**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of the medical record for Resident #44 revealed an initial admission date of 12/27/21 and a re-entry date of 07/16/23. Diagnoses included Bipolar disorder with current episode manic severe with psychotic features, schizoaffective disorder, bipolar type, dementia with other behavioral disturbance, psychotic disorder with delusions, lack of coordination, and need for assistance with personal care. Review of the plan of care (dated 09/14/23) revealed Resident #44 was at risk for falls and/or injuries related to a lack of coordination. Interventions included to encourage to allow staff to carry items when walking, the use of a call light, and to ensure room is free from accident hazards. Review of Resident #44's quarterly Minimum Data Set (MDS) 3.0 assessment (dated 10/16/23) revealed a Brief Interview for Mental Status (BIMS) score of 04 indicating a severely impaired cognition for daily decision making abilities. Resident #44 was also noted to experience hallucinations. Observation of Resident #44 on 11/20/23 at 10:45 A.M. revealed the resident was using an electrical curling iron in private room to curl her own hair with no assistance from facility staff. Continued observation revealed STNA #300 entering Resident #44's room, observing resident in bathroom using electrical curing iron to curl her hair, telling the resident her hair looked nice, and exiting the resident's room. Interview with STNA #300 on 11/20/23 at 10:50 A.M. revealed she didn't know Resident #44 had a curling iron but she thinks one of her family members brought it in for her to use. Interview on 11/20/23 at 11:00 A.M. with the DON revealed no knowledge of the resident having a curling iron but someone would check on this. Observation on 11/20/23 at 11:05 A.M. revealed STNA #302 entering Resident #44's room and shortly after wards exiting the resident's room with the electrical curling iron in his hand. Review of the progress note dated 11/20/23 at 5:06 P.M. created by the DON revealed, Resident noted to have curling iron in room this morning and curling hair. Removed curling iron from room and educated resident we would leave at nurses station and she can come get it daily to curl hair and to have staff help her with this task to prevent any injury. Resident feels she can curl her hair by self and appropriately. Resident did agree to letting us keep the curling iron. Resident was assessed and no injury or anything noted from having curling iron. Medical Director (MD) and responsible party made aware. Based on observation, record review, review of the facility's fall investigation, staff interview, and policy review, the facility failed to ensure Resident #55 was provided the assistance needed to prevent an avoidable fall from occurring that resulted in major injury to the resident and failed to ensure Resident #44's room was free of a safety hazard (an electrical heated curling iron). This affected two residents (#55 and #44) of three residents reviewed for accidents. The facility census was 65. Actual harm occurred on 09/26/23 when Resident #55, who was severely cognitively impaired was observed ambulating in the hall, without the use of her walker, and was only educated by a staff member that she needed her assistive device when ambulating. At the time of the incident, Resident #55 was encouraged to return to her room, without being provided the appropriate staff assistance needed and fell fracturing her left hip requiring surgical repair Findings include: 1. A review of Resident #55's medical record revealed she was admitted to the facility on [DATE]. Her diagnoses included unspecified dementia, muscle weakness, unsteadiness on her feet, lack of coordination, and need for assistance with personal care. Her diagnoses list was updated to reflect she had a displaced fracture of the base of the left femur that was added on 10/02/23. A review of Resident #55's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident's cognition was assessed as being severely impaired. She was sometimes able to understand others and was sometimes able to make herself understood. She required supervision with the physical assist of one for ambulation in her room and in the corridor. Balance issues were indicated to be present with transfers and ambulation but the resident was able to stabilize herself without the assistance of staff. A walker was listed as the only mobility device being used at that time. A review of Resident #55's care plans revealed she was at risk for falls related to unsteadiness on her feet, lack of coordination, and a closed fracture of the left femur. Interventions included visual cues in room to remind the resident to use call light, educate resident on safety interventions, encourage the resident to keep needed items within reach, encourage the resident to use her call light, and to place call light in reach. A review of Resident #55's progress notes revealed a nurse's note dated 09/26/23 at 10:06 P.M. by Registered Nurse (RN) #120 that indicated she was walking up from the back hall of B unit to go answer a phone call. On her way up, she saw Resident #55 fall. Resident #55 landed on her left hip. The resident was ambulating without the use of her walker. She was sent out to the emergency room for an evaluation and was transported to another local hospital with the diagnosis of a left hip fracture. She remained in the hospital until her return to the facility on [DATE]. A review of the facility's fall investigation for Resident #55's fall that occurred on 09/26/23 revealed the fall occurred on 09/26/23 at 8:05 P.M. She resided on the front hall of the B unit at the time the fall occurred. The nurse's description of the fall revealed the same information the nurse documented in her progress note on 09/26/23 at 10:06 P.M. In addition, the nurse further indicated an aide was present speaking to another resident when Resident #55 walked up. The aide gave Resident #55 a verbal cue and encouraged the resident that she needed to have her walker. Resident #55 walked off while the aide's back was turned towards her as the aide continued to speak with the other resident. Resident #55 then fell. When assessed for injuries, Resident #55 complained of left hip pain. The physician was notified and an order was received to send the resident to the emergency room. Injuries observed at the time of the incident was a fracture of the left hip. Predisposing factors of the fall included confusion, impaired memory, gait imbalance, and weakness. Predisposing situational factors included ambulating without assistance. Witnesses to the incident included RN #120 and State Tested Nurse Aide (STNA) #125. STNA #125's statement regarding the fall revealed Resident #55 had walked up to her while she was talking to another resident. She reminded the resident that she needed her walker. The resident then went walking towards her room. She turned around from talking to the other resident and observed Resident #55 on the floor by the nurse's station. She further indicated on a statement given on 09/29/23 that Resident #55 brought her bowl from her snack while she was talking with another resident. She asked the resident where her walker was because she needed to use it. She told the resident she needed to have it. The aide then reported she turned around to finish with the other resident for maybe two seconds and turned back around seeing Resident #55 on the floor. A review of Resident #55's hospital records for her hospital stay between 