**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews the facility failed to ensure one (#14) of one residents reviewed for activities of daily living were provided with services or treatments to prevent the reduction in range of motion out of 39 sample residents. Specifically, the facility failed to ensure Resident #14 was provided with preventative measures to help minimize the development of and the worsening of contractures. Resident #14 had a contracture to his left hand and no preventative measures were implemented. When Resident #14 was assessed during the survey on 10/31/23, his left hand finger contractures worsened and he developed a contracture to his right hand. Findings include: I. Facility policy and procedures The Activities of Daily Living (ADL) Supporting policy, revised in March 2018, was provided by the nursing home administrator (NHA) on 10/30/23 at 8:29 p.m. The policy revealed residents would be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who were unable to carry out ADLs independently would receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. Appropriate care and services would be provided for residents who were unable to carry out ADLs independently. The Resident Mobility and Range of Motion policy, revised July 2017, was provided by the regional director of clinical services (RDCS) on 11/7/23 at 12: 17 p.m. The policy revealed that residents would not experience an avoidable reduction in range of motion (ROM). Residents with limited range of motion would receive treatment and services to increase and/or prevent a further decrease in ROM. Residents with limited mobility would receive appropriate services, equipment and assistance to maintain or improve mobility unless reduction in mobility was unavoidable. -As part of the resident's comprehensive assessment, the nurse would identify the resident's current range of motion of his or her joints, limitations in movement or mobility, opportunities for improvement, and previous treatment or services for mobility. -As part of the comprehensive assessment, the nurse would also identify conditions that placed the resident at risk for complications related to ROM and mobility. This included muscle wasting/atrophy, contractures and/or other complications that could cause or contribute to immobility, impaired ROM or injury from falls (postural hypotension, urinary incontinence). -During the resident's assessment, the nurse would identify the underlying factors that might have contributed to a range of motion or mobility problems. These include immobilization (bedfast, chair or wheelchair usage), neurological conditions (cerebral palsy, cerebral-vascular accident), conditions in which movement might lead to pain and/or conditions that limit or immobilize movement of limbs or digits (splints). -The resident's care plan would be developed by the interdisciplinary team based on the comprehensive assessment, and would be revised as needed. The care plan would include specific interventions, exercises and therapies to maintain, prevent avoidable decline in and/or improve mobility/range of motion. Interventions might include therapies, the provision of necessary equipment/exercises, based on professional standards of practice that were consistent with state laws and practice acts. -The care plan would include the type, frequency, duration of interventions, as well as measurable goals and objectives. The resident and representative would be included in determining these goals and objectives. Documentation of the resident's progress toward the goals and objectives would include attempts to address any changes or decline in the resident's condition or needs. The Functional Impairment - Clinical Protocol, revised in March 2018, was provided by the RDCS on 11/6/23 at 12:17 p.m. The policy revealed, upon admission to the facility, whenever a significant change of condition occurred, and periodically during a resident's stay, the physician and staff would assess the resident's function along with their physical condition. As part of the physical examination, the physician would include items that related to function as well as the potential to benefit from rehabilitative services; for example, proprioception, sensation, muscle tone, range of motion, gait, balance, joint swelling/abnormalities, strength, edema, and cognition. The staff and physician would identify individuals with the potential for significant improvement in function or significant decline in function, including the ability to perform ADLs. -As appropriate, the physician would identify and evaluate medical conditions and medications that impacted a resident's function (for example, muscle weakness or pain due to adverse medication effects, persistence of complications from recent hospitalization, and sedation or confusion due to fluid/electrolyte imbalance). The physician and staff would review and