**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the medical record, review of the facility investigation, and interviews with staff, the facility failed to ensure Resident #41 was free from accident hazards. Actual harm occurred on 10/16/23 when Resident #41, who was cognitively impaired, at risk for falls, and dependent on two staff for bed mobility, fell out of bed while State Tested Nursing Assistant (STNA) #112 was providing incontinence care by himself. Resident #41 sustained a fracture to the right hip and hematoma to the back of her head. Resident #41 was transferred to the hospital and received surgical intervention to her right hip. This affected one resident (Resident #41) of three residents reviewed for accident hazards. The facility census was 57. Findings include: Review of the medical record revealed Resident #41 was admitted to the facility on [DATE]. Resident #41's list of diagnoses included diabetes, diabetic polyneuropathy, protein-calorie malnutrition, intertrochanteric fracture of the right femur, atrial fibrillation, dysphagia, contusion to the scalp, psychotic disorders, major depressive disorder, mood disorder, anxiety disorder, malignant neoplasm of the skin, osteoarthritis, hypothyroidism, kidney disease, and glaucoma. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #41 had severely impaired cognition and had delusions. She had physical symptoms such as hitting or scratching herself and screaming daily. She required total assistance from two staff members for bed mobility and transfers. Review of the plan of care dated 03/17/23 revealed Resident #41 was at risk for falls and fall related injuries related to dementia with behaviors, visual impairment, psychosis, osteoarthritis, anxiety, mood disorders, depression, abnormalities of gait and mobility, lack of coordination, muscle weakness, decreased sensation, physical debility, impaired cognition, incontinence, medication use, and poor safety awareness. Interventions included assist resident with wheelchair or walker for mobility as needed, assist with wearing proper footwear, assist with toileting needs and incontinence care, keep call light within reach, and non-skid gripper socks when not wearing shoes. On 10/07/23 the plan of care was revised to include mat to the floor and revised again on 10/16/23 to include two persons to assist for bed mobility and transfers. Review of the physician orders revealed Resident #41 had an order for bilateral grab bars dated 10/24/22, padding added to the bilateral grab bars for altered skin integrity dated 07/28/23, and her bed to be in the lowest position when not providing direct care dated 10/07/23. Further review of Resident #41's medical record revealed the State Tested Nursing Assistant (STNA) task documentation for October 2023 indicated the staff were using total or extensive assistance of two staff members for all bed mobility for Resident #41. Review of an incident note dated 10/16/23 at 1:00 A.M. revealed the nursing assistant (STNA #112) was assisting Resident #41 during care when the resident became combative and rolled out of bed. Resident #41 was assessed and noted to have a golf ball size fluid filled hematoma to back of her head. Resident #41 was complaining of right hip pain, her pupils were equal and reactive to light. Two-person assistance with bed mobility and transfer was listed as a potential new intervention. Resident #41 was sent to the emergency room for evaluation. Review of the hospital emergency room radiology report dated 10/16/23 at 3:33 A.M. revealed Resident #41 had an acute, displaced intertrochanteric right femur fracture and a right scalp hematoma with no fracture. Review of health status reports dated 10/16/23 at 8:10 A.M. and 10/16/23 at 11:11 A.M. revealed Resident #41 returned to the facility with no surgical intervention. Resident #41's physician was on the unit, the son was at the bedside and the son wanted Resident #41 to be sent to another hospital for another evaluation of the fracture and the physician agreed. Review of the second hospital emergency room report dated 10/16/23 revealed Resident #41 had been seen at another hospital the same day, diagnosed with right hip fracture, was sent back to the facility then the family requested she be sent back to another hospital. Resident #41 was in no distress, appeared comfortable, was alert to person and had an internally rotated right hip with mild angulation but not displaced and no skull fractures or brain bleed. Resident #41 would be cleared for surgery for the hip fracture. Review of a psychosocial note dated 10/17/23 at 11:00 A.M. revealed Resident #41 was still at the hospital and would be having surgery for her fractured hip. Review of the progress note dated 10/22/23 revealed Resident #41 returned