Based on observation, medical record review, and interview, the facility failed to develop and implement comprehensive, effective and individualized pain management programs for all residents. The facility failed to ensure Resident #104 received pain medication as ordered and the facility failed to ensure Resident #60 was re-assessed timely following complaints of severe pain to determine if changes were needed to his medication regimen. This affected two residents (#60 and #104) of six residents reviewed for pain. Actual harm occurred on 11/14/24 when Resident #104, who had a diagnosis of metastatic (cancer cells have spread to areas other than the original tumor) lung cancer did not receive routine/scheduled pain medication as ordered to achieve effective pain relief/pain management and prevent shortness of breath resulting in complaints of increased pain which included facial grimacing and shortness of breath with pursed lip breathing. Findings include: 1. Review of Resident #104's medical record revealed the resident had diagnoses including malignant neoplasm of the lungs and chronic obstructive pulmonary disease. On 11/13/24 (at 8:00 P.M.) a new order was written for the administration of Morphine Sulfate (an opiate (narcotic) analgesic) 15 milligrams (mg) every four hours for metastatic lung cancer. Review of the medication administration record (MAR) revealed the 8:00 P.M. dose on 11/13/24 was not administered because Resident #104 was sleeping. In addition, the 12:00 A.M. and 4:00 A.M. doses of Morphine were not administered on 11/14/24 with a code to see nursing notes. However, the notes were devoid of a reason the medication was not administered. On 11/14/24 at 8:50 A.M., Resident #104's call light was observed on. The length of time it had been on was unknown at that time. At 8:55 A.M., Resident #104 ambulated to his doorway and spoke to Licensed Practical Nurse (LPN) #240 about getting pain medication. LPN #240 stated she was told Resident #104 did not receive pain medication over night or his morning doses because he was sleeping which Resident #104 denied. LPN #240 stated she would be with Resident #104 when she was done (preparing medication for another resident). At 8:57 A.M., Resident #104 had returned to his room and was sitting on the side of his bed. An interview with Resident #104 at the time of the observation revealed concerns he was having trouble getting his Morphine, stating he was supposed to get it every four hours. Resident #104 stated he had received no Morphine since 9:00 P.M. on 11/13/24. Pursed lip breathing, shortness of breath and facial grimacing were noted. Resident #104 stated the night nurse told him the facility was out of the Morphine. LPN #240 administered Resident #104's medication at 9:05 A.M. including the Morphine 15 mg. An interview on 11/14/24 at 9:09 A.M. with LPN #240 verified Resident #104's Morphine was scheduled every four hours. The last dose was signed out on the narcotic count sheet on 11/13/24 at 6:08 P.M. and she stated the Morphine was ordered for shortness of breath for terminal cancer. Further interview with Resident #104 on 11/14/24 at 9:10 A.M. revealed he was ordered the Morphine for both pain and shortness of breath. Resident #104 rated his pain an eight on a scale of zero to 10 with 10 being the most severe pain. On 11/14/24 at 11:55 A.M., Resident #104 stated he had received little relief from the Morphine administered that morning. His breathing continued to be labored and he rated his pain a six on a scale of zero to ten at that time. On 11/14/24 at 9:45 A.M., an interview with Registered Nurse (RN) #350 revealed he investigated the concern related to Resident #104's Morphine Sulfate administration. RN #350 verified the Morphine Sulfate was not administered in accordance with the physician's order and stated the nurses did not seem to understand when pain medication was ordered on a routine basis that it was necessary to offer it to maintain effective pain control even if a resident was sleeping. On 11/14/24 at 3:40 P.M., Nurse Practitioner (NP) #300 verified the order for Morphine indicated it was to be administered every four hours routine, not while awake or as necessary. The NP revealed attempts had been made to administer the Morphine while awake in the past and it was not effective and the NP indicated it was better to administer the medication around the clock. NP #300 stated it would take a while now for Resident #104 to obtain relief since he had not received the Morphine as ordered and that was why she wanted him to have it on a routine basis. When observations of purse lip breathing were shared with NP #300 she stated that could have been due to his respiratory status alone. Observations of facial grimacing were shared with no additional information/explanation provided. On 11/18/24 at 9:10 A.M., an interview with Hospice Nurse #270 revealed Resident #104's pain medication had been increased because he wasn't getting it routine and he had to wait when he asked for pain medication ordered on an as necessary (prn) basis. Hospice Nurse #270 revealed Resident #104 would not ask consistently for the as needed (prn) pain medication because he did not want to bother staff. 