09/26/23 and 10/02/23 revealed a history and physical from the hospitalist revealed the resident presented to the emergency room for complaints of a fall. She was noted to have fallen from a standing position onto the floor and complained of left hip pain that was worse with movement. A CT scan of her left hip revealed a left femoral neck fracture with superior and anterior displacement of the distal components with compaction. Morphine had been given twice in the ER for pain. Her diagnosis was as indicated on the CT scan. An orthopedic follow up was ordered. The plan was for her to have a left hemiarthroplasty performed on 09/27/23 pending medical clearance and surgical risks were acceptable. On 11/22/23 at 3:00 P.M., an interview with STNA #125 confirmed she was on duty 09/26/23 when Resident #55 had her fall. She reported the resident resided on the front hall of B unit at the time the fall occurred. They had passed her a snack and the resident came walking out of her room to take the bowl back to the snack cart. The snack cart was on the back hall of B unit just past the nurse's station (approximately 65 feet from the resident's room). The aide was on the back hall of B unit talking to another resident when she observed Resident #55 walking without a walker. She reminded the resident she needed to have her walker when ambulating. The resident fell while she was walking back to her room. The aide had her back to the resident when she fell as she continued to talk to the other resident she had previously been engaged in a conversation with. She denied she stopped talking with the other resident to immediately assist Resident #55, after she observed her walking without her walker. She received education from the facility's administrative staff (after the incident occurred) informing her she should have intervened and assisted the resident when she noted her to be walking without her assistive device. The facility's administrative staff also told her she should not have continued talking with the other resident while failing to assist Resident #55 with returning safely to her room. On 11/22/23 at 3:25 P.M., an interview with the Director of Nursing (DON) confirmed Resident #55 did have a fall on 09/26/23 that resulted in a hip fracture. The fall investigation showed Resident #55 fell while ambulating without the use of her walker. STNA #125 observed the resident ambulating without her walker and did not provide the immediate assistance needed to prevent the fall from occurring. They provided education to the aide, as well as all other staff. The education provided included the following: If they see a resident ambulating without an assistive device that was needed, they were to wait with the resident while someone else went to get the assistive device. They were not to tell the resident that they needed to go get the assistive device and leave them unattended. Safety was to come first. A review of the facility's Fall Prevention Program policy (revised 10/26/23) revealed each resident would be assessed for the risks of falling and would receive care and services in accordance with the level of risk to minimize the likelihood of falls. Each resident's risk factors and environmental hazards would be evaluated when developing the resident's comprehensive plan of care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of a self reporting incident (SRI), medical record review, resident interview, staff interview and policy review, the facility failed to ensure one resident (Resident #65) was free from physical abuse. This affected one of six residents reviewed for abuse. Actual Harm occurred to Resident #65 when Resident #1, who was known to be aggressive and wander throughout the facility, entered her room and struck the resident with a closed fist multiple times resulting in a hematoma to her left forehead, a bloody nose and a black eye. Findings include: 1. A review of self reporting incident (SRI) #229111 revealed an allegation of physical abuse was reported on 11/12/22. The initial source of the investigation was a staff member and the alleged perpetrator was another resident. The involved residents were identified as Resident #1 (alleged perpetrator) and Resident #65 (alleged victim). Resident #1 was not able to provide any meaningful information when interviewed. Her relevant conditions included unspecified psychosis, major depressive disorder, and schizo-affective disorder. Resident #65 was indicated to have been able to provide meaningful information when interviewed. The date/time and location of the occurrence was on 11/12/22 at 2:09 P.M. in a resident's room. The narrative summary of the incident revealed staff heard residents yelling. When staff went into Resident #65's room, they noted her to be grabbing Resident #1's shirt. The staff also noted blood on Resident #65's face and on Resident #1's hand. The staff immediately separated and removed Resident #1 from the room and placed her on one on one supervision. Resident #1 had a BIMS score of 3 (cognition severely impaired) and had a history of wandering about the facility in her wheelchair. Resident #65 stated that Resident #1 came into her room and was attempting to take the remote control and a sandwich that were located on her bed. Resident #65 was in her wheelchair by her bed and attempted to redirect Resident #1. She was struck in the face by Resident #1. Both residents' skin was assessed and no injuries were noted to Resident #1. Resident #65 was noted to have a hematoma to the left upper eye brow, an abrasion under her left eye, a small abrasion to the left chest, and a bloody nose. Neuro checks were completed immediately on Resident #65 and continued for 72 hours with no adverse reaction noted. Resident #65 was indicated to have a BIMS of 15 (cognitively intact). She was indicated to not be fearful, afraid or tearful when the incident occurred. Resident #65 had been followed by social services and had not voiced any concerns since the incident occurred. Resident #1 was placed on one on one supervision until she was sent to the emergency room for a psychiatric evaluation. Resident #1 was admitted to the hospital for inpatient geri-psych services. Skin assessments were completed on all residents with a BIMS score under 10 (cognition moderately to severely impaired) and all residents with a BIMS score above 10 (high end of cognition being moderately impaired to being cognitively intact) were interviewed. No additional issues were noted as a result of those skin assessments and interviews. The physician and responsible parties for both residents were made aware. The facility unsubstantiated the allegation of abuse as Resident #1 was deemed to lack the capacity to understand consequences to her actions. The facility's DON was identified as the facility's investigator and the incident was reported to the local sheriff's department. As a result of it's investigation, the facility indicated they placed Resident #1 on one on one supervision and she was sent to the emergency room for a psychiatric evaluation. She was later admitted . Treatments were ordered and ice was applied to Resident #65's new areas. Social services was following Resident #65 for any concerns. Neuro checks were started immediately and continued for 72 hours with no adverse reactions noted. The facility's investigation included an incident report completed by Licensed Practical Nurse (LPN) #7 for an incident involving Resident #65 that occurred on 11/12/22 at 2:09 P.M. The incident report included an