and implement a comprehensive and individualized prevention program to prevent the development of avoidable pressure ulcers and ensure interventions were in place as ordered to prevent new or worsening pressure injuries for Resident #8 and #34. Actual Harm occurred on 04/17/25 when it was discovered that Resident #8, who was determined to be at risk for skin breakdown with no pressure ulcers upon admission, was assessed as cognitively impaired, incontinent, and required moderate (staff) assistance with bed mobility, developed an unstageable (dead or devitalized tissue that is hard or soft in texture; usually black, brown, or tan in color, and may appear scab-like. Necrotic tissue and eschar are usually firmly adherent to the base of the wound and often the sides/ edges of the wound.) pressure ulcer to her coccyx. Between 05/05/25 and 05/06/25 Resident #8's low air loss mattress was set to the wrong weight settings and on 05/07/25 staff failed to turn/reposition and/or offer turning and repositioning for three hours to Resident #8 to alleviate pressure to the coccyx area. This affected two residents (#8 and #34) of two residents reviewed for pressure ulcers. The facility census was 40. Findings include: 1. Record review revealed Resident #8 admitted to the facility on [DATE] with diagnoses including malignant neoplasm of cervix uteri, dementia, and hyperlipidemia. Review of an order dated 04/01/25 revealed Resident #8 was to receive incontinence care every two hours and as needed. Review of a nurse's note dated 04/02/25 revealed Resident #8 had edema to bilaterally lower extremities and no mention of any other skin issues. Review of physician progress note dated 04/03/25 revealed Resident #8 with skin dry and no mention of any (skin) breakdown. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #8 had moderately impaired cognition, had no behaviors, required moderate (staff) assistance for bed mobility and transfers, was frequently incontinent of bladder, occasionally incontinent of bowel, was at risk for pressure ulcers and had no pressure injuries noted. Review of dietary note dated 04/09/25 revealed Resident #8 was assessed with skin being intact per nursing evaluation upon admission. Review of nurse's note dated 04/14/25 revealed incontinence care given to Resident #8 and protective ointment applied to coccyx area. Review of a nursing note dated 04/17/25 at 12:47 P.M. revealed Resident #8 had a discolored area to her coccyx, the provider and family were aware. Review of orders revealed an order dated 04/17/25 for Resident #8 to have an alternating air mattress to her bed and to check it every shift for proper function every day and night shift for continued care. Review of a nursing note dated 04/17/25 at 4:51 P.M. revealed new orders were received for a discolored area on Resident #8's coccyx. Resident and family wished to discontinue all medications except for comfort care. The provider was made aware. Review of a Skin & Wound Evaluation dated 04/17/25 revealed Resident #8 had an unstageable pressure area due to slough and/or eschar to the sacrum which was in-house acquired on 04/17/25. The area of the wound was 0.9 centimeters (cm) squared with the length measuring 1.3 cm, the width 1.0 cm and the depth 0.1 cm. The wound bed was 100% eschar, no exudate or odor noted. The edges, surrounding tissue, induration, edema, peri wound temperature and wound pain were not assessed. The treatment was a generic wound cleanser and foam dressing. Review of a nursing note dated 04/21/25 at 5:18 A.M. revealed Resident #8 had a pressure area to her coccyx open with creamy, yellowish slough. It was cleansed with soap and water, triad paste applied then covered with Allevyn. The note documented Resident #8 refused to lay on her side and preferred to lay on her back. However, there was no evidence the facility attempted additional effective interventions to reduce pressure to the area. Review of a nursing note dated 04/22/25 at 12:52 P.M. revealed Resident #8 had a pressure area to coccyx open with white/yellow slough, wound care was provided per orders, and incontinence care/repositioning were completed every two hours. The note included Resident #8 was refusing to stay on her side. However, there was no evidence the facility attempted additional effective interventions to reduce pressure to the area. Review of a Skin & Wound Evaluation dated 04/24/25 revealed Resident #8 had an unstageable pressure area due to slough and/or eschar on her sacrum which was in-house acquired. The wound area was 1.6 cm squared, the length was 1.3 cm and the width was 1.5 cm. The depth was not able to be determined. The wound bed had slough, but did not specify what percentage. It was not assessed for evidence of infection or other concerns. There was no exudate. The surrounding tissue had erythema (redness of the skin- may be intense bright red to dark red or purple). The edges were not assessed. The wound was not assessed for induration or edema. The peri wound temperature was normal. The wound was not assessed for pain. The previous dressing was dry and intact. No information was provided regarding the application of a treatment and new dressing. The wound was classified as stable despite