analyze the preceding information to evaluate the influence of medical factors on function and vice-versa, to help guide subsequent treatment and care planning. The physician would identify and document the impact of medical conditions on function and identify a resident's potential to benefit from rehabilitative services, such as physical and occupational therapy. The staff and physician would collaborate to identify a rehabilitative or restorative care plan to help improve function, quality of life, meet a resident's goals/needs and attain other desired outcomes such as discharge to the community. Based on a review of available information (including results of the evaluation), the physician would determine if a resident met the criteria for skilled therapy services. The physician and staff would address risk factors related to exercise or activity, and consider any relevant precautions. The physician would order any therapy services based on the above considerations. The physician would pay attention to the relevance and effectiveness of such interventions. The physician would not just sign off therapy orders perfunctorily. -The staff would monitor and document the resident's function (for example, evidence of reduced ADL dependency, improved ambulation, improved balance and gait) and would discuss this with the physician periodically in conjunction with a discussion of medical interventions and plans of care. The physician would identify the subsequent relevance of therapy services, based on reviewing the resident's progress relative to his/her care goals (functional stabilization or improvement), the status of conditions and the current treatment regimen that have been identified as affecting his/her function. II. Resident interview and observations The resident was observed on 10/30/23 at 10:54 a.m., seated in a motorized wheelchair in his room. He had bilateral wrist/hand/finger contractures. He did not have any bilateral splints in place. He said he wanted splints for both of his wrists/hands/fingers. He said he had been asking staff for bilateral splints for over a year and they told him that they would see about getting him some. The resident was observed on 10/30/23 at 12:12 p.m. seated in a motorized wheelchair in the dining room. He had contractures on both of his wrists/hands/fingers. He did not have a splint in place for either wrist/hand/fingers. A staff member was assisting the resident with his meal. The resident was observed on 10/31/23 at 8:45 a.m. seated in a motorized wheelchair by a nurse medication cart. The resident was being administered medication by the nurse. He had contractures on both of his wrists/hands/fingers. He did not have a splint in place for either wrist/hand/fingers. The resident was observed on 11/1/23 at 7:31 a.m., seated in a motorized wheelchair in the dining room. He had contractures on both of his wrists/hands/fingers. He did not have a splint in place for either wrist/hand/fingers. The resident was observed on 11/1/23 at 1:43 p.m., seated in a motorized wheelchair in the common television area near hall 500-600. He had contractures on both of his wrists/hands/fingers. He did not have a splint in place for either wrist/hand/fingers. The resident was observed on 11/2/23 at 12:49 p.m., seated in a motorized wheelchair in the common television area near hall 500-600. He had contractures on both of his wrists/hands/fingers. He did not have a splint in place for either wrist/hand/fingers. The resident demonstrated he was unable to open his fingers on either hand. III. Resident #14 A. Resident status Resident #14, age under 65, was admitted on [DATE] and readmitted on [DATE]. According to the November 2023 computerized physician orders (CPO), diagnoses included quadriplegia, spinal stenosis in the cervical region, anxiety, schizoaffective disorder, chronic obstructive pulmonary disease, history of transient ischemic attack, muscle weakness, abnormal posture, reduced mobility, history of musculoskeletal system and connective tissue disorders. The 7/25/23 minimum data set (MDS) assessment revealed the resident's cognitive status was intact with a brief interview for mental status (BIMS) score of 15 out of 15. According to the assessment, the resident did not exhibit behaviors or refuse care. The resident required extensive staff assistance with two plus persons to physical assist for bed mobility, dressing toileting and personal hygiene. The resident was totally dependent on staff and required physical assistance from two or more persons for transfers. The resident had functional limitations in ranges of motion with impairment on both sides that included his upper extremity (shoulder, elbow, wrist, hand). The resident did not receive any therapy services during the seven-day review period. B. Record review A care plan for dependence with ADL care related to quadriplegia, and chronic pain, cognitive