incident description which indicated the resident (Resident #65) was hit by another female resident (Resident #1) on the left forehead causing a large hematoma that was raised and purple in color. She was also indicated to have sustained a small abrasion under her left eye, a small abrasion on the right chest, and moderate bleeding from the nose. Cold compresses were applied to stop the bleeding and ice was applied to the hematoma to the head. The resident's description of the incident revealed the other resident was trying to take her sandwich and remote control. When Resident #65 started to stop her, the other resident started hitting her with her first. Immediate action taken included staff entering the room and redirecting the other resident out of the room. She (other resident/Resident #1) was angry and yelling at the staff while trying to hit them. She was assisted over to B- Hall, where she resided, and passed to the staff on that hall. Witnesses identified on the incident report included State Tested Nurse Aide (STNA) #11 and Resident #60 (roommate of Resident #65). STNA #11 reported in her statement that she overheard residents yelling so she went into Resident #65's room. She saw Resident #65 have a hold of Resident #1's shirt. Resident #1 was taking objects from Resident #65. Resident #65 had blood on her face, arms, and clothing and there was blood on the floor. Resident #65 stated Resident #1 hit her multiple times in the face with her hand when she told her not to take her belongings. A statement from Resident #60 (as documented on the incident report) revealed she was the only witness to the incident. She reported the other resident (Resident #1) came in the room and attempted to take a sandwich and TV remote. The other resident then started to hit Resident #65 with her fist when she tried to stop her. The incident report indicated the Director of Nursing (DON) was notified of the incident on 11/12/22 at 2:09 P.M. An incident note on behalf of Resident #1 dated 11/12/22 at 2:09 P.M., as completed by the Director of Nursing (DON) revealed she was alerted by staff that Resident #1 had hit Resident #65 while Resident #65 was in her room. Resident #65's sandwich and remote were in place on her bed. Resident #1 was not able to give a description of the incident. Immediate action taken included immediately removing Resident #1 from the room and returning her back to her room while being placed on one on one supervision. The physician was notified and an order was received for her to be sent to the emergency room for an evaluation and treatment. The hospital called at 8:06 P.M. and reported Resident #1 was being admitted to the psychiatric unit. Witnesses were indicated to be Resident #65 and STNA #11. Resident #65 indicated in her statement (as documented on the incident report) she (Resident #1) was trying to take her (Resident #65's) stuff and when she told Resident #1 to stop, Resident #1 started to hit her. STNA #11's statement was the same that was on the incident report completed on behalf of Resident #65. She also indicated she removed Resident #1 from the room and notified the nurse. The facility's investigation file included written statements from STNA #11 and STNA #15. Both were assigned to work Resident #65's hall the afternoon of 11/12/22, when the incident between Resident #1 and Resident #65 occurred. A written statement from STNA #11 dated 11/12/22 revealed she overheard residents yelling so she went into Resident #65's room. She saw Resident #65 have a hold of Resident #1's shirt. Resident #1 was taking objects from Resident #65. Resident #65 was noted to have blood on her face, arms, clothing and floor. Resident #65 stated Resident #1 hit her multiple times in the face with her hand when she told her not to take her belongings. A written statement from STNA #15 dated 11/12/22 revealed he heard screaming from Resident #65's room. He went into the room and the other aide (STNA #11) broke them up. He didn't see any behaviors leading up to that before the incident happened. Additional written statements were obtained from STNA #11 and STNA #15 on 11/16/22. The statement from STNA #11 revealed she was asking Resident #65 how she was feeling since the incident with the other resident (Resident #1). At that time, she alleged Resident #65 told her she grabbed the other resident's (Resident #1) shirt first because she was taking her sandwich. That was when the other resident hit her in the face. The second written statement from STNA #15 revealed Resident #65 told him, when he was getting her up that morning, that she (Resident #65) grabbed her (Resident #1's) shirt first. 1 (a). A review of Resident #65's medical record revealed the resident was admitted to the facility on [DATE]. Her diagnoses included glaucoma, bilateral cataracts, hemiplegia and hemiparesis affecting unspecified side following a CVA, schizo-affective disorder, generalized anxiety disorder, borderline personality disorder, adjustment disorder with anxiety, bipolar disorder, and rheumatoid arthritis. A review of Resident #65's quarterly Minimum Data Set (MDS) assessment completed 09/07/22 revealed the resident did not have any communication issues and her vision at that time was moderately impaired. Her cognition was moderately impaired with a BIMS score of 11. She was not known to have displayed any behaviors. She required an extensive assist of two for transfers. Ambulation did not occur. She required a limited assist of one for locomotion on the unit and a wheelchair was listed as a mobility device used. A review of Resident #65's progress notes revealed a nurse's note dated 11/12/22 and documented at 3:34 P.M. that indicated the resident was sitting in her room when another resident came in. The other resident was trying to take her sandwich and remote. The resident's roommate yelled and Resident #65 tried to stop her. The other resident started hitting Resident #65 with her fist. The staff responded and assisted the other resident out of her room. A large hematoma was noted to the left forehead, she was noted to have a bloody nose and abrasions were noted under her left eye and to her right chest. 1 (b). A review of Resident #1's medical record revealed she was admitted to the facility on [DATE]. Her diagnoses included unspecified psychosis, major depressive disorder, schizo-affective disorder, and vascular dementia with behavioral disturbances. A review of Resident #1's quarterly MDS dated [DATE] revealed the resident had clear speech and her cognition was severely impaired. She was known to have delusions but not indicated to have any other behaviors. She required an extensive assist of two for transfers. Ambulation did not occur. She required supervision with one person assist for locomotion on and off the unit and a wheelchair was listed as a mobility device used. A review of Resident #1's active care plans revealed she had a care plan in place for having the potential to be physically aggressive or agitated related to dementia. The care plan had been in place since 07/11/22. The goal was for her to not harm herself or others. Interventions included administer medications as ordered, analyze times of day/ places/ circumstances/ triggers/ and what de-escalates behaviors and document, monitor/document/report as needed any signs or symptoms of the resident posing a danger to herself and/or others, and obtain psychiatric consult as indicated. Resident #1 also had a care plan for exhibiting inappropriate social behavior of impulsiveness, at times