Based on observation, record review, and staff interview the facility failed to implement a care plan related to contracture devices. This failed practice was found true for (1) one of (4) four residents reviewed for Range of Motion (ROM) during the Long Term Care Survey Process. Resident identifier: #1. Facility Census: 59. Findings include: a) Resident #1 During the initial observservation on 09/03/24 at 1:30PM showed that Resident #1 had multiple contractures. A record review on 09/03/24 at 2:00 PM of Resident #1 diagnoses reads as follows: Contracture, right knee Contracture, left knee Contracture, left hip Contracture , left ankle Contracture, right ankle Further Record review revealed a Care plan that reads as follows: Focus Area: (Resident #1) has limited physical mobility r/t: weakness and remote history of right kneeinjury that did not heal properly with severe arthritis that resulted in contracture. She also has a left knee contracture, left hip contracture, bilateral ankle contractures and contractures of toes bilaterally. She usually keeps her hands tightly clenched. She is at risk for additional contractures. Goal: Resident will receive the needed assistance with mobility and ADLs through the review date. Intervention: Therapy carrots to bilateral hands at all times to prevent hand contractures. May remove for bathing, skin checks and skin care and then reapply. Notify the physician with any concerns. A review of Resident #1's orders read as follows: Carrot to Bilateral hands at all times every shift to prevent contractures Remove Q-shift for skin checks; Notify physician with any concerns. Tube-sleeves to bilateral arms at all times. (every shift) During an observation, on 09/03/24 at 2:15PM, revealed Resident #1 lying in bed. Resident #1 did not have a carrot to hands nor her bilateral arm tubes. During an observation, on 09/04/24 at 9:15 AM, revealed Resident #1 lying in bed. Resident #1 did not have a carrot to hands nor her bilateral arm tubes. During an interview, on 09/04/24 at 10:33 AM, the Director of Nursing confirmed that the carrot or the are tubes were not in place.

Based on observation, record review and staff interview the facility failed to follow physician's orders related to contracture devices. This failed practice was found true for (1) one of (4) four residents reviewed for Range of Motion (ROM) during the Long Term Care Survey Process. Resident identifier #1. Facility census 59. Finding Include: a) Resident #1 During the initial observservation on 09/03/24 at 1:30PM showed that Resident #1 had multiple contractures. A record review on 09/03/24 at 2:00 PM of Resident #1 diagnosis reads as follows: Contracture, right knee Contracture, left knee Contracture, left hip Contracture , left ankle Contracture, right ankle Further record review of Resident #1's orders read as follows: Carrot to Bilateral hands at all times every shift to prevent contractures Remove Q-shift for skin checks; Notify physician with any concerns. Tube-sleeves to bilateral arms at all times. every shift During an observation on 09/03/2024 at 2:15PM revealed Resident #1 lying in bed. Resident #1 did not have a carrot to hands nor her bilateral arm tubes. During an observation on 09/04/24 at 9:15 AM, revealed Resident #1 lying in bed. Resident #1 did not have a carrot to hands nor her bilateral arm tubes. During an interview on 09/04/24 at 10:33 AM, The Director of Nursing confirmed that the carrot or the are tubes were not in place as ordered.