2. Review of Resident #60's medical record revealed diagnoses including osteoarthritis of both hips and osteonecrosis of the left femur (death to the bone that occurs when there is a disruption of blood supply to the thigh bone and could result in destruction of the hip joint and severe arthritis). On 11/01/24 an order was written for the pain medication Ultram 50 mg every eight hours as needed (prn) for pain. Review of the November 2024 MAR revealed pain severity levels recorded with prior administration of Ultram ranged from zero to ten with only one dose on 11/03/24 at 9:28 A.M. being ineffective. Review of the controlled drug administration record revealed the last dose was removed on 11/13/24. The time was difficult to read but appeared to be between 8:00 P.M. and 10:00 P.M. On 11/14/24 at 8:00 A.M., LPN #200 was observed conversing with Resident #60 when she entered his room to administer his medication. Resident #60 was in the bathroom and complained he had been in pain all night. LPN #200 responded the night nurse had reported when she went to administer Resident #60's pain pill the previous night he was sleeping so she and another nurse had to waste it. There were no more Ultram (pain pills) in the cart as the last dose had been wasted LPN #200 stated the Nurse Practitioner (NP) was supposed to be later (on this date) and would address the pain. When Resident #60's medication was administered on 11/14/24 at 8:34 A.M. and included gabapentin 200 milligrams (anticonvulsant which could be used for neuropathic pain) and Naproxen 250 milligrams (anti-inflammatory medication). On 11/14/24 at 11:58 A.M., interview with Resident #60 revealed he rated his pain at an 11 (on a scale of zero to 10). Resident #60 stated he had received Norco at the hospital and it was effective. Resident #60 stated he had discussed this with staff (could not provide names) but it had not been ordered yet. An interview with LPN #200 on 11/14/24 at 12:10 P.M. verified she had not reassessed Resident #60 to determine if his routine medication had been effective in relieving pain. LPN #200 verified she had not seen the nurse practitioner visit yet that day but stated Resident #60's Ultram was supposed to be delivered with medications that night. The November MAR indicated Resident #60 was provided 650 mg of acetaminophen on 11/14/24 at 12:40 P.M. for pain rated at ten on a scale of 0-10. The MAR indicated the acetaminophen was ineffective. On 11/14/24 at 3:40 P.M., NP #300 stated Resident #60 did not generally complain of pain when she visited. Resident #60's Gabapentin had been increased recently and staff were monitoring effectiveness. NP #300 stated Norco (pain medication) probably would be more effective if it had been effective when used previously. On 11/14/24, an order was written for hydrocodone/acetaminophen (Norco a narcotic pain medication) 5/325 mg one tablet every eight hours as needed (prn) for pain. On 11/18/24 at 10:38 A.M., Resident #60's facial expressions were noted to be more relaxed. Resident #60 stated he had been receiving Norco over the weekend and stated he was feeling great. Resident #60 stated he was sleeping better and he was now able to bend and stretch his left leg which he demonstrated. Resident #60 stated he had not been able to move his left hip and leg like that previously due to pain. Review of the facility's Pain Management and Assessment policy (implementation date not recorded) indicated the use of a one to ten pain scale revealed a ten severity represented it being the worst pain a resident had ever experienced. This deficiency represents non-compliance investigated under Complaint Number OH00159033.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on observation, record review, facility policy and procedure review and interview, the facility failed to meet the total nutritional needs of Resident #71, who received all nutrition/hydration via a percutaneous enteral gastronomy (peg) tube, to prevent a severe weight loss and abnormal sodium levels. The facility also failed to timely identify the weight loss and implement effective interventions to prevent additional weight loss for the resident. Actual harm occurred beginning on 04/02/23 when Resident #71, who was severely cognitively impaired, received nothing by mouth and received enteral feeding as her only source of nutrition/hydration was noted to have a 14.8-pound weight loss (from 03/21/23 209.4 pounds to 04/02/23 194.6 pounds) with no evidence the facility identified the weight loss or implemented effective interventions to prevent