difficult to redirect, careless in wheelchair, wanders throughout hallways, argumentative with staff and physical aggression towards staff and residents. The care plan was updated 11/15/22 to reflect a resident to resident altercation. The goal was for the resident's inappropriate behaviors would be managed. The interventions included during episodes of socially inappropriate behavior, redirect by staff, observe for change or increase in agitation, one on one (11/15/22), send to emergency room for inpatient psychiatric stay (11/15/22), and separate from others when demonstrating socially inappropriate behaviors (05/22/20). Resident #1 also had a care plan for being disoriented to place, impaired safety awareness, and wanders aimlessly. The goal was for her safety to be maintained. The interventions included distract the resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book, maintain consistent daily routine and consistent bedtime routine, and use of a wander alert as ordered. A review of Resident #1's physician's orders confirmed she had an order to send her to the emergency room (ER) on 11/12/22. She was to be one on one until she was able to be sent to the ER. The physician's orders also indicated the resident was being monitored for physical aggression, increased agitation, wandering in hallways, carelessness in wheelchair, and increased agitation of other residents as target behaviors. A review of Resident #1's progress notes revealed the facility had been seeking alternate placement at other nursing facility's following the resident's return from the hospital on [DATE]. Her family was in agreement for seeking alternate placement and referrals had been made. On 11/17/22 at 12:53 P.M., an interview with Resident #60 (roommate of Resident #65) revealed she was witness to the alleged incident that occurred between Resident #1 and Resident #65 on 11/12/22. Resident #1 came into their room while Resident #65 was sitting in her wheelchair by her bed. Resident #1 grabbed a hold of Resident #65's sandwich and wouldn't listen when she was told to let go of it. Resident #1 then hit Resident #65. She denied Resident #65 grabbed Resident #1 and claimed Resident #65 just told her to leave her alone. She reported Resident #1 had a closed fist when hitting Resident #65 and Resident #65's nose was bleeding. Resident #1 had been known to come in their room before, but she had not known her to hit anyone before. On 11/17/22 at 12:58 P.M., an interview with Resident #65 confirmed Resident #1 came into her room on 11/12/22. She reported she was blind and could not see but her roommate told her that woman (Resident #1) was in there. She stated she pushed Resident #1 away in her wheelchair. She denied touching her when pushing her wheelchair away. She was asked if she had grabbed Resident #1's shirt during the incident. She admitted that she had, but it was after trying to push her away. When she pushed Resident #1 away, that was when Resident #1 began beating her with her fist. She then stated she grabbed Resident #1's shirt after Resident #1 started hitting her. She just wanted the resident to go away as the resident was hurting her. She claimed she was hit six times and her nose and mouth was bleeding. She pulled down her shirt to reveal the abrasion that remained on her right chest. Her left eye was still black/ blue around the eye. She denied she was afraid since Resident #1 left the facility but it was still shocking to her. She stated she would be afraid if the resident returned. She had not been informed of the other resident's return and kept asking if she had. She reported Resident #1 had a history of coming into her room before the latest incident took place. She claimed the other resident has pushed her before but that was the first time she had beat her. She denied that she recalled telling staff on 11/16/22 that she grabbed the other resident's shirt first. She said again she did grab her shirt at one point but was not exactly sure when it occurred as it all happened so fast. On 11/17/22 at 1:12 P.M., an interview with STNA #15 revealed he was there on 11/12/22, when the incident occurred between Resident #1 and Resident #65. He was assigned to Resident #65's hall that night. He stated he heard screaming from Resident #65's room. His coworker (STNA #11) was the first in the room and had already separated them. He stated he grabbed Resident #1 and took her back to her hall. He noticed Resident #65 was bleeding. He stated Resident #65 told him she grabbed Resident #1 first by her shirt. He thought the other resident had a trigger about being grabbed. If she would not have grabbed Resident #1, then Resident #1 would not have hit her. He then stated there would be no way to know that for sure. He confirmed he did write up statements on the incident at the time of the incident but had given a second statement four days when Resident #65 told him she grabbed Resident #1 first. He claimed the conversation about Resident #65 grabbing Resident #1 first was brought up by Resident #65 when they were providing her with care. She told him she grabbed the other resident first. He was asked about his initial statement he gave indicated that Resident #65 told him when he entered the room on 11/12/22 that she had grabbed Resident #1 first. He denied saying that and indicated he must have been misunderstood as it was not until four days later (11/16/22) that Resident #65 told him that. He denied he was asked to provide the second written statement given on 11/16/22 by anyone else. On 11/17/22 at 1:20 P.M., an interview with STNA #11 confirmed she was working A- Hall when the incident between Resident #1 and #65 took place. She reported she was the first one there and separated the residents. She recalled being down the hall when she heard screaming. She heard Resident #65 say give me my sandwich back. When she got there, Resident #65 had blood all over her and had a hold of Resident #1's shirt. Resident #1 had Resident #65's sandwich and remote control in her hand. She stated she told Resident #65 to let go of Resident #1's shirt. She then told Resident #1 to give Resident #65 her remote control. She reported, at that point, the sandwich was already on the floor. Resident #1 was yelling back at her and was saying that was her sandwich. After the residents were separated, she stepped out in the hall and called for the nurse (LPN #7). Her coworker (STNA #15) took Resident #1 out of the room. A nurse from B- Hall came and got Resident #1 and LPN #7 assessed Resident #65. She began assisting with cleaning up Resident #65. She asked Resident #65 to remove her dentures as she had blood coming from her mouth. Resident #65 reported being hit four to five times but her roommate had said she was hit only twice. Resident #1 was known to wander into rooms and take things. It was mainly remote controls that she tried to take but had been known to try to take other things such as candy too. She had known Resident #1 to be aggressive. She was known to grab staff during care and run her wheelchair into other residents. She confirmed she had been known to hit staff before but couldn't recall her hitting other residents. She (Resident #1) was aggressive though. She confirmed Resident #1 had been in Resident #65's room in the past. They were usually able to catch her first and redirect her. She confirmed she wrote a statement the day of the incident and wrote another statement after that on 11/16/22. She stated they were asking Resident #65 about how she was doing