growth of wound area. Review of a nursing note dated 04/26/25 at 12:57 P.M. revealed Resident #8 continued to refuse to lay on her sides and would turn over on her back after repositioning. The dressing to coccyx was changed with no sloughing notes, the wound bed was pink and peri wound was pink and blanchable with no odor or pain present. Review of a Skin & Wound Evaluation dated 05/01/25 revealed Resident #8 had an unstageable pressure area due to slough and/or eschar to the sacrum. The wound was 2.2 cm squared. The length was 1.9 cm and the width was 1.5 cm. The depth was undetermined. The wound bed contained slough, but the percentage was not specified. It was not assessed for evidence of infection or other concerns. There was no exudate. The edges were not assessed. The surrounding tissue had erythema. The wound was not assessed for induration, edema, peri wound temperature or pain. The treatment which was removed was not assessed and there was no additional about a new treatment and dressing being applied after assessment. The wound was classified as stable despite growth of the wound area. Review of an order dated 05/02/25 revealed a treatment to Resident #8's coccyx including cleanse the discolored area on coccyx, apply triad paste and cover with Allevyn every shift. An additional order for 05/02/25 revealed Resident #8 needed turned and repositioned every two hours and as needed. Review of turn and repositioning documentation from 04/08/25 through 05/06/25 revealed staff were marking turning and repositioning as completed. Review of a dietary note dated 05/07/25 revealed Resident #8 weighed 70 pounds. Observation on 05/05/25 at 9:27 A.M. revealed Resident #8 was in bed with an alternating air mattress in place set to 320 pounds. Observation on 05/06/25 at 8:37 A.M. revealed Resident #8 was resting in her bed laying flat on her back. She had an alternating air mattress in place which was set to 320 pounds (firm). Observation and interview with Certified Nursing Assistant (CNA) #168 revealed Resident #8 was laying in her bed on her back and the alternating air mattress was set to 320 pounds. CNA #168 confirmed Resident #8 weight approximately 70 pounds. CNA #168 stated she does not know who would have adjusted the bed because she applied the mattress herself and had it set to the correct weight. Continuous observations were made of Resident #8 on 05/07/25 from 9:10 A.M. to 12:03 P.M. During that time, Resident #8 was laying on her back. No staff entered the room to completed turning and repositioning every two hours as ordered. Interview on 05/07/25 at 12:03 P.M. with Registered Nurse (RN) #158 confirmed Resident #8 was laying on her back and had not been repositioned. RN #158 stated Resident #8 did not like to be turned anyway. RN #158 then stated staff should still attempt to turn Resident #8. Observation of wound care for Resident #8 was made on 05/07/25 at 4:15 P.M. with RN #158. She assisted the CNA to position the resident onto her left side. Observation of the wound revealed top layer of skin missing, no bleeding, no drainage, no odor noted. The wound bed was clean, dark pink, surrounding tissue was intact pink blanchable. RN #158 applied Triad paste to the wound, covered with the Optifoam. CNA and nurse repositioned the resident. RN #158 wanted the resident to be on her side off of her back, resident kept saying no. RN #158 asked resident if they put a pillow under hip area, to keep pressure from bottom, and will set watch for 5 minutes and come back in and reposition her. Resident agreed and was placed on her right side. Interview on 05/08/25 at approximately 2:00 P.M. with Director of Nursing (DON) confirmed Resident #8's wound was in house acquired and her wound assessments were not completed in full as noted above.

Based on observation, record review, facility policy and procedure review and interview the facility failed to implement interventions to prevent the development of a pressure ulcer for Resident #10. Actual harm occurred on 10/07/21 when Resident #10, who was severely cognitively impaired was identified to have a Stage III (full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining or tunneling) pressure ulcer to the ball of his left foot. There was no evidence the facility had adequate interventions in place to prevent the development of the ulcer and to promote healing once the ulcer was identified. The facility failed to ensure the pressure ulcer was timely identified prior to being found as a Stage III and failed to ensure a treatment was initiated at the time the ulcer was first identified. This affected one resident (#10) of four residents reviewed for pressure ulcers. Findings include: Review of Resident #10's medical record revealed an admission date of 04/09/21 with diagnoses including shortness of breath, chronic obstructive pulmonary disease, hypertension, osteoarthritis, underweight, cachexia and dementia with behavioral disturbances. Review of the resident's physician's orders, revealed an order dated 04/09/21 for a pressure reduction mattress to bed, cushion to wheelchair, body audit weekly every Monday, encourage to turn and reposition every two hours and as needed, barrier cream to buttocks every shift and