additional weight loss at that time. On 04/17/23 Resident #71 was noted to weigh 180.2 pounds which reflected a severe weight loss of 29.2 pounds/13.9 percent from 03/21/23 to 04/17/23. On 04/19/23 the resident's sodium level was noted to be critically high at 163 milliequivalents per liter (normal 135-148). The facility determined the weight loss and elevated sodium level were a result of the resident being administered an incorrect rate of enteral feeding. This affected one resident (#71) of seven residents reviewed for alternate means of nutrition and hydration. The facility identified five residents (#34, #58, #66, #67, and #71) who received enteral nutrition and hydration through a peg tube. The facility census was 87. Findings include: Review of the medical record for Resident #71 revealed an admission date of 12/14/22 with diagnoses including cerebral infarction (stroke), cognitive communication deficit, aphasia (difficulty speaking), and dysphasia (difficulty swallowing). Review of the nutritional care plan, initiated on 12/29/22, revealed Resident #71 had a potential for altered nutrition status and nutrition related problems due to a therapeutic diet order, percutaneous endoscopic gastrostomy (peg) tube, need for enteral nutrition to meet estimated needs, obesity, history of weight loss, and weight refusals. The goals were for Resident #71 to maintain weight without significant weight loss, maintain/improve skin integrity, remain free of signs or symptoms of dehydration, be without weight loss, and not exhibit any signs or symptoms of aspiration through the next review. Interventions included dental referral as needed, observe for sign and symptoms of aspiration, obtain labs per medical providers order, obtain weekly weights if unplanned weight loss was identified, position resident properly for swallowing, and speech therapy and occupational therapy as needed. Further review of Resident #71's medical record revealed the resident was discharged to the hospital on [DATE] related to a stroke and returned to the facility on [DATE]. The physician orders for enteral feeding, ordered from 01/21/23 to 02/20/23 (hospitalization) consisted of Glucerna 1.5 at 65 milliliters per hour (ml/hr) from 6:00 P.M. to 6:00 A.M., 45 ml/hr of water from 6:00 P.M. to 6:00 A.M., 200 ml bolus of Glucerna 1.5 with a 180 ml water flush twice a day in the A.M. and P.M. Review of the Medication Administration Record (MAR) for February 2023 revealed Resident #71 had no gastric residuals and all enteral feeding was delivered to Resident #71 as ordered. Review of Resident #71's weights dated 01/04/23 208 pounds (lbs), 02/08/23 210 lbs, 03/01/23 210 lbs revealed weights were stable plus or minus two lbs. Review of the physician orders upon readmission from the hospital on [DATE] revealed an enteral tube feeding order of Glucerna (the order did not specify if the Glucerna should be 1.2 or 1.5 calorie per milliliter) to run continuously at 45 milliliters per hour (ml/hr) with 100 ml (water) flush every four hours. Review of the dietary progress notes dated 03/01/23 revealed the registered dietitian completed a readmission assessment of Resident #71 and recommended to resume the prior tube feeding and flushes which had been meeting 100% of Resident #71's needs prior to the hospitalization. Resident #71's power of attorney agreed with the recommendation. Resident #71's care plan was updated on 03/01/23 to include the resident required tube feeding since the resident did not eat by mouth (NPO) with a goal to maintain nutrition and hydration status. Interventions included provide tube feeding per medical provider orders, administer flushes per medical provider's order, administer medications via tube per orders, check for place and residuals, head of bed elevated 30 degrees or higher, notify medical provider and resident representative of unplanned weight changes, nutritional consult on admission, quarterly, and as needed, obtain labs per medical provider's order, provide insertion site care, per orders, provide oral care. Review of the physician order dated 03/06/23 revealed Resident #71 to receive Diabetisource 1.2 at 30 ml/hr with a water flush of 30 ml/hr from 7:00 P.M. to 9:00 A.M and bolus feedings of 250 ml of Diabetasource 1.2 with 120 ml water flush two times a day at 9:00 A.M. and 12:00 P.M. The order was initiated on 03/07/23. Review of the Medication Administration Record (MAR) for March 2023 revealed Resident #71 had no gastric residuals and all enteral feeding was delivered to Resident #71 as ordered. Review of the weight records for March and April 2023 revealed on 03/07/23 Resident #71's weight was 210.8 lbs, on 03/14/23 and 03/21/22 the resident's weight was documented to be 209.4 lbs and on 04/02/23 the resident's weight was noted to be 194.6 lbs. This weight reflected a 14.8-lbs weight loss. There was no re-weight obtained after 04/02/23 in relation to the 14.8 lbs loss. Review of the dietary progress notes dated 04/06/23 and 04/10/23 revealed a recommendation by the dietitian to obtain a reweight to verify accuracy of the weights (referring to the 04/02/23 weight of 194.6 lbs, as there were no other weights documented in the medical record through the dietitian's note on 04/10/23). Review of the physician progress notes dated 02/12/23, 03/02/23, and 04/09/23 and authored by Physician #378 revealed Resident #71 did not have any edema, was not being treated with diuretic medication and there was no reference to her weight of 194.6 lbs on 04/02/23. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE], revealed Resident #71 had severe cognitive impairment and was receiving an enteral tube feeding with water flushes through a PEG tube. This assessment included the feeding method provided 51% or more of the resident's calories and 501 cubic centimeter (cc) or more of fluids through the PEG tube. On 04/14/23 a new order was received for Diabetisource 1.2 at 40 ml/hr with the same water flush of 30 ml/hr from 9:00 P.M. to 7:00 A.M. The bolus feedings also remained as ordered on 03/06/23. On 04/17/23 the resident was noted to weigh 180.2 lbs. This was noted to be an unplanned, severe weight loss of 29.2 lbs/13.9 percent from 03/21/23 to 04/17/23 for the resident. On 04/19/23 a re-weight was obtained of 182.6 lbs which continued to reflect a severe weight loss of 26.8 lbs. or 12.7%. A nutritional assessment dated [DATE] and authored by Registered Dietitian (RD) #327 revealed Resident #71 had estimated caloric needs of 1500-1800 per day, 50 to 80 grams protein per day and 1500 ml to 1800 ml fluid per day. With the resident receiving 40 ml of nocturnal enteral feeding of Diabetisource 1.2 over 14 hours, 30 ml water flush over 14 hours, and 250 ml bolus of Diabetisource 1.2 with a 120-cc water flush two times a day, Resident #71 was receiving 1272 kcal, 63 grams of protein, 1524 cc from flushes and tube feeding. Per RD #327, the tube feeding, and flush rate was meeting 85% of the resident's low end of estimated caloric needs of 1500. (It was important to note the tube feeding was meeting 70% of the high end of the estimated daily calorie needs of 1800 calories per day which over time would cause a caloric deficit to support weight loss). RD #327 noted 100% of the low end of estimated protein and fluid needs were being met. (It was also important to note the water flushes were meeting 70% of the high end of the estimated daily fluids which over time could cause a hydration deficit in the body leading to dehydration). The note indicated Resident #71 had lost 6.5 percent between 03/01/23 and 04/02/23 for a significant weight loss. RD #327 recommended to increase Diabetisource to 70 ml for 14 hours which would provide 1176 calories, continue bolus as ordered 250 ml twice a day to provide 600 kcal/500 ml for a total of 1776 kcal, 84 g protein, and 1142 ml free water. RD #327 charted this would meet Resident #71's estimated needs. Review of Resident #71's physician's orders revealed Diabetisource 1.2 was increased to 70 ml/hr on 04/17/23. No changes were made to the Diabetasource 1.2 bolus twice a day and no changes were made to the (water) flushes. Review of laboratory testing for Resident #71, dated 04/19/23, revealed a critically high serum sodium level of 163 milliequivalents per liter (mEq/l) with the normal serum sodium level reference of 135 to 148 mEq/l. An elevated serum sodium level can be an indicator of underhydration. Hypertonic dehydration happens when you lose water from your body but don't lose an equal quantity of electrolytes, specifically sodium. You will have high sodium concentration in your blood and other body fluids. Review of a progress note, dated 04/19/23, revealed the facility had received a call from the lab that Resident #71's sodium level was 163. Nurse Practitioner (NP) #328 was notified with a new order to hold bolus feeds and flushes at this time and start tube feeding of Diabetisource 1.2 continuous at 75cc/hr with water flush at 150cc/hr for two days. Review of Resident #71's physician's orders revealed on 04/19/23 an order was written at 1:00 P.M. to hold Diabetisource 1.2 at 70ml/hr with 30 ml water flush from 7:00 P.M. to 9:00 A.M. and the Diabetisource 250 ml bolus with 120 cc water flush and start Diabetisource 1.2 continuous at 74 cc/hr (this order for the rate of 74cc/hr did not match the 75cc/hr order given by the NP as documented in the 04/19/23 progress note) with 150 ml water flushes every hour for two days. On 04/19/23 at 5:00 P.M. an order was written to decrease the water flush to 100 ml/hr for 24 hours. Review of Resident #71's labs revealed on 04/24/23 the sodium level had improved to 152 mEq but remained elevated. Review of physician's orders for Resident #71 revealed on 04/24/23 water flushes were changed to 100 ml/hr overnight