after the incident and Resident #65 reported she grabbed Resident #1's shirt after she took her sandwich. She denied she was prompted by anyone to write the second statement. She denied that grabbing Resident #1's shirt first justified Resident #1's action or Resident #65 being hit. She stated she would consider what happened to Resident #65 to be abuse. She knew Resident #65 felt she was abused too. Resident #65 told her that was the first fight she had been in her entire life. She confirmed Resident #1 had been on one on one supervision since her return from the hospital. On 11/17/22 at 3:40 P.M., an interview with the Administrator and DON revealed most of the facility's investigation for SRI #229111 was completed by DON as the Administrator was out of the building that week and only participated via FaceTime. He was involved in the latter part of the investigation, when he returned on Monday (11/14/22). He stated the facility unsubstantiated the allegation of physical abuse based on Resident #1's inability to understand the consequences of her actions. They felt since she was cognitively impaired there was no willful intent. They reviewed the definition of abuse and willful intent as defined in their Abuse policy. They acknowledged the definition of willful meant the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. They were not aware that abuse could come from a cognitively impaired resident and the resident did not have to have an understanding of what they were doing to make it abuse. The act just needed to be deliberate and Resident #1 hitting Resident #65 in the face was a deliberate act. A review of the facility's Abuse, Neglect, and Exploitation policy revised 10/24/22 revealed it was the policy of the facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Abuse was defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish, which could include staff to resident abuse and certain resident to resident altercations. Willful was defined as the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. This deficiency represents non-compliance investigated under Complaint Number OH00137556.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Record review revealed Resident #7 was admitted to the facility on [DATE] with diagnoses including hemiplegia and hemiparesis following nontraumatic intracerebral hemorrhage (stroke) affecting left non-dominant side, diabetes mellitus, need for assistance with personal care, and generalized muscle weakness. There was no documented evidence of left hand/wrist contractures on admission. A plan of care, dated 09/15/21 revealed Resident #7 required activity of daily living assistance for personal care. The care plan revealed physical therapy, occupational therapy and speech therapy were to evaluate and treat resident as needed. Review of Resident #7's Nursing admission Evaluation Part 2 document, dated 09/16/21, revealed Resident #7 had limited range of motion (ROM) to the left lower extremity (LLE). There was no documented evidence of limited ROM to the left upper extremity. Review of Resident #7's admission Minimum Data Set (MDS) 3.0 assessment, dated 09/22/21 revealed the resident had moderate cognitive impairment and had functional limitations in ROM in both upper extremities and one lower extremity. Review of Resident #7's physician's orders, dated 10/20/21 revealed an order for physical therapy (PT), occupational therapy (OT) and speech therapy (ST) to evaluate patient and treat as needed. Review of Resident #7's quarterly therapy screens, dated 11/16/21 and 03/02/22 revealed no evidence of quarterly screenings for physical or occupational therapy were completed. Review of Resident #7's quarterly MDS 3.0 assessment, dated 01/05/22 revealed the resident was severely cognitively impaired and had functional limitation in ROM with upper extremity and lower extremity impairment on one side. Further review of Resident #7's medical record revealed no evidence the resident was receiving therapy or a restorative program. On 04/05/22 at 9:48 A.M. Resident #7 was observed lying in bed with her left hand in a tight fist. The resident's left elbow was observed at a 90-degree angle with her fist positioned on her abdomen. The resident did not move her left hand or the fingers on her left hand freely. On 04/06/22 at 9:00 A.M. interview with Certified Nursing Assistant (CNA) #240 revealed she was not aware of any therapies or restorative programs for Resident #7. On 04/06/21 at 12:52 P.M. observation of Resident #7's left hand with Registered Nurse (RN) #100 present revealed RN #100 attempted to place her finger inside the fist of Resident #7 and passively move Resident #7's fingers. Resident #7 cried in pain. RN #100 immediately stopped the attempt. On 04/06/22 at 3:05 P.M. interview with RN #100 revealed she had spoken with occupational therapy staff and they were not aware of Resident #7's left hand being tightly closed and an inability to do passive ROM on the hand and fingers due to the resident crying out in pain. On 04/06/22 at 4:53 P.M. interview with CNA #660 revealed she wasn't sure how long Resident #7's left hand had been in a fist (contracted). CNA #660 reported she hadn't worked on the resident's hall very long and hadn't care for Resident #7 very much. The CNA then added, I know it takes a while for a hand to get in a tight fist like that. On 04/06/22 at 4:54 P.M. interview with CNA #380 verified she usually worked the unit where Resident #7 resided. CNA #380 reported she wasn't sure how long Resident #7's left hand had been in a tight fist and then indicated it had been that way for approximately one month. Review of an occupational therapy evaluation noted, dated 04/07/22 revealed Resident #7's left upper extremity ROM was impaired. The document also identified a functional limitation in the left arm due to contracture (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints). Review of the facility policy titled Range of Motion, dated 01/01/21 revealed the facility in collaboration with the medical director, director of nursing and as appropriate physical/occupational consultant shall establish and utilize a systematic approach for prevention of decline in range of motion, including the assessment, appropriate care planning, and preventive care. Range of motion (such as current extent of movement of his/her joints and the identification of limitation) would be assessed on admission/readmission, quarterly and upon a significant change. Review of facility policy titled Restorative Nursing Programs, dated 01/01/21 revealed residents could benefit from a restorative program to prevent contractures. 