to the facility with post-surgical aftercare orders following hip repair surgery. Review of the facility's fall investigation dated 10/16/23 revealed Resident #41 fell out of bed during care being provided by STNA #112. Review of the signed witness statement from STNA #112 dated 10/16/23 at 1:00 AM revealed he was assisting the resident with her disposable brief change and the resident reached out, scratched him, he lost his grip and she fell out of bed. Review of a second signed witness statement from STNA #112 dated 10/27/23 revealed he noticed Resident #41 had a bowel movement, so he gathered all the stuff he needed, raised the bed, lowered her head and feet in bed and removed the wedge and pillow from under her legs. STNA #112 then tucked the adult brief the resident was wearing to one side so he could pull the brief when he turned Resident #41. After telling the resident what he was about to do and turning her, he was getting ready to pull the old brief out when Resident #41 pinched and scratched the hand and arm he was using to steady her. STNA #112 reacted by letting go of her and that was when she fell out of the bed. Review of the signed witness statement from LPN #114 dated 10/16/23 revealed the nursing assistant came running down the hall stating the resident fell on the floor. LPN #114 followed him back to the room and a head-to-toe assessment was completed. Vital signs were normal, and the resident was found to have an area to the back of her head and a red area to the right hip. LPN #114 initiated neurological checks while another nurse arranged transportation to the emergency room at the hospital. Review of the signed witness statement from Licensed Practical Nurse (LPN) #113 dated 10/16/23 revealed LPN #113 assessed the resident with the other nurse, the resident was having pain with palpation to the right hip, and she had redness noted to the area. She had a hematoma to the back of her head. Her range of motion (ROM) to the right hip was abnormal and she complained of pain with ROM. On 11/21/23 at 2:24 P.M. an interview with the Director of Nursing (DON) verified STNA #112 was the aide working when Resident #41 had fallen out of bed. The DON stated STNA #112 was providing care to Resident #41, and she fell out of bed. The DON verified Resident #41 was a two person assist with turning and repositioning. On 11/21/23 at 2:40 P.M. an interview with STNA #109 revealed he had provided care to Resident #41 prior to her fall on 10/16/23 and Resident #41 required two staff members to provide care. On 11/21/23 at 2:45 P.M. an interview with STNA #110 revealed she provided care to Resident #41 prior to her fall on 10/16/23 and Resident #41 required two staff members to provide care. On 11/21/23 at 2:47 P.M. an interview with STNA #111 revealed Resident #41 required two staff members to provide incontinence care prior to her fall because she usually became combative and resisted care. STNA #111 stated she was very hard to roll with only one staff person so two staff were required, and the resident was a two person assist for transfers. On 11/21/23 at 2:53 P.M. an interview with LPN #103 revealed the nursing assistants usually used two STNAs when providing care to Resident #41 because she was difficult to turn and could become combative. On 11/21/23 at 4:00 P.M. an interview with STNA #112 verified on 10/16/23 he provided incontinence care to Resident #41 by himself, and Resident #41 rolled out of bed onto the floor. STNA #112 stated he did have another aide working with him, but she was in the other room. STNA #112 stated he was rolling Resident #41 to change her brief and she did not like to be rolled in the bed so would become combative and grab at staff. STNA #112 stated when he rolled her towards the window to pull the brief out from under her, she reached around, grabbed at his arm and hand, and scratched him. STNA #112 stated he let go of her as a reaction to being scratched and she fell out of the bed onto the floor between the bed and the wall and from a waist high position of the bed. He stated this was the first time he had ever had anyone fall out of bed and he ran out to get the nurse. On 11/22/23 at 10:15 A.M. an interview with STNA #106 revealed the STNAs have always used two staff to turn and position, provide incontinence care, and transfer Resident #41 because she was a heavy woman and had very limited mobility. STNA #106 added Resident #41 could become combative very easily with care. Review of the facility policy titled, Falls and Fall Risk Managing, date revised 05/06/2020, indicated staff would identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. This deficiency represents non-compliance investigated under Complaint Number OH00147981.