from 7:00 P.M. to 9:00 A.M. Review of a 04/24/23 Significant Change Nutritional Assessment revealed RD #327 charted 04/24 Na H (sodium high) under the lab results section of the assessment, a weight of 182.9 pounds on 04/24, and that weight trends were difficult to assess at the time due to possible scale error. The assessment indicated the resident appeared well hydrated but did not give any specific physical characteristics of the resident to explain how this was assessed. RD #327 indicated the resident was tolerating her tube feeding and 100% of her nutrition and hydration needs were being met. Review of Resident #71's progress note dated 05/01/23 revealed a sodium level of 139 mEq had improved to within normal range. NP #326 gave a new order to decrease the water flush to 50 cc/hr from 7:00 P.M. to 9:00 A.M. Review of Resident #71's physician's orders revealed on 05/01/23, water flushes were decreased to 50 ml/hr from 7:00 P.M. to 9:00 A.M. On 07/11/23 at 11:42 A.M. an interview was conducted with RD #327 who verified Resident #71 had a severe, unplanned weight loss related to a data entry error for the tube feeding orders initiated on 03/07/23. RD #327 explained Resident #71's enteral tube feeding administration rate was incorrectly entered at 30 cc/hr on 03/07/23 when it should have been entered at a higher rate of 70cc/hr on 03/07/23. RD #327 verified on 04/14/23, the rate was increased to 40cc/hr. RD #327 explained Diabetisource 1.2 at 30cc/hr continuous and at 40cc/hr did not meet the full range of Resident #71's nutrition or hydrational needs. RD #327 was unaware the enteral order had been entered incorrectly until it was pointed out to her when Resident #71 was found to have lost a significant amount of weight on 04/17/23. RD #327 explained the tube feeding rate was then increased to Diabetisource at 70 cc/hr. RD #327 stated residents on tube feeding should be weighed weekly, however, Resident #71 had not been weighed weekly between 04/02/23 and 04/17/23. RD #327 stated she gave nursing a list of the residents who needed to be weighed weekly, but she never received the completed list back. RD #327 said if Resident #71 had been weighed weekly as she should have been, the error may have been caught sooner. RD #327 verified Resident #71 was not on a physician ordered weight loss plan and the severe weight loss was not a planned weight loss. Observation on 07/12/23 at 11:15 A.M. of Resident #71 revealed an elderly woman who was alert but disoriented to person, place and time. She was unable to answer simple yes/no questions and was dependent on staff to provide her nutrition and hydration needs via PEG tube. Interview on 07/12/23 at 12:04 P.M. with Nurse Practitioner (NP) #328 revealed NP #328 was informed by the facility that Resident #71 had a significant weight loss identified on 04/17/23 and a critically high sodium level of 163 on 04/19/23. NP #328 verified Resident #71's weight loss and hydration issues required changes to her fluid and enteral feedings. The NP revealed Resident #71 was less alert when the Diabetasource 1.2 was running at 30ml/hr and then 40ml/hr with a flush of 30cc/hr from 7:00 P.M. to 9:00 A.M. between 03/07/23 to 04/17/23. Review of the facility policy titled Resident Weight, revised 05/19/16, revealed resident's weight would be accurately obtained within 24 hours of admission, with a significant change or as ordered by the physician. Weekly weights for four weeks would be obtained on new admissions and residents with unstable weights would be reviewed by the IDT (interdisciplinary team) to determine weekly or other frequency of weights. Residents on tube feedings would be weighted weekly unless otherwise ordered. A plus or minus five-pound weight change in one week would indicated the need for a reweight in 24 hours and notification to the physician, family and IDT is there was a plus or minus five pound confirmed change in weight. Weight loss concerns would be discussed at weekly clinical meetings. Review of the facility policy titled General Enteral Feeding Guideline, revised 08/12/16, revealed residents would be weighed weekly, water flushes would include the rate and interval, nutritional feeding would include the type, strength, amount and rate of the formula and feeding bolus or intermittent feeding would include the type, strength, amount and rate of the formula. The deficient practice was corrected on 04/19/23 when the facility implemented the following corrective actions: • On 04/17/23 chart audits were completed on all resident with nutritional feeding. All residents had the correct orders, were receiving the correct amounts of formula, flushes and gastric residual and tube placement checks were signed off as completed. Also, charts were audited for timely assessments at a minimum of once per month by the dietitian and all of the resident audits were found to be completed