loss was initiated on 3/16/21 and revised on 10/27/23. The plan also revealed the resident exhibited or was at risk for alterations in functional mobility related to quadriplegia, osteoarthritis, degenerative disc disease, history of a fall with spinal cord injury at the cervical levels of 4-7, cervical stenosis of the spine, history of lumbar surgery, history of an open reduction and internal fixation right hip. The relevant interventions were the resident required one to two staff persons for assistance with ADL. Staff were to monitor the resident for shortness of breath, fatigue and/or a change of condition and adjust the ADL task accordingly. Staff were to also encourage the resident to pace himself during an ADL task. Staff were to provide cueing for safety and sequencing to maximize the resident's current level of function. The plan did not reveal the resident had bilateral contractures of his wrist/hands/fingers. A care plan for restorative nursing program related to bed mobility/transfers was initiated on 9/14/22 and revised on 8/21/23. The relative interventions were to encourage the resident to utilize the bed bar for repositioning on his wide bariatric bed. The plan did not reveal the resident had bilateral contractures of his wrist/hands/fingers. A care plan for being at risk for decreased ability to perform ADLs related to recent hospitalization, weakness, decreased mobility, diabetes mellitus, and dizziness was initiated on 5/12/21 and revised on 6/6/23. Relevant interventions were for staff to monitor for decline in ADL function. Staff were to refer to rehabilitation therapy if a decline in ADL was noted. Staff were to monitor for complications of immobility (pressure ulcers, muscular atrophy, contractures, incontinence, urinary/respiratory infections). The plan did not reveal the resident had bilateral contractures of his wrist/hands/fingers. The occupational therapy (OT) initial evaluation dated 10/27/2020 noted range of motion for the musculoskeletal right upper extremity (elbow/forearm) was impaired. The left upper extremity hand had impaired range of motion. The musculoskeletal strength for the right upper extremity and the left upper extremity were impaired. -The passive range of motion for the left index finger metacarpophalangeal joint was 70 degrees and for the proximal interphalangeal joint was 75 degrees. -The passive range of motion for the left middle finger metacarpophalangeal joint was 70 degrees and for the proximal interphalangeal joint was 75 degrees. -The active range of motion for the left ring finger metacarpophalangeal joint flexion was 0 (zero) degrees and for the proximal interphalangeal joint flexion was 0 (zero) degrees. -The passive range of motion for the left right finger metacarpophalangeal joint was 75 degrees and for the proximal interphalangeal joint flexion was 75 degrees. -The passive range of motion for the left little finger metacarpophalangeal joint flexion was 70 degrees and for the proximal interphalangeal joint flexion was 75 degrees. -The short term goals were for the resident to tolerate use of a left wrist splint for one hour without sign of skin breakdown or complaint of pain in the left thumb with a target date of 11/16/2020. The long term goals were for the resident to wear a left splint for eight hours without skin breakdown or complaint of pain with a target date of 11/25/2020. -There were no short or long term goals for the resident's right wrist/hand/fingers. The occupational therapy (OT) evaluation dated 12/17/22 revealed the right upper extremity was not tested due to mixed tone; non-functional upper extremity loss of motor control that was chronic in nature. The range of motion of the upper extremity was not tested due to clinical reasons of other tone; non-functional upper extremity that was chronic in nature. The left upper extremity range of motion was not tested related to clinical reasons of mixed tone; non-functional upper extremity. The tone was abnormal; upper extremity muscle tone was spastic, hypertonic, and/or hypertonic flaccid. -There was no recommendation for the use of splints. The occupational therapy (OT) evaluation on 1/26/23 revealed the right upper extremity wrist strength was impaired (no measurements were taken). The left upper extremity was impaired (no measurements were taken). The range of motion of the right upper extremity revealed wrist and hand impairment. -There was no recommendation for the use of splints. The Rehabilitation Screening form dated 10/27/23 (completed during the survey) revealed contractures present and a need for splints. The left wrist and right wrist demonstrated moderately and reflected approximately 50% of full ROM. The left and right fingers were severe and reflected 25% or less of full ROM. Occupational Therapy Evaluation and Plan of Treatment start date of 10/31/23 (completed during the survey) revealed the left