3. Review of the medical record for Resident #22 revealed an admission date of 11/20/20 with diagnoses including cerebral infarction due to unspecified occlusion or stenosis or the right middle cerebral artery, chronic atrial fibrillation, type II diabetes mellitus (DM2), hypertension (HTN), hypomagnesemia, major depressive disorder, dysphagia, anemia, restless leg syndrome, gastro-esophageal reflux disease without esophagitis (GERD) and hyperlipidemia. Review of an occupational therapy Discharge summary, dated [DATE] revealed the resident was tolerable of her soft, left elbow and knee splints without sign of skin breakdown to decrease her risk of further contracture for up to four hours. Further review of the discharge summary revealed the resident was able to demonstrate left shoulder abduction of 52 degrees which had improved from 48 degrees on 08/09/21. The resident was also able to demonstrate left shoulder flexion of 74 degrees which had improved from the 70 degrees she was previously able to do on 08/09/21. She was also able to demonstrate 52 degree left shoulder abduction on 09/03/21 which improved from 48 degrees on 08/09/21. She was able to demonstrate a left shoulder flexion of 74 degrees on 09/03/21 which improved from 70 degrees on 08/09/21. She was discharged from OT with the recommendations for staff to maintain range of motion (ROM) and splinting tolerance. Review of the therapy quarterly screen by Physical Therapy (PT), dated 10/05/21 revealed restorative staff indicated the left lower extremity (LLE)/knee brace was too tight to apply to the resident. The therapy quarterly screen, dated 10/07/21 by PT #210, revealed the resident was added to the physical therapy caseload for contracture management to the LLE/knee. Review of a physical therapy Discharge summary, dated [DATE] by PT #210 revealed the resident was able to safely wear her knee extension splint on her left knee for up to four hours with minimal signs or symptoms of redness, swelling, discomfort or pain. Further review of the discharge summary revealed the resident's demonstrated left knee extension was -42 degrees on 11/04/21 which had improved from her baseline of -95 degrees on 10/07/21. Review of the quarterly MDS 3.0 assessment, dated 01/19/22 revealed the resident had moderately impaired cognition with a Brief Interview of Mental Status (BIMS) score of 12 of 15 and no documented behaviors. The resident required extensive to total assistance from one to two or more staff members for all activities of daily living (ADL) care. Review of the plan of care, dated 01/26/22 revealed the resident would benefit from a restorative active range of motion (AROM) for impaired physical mobility of her right upper extremity (RUE). Interventions included AROM over 15 minutes, one to two times daily, six to seven days a week, and AROM to her RLE for 15 minutes each. Further review of the care plan revealed the resident would benefit from a passive range of motion (PROM) restorative program related to cerebral vascular accident (CVA). Interventions included PROM to the resident's affected joints for LLE and LUE, one to two times daily for 15 minutes, and six to seven days a week. Continued review of the resident's care plan revealed she would benefit from splint/brace program for impaired physical mobility to left knee and LUE related to CVA. Interventions included left knee extension brace two to four hours daily, skin checks before and after brace use, resting hand splint to the left hand to be on for two hours and off for two hours, and soft elbow splint to her left elbow to be on for two hours and off for two hours. Review of the progress note, dated 02/04/2022 at 10:55 A.M. by the Director of Nursing revealed the resident's family was called to inform of the resident being positive for COVID-19 and being moved to the facility Covid unit. Review of the progress note, dated 2/06/2022 at 1:57 P.M. by Licensed Practical Nurse (LPN) #860 revealed the resident was moved to the COVID unit. Review of an occupational therapy (OT) evaluation and plan of treatment, dated 03/27/22 by Occupational Therapist (OT) #1000 revealed the resident would be treated daily, three to five times per week for four weeks from 03/26/22 through 04/24/22. Further review of the evaluation revealed one of the goals for the resident was to tolerate two hours of orthotic wear time with no signs or symptoms of skin integrity issues with a baseline of zero hours on 03/26/22. Another listed goal on the evaluation was for the resident to tolerate her left upper extremity orthotic for six hours with no signs or symptoms of skin integrity issues with a baseline of zero hours on 03/26/22. Further review of the evaluation revealed prior therapy treatment outcome was for the resident to be on restorative nursing program for daily wear of her left resting hand splint. Her prior levels of function (PLOF) for eating, oral hygiene, toileting hygiene, shower/bathing, upper body dressing was substantial/maximal assistance and she was dependent for lower body dressing and putting on/taking off footwear. The resident utilized a left upper extremity orthotic in the past but was no longer wearing the orthotic for unlisted reasons. Further review of the OT evaluation revealed the resident was dependent for eating, hygiene, bathing and dressing and resulted a self-care score of zero out of 12 (12 being the highest function) in the initial assessment/current level of function and underlying impairments section. She was initially assessed on 03/26/22 and determined to have Active Range of Motion (AROM) in the left shoulder that allowed her to have a zero-degree flexion and zero-degree extension. The resident was determined to have passive range of motion (PROM) in the left shoulder that allowed her to have a 45-degree flexion which was a decline from the occupational therapy Discharge summary, dated [DATE]. The resident demonstrated AROM of her left elbow flexion of 110 degrees and -90-degree extension. The resident demonstrated PROM of her left wrist extension of -50 degrees. Her left upper extremity strength was not treated due to contractures and pain. There were functional limitations present due to contracture, but functional limitations were not because of contractures since there was no functional use of her Left upper extremity (LUE) and her current orthotic device would be further assessed and ordered/fabricated. The reason for therapy revealed the resident reported pain in the shoulder and increased pain in the LUE with attempts at PROM, the resident required skilled treatment intervention for manual treatment to increase PROM and utilization of LUE orthotic to decrease upper extremity pain and decrease the opportunity for skin integrity issues. On 04/04/22 at 8:52 P.M. observation and interview with Resident #22 revealed her left elbow and wrist were in a bent condition (flexion) and she was unable to extend the joints upon request. The resident confirmed she was supposed to wear a resting hand splint (which was not in place) but denied wearing any type of elbow splint or leg brace. The resident's hand splint was observed on a dresser in between the resident and her roommate's bed. On 04/05/22 at 3:15 P.M. observation revealed Resident #22 she did not have any braces or splints in place and she continued to have left elbow and wrist flexion. The resident's hand splint remained in the same place on the dresser in between the resident and her roommate's bed. On 04/05/22 at 3:22 P.M. interview with Resident #22 revealed her hand splint had been applied and removed by therapy earlier on this date. The hand splint was not visible in the resident's room at the time of the observation and the resident denied being provided any type of leg brace or elbow splint. On 04/06/22 at 12:18 P.M. observation and interview with Resident #22 revealed her hand splint was not in place and the resident revealed staff had not applied the splint on this date. The resident denied any leg brace or elbow splint being applied. On 04/06/22 at 12:24 P.M. interview with Registered Nurse (RN) #650 revealed nursing was not responsible for the application of splints and denied Resident #22 having any current orders for splints/braces although the RN thought the resident might have had a hand splint at one point. RN #650 revealed therapy staff were responsible to apply ordered splints and nursing did not apply any braces or