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview the facility failed to provide an activity program to meet the needs and interest of the residents. This failed practice was found true for (2) two of (5) five residents reviewed for activities during the Long-Term Care Survey Process. Resident identifiers: #39 and #1. Facility census: 59. Findings include: a) Resident #39 During the initial tour of the facility, on 09/03/24 at 1:00 PM, it was found that Resident #39 had her knees in her recliner with her head between her knees. No stimulation was noted in the room. It was also found that the door was shut due to Resident #39 having Covid-19 and being on isolation precautions. A record review, on 09/04/24 at 10:30 AM, of Resident #39's Activity Participation Records (APR) for the months of 06/24, 07/24, 08/24, and 09/24 revealed that Resident #39 had no group participation recorded. Further record review revealed an annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/27/24, under section F0500, question E is marked that it is important for Resident # 39 to participate in group activities. The record review also revealed an Activity Preference Interview dated 07/08/24, Section C, number 6 reads that Resident #39 likes for the television to be on and that is a current interest. No Television noted in the room throughout the survey process. A review of Resident #39's Activity Care plan reads as follows: Focus: (Resident #39 named) is dependent on staff for activities, cognitive stimulation, social interaction due to Cognitive deficits Goal: Patient will actively participate during in-room visits (3) three times a week through next review Interventions: Assist/escort patient to activity functions. Encourage patient to attend group activities. Invite patient to scheduled activities and provide reminders of activities as needed. Patient enjoys listening to music. Preferred type of music is Country. Provide 1 to 1 bedside/in-room visits and activities if unable to attend out of room events. Provide an activities calendar. Notify patient of any changes to the calendar of activities. During an interview on 09/04/24 at 2:30, The Activity Director (AD) stated, We typically drop off the daily schedule to residents and put it in as a one-to-one visit. We haven't been in Resident #39's room since she had covid. I am not sure If I have ever seen her in group activities. b) Resident #1 During the initial observation of Resident #1's room on 09/03/24 at 1:30 PM revealed Resident #1 lying in bed hollering out, Help me several times. No stimulation noted in Resident #1's room. An observation on 09/04/24 at 10:00 AM revealed Resident #1 in her room lying in bed staring at the ceiling. No stimulation noted in Resident #1's room. A record review on 09/04/24 at 1:00 PM of Resident #1's APR'S showed no group activity participation for the months of 06/2024, 07/2024, 08/2024 and 09/2024 to the present day. Further record review revealed an Annual Activity assessment dated [DATE], that indicates Resident #1 has a current interest in listening to music and watching TV. Record review also revealed an MDS with an ARD of 02/03/24, section F0800 M is marked that Resident #1 enjoys listening to music. Letter P is marked that the resident enjoys doing things with groups of people. During an interview on 09/04/24 at 2:30, The Activity Director (AD) stated, We typically drop off the daily schedule to residents and put it in as a one-to-one visit. She further confirmed that Resident #1 does not get up and needs more stimulation.

. Based on medical record review and staff interview, the facility failed to revise the comprehensive care plan in the area of contractures. This was true for one (1) of two (2) residents reviewed for the care area of position and mobility. Resident identifier: #15. Facility census: 56. Findings included: a) Resident #15 Review of Resident #15's medical records showed the resident had diagnoses of left hand and left wrist contractures. Review of Resident #15's comprehensive care plan showed the following focus, [Resident's name] has impaired mobility r/t [related to]: weakness and poor balance. She has left hand stiffness and is at risk for contracture. The focus had been initiated on 02/20/2017 and last revised on 11/05/2019. During an interview on 12/13/22 at 10:49 AM, the Registered Nurse Assessment Coordinator (RNAC) confirmed Resident #15 had diagnoses of left hand and left wrist contractures. The RNAC also confirmed Resident #15's comprehensive care plan had not been updated when the resident developed contractures. No further information was provided through the completion of the survey. .