wrist had no displays of contractions during active or passive range of motion. The left proximal interphalangeal joints had resting contractures at 90 degrees and passive range of motion to 145 degrees. The right wrist had no displays on contractures. The right wrist active range of motion was limited and would benefit from a resting hand splint. The right interphalangeal joints had resting contractures at 145 degrees, passive range of motion at 170 degrees and would benefit from a resting hand splint. One new goal revealed that the resident would present with a functional wear schedule wearing bilateral hand splints with no redness, or areas of concerns for 15 minutes to preserve joint mobility (target 11/13/23). -The OT assessment dated [DATE] (approximately three years later from 10/27/2020) revealed the resident had contractures of both the left and right interphalangeal joints. This assessment's new goal was for bilateral splints for these areas. This assessment revealed the resident now needed a splint for both hands. -The resident's left hand finger contractures worsened at the hand/knuckle joint based on the decline over three years. -The resident did not have any known contractures to his right hand at baseline and based on the current measurement developed a decline in range of motion. IV. Staff interviews The director of rehabilitation (DOR), registered nurse consultant (RNC) and the quality improvement specialist consultant (QISC) were interviewed on 11/2/23 at 12:02 p.m. They said the resident only had contracture measurements on 10/27/2020 and during the survey on 10/31/23. They said the OT initial evaluation on 10/27/2020 revealed the resident's range of motion for the musculoskeletal right upper extremity (elbow/forearm) was impaired. The left upper extremity hand had impaired range of motion. The musculoskeletal strength for the right upper extremity and the left upper extremity were impaired. The evaluation revealed left hand passive/active range of motion measurements of the resident's fingers and there were no measurements for the resident's right hand. The evaluation had short term goals, that the resident would tolerate use of a left wrist splint for one hour without sign of skin breakdown or complaint of pain in the left thumb with a target date of 11/16/2020. The long term goals were the resident would wear a left splint for eight hours without skin breakdown or complaint of pain with a target date of 11/25/2020. There were no short or long term goals for the resident's right wrist/hand/fingers. They said the evaluation only mentioned the resident's left hand, with a recommendation for the use of a splint for the left hand and did not mention the right hand. They said the documentation on the Rehabilitation Screening form dated 10/27/23 revealed the resident had contractures and there was a need for splints. This screening occurred during the survey process. They said the documentation on the Occupational Therapy Evaluation and Plan of Treatment start date of 10/31/23 revealed a new goal for the resident was to provide bilateral hand splints with no redness or areas of concern for 15 minutes to preserve joint mobility (target 11/13/23). This screening occurred during the survey process. They said the resident did not have any current services for his bilateral hand contractures nor was he on a restorative program for his hand contractures. They acknowledged there was no specific care plan for the resident's bilateral hand contractures.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to provide effective pain management program for two (#53 and #4) of three residents reviewed for pain management out of 39 sample residents. Resident #53 had pain control during a wound dressing change on 10/31/23 at 4:15 p.m. The resident experienced severe pain during the dressing change. The resident was administered a pain medication at 3:40 p.m., although the resident told the nurse that she was in pain, the dressing change continued. The resident was not offered any other type of pain intervention. In addition, the facility failed to for Resident #4: -Have a pain parameters for as needed (PRN) pain medications; and, -Thoroughly assess the resident's pain. Findings include: I. Facility policy The Pain -Clinical Protocol policy, updated October 2022, was received on 11/2/23 at 1:00 p.m. from the nursing home administrator. The policy read in pertinent part, The staff and physician will identify the characteristics of pain such as location, intensity, frequency pattern and severity. Staff will use a consistent approach and a standardized pain assessment instrument appropriate to the resident's cognitive level. The nursing staff will identify any situations or interventions where an increase in the resident's pain may be anticipated; for example wound care. II. Resident #53 A. Resident status Resident #53, age [AGE], was admitted