as needed for prevention and incontinence care every two hours and as needed. Review of the plan of care, dated 04/15/21 revealed the resident was at risk for pressure ulcer development or skin integrity complications. Interventions included skin prep to bilateral heels twice daily and as needed, encourage to turn every two hours, barrier cream to buttocks every shift as needed, foam cushion to my chair of choice, nurse to provide complete body audit weekly, shower twice weekly as needed and pressure reduction mattress to bed. Review of the resident's Braden Scale dated 07/13/21 revealed a score of 15 indicating a low risk for skin breakdown. Review of the resident's Minimum Data Set (MDS) 3.0 assessment, dated 07/17/21 revealed the resident had clear speech, understood others, made himself understood and had a severe cognitive deficit as indicated by a BIMS score of three. The assessment revealed the resident was independent with bed mobility, transfers and ambulation. The resident was identified as being at risk for skin breakdown and had no unhealed skin breakdown at that time. The MDS identified the facility implemented a pressure reducing device to bed/chair and applications of ointments/medications other than to feet. Review of the resident's skin profile document, dated 10/07/21 revealed the resident acquired a Stage III pressure ulcer to his left outer foot (the ball of the left foot) measuring 2.0 centimeters (cm) in length by 2.0 cm width with 0.1 cm depth and yellow slough to the wound bed. Comments included: Weekly wound assessment complete. No odor present at this time. Denies any pain to area. Tolerated assessment and dressing change well. On 10/07/21 an order for a nutritional supplement, Juven twice daily for wound healing was obtained. Review of the plan of care, dated 10/12/21 revealed the resident had an actual Stage III pressure area on his left foot related to history of ulcers (the resident had been admitted with a pressure ulcer to the buttocks that had healed after admission). Interventions included assess wound, record/monitor status weekly and don't put shoes on left foot. On 10/12/21 at 2:28 P.M. observation of the resident revealed he was positioned on his left side with the Stage III pressure ulcer directly on the bed. The resident was very thin in appearance and there was no evidence of any type of pressure reduction to the resident's feet. On 10/13/21 (six days after the pressure ulcer was first identified) an order was obtained to cleanse wound to left foot with wound cleanser, pat dry, apply Medihoney and cover with an Allevyn. Review of the resident's October 2021 Treatment Administration Record (TAR) revealed no treatment was documented to have been completed until 10/13/21. Review of the resident's progress noted failed to provide evidence a treatment was administered for the pressure ulcer from 10/07/21 until 10/13/21. On 10/13/21 at 9:23 A.M. observation of the resident revealed he was positioned on his back with his left foot resting directly on the foot board of the bed. There was no evidence of any type of pressure reduction to the resident's feet. Although, the MDS from July 2021 identified the resident was independent with bed mobility and ambulation, the resident was not observed during any observations on 10/12/21 or 10/13/21 to be out of bed and was not observed to be able to reposition himself in bed. At multiple times the ball of the resident's left foot was observed either directly pressing against the foot board of the bed or resting on his right foot. The resident was tall and appeared to be too long for the bed with the foot board which created additional pressure to the ball of the left foot when it pressed again the foot board and resulted in the pressure ulcer development. On 10/13/21 at 2:25 P.M. observation of Licensed Practical Nurse (LPN) #128 provide the physician ordered treatment to the Stage III pressure ulcer to the ball of the left foot revealed the resident was positioned on his left side with the ball of his left foot resting on his right foot. The LPN entered the room in personal protective equipment (PPE) and set-up the required supplies on a barrier on the resident's bedside table. The LPN had to assist the resident to position on his back at which time the resident's foot rested against the foot board of the bed. The LPN then exited the room to obtain wound cleanser. The LPN entered the room with PPE, washed her hands and applied gloves. She cleansed the wound with wound cleanser and four by four dressing. The LPN then placed Medihoney on the wound and covered the pressure ulcer with an Allevyn patch. She placed a pillow over the resident's right leg but the left foot continued to touch the resident's right foot. The LPN verified the current pressure ulcer interventions were ineffective and the Stage III pressure ulcer continued to have direct pressure to it. On 10/13/21 at 4:12 P.M. interview with the Director of Nursing (DON) revealed she believed a pressure ulcer treatment had been ordered on 10/07/21 at the time the ulcer was discovered but the order was not put in the resident's electronic medical record. The DON verified the resident's medical record contained no evidence of a treatment