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to ensure therapy recommendations were implemented upon discontinuation of therapy services. Actual harm occurred when Resident #1 had worsening contractures and decline in range of motion when restorative/maintenance programs for application of hand splints, passive range of motion (PROM) exercises and a timed out of bed schedule was not provided as recommended impacting the resident's mobility and skin integrity. This affected two residents (Resident #1 and #40) of three residents reviewed for range of motion. The census was 59. Findings include: 1. Review of Resident #1's medical record revealed an admission date of 06/03/22 with diagnoses including anoxic brain damage, nontraumatic intracerebral hemorrhage, neuromuscular dysfunction of bladder, presence of cerebrospinal fluid drainage device, need for assistance with personal care, contracture left elbow, right hand, left hand, muscle wasting and atrophy. Review of the admission five-day Minimum Data Set Assessment (MDS) dated [DATE] included the resident was never understood, required extensive two-person physical assist with bed mobility, and dressing; total dependence and two-person physical assist with transfer, eating, and toileting. Review of an impaired range of motion as evidenced by contractures of bilateral hands, left elbow and paraplegia plan of care dated 06/11/22 revealed interventions including to apply any assistive devices needed for contracture management. Review of Resident #1's therapy evaluations revealed she was initially admitted [DATE] and evaluated by occupational therapy on 06/06/22. The resident was totally dependent (on staff) for all activities of daily living. She was unable to follow commands, or track with visual movements. She did open her eyes and fixate (her) gaze on the therapist. She was admitted with resting hand splints (a splint used to maintain hand(s) in functional positioning by supporting the hand and wrist joint during periods of inactivity). The resident was evaluated by physical therapy on 06/07/22. Initial evaluation included the resident was totally dependent for sitting, with no right or left upper or lower extremity strength. The resident was readmitted to the hospital and returned to the facility 06/18/22. The Occupational therapy evaluation (upon re-admission) was unchanged and included she was admitted with two resting hand splints however they would need to be trialed and slightly modified due to bilateral upper extremity contractures and wear tolerance of two hours. The resident had a left elbow contraction with 55-140 degrees of motion on the left and 40-150 degrees on the right elbow (normal ROM of the elbow is 180 degrees). The resident was approved for a specified number of therapy visits, three of which were used for Occupational Therapy, and discharged from therapy on 06/24/22 until she could be re-evaluated under Medicaid part B. She was discharged with hand splints up to two hours a day and weighted stuffed animals to her arms since the left arm brace did not arrive. The resident resumed services on 07/20/22 under Medicaid part B and provided services until 10/10/22. She was thin and the elbow brace was too large for her. The therapists were looking for a pediatric elbow brace and utilized weighted stuffed animals in her arms to extend her elbows. Upon discharge from therapy, restorative/maintenance programs included out of bed up to four hours a day, passive range of motion (PROM) bilateral upper extremities two sets of 10 and bilateral resting hand splints four hours on and four hours off after PROM with skin checks. The resident was also to hold a large stuffed animal to left elbow to prevent contracture. Education was provided to the Director of Nursing, Assistant Director of Nursing and restorative/ MDS nurse on donning resting hand splints every four hours and not using washcloths because they do not prevent worsening of contractures. PROM education prior to donning splints was provided. Review of the medical record revealed no evidence a restorative or maintenance program was written for the nursing staff to provide. There were no instructions for the STNAs to follow, there was no physician order or treatment orders written and there was no restorative plan of care. On 03/06/23 a therapy screening was completed for Resident #1 and therapy services for contractures, positioning for promotion of skin integrity, as well as increased out of bed participation was planned. The resident was re-evaluated on 03/08/23 by occupational therapy secondary to having an increase of contractures and poor out of bed tolerance. The resident presented with decreased joint mobility in bilateral upper extremities impacting her positioning and skin integrity. The resident was re-evaluated 03/15/23 by physical