on [DATE]. According to the November 2023 computerized physician orders (CPO)diagnosis included bilateral venous stasis ulcers in lower extremities. The 9/21/23 minimum data set (MDS) assessment documented the resident had no cognitive impairment with a brief interview for mental status (BIMS) score of 15 out of 15. The he resident as having two venous and arterial ulcers. The resident had an open lesion and received non sterile dressings. The pain section documented that the resident received PRN (as needed) pain medication. Resident #53 did not receive non-medication interventions for pain. B. Resident interview and observation Resident #53 was interviewed on 10/31/23 at 9:45 a.m. The resident said she had two wounds on both of her lower legs. She said the dressings were changed daily. The resident was observed to have both of her legs wrapped in Curlex wrap with the date of 10/30/23 written on the dressing. C. Wound care observations and resident interview Wound care treatment was observed for Resident #53 on 11/1/23 at 4:15 p.m. The wound care was completed by registered nurse (RN) #1, registered nurse (RN) #3. The quality improvement specialist consultant (QISC) was in the room for a short while. RN #3 was the wound nurse. Certified nurse aide (CNA) #5 was in the room to assist with resident care. The overbed table was used to hold the wound care supplies. RN #1 began to remove the old dressing, spraying the area where the dressing was being pulled away to expose the skin. The dressing was not pre soaked or saturated. As a result when RN #1 pulled off the dressing, Resident #53 verbalized her pain as RN #1 was pulling off the dressing. The resident said, you are debriding the wound. It hurts. Stop! RN #1 did not stop and continued, she responded by saying this was how it was performed and she had performed rounds with the wound physician. She said this as she sprayed the bandage. The resident continued to state the pain she felt as RN #1 continued with the above actions. The QISC intervened and asked if the resident had been given any pain medications before the procedure began. The resident stated that she had not received any pain medications. The QISC asked for a check of the medication administration record (MAR) to see if the resident had received any pain medications prior to the procedure. The QISC returned to the room and said the MAR showed the resident had received Oxycodone 5mg by mouth at 3:40 p.m. The resident was notified and no further medications were administered. The QISC left the resident's room. The resident continued to complain of the pain as RN #1 removed the bandage. RN #1 responded by saying; I know. I know. The resident responded by saying, you have no idea what another person's pain is! After the dressing was removed from each lower extremity, the outer layer of the resident's skin (epidermis) was absent and exposed the second layer of skin (dermis) on the back of the resident's lower leg. The dressing was removed and as the wound cleaner was sprayed on the open wounds, she would say each time it was sprayed that her skin stung, as it was sprayed on the open wounds. Resident #53 was interviewed on 11/2/23 at 8:20 a.m. The resident expressed that during the dressing change on 11/1/23 she sustained a lot of pain and she felt her stated feelings were disregarded, as she expressed the amount of pain she was in, although RN #1 continued with the dressing change. D. Record review The care plan last updated on 9/27/23 identified the resident was at risk for skin breakdown related to decreased activity, diabetes, peripheral vascular disease. The care plan showed the resident had actual wounds to her bilateral lower extremities. Pertinent approaches were to observe for verbal and nonverbal signs of pain related to wound or wound treatment and medication as ordered. Complete a weekly skin check by licensed nurse weekly. According to the medication administration orders (MAR) for November 2023 the resident was receiving following medications for pain: Acetaminophen 325 milligram (mg), two tablets every eight hours as needed for mild pain. The order was started on 9/23/22. The order directed to notify the physician if more than three doses in 48 hours. Do not exceed 3 grams a day. Oxycodone HCI oral tablet 5 mg, give one tablet by mouth every six hours as needed for pain 6-10 (with 10 being the worst on the scale). The most recent wound assessment completed on 10/27/23 by the wound care physician (WCP) revealed the resident had two wounds on her bilateral lower extremities. The November 2023 treatment administration record (TAR) showed the physician order was as follows: Left lower leg wash with wound cleaner and pat dry with a 4 X 4 gauze. Apply xeroform to open areas. Cover with ABD (absorbent dressing) and kerlix (to cover wounds) every day and as needed every day shift for wound care. The order was started