appropriately. • On 04/18/23 the DON provided education to RD #327 on enteral feeding orders and the policy and procedures for general enteral feeding and resident weights. • On 04/19/23 the DON provided education to 32 nurses on the list of weekly weights and consistent technique of obtaining resident weights, timely completion of weights, scale types in the facility and accuracy of confirming tube feeding orders to include type and strength of the formula, rate of the formula and water flushes, caloric needs, mechanism of administration, and orders for residual checks and tube placement. • On 04/19/23 the DON reviewed the policies and procedures for general enteral feeding guidelines and resident weights with the 32 nurses. • Beginning on 04/24/23 the facility implemented a plan for weekly chart audits which continued through 05/22/23. All residents were found to have correct orders, correct amounts of enteral feeding formula, flushes and gastric residual checks. In addition, tube placement checks were signed off as completed. Also, charts were audited for timely assessments at a minimum of once per month by the dietitian and found to be complete. • There were no further residents experiencing unplanned, significant weight loss related to incorrect data entry of the tube feeding orders from 04/17/23 through the date of this survey on 07/11/23. This deficiency represents non-compliance investigated under Complaint Number OH00144121.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to develop and implement a comprehensive and individualized restorative range of motion plan for Resident #94 to prevent a decline in range of motion and to prevent the development of hand contractures. Actual Harm occurred on 10/12/21 when Resident #94, who was admitted with no impairment in functional range of motion to his bilateral upper extremities developed contractures to both hands, increased pain with hand movement and the loss of function. Prior to the development of the contractures, the facility failed to develop a comprehensive and individualized plan of care for restorative nursing services, failed to consistently implement therapy recommended range of motion (ROM) services and failed to timely identify, report and implement new interventions for the resident to prevent the contractures and then adequately treat limitations in range of motion. This affected one resident (#94) of two residents reviewed for range of motion. Findings Include: Review of Resident #94's medical record revealed an admission date of 02/04/21. Resident #94 had diagnoses including cerebral infarction, type 2 diabetes mellitus, developmental disorder and obesity. A clinical admission evaluation, dated 02/05/21 indicated Resident #94 was able to move all extremities. There was no impairment in functional range of motion (ROM) of the upper or lower extremities. An Occupational Therapy (OT) evaluation, dated 02/06/21 indicated ROM of both upper extremities was within functional limits. An OT Discharge summary, dated [DATE] indicated Resident #94 was referred to restorative nursing for a ROM program for both upper extremities. Record review revealed no restorative plan of care was developed or initiated following the resident's discharge from therapy. Active range of motion (AROM) was added to the electronic task bar to be to be provided by staff but did not indicate a frequency or what joints were to be included. An admission Minimum Data Set (MDS) 3.0 assessment, dated 02/11/21 indicated Resident #94 had no impairment in functional ROM in upper extremities but did have impairment of functional ROM in both lower extremities. Review of the monthly restorative AROM delivery records revealed the following: • March 2021 records revealed two days of refusals and one day with no documentation of AROM being offered/provided. • April 2021 records revealed four days of refusals and 13 days with no documentation of AROM being offered/provided. • May 2021 records revealed one day of refusal and 19 days with no documentation of ROM being offered/provided. • June 2021 records revealed 23 days with no documentation of AROM being offered/provided and one day of which staff documented ROM services were not applicable. • July 2021 records revealed two days of refusals, 11 days with no documentation of AROM being offered/provided and three days marked not applicable. • August 2021 records revealed nine days with no evidence of AROM being offered. • September 2021 records revealed 16 days with no evidence of AROM being offered. • October 2021 records revealed one refusal and 22 days with no evidence of AROM being offered. Review of a nurse practitioner progress note, dated 10/12/21 revealed Resident #94's hands had contractures. The degree of contracture was not indicated and no plan was documented to address the contractures at that time. In addition, there was no evidence the resident was