until 10/13/21. Review of the facility policy titled, Prevention of Pressure Ulcers, dated 04/2020 revealed the purpose of the procedure was to provide information regarding identification of pressure injury risk factions and interventions for specific factors. Inspect the skin on a daily basis when performing or assisting with personal care or activities of daily living and reposition resident as indicated on the care plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of the medical record for Resident #5 revealed an admission date of 07/06/20 with diagnoses including metabolic encephalopathy, unspecified dementia without behavioral disturbance and depression. Review of the admission nursing assessment, dated 07/07/20 for Resident #5 revealed no impairment with range of motion to the left upper extremity including the shoulder, elbow, wrist and hand. Review of the Occupational Therapy (OT) notes and OT plan of care revealed Resident #5 received OT services from 07/07/20 through 08/04/20 to increase bilateral upper extremity strength to facilitate participation in activities of daily living. The assessment, dated 07/07/20 revealed the resident had range of motion within functional limits to left hand with no diagnosis of left hand contracture. Review of the OT services provided 01/11/21 through 02/08/21 revealed the resident was seen to increase bilateral upper extremity strength to facilitate participation in activities of daily living/self care tasks and to increase metacarpophalangeal joint of the hand extension to increase functional abilities. The assessment, dated 01/11/21 revealed the resident had range of motion within functional limits to the left hand and no diagnosis of left hand contracture. Review of the OT services provided 05/26/21 through 07/22/21 revealed the resident was seen to increase active range of motion to left middle finger and left ring finger to improve dexterity skills and improve function grasp/release skills. The OT notes revealed the resident would safely wear a hand roll on the left fingers and hand for up to four hours daily. A diagnosis of contracture to the left hand was first noted on 05/26/21. The assessment dated [DATE] revealed the resident had impaired range of motion to left hand. Review of the annual MDS 3.0 assessment, dated 07/14/21 revealed Resident #5 was cognitively impaired and was totally dependent on staff for personal hygiene needs and bathing. The resident was receiving occupational therapy services three to five times per week and was not identified to have limited range of motion to bilateral upper extremities including shoulder, elbow, wrist or hand. Review of a Restorative Nursing Communication form for Resident #5 dated 07/22/21 recommended left upper extremity hand roll, four hours on, four hours off as tolerated. Review of the 10/2021 physician orders for Resident #5 revealed there were no orders for restorative nursing care or a device to the left hand to prevent decreased range of motion or contracture. Observations on 10/12/21 and 10/13/21 at various times including on 10/12/21 at 11:05 A.M. and 2:03 P.M. and on 10/13/21 at 8:01 A.M. and 11:15 A.M. revealed the resident's left hand was contracted with very limited range of motion. The resident was not observed with a hand splint, hand roll or device in place to prevent further decline during any of the observations made. On 10/12/21 at 12:48 P.M. interview with the Assistant Director of Nursing (ADON) revealed the communication form from therapy for restorative nursing care would be given to the ADON, who would write the order and inform the restorative STNA of the orders. The ADON confirmed there was no order in Resident #5's medical record for restorative nursing care or splint to left hand. An interview on 10/13/21 at 8:07 A.M. with Licensed Practical Nurse (LPN) # 102 confirmed Resident #5's left hand was contracted and the resident did not have a splint, hand roll or device in place to prevent further decline. An interview on 10/13/21 at 8:18 A.M. with Occupational Therapist (OT) #164 revealed the resident was discharged from therapy approximately two months ago and was placed on a restorative program for a hand roll to be in place every four hours as tolerated. OT #164 confirmed the resident did not have a contracture of the left hand upon admission to the facility but had subsequently developed the contracture. On 10/13/21 at 10:35 A.M. interview with STNA #145 revealed Resident #5 was to receive restorative care daily including range of motion to hands and apply a left hand splint/brace. However, the STNA could not find a hand roll or splint in the resident's room at that time. A review of the facility's policy on Restorative Nursing Services, revised July 2017 revealed residents would receive restorative nursing care as needed to help promote optimal safety and independence. Restorative nursing care consisted of nursing interventions that may or may not be accompanied by formalized rehabilitation services (e.g., physical, occupational or speech therapies). Residents may be started on a restorative nursing program upon admission, during the course of stay or when discharged from rehabilitative care. Restorative goals and objectives