on 10/21/23 E. Interview The director of nurses (DON) and the QISC were interviewed on 11/2/23 at 1:40 p.m. The QISC said the resident had bilateral venous stasis wounds on her lower extremities. She said the wound physician was involved and saw her weekly. The DON said the dressing changes were to be completed one time a day and as needed. The DON said the resident's legs were to be washed with wound cleanser and the order was to pat it dry with gauze. The DON said after hearing how the dressing was removed (see above) she said the orders would have to be clarified with the physician, as it did not direct how to remove the dressing. The QISC said she had left the room to verify the medication which was administered. She said once they saw the resident had received pain medication and it was not effective for the dressing change, then they should have stopped the dressing changes until the physician could have been called for additional pain medications. The QISC was interviewed a second time on 11/2/23 at approximately 5:30 p.m. The QISC said they spoke with the resident and she verified that the resident had excessive pain with the dressing change on 11/2/23. III. Resident #4 A. Resident status Resident #4, age [AGE], was admitted on [DATE]. According to the November 2023 computerized physician orders (CPO) the diagnoses included chronic obstructive pulmonary disease (COPD), right femoral fracture and opioid dependence. The 8/3/23 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status score of 14 out of 15. She was dependent with toileting, transfers, personal hygiene and required set up assistance only with eating. It indicated the resident was on a scheduled pain medication program, received PRN medications and did received pharmacological interventions for pain management. B. Record review The pain management care plan, initiated on 9/12/19 revised on 4/16/21, indicated the resident had pain related to chronic pain with narcotic dependence history. Interventions included pain medications per physician order, assist with repositioning for comfort, document complaints and non verbal signs of pain, encourage resident to communicate pain, implement relaxation and distraction techniques, observe for potential side effects of medication, therapy to screen as necessary, utilize pain scale as indicated. -A review of Resident #4's comprehensive care plan did not reveal a person centered approach with identification of location, type or intensity of pain the resident experienced. It did not include personalized non-pharmacological interventions to address the resident's pain. It did not identify a baseline assessment of pain or person centered pain management goals. The October 2023 medication administration record (MAR) documented the resident was prescribed the following medications: -Acetaminophen 650 milligrams (mg) at bedtime for pain, ordered 6/9/21. -Methadone 5 mg at bedtime for pain, ordered 6/12/22. -Methadone 2.5 mg once a day for pain, ordered 7/1/22. -Acetaminophen 650 mg every 6 hours as needed for mild pain, ordered 3/31/23. -Hydromorphone 2 mg every two hours as needed for pain, ordered 9/18/23. -A comprehensive review of the October 2023 MAR failed to document location, intensity and type of resident's pain being treated for Acetaminophen, Methadone and Hydromorphone. -The physician orders did not include specific pain scale parameters for the PRN Acetaminophen and Hydromorphone. -The documentation did not include a pain assessment prior to or after the administration of pain medications. C. Staff interviews Licensed practical nurse (LPN) #2 was interviewed on 11/2/23 at 11:40 a.m. She said pain assessment should be done prior and after any administration of a pain medication. She said residents that were on multiple pain medications, had been determining which pain medications they wanted to take and parameters were not always ordered for pain medications. The DON was interviewed on 11/2/23 at 1:23 p.m. She said pain medication assessment evaluations should be done on admission and quarterly and when there was a change in the resident's condition. She said there should be physician ordered parameters for all pain medications. She said that pain assessments should be done before and after pain medications administration and documented on the MAR. She said that it had been identified that pain assessment evaluations and pain assessment documentation on the MAR were not being done and were an issue.