splints to any residents on her assignment, including Resident #22. Review of a Quality Assistance Form, dated 04/06/22 revealed staff informed Unit Manager #850 Resident #22 was missing her splints and the Laundry and Housekeeping Supervisor #999 was assigned to look for them. On 04/06/22 at 12:48 P.M. interview with Occupational Therapy Assistant (OTA) #160 revealed Resident #22 was being seen by occupational therapy for left arm splinting and the resident was on the physical therapy (PT) list to screen for a left leg brace. OTA #160 confirmed Resident #22 moved rooms when she tested positive for COVID-19 and again after her quarantine period which resulted in her elbow and leg brace being lost/misplaced. OTA #160 revealed a new elbow splint was ordered on 04/06/22 (after surveyor intervention) by central supply staff, she was unsure of the exact date the splint and brace were lost but confirmed it was during the COVID outbreak when the resident was moved from room to room approximately one month ago. She confirmed the resident's leg brace and elbow splint had not been applied since moving rooms approximately one month ago. On 04/06/22 at 12:52 P.M. interview with State Tested Nursing Assistant (STNA) #720 confirmed she ordered an elbow brace on 04/06/22 (after surveyor intervention), after searching for the splint and being unable to locate it. She revealed the brace and splint went missing about one month ago during the COVID outbreak and when the resident was moved from room to room. There was no evidence the facility looked to find the brace or re-ordered it timely. On 04/06/22 at 5:46 PM interview with Registered Nurse (RN) #100 confirmed Resident #22's missing brace/splints and confirmed the resident was ordered therapy intervention as a result of a decline in functional mobility associated with the lack of splinting. On 04/07/22 at 8:37 A.M. interview with Physical Therapy Assistant (PTA) #140 and Director of Rehabilitation #130 revealed Resident #22 had been seen by occupational (OT) and physical Therapy (PT) on several occasions for decline in condition. They confirmed the resident was recently placed on PT and OT services for a decline in her functional abilities and confirmed she had a decline in range of motion (ROM) as a result of lack of restorative care. They both confirmed the resident's elbow splint and leg brace were also missing and had not been used since at least the resident's room changes during a COVID outbreak last month. On 04/07/22 at 8:54 A.M. interview with RN #230 revealed she was still learning restorative care and was unsure who was to provide restorative services. She stated she would think an STNA, nurse, therapy or anyone could apply a brace. RN #230 denied applying any braces or splints to residents' on her assignment which included Resident #22. On 04/07/22 at 10:00 A.M. interview with Regional Support RN #100 confirmed there was no policy for splints/braces or missing items. Review of the facility policy titled Range of Motion, dated 01/01/21 revealed the facility in collaboration with the medical director, director of nursing and as appropriate physical/occupational consultant shall establish and utilize a systematic approach for prevention of decline in range of motion, including the assessment, appropriate care planning, and preventive care. Range of motion (such as current extent of movement of his/her joints and the identification of limitation) would be assessed on admission/readmission, quarterly and upon a significant change. Review of facility policy titled Restorative Nursing Programs, dated 01/01/21 revealed residents could benefit from a restorative program to prevent contractures. 4. Review of the medical record for Resident #41 revealed an admission date of 08/30/16 with diagnoses including Alzheimer's disease, generalized osteoarthritis and abnormal posture. Review of an OT Evaluation and Plan of Treatment, by OT #4000 dated 06/08/21 revealed the resident had no contractures and no upper extremity impaired strength. The summary did not include any information about the resident's left hand. Review of the quarterly MDS 3.0 assessment, dated 01/03/22 revealed the resident had severe cognitive impairment with a Brief Interview of Mental Status (BIMS) score of three of 15 and no documented behaviors. The assessment revealed the resident required extensive to total assistance from one to two or more staff members for all activities of daily living (ADL) care. Further review of the MDS revealed the resident did not have any functional impairment of the upper or lower extremities. Review of the plan of care dated 01/17/22 revealed the resident had an alteration in musculoskeletal status. Interventions included education of the resident/family/caregivers on joint conservation techniques, monitor for fatigue and plan activities during optimal times when pain and stiffness was abated. There was no specific care plan for contractures or contracture prevention and no physician's orders related to any contractures, contracture prevention, or the resident's left hand. The facility was unable to provide any physical therapy (PT) discharge summary for the resident following attempts on several occasions to request the information through the Administrator and RN #100 during the survey. The facility was unable to provide any documented PT discharge summary. Review of the statement, dated 04/07/22 by Director of Therapy Services #130 revealed she contacted the resident's power of attorney (POA) to address questions and concerns related to Resident #41's hands and hand contractures offering the option for therapy intervention. Further review of the statement revealed the resident's POA, in the past, had adamantly declined therapy services for any reason prior to verbal authorization from her and consent was given. On 04/07/22 at 2:05 P.M. Resident #41 was observed being assisted back to bed. The resident's left hand was observed to be clenched and she was intermittently holding onto her left wrist during care. The resident opened and moved her right hand and fingers and held onto things such as her wheelchair and bed rail with her right hand, but her left hand remained clenched. Upon an attempt to request the resident open her hand, she stated no. STNA #760 and STNA #450 denied the resident opening her hand, using a splint or that the resident received any type of restorative program. On 04/07/22 at 2:21 P.M. interview with Physical Therapy Assistant (PTA) #140 revealed Resident #41 had no contractures that she was aware of. The PTA did confirm the resident tended to keep her left hand clenched but on assessments she was able to open her hand. She confirmed the resident was not receiving therapy services at this time and as far as she remembered the resident did not have a splint for her left hand. On 04/07/22 at 2:28 P.M. interview with Unit Manager #850 revealed she was responsible for the restorative programs and Resident #41 was not receiving restorative therapy for contractures or contracture prevention to her knowledge. Unit Manager #850 revealed she was unsure if Resident #41 was able to open her left hand or if her hand was contracted. She was also unable to report if the resident had a decline in ROM. On 04/07/22 at 2:33 P.M. interview with UM #850 revealed Resident #41 kept her left hand clenched and did not open her fingers despite several attempts for AROM and PROM. On 04/08/22 at 9:47 A.M. Resident #41 was observed up in her wheelchair in the hallway, being assisted to activities. The