therapy due to decreased range of motion in her lower extremities and had a decrease in her prior level of function with PROM of left hip abductor declining from 30 degrees of motion to 15 degrees, left hip flexion declining from 100 degrees of motion to 70 degrees, and PROM to knee extension declining from zero extension to minus 15 degrees. The goal was to improve trunk and lower extremity range of motion to improve positioning in bed and up in chair. The resident had no existing lower extremity contracture. The left lower extremity was tight in all muscle groups. The resident presented with decreasing range of motion in bilateral lower extremities and trunk due to neurological insult of traumatic brain injury and being bedfast. The Quarterly MDS dated [DATE] revealed the resident required total dependence, two-person assist for bed mobility, transfer, and personal hygiene. The resident was total dependence, one-person assist for dressing and eating. The resident had functional range of motion (ROM) impairment on both sides of upper and lower extremities. Review of the 06/01/23 occupational therapy discharge note included a referral for a restorative nursing program and functional maintenance program to be completed to maintain progess. Review of the STNA TASK section and care plans dated 06/02/23 included a Restorative Range of Motion Program: Needs Passive Range of Motion: Gentle stretching to bilateral upper and lower extremities, three sets of five, two times a day for at least 15 minutes. Ensure completing upper extremity stretching before and after palm guard application. A 06/02/23 Restorative: splint application and removal program-complete passive range motion gentle stretching prior to applying and after removing palm guards. Guards to be encouraged to be in place six to eight hours daily, six to seven days a week, at least 15 minutes of staff restorative direct care per day. Observation on 06/12/23 at 9:28 A.M. revealed Resident #1 sitting in tilt-in-space wheelchair, in the common area beside the nursing station. There were no splints, braces, or rolled washcloths applied to either hand. An observation was completed at 11:18 A.M. and remained unchanged. Observation on 06/12/23 at 11:26 A.M. revealed Resident #1 was removed from the common area to receive care. No washcloths, splints, palm guards, or braces were in her hands. Observation on 06/12/23 at 11:52 A.M. revealed Resident #1 was she was in the hall with a stuffed animal in each arm. No washcloths, splints, palm guards or braces were observed to the resident's hands. Interview 06/12/23 at 2:58 P.M. with Certified Occupational Therapy Assistant (COTA) #140 revealed when Resident #1 was screened on 03/08/23 therapy became aware staff were not utilizing the resting hand splints and were not getting Resident #1 up in the custom chair. Some staff said they were providing restorative recommendations from the 10/10/22 discharge from therapy and other staff stated they were not providing the recommendations. Therapy stated facility staff had been educated on out of bed transfers and splint placement in October when therapy was discontinued. The restorative program would have been given to the MDS nurse when the resident was discharged from therapy for follow-up and/or implementation. When the resident was discharged from therapy, she was wearing the resting hand splints. The resident's hands were now rigid. Therapy located her resting hand splints and she was not able to wear them at that time, due to the worsening of her hand contractures. The resting hand splints did not move enough and she could not use them. The COTA stated panacea palm guards were trialed and they were misplaced. She had skin sloughing with them and could not tolerate them (palm guards) and therapy noted the panacea palm guards were heavy. On 05/23/23 COTA #140 emailed supply to order sheep skin palm guards and they have not yet arrived. She included they are currently using washcloth roll ups on Resident #1's hands until the ordered palm guards arrive. The therapy department was never able to restore motion back to her hands to resume use of the resting hand splints. Observation on 06/12/23 at 3:09 P.M. revealed Resident #1 lying in bed on her back. There were no splints, braces, palm guard or rolled washcloths applied to either hand. Interview 06/12/23 at 5:24 P.M. with State Tested Nurse Aide (STNA) #122 revealed she had never been trained on splints. She had never been trained to put washcloths in Resident #1's hands. She had never been told to do it. She has rarely seen washcloths in Resident #1's hands. She verified she did not see washcloths in the resident hands today. She is usually only able to put one finger in her fist to make room to clean her hands. She cannot