. Based on observation and staff interview, the facility failed to ensure the resident environment over which it had control was as free from accident hazards as possible. The doors to four (4) rooms containing potentially hazardous materials were not locked. This deficient practice had the potential to affect any residents in the facility who wander and were able to access the rooms. Resident identifiers: #42, #4. Facility census: 56. Findings included: a) Accident Hazards On 12/12/22 at 11:21 AM, the soiled linen closet was noted to be unlocked and was accessed by the surveyor. There was a keypad on the door to use to unlock the door when it was locked. There was also a biohazard sign on the door. The soiled linen closet contained a refrigerator for blood and urine samples. Also, the room contained a sharps container containing used razor blades. The sharps container was on the counter and not affixed to the wall. This allowed the sharps container to potentially be removed from the room by any residents who might enter the room. The Director of Nursing (DON) confirmed the door was unlocked but should have been locked. The DON stated the door should have locked automatically when closed and demonstrated that the door locked when closed with the proper amount of force. On 12/12/22 at 11:30 AM, the janitor closet in the A hallway was noted to be unlocked and was accessed by the surveyor. There was a keypad on the door to use to unlock the door when it was locked. The room contained the cleaning compound Clorox Healthcare Fuzion Cleaner Disinfectant. The DON confirmed the door was unlocked but should have been locked. The DON stated the door should have locked automatically when closed, and demonstrated that the door locked when closed with the proper amount of force. On 12/12/22 at 11:37 AM, the janitor closet in the dining room hallway was noted to be unlocked and was accessed by the surveyor. The activity department and a resident lounge were also located in this hallway. There was a keypad on the door to use to unlock the door when it was locked. The room contained the cleaning compounds Clorox Healthcare Fuzion Cleaner Disinfectant, Virex Plus One-Step Disinfectant Cleaner and Deodorant, Clorox Commercial Solutions [NAME] Works Glass and Surface Cleaner, Comet Cleaner with Bleach, and Good Sense RTU Odor Counteractant. Activities Assistant #52 verified the janitor closet was unlocked. On 12/12/22 at 11:40 AM, the soiled laundry room was noted to be unlocked and was accessed by the surveyor. There was a keypad on the door to use to unlock the door when it was locked. There was also a biohazard sign on the door and a sign stating authorized personnel only. The room contained the cleaning compounds Clorox Healthcare Fuzion Cleaner Disinfectant, Shine-up Lemon Furniture Polish, and Comet Cleaner with Bleach. Environmental Assistant #81 verified the soiled laundry room was unlocked. On 12/12/22 at 11:48 AM, the DON confirmed the doors to the janitor closet in the dining room hallway and the soiled laundry room should have been locked. On 12/13/22 at 11:30 AM, the Clinical Specialist Coordinator stated Resident #42 and Resident #4 were the only residents in the facility who wandered. The Material Safety Data Sheet (MSDS) for Good Sense RTU Odor Counteractant stated to rinse with plenty of water for eye and skin contact. The MSDS for Comet Cleaner with Bleach stated the substance may cause eye irritation. For eye and skin contact, instructions were given to rinse with plenty of water and get medical attention if irritation develops and persists. For ingestion, instructions were given to drink one (1) or (2) glasses of water and get medical attention immediately if symptoms occur. The MSDS for Virex Plus One-Step Disinfectant Cleaner and Deodorant gave instructions to rinse eyes cautiously with water for at least 15 minutes for eye contact. For skin or hair contact, contaminated clothing was to be removed immediately and the skin was to be rinsed with water for at least 15 minutes. For ingestion, instructions were given to rinse the mouth and to drink a cupful of milk or water. The MSDS for Clorox Commercial Solutions [NAME] Works Glass and Surface Cleaner stated the substance may cause slight eye irritation. For eye contact, instructions were given to rinse the eyes for 15-20 minutes and a poison control center or doctor was to be called for further treatment advice. For skin contact, instructions were given to rinse the skin with plenty of water and call the doctor if irritation persists. For ingestion, instructions were given to drink a glassful of water and call a doctor or poison control center. The MSDS for Clorox Healthcare Fuzion Cleaner Disinfectant gave instructions to rinse thoroughly with plenty of water for eye contact and to get medical attention if symptoms occur. For skin contact, instructions were given to wash skin with soap and water. For ingestion, instructions were given to rinse mouth immediately and drink plenty of water. The MSDS for Shine-up Lemon Furniture Polish gave instructions to rinse with plenty of water for eye and skin contact. .

. Based on observation, record review, and staff interview, the facility failed to ensure residents were provided with assistive devices at meals as ordered. Resident #45 was not provided with a straw as ordered by the physician. This was true for one (1) of eight (8) residents reviewed for the care area of nutrition. Resident identifier: #45. Facility census: 56. Findings included: a) Resident #45 Review of Resident #45's physician's orders showed an order for a minced and moist texture consistent carbohydrates diet. The order stated the resident was to have a cup with a lid and straw. On 12/13/22 at 1:06 PM, Resident #45 was observed eating in the dining room. He had three (3) cups containing beverages. The cups had lids, but the resident did not have a straw. The resident's tray ticket indicated the resident was to have a two (2) handled cup but did not specify the resident was to have a straw. The Certified Dietary Manager confirmed Resident #45 did not have a straw as ordered by the physician. No further information was provided through the completion of the survey. .