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility failed to ensure residents had the right to a dignified existence out of 42 sample residents. The facility failed to ensure residents experienced a dignified living experience by ensuring residents were treated with respect and dignity. Residents of the facility expressed being yelled and chastised by staff and retaliation by the facility. A resident stated he was tired of feeling like we are nobody, he served his country for freedom and he can't die with dignity; he wanted to be treated like a human being, not a child. Furthermore, the facility failed to treat Resident #83 with respect and dignity. Findings include: I. Residents being treated with respect and dignity (cross-reference F565 resident group response) A. Resident group interview The resident group interview was conducted on 4/20/23 at 11:00 a.m., with 12 alert and oriented residents. The resident in the council meeting said the following: The residents said that dignity and respect had always been a thing around here as residents were always being yelled at and chastised by the staff. One resident said I am tired of the retaliation. When you blow the whistle they retaliate. One of the residents said I am tired of feeling like we are nobody, we are grown adults. The resident then said it makes me wonder why I served my country for freedom and we can't die with dignity. I want to be treated like a human being, not like a child. B. Administrative interview The director of nursing (DON) was interviewed on 4/20/23 at 5:00 p.m. The DON said the staff treat the residents with respect and dignity. She said when she received a complaint, she would ensure it was investigated to rule out abuse. She said at times the complaint could be customer service oriented, then the staff would be educated on customer service. She said customer service was taught at orientation and it included respect and dignity. Staff were trained to listen to residents and to ensure the resident was cared for in a dignified manner. She said residents had the right to complain and not to be fearful of retaliation. II. Resident #83 A. Resident status Resident # 83, age [AGE], was admitted to the facility on [DATE]. The April 2023 computerized physicians orders (CPO) indicated that the resident had a diagnosis of chronic obstructive pulmonary disease, insomnia, anxiety disorder, hallucinations, type 2 diabetes and chronic kidney disease. The 3/22/23 minimum data set (MDS) assessment indicated the resident was cognitively intact with a brief interview of mental status score of 15 out of 15. Resident #83 required supervision with eating, support was provided with showers, however the resident refused each time. The resident required the use of a manual wheelchair. The resident was independent with toilet use, dressing, and bed mobility. B. Observation On 4/19/23 at approximately 1:45 p.m. loud arguing between Resident #83 and the receptionist could be heard. Resident #83 was at the front receptionist desk. The resident was telling the receptionist that she had not done something that he had requested. He was talking loud, using foul language and his tone of voice was argumentative. The receptionist was observed to engage the resident with her tone of voice, was also argumentative and she continued to reply back to the resident in a disrespectful manner. She did not talk to the resident in a manner which provided dignity. C. Resident interview Resident # 83 was interviewed on 4/18/23 at approximately 2:00 p.m. The resident said he did not like how the facility staff spoke to him. He said he had to deal with a lot of issues in his life, but the way he was spoken to by facility staff made him upset. He said the staff would not believe him when he asked for assistance and the request was always matched with an argument from the staff. He said he knew he did not communicate his needs in a pleasant manner. The resident was interviewed a second time on 4/19/23 at approximately 2:45 p.m. The resident said that he felt like his right to be treated with dignity was taken from him. He said that he did not think the receptionist should talk to him the way she did. D. Record review The care plan, revised 1/27/23, included that arguing with Resident # 83 made his situation worse which made him feel like he had been scolded in front of the other residents. The social services (SS) advised the staff for the resident to be spoken to in a calm manner which diffuses a situation. E. Staff interviews The DON was interviewed on 4/19/23 at 2:08 p.m. She said Resident #83 had been asking the staff all day about the refrigerator in his room to be repaired. She said Resident #83 told her he felt like he had been disrespected by the staff. Resident #83 spoke of an incident in which he spoke to the receptionist about his refrigerator. He said she told him that it was not her job to look at his refrigerator and that he should go talk to the maintenance department about his problem. Certified nurse aide (CNA) #9 was interviewed on 4/19/23 at 4:00 p.m. The CNA confirmed she observed the interaction between the receptionist and Resident #83. She said that although Resident #83 could be difficult, the receptionist should have walked away when he was using foul language rather than using the disrespectful tone.