referred to therapy for an evaluation of the contractures and no evidence the previous therapy recommended ROM program was evaluated for effectiveness. Continued review of the monthly restorative delivery revealed November 2021 records reflected 19 days with no evidence of AROM being offered. December 2021 records revealed 12 days with no evidence of ROM being offered. Resident #94 was in the hospital from [DATE] to 12/31/21 (not included in the 12 day count). A skin/wound note, dated 01/04/22 at 1:37 P.M. revealed Resident #94 had decreased ROM and contractures, including of the fingers of both hands. A therapy screen, dated 01/10/22 indicated Resident #94 had increased stiffness in his upper extremities and determined an OT evaluation was indicated. An OT evaluation, dated 01/10/22 indicated the evaluation was completed based on an OT screen for contractures of both hands. Resident #94 had limited functional use of his upper extremities. Resident #94 was assessed with pain at a severity of 5 on a scale of 0-10 (with 10 being the worst pain) when passive ROM was completed to his hands. Upper extremity muscle tone was hypertonic (stiff, difficult to move). Resident #94 had a decreased ability to grasp/release items and was at risk for skin breakdown of his palm. The evaluation indicated OT services were required to increase finger ROM, provide appropriate splints and to design, implement a restorative nursing program, and decrease painful condition of the upper extremities in order to enhance Resident #94's quality of life. An OT Discharge summary dated [DATE] indicated recommendations for a right hand palm guard and passive ROM (PROM). On 02/07/22 at 9:25 A.M. Resident #94 was observed lying in bed with contractures of both hands. A palm protector was in place in the right hand. On 02/07/22 at 1:24 P.M. interview with Resident #94's guardian revealed Resident #94 did not have contractures prior to his admission to the facility. On 02/09/22 at 11:30 A.M. interview with Occupational Therapist (OTR) #1180 revealed therapy screened residents on a quarterly basis. It was during a screen on 01/10/22 Resident #94 was assessed with hand contractures. When asked if the facility had any interventions in place prior to development of the hand contractures to maintain ROM, OTR #1180 stated she did not think so because the resident did not have the tone he used to. OTR #1180 revealed Resident #94 had no functional use of his left hand now and use of his right hand varied. OTR #1180 revealed no one had previously reported a decline in ROM to Resident #94's hands or referred him to therapy for evaluation (prior to the screening done by therapy on 01/10/22). On 02/09/22 at 12:04 P.M. interview with Nursing Assistant (NA) #1090 revealed Resident #94 was totally dependent on staff for all care. NA #1090 revealed she had worked at the facility four months and Resident #94's hands had contractures the entire time. NA #1090 revealed she was unaware Resident #94 was supposed to receive ROM services. On 02/09/22 at 12:20 P.M. interview with State Tested Nursing Assistant (STNA) #820 revealed when Resident #94 was admitted he had limitations in finger ROM of about 10 degrees. STNA #820 revealed she had provided ROM to Resident #94's hands but believed the contractures happened quickly within a few months time. STNA #820 stated she recognized the fingers were getting tighter and tighter until the resident had contractures. When asked if there had been a referral to therapy when the decline was noted STNA #820 offered no additional response. On 02/09/22 at 12:39 P.M. interview with Licensed Practical Nurse (LPN) #235 revealed Resident #94 had received restorative services off and on. During the interview, LPN #235 revealed ROM programs were supposed to be provided every day. On 02/09/22 at 1:33 P.M. interview with the Director of Nursing (DON) revealed she had been working at the facility for seven months and Resident #94 had contractures of his hands for at least that long. The DON verified restorative records did not reveal Resident #94 received ROM services consistently. On 02/09/22 at 1:57 P.M. interview with the DON revealed the facility had a lot of staff turnover and staff probably did not recognize the decline in ROM in order to refer Resident #94 to therapy for services sooner. The DON was unable to provide an explanation as to why the restorative program remained a program for active ROM instead of a change to passive ROM when staff started noting contractures. On 02/10/22 at 7:10 A.M. interview with Certified Nurse Practitioner (CNP) #1200 revealed she noticed Resident #94 exhibiting weakness in July 2021 and first identified the hand contractures in October 2021. CNP #1200 revealed Resident #94 was sickly when he was admitted and progressively worsened. When asked if she believed the contractures were unavoidable she stated not necessarily.