manually straighten her fingers or elbows. Interview 06/12/23 at 5:31 P.M. with STNA #152 revealed she had not been trained in putting on splints on Resident #1's hands. She has never put them on. She said therapy would put them on. She is not able to straighten the residents fingers out all the way. We put a washcloth in her hand when we shower her and check her nails. The nurse cuts them every other weekend at least; to keep her fingernails from cutting into her palm. She has not been told to put washcloths rolls in her hands during the day but has seen them in there before. She assumed therapy was putting them in. She is not able to straighten the resident's elbows. She always has the weighted stuffed animals in her arms. She is not able to straighten the resident's knees. Observation on 06/12/23 at 6:04 P.M. revealed Resident #1 was in bed with stuff animals in her arms. Her fingers/hands were clenched into fists. There were no splints, braces, or rolled washcloths applied to either hand. Interview and observation 06/12/23 at 6:04 P.M. with STNA #117 revealed she attempted to provide range of motion to Resident #1's fingers and was unable to move them on either hand. STNA #117 was able to get the resident's right wrist to straighten but not the left. Both knees were contracted with the left knee worse than the right knee. The STNA was unable to straighten either knee fully. STNA #117 verified the resident did not have a washcloth, splints or palm guards on her hands. Interview 06/12/23 at 7:28 P.M. with the Administrator and the Director of Nursing revealed the Director of Nursing just started the end of March so she would not of been the one taught about the restorative program for Resident #1 in October. The Administrator verified they did not have a restorative program in October of 2022. They had a maintenance program the aides were to do. The Administrator and Director of Nursing verified they could not find where the October programs were written for Resident #1. A paper referral would have been written for nursing. They verified the staff would not know to do it when the programs were not written in the TASK or treatments. They included a nurse was trained for restorative 03/16/23 and they started a restorative program 03/29/23. A new unit manager had been hired with restorative experience, but he had not started yet. 2. Review of Resident #40's medical record revealed a 04/23/21 admission with diagnosis including wedge compression fracture of first lumbar vertebra, Vitamin D deficiency, dementia with behavioral disturbance and mood disturbance, spinal stenosis, and Alzheimer. Review of the 03/02/23 Quarterly MDS revealed the resident was severely impaired for daily decision making with delusions, but no rejection of care or other behaviors. The resident was extensive, two-person assistance for bed mobility, transfer, and toileting. Extensive, one-person assistance for dressing, and walking in room. The resident was supervision, one-person assistance for eating. She had no impairment of the upper or lower extremities. Mobility devices included a walker and wheelchair. She was always incontinent of urine and frequently incontinent of bowel with no venous or pressure ulcers. Review of therapy records revealed the resident was in occupational therapy from 01/02/23 to 03/02/23 working on sitting with functional endurance, bilateral upper extremity strength, good positioning in bed for feeding, improving wheelchair posture and the ability to complete toileting with contact guard assist. Review of the Occupational therapy discharge revealed a 03/02/23 discharge date . The discharge read a referral was completed to the restorative nursing/functional mobility program. There was no evidence of what the program was related to and no evidence the program was written by the nursing department. There were no instructions in Task for the State Tested Nurse Aides to follow, there was no physician order or treatment orders written. There was no restorative plan of care for March of 2023. Interview 06/12/23 at 7:21 P.M. with COTA #140 revealed the resident was picked up for therapy based on a screening. A handwritten referral sheet would have been given to nursing outlining what the restorative program was to include/address. COTA #140 included the resident was picked up by physical therapy on 03/17/23. Interview on 06/12/23 at 7:28 P.M. with the Administrator and the Director of Nursing revealed they did not have any evidence of the resident receiving a restorative/maintenance program after her 03/02/23 discharge from occupational therapy. The facility did not provide a restorative program policy. This deficiency represents noncompliance investigated under Master Complaint Number OH00143484 and Complaint Number OH00138029.