were individualized and resident-centered, and were outlined in the resident's plan of care. Restorative goals may include supporting and assisting the resident in developing, maintaining, or strengthening his/ her physiological and psychological resources. Based on observation, record review, facility policy and procedure review and interview the facility failed to provide adequate and necessary care and services to prevent the development of hand contractures for two residents (#5 and #25). Actual harm occurred when Resident #25 who was severely cognitively impaired was not provided range of motion services or the application of splint/ orthotic devices resulting in the development of bilateral hand contractures. Actual Harm also occurred for Resident #5 when the facility failed to provide range of motion and/or hand roll/splinting care for the resident's left hand to prevent a decline in range of motion and development of a contracture to the hand. This affected two residents (#5 and #25) of three residents reviewed for positioning/ mobility. Findings include: 1. A review of Resident #25's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including Parkinson's disease, muscle wasting and atrophy, polyosteoarthritis and dementia with behavioral disturbances. The resident's diagnoses list was updated to reflect a diagnosis of a contracture of the right hand, which was added on 06/23/21. A review of Resident #25's nursing admission assessment completed on 06/24/20 revealed no indication of any contracture or limitations to range of motion at the time of her admission. A review of Resident #25's Occupational Therapy (OT) Recertification/ Progress Report/ Updated Therapy Plan for a certification period of 02/08/21 to 03/08/21 revealed the resident's diagnoses included muscle wasting and atrophy, Parkinson's disease, abnormal posture, stiffness of an unspecified joint, muscle weakness and abnormalities of gait and mobility. Contractures were not included in the resident's diagnoses at that time. The goals for the resident's treatment were to increase her bilateral upper extremity (BUE) strength and to improve her activities of daily living (ADL) self care ability and her ability to perform self dressing of her upper and lower extremities. The assessment did not include anything about limitations in range of motion (ROM) or the resident having any known contractures. A review of Resident #25's OT Discharge Summary, for date of service of 01/12/21 to 03/19/21 revealed the resident's discharge recommendations included a restorative ROM program. The ROM program established/ training included bilateral upper extremity (BUE) ROM in all planes three times a week as tolerated. A review of Resident #25's OT Recertification/ Progress Report/ Updated Therapy Plan for a certification period of 03/15/21 to 04/13/21 revealed the resident was having issues with her ring finger (fourth digit) of her right hand. Listed diagnoses did not include contractures as one of the resident's diagnoses for treatment. The resident was assessed to be experiencing deficits in ROM and strength. The short term goal was for the resident to increase her right ring finger metacarpophalangeal (MCP)/ proximal interphalangeal (PIP) joint extension to -15 degrees to increase her grasp for self feeding. A review of Resident #25's physician's progress note, dated 06/24/21 revealed the resident was noted to have bilateral hand contractures. The physician's plan for the bilateral hand contractures was for her to have occupational therapy. A review of Resident #25's OT Recertification/ Progress Report/ Updated Therapy Plan for a certification period of 06/23/21 to 07/21/21 revealed the resident's diagnoses added contractures of the right and left hand that were not previously identified. The onset date of the contractures were noted to be 06/23/21. The reason for the OT referral was for BUE digit contractures increasing the resident's risk for skin breakdown. Her right upper extremity (RUE) and left upper extremity (LUE) ROM was noted to be impaired. An assessment of the RUE and LUE ROM revealed the resident's wrists, hands, middle finger, ring finger and little fingers were impaired. Recommendations were made for the resident to use hand rolls to decrease her risk for skin breakdown and to assist with extension of her digits (fingers). A review of Resident #25's OT Discharge Summary for date of service of 06/23/21 to 08/19/21 revealed discharge recommendations included the use of hand rolls to the resident's BUE and a hand roll schedule to decrease the resident's risk for skin breakdown. Restorative programs recommended by OT were a restorative splint and brace program. The resident was to wear hand rolls in her BUE four hours on and four hours off to decrease the risk for skin breakdown. A review of a Therapy to Restorative Nursing Communication form, dated 08/20/21 revealed the resident had been discharged from physical therapy (PT) and OT. OT recommendations included BUE hand stretching/ passive range of motion (PROM) in all planes daily as tolerated. Adaptive equipment/ orthotic devices issued with schedule included BUE hand rolls four hours on/ four hours off daily as tolerated. A review of Resident #25's most recent quarterly Minimum Data Set (MDS) assessment, dated 07/09/21 revealed the resident did not have any communication issues but her cognition was severely impaired. She was not known to display any behaviors during the assessment reference period (seven days) but was known to reject care one to three days during the seven day assessment period. The resident was totally dependent on two for transfers and an extensive assist of two staff for dressing. Ambulation did not occur. The resident had functional limitations in range of motion on both sides of her upper and lower extremities. Contracture of the right hand was listed as an active diagnosis and OT and PT minutes were indicated to have been provided. A review of Resident #25's active care plans revealed she did not have a care plan in place to address her contractures. There was no indication in the care plans the resident was to receive any type of restorative nursing program for ROM/ hand stretching or the use of BUE hand rolls/ splints to help prevent contractures. A review of Resident #25's [NAME], used by the State tested Nursing Assistants (STNAs) to identify a resident's care needs, revealed there was no indication the resident was to receive any type of ROM programming. The [NAME] also failed to include the use of hand rolls that had been recommended by OT, to be on for four hours and off for four hours (per schedule). A review of Resident #25's active physician's orders revealed there were no orders in place for the resident to receive any ROM services or hand rolls/ orthotic devices to help manage her contractures. Resident #25's electronic health record was absent for any evidence of her receiving any type of restorative nursing services as part of a program to provide her with PROM exercises. It also did not include evidence of hand rolls being used on the on for four hours/ off for four hours schedule recommended by OT. On 10/12/21 and 10/13/21 ongoing observations at various times each day, including specific observations on 10/12/21 at 10:38 A.M. and 10/13/21 at 9:37 A.M., 10:55 A.M. and 1:42 P.M. revealed no evidence of Resident #25 having any hand rolls in place to her bilateral hands. Contractures were noted to her bilateral hands. It was not until 10/14/21, when the facility was asked to provide information on the resident's development of her contractures, that she was observed to have hand rolls put in place. An observation on 10/14/21 at 8:45 A.M., was the first observation in the previous three days of the resident having hand rolls in place. The hand rolls had Velcro straps wrapped around the resident's posterior hands to hold them in place. On 10/14/21 at 8:59 A.M. interview with STNA #145 revealed Resident #25 required extensive assistance/total dependence from staff for personal care. The STNA initially reported the resident had full ROM to her arms and legs and then reported the resident's legs had limited ROM. The STNA was then asked about the resident's hands and indicated staff were putting hand rolls in them. The STNA revealed they had black hand rolls to use that were given to them by therapy. The STNA reported staff (the STNAs) knew what the care needs of each resident were based on the [NAME] they had for reference. The STNA was not aware the resident's [NAME] did not include the need for ROM to be provided or the use of hand rolls for the resident. She stated she knew the resident needed those things but could not speak to whether or not the other staff would know as well. She reported she had been off work the past couple of days and last worked with the resident this past Saturday. On 10/14/21 at 9:10 A.M. interview with the Director of Nursing (DON) revealed the facility did have a restorative nursing program but not all programs were being implemented by a restorative aide. She stated if the need arose, the facility might pull the restorative aide to work the floor due to a call-off. The DON revealed things like ROM would still be provided during a resident's bath or during other personal care. She reported, if ROM was provided as part of a restorative program, it should be documented in the electronic health record under the task tab so the minutes provided could be recorded. She denied ROM or the use of hand rolls would be in the physician's orders as she stated that was a nursing measure. The DON acknowledged Resident #25's plan of care did not address her contractures as there was not a care plan in place for it and the [NAME] that was used by the STNAs to direct the resident's care did not include the need to provide range of motion or use of hand rolls to prevent worsening of her existing contractures. The DON was not able to explain why that information was not included on the [NAME] or why a care plan had not been developed. The DON revealed this must have been missed. She acknowledged without it being included on the [NAME] and no documented evidence range of motion and hand rolls were being used, it was hard to show staff were providing the care and services to prevent the resident's contractures from developing. She agreed contractures were considered avoidable, if those types of interventions weren't being implemented on a routine basis.