resident's left hand remained in the a fist position. On 04/08/22 at 9:51 A.M. interview with RN #100 revealed she was unfamiliar with Resident #41 but stated a progress note from 2018 revealed the resident's family did not want therapy services. She was unsure if the care plan reflected the family's choice for no therapy services but stated she would check. She revealed since the family declined therapy the resident should have been receiving ROM services through a restorative nursing program. RN #100 did not dispute the restorative services were not being provided to Resident #41. On 04/08/22 at 12:17 P.M. interview with RN #100 confirmed there was no care plan for Resident #41 family's refusal of therapy services. On 04/08/22 at 12:45 P.M. interview with RN #100 revealed the resident was able to open her left hand and extend her fingers but would pull her hand away and grimace and when asked if her hand hurt, the resident stated yes, hurt, hurt, hurt and continued to pull her hand away. RN #100 also identified the resident's nails were long, extended past the tips of her fingers and jagged. The resident had a tight grip with her left hand but did not have resistance when opening her hand nor did it appear the resident had tightened muscles although the resident immediately balled her fingers back into a fist when she removed her hand. RN #100 confirmed restorative care was needed to ensure the resident maintained ROM, did not experience a functional decline and should have been receiving restorative nursing services for ROM. During the survey, it could not be determined if the resident's functioning of her left hand was her baseline or if there had been a decline in ROM. Review of the facility policy titled Range of Motion, dated 01/01/21 revealed the facility in collaboration with the medical director, director of nursing and as appropriate physical/occupational consultant shall establish and utilize a systematic approach for prevention of decline in range of motion, including the assessment, appropriate care planning, and preventive care. Range of motion (such as current extent of movement of his/her joints and the identification of limitation) would be assessed on admission/readmission, quarterly and upon a significant change. Review of facility policy titled Restorative Nursing Programs, dated 01/01/21 revealed residents could benefit from a restorative program to prevent contractures. Based on observation, record review, facility policy and procedure review and interview the facility failed to develop and implement comprehensive and individualized restorative nursing services to ensure interventions and treatments were provided to prevent a decline in range of motion or maintain current range of motion (ROM) status for all residents. Actual Harm occurred for Resident #49, who was admitted with no limitations to range of motion, when the facility failed to timely identify and implement effective interventions to prevent and treat contractures to the resident's bilateral lower extremities. Although the facility was unable to determine an exact date when the resident started to exhibit decreased ROM of the lower extremities, staff reported they had noticed a change in the resident in the last year. There was no documented evidence the resident had received any type restorative or ROM services to the lower extremities to prevent the contractures or prevent them from worsening resulting in the resident experiencing increased pain and immobility. Hospice notes indicated the resident was badly contracted and had pain with transfers due to the contractures requiring an increase in his pain medication. Actual Harm occurred for Resident #7, who was cognitively impaired and dependent on staff for care, when the facility failed to identify and implement effective interventions to prevent and treat a contracture to the resident's left hand resulting in increased pain and decreased mobility. Although the facility was unable to determine an exact date when the resident started to exhibit decreased range of motion/contracture to the left hand one staff member reported she had noticed the contracture about a month ago. The facility failed to provide ROM services to prevent the development of the contracture and to properly treat once it was first identified. The resident was observed to exhibit increased pain during passive range of motion. Actual Harm occurred for Resident #22, when the facility stopped applying ordered splinting devices ordered for the left elbow and leg because they were lost during a room change which resulted in an identified decline in the resident's functional abilities. In addition, the facility failed to provide range of motion services as ordered resulting in a decline in range of motion for the resident. This affected five Residents (#7, #22, #41, #49, and #59) of six residents reviewed for mobility. The facility census was 74. Findings include: 1. Record review revealed Resident #49 was admitted to the facility on [DATE] with diagnoses including alcohol dependence with alcohol-induced persisting dementia, cerebral ischemic attack, anxiety and low back pain. Record review revealed the resident was admitted to Hospice services on 11/13/19. Review of Resident #49's admission assessment, dated 07/30/18 revealed the resident had no limitations in range of motion. The resident ambulated independently, however liked to sit and crawl around on the floor. Record review revealed a plan of care, initiated on 08/01/18 and revised 11/18/21 related to limitations in physical mobility. The goal developed was for the resident to maintain current level of mobility. Interventions included staff would monitor, document, report as needed any signs or symptoms of immobility including contractures forming or worsening, thrombus formation, skin-breakdown or fall related injuries. Review of Resident #49's medical record revealed the last documented evidence the resident received any type of range of motion (ROM) services was from 05/15/20 to 06/2020 with ROM being provided to the resident's bilateral upper extremity. However, the documentation revealed the services were discontinued because the resident did not meet goal. There was no evidence the resident received any type of restorative treatment or ROM services since 06/2020. Review of Resident #49's quarterly Minimum Data Set (MDS) 3.0 assessment, dated 02/15/22 revealed the resident had functional impairment on both sides of the lower extremities. The assessment revealed walking did not occur during the assessment reference period and the resident required a wheelchair for mobility with extensive physical assistance from one or two staff (for mobility). Review of Resident #49's Hospice notes revealed a note, dated 12/28/21 indicating the resident was dependent on the nursing facility for all activities of daily living (ADL) care. The note indicated the resident was badly contracted to the upper and lower bilateral extremities which made measuring circumferences difficult as the resident's limbs become more drawn up. The contractures were worse on the left side. The resident's neck needed significant support and repositioning or it stayed strained and fallen over towards the left side. The resident required a sizing up in briefs because the contractures were making care and repositioning more difficult. The sizing up in the briefs was NOT due to weight gain. On 03/09/22 a Hospice note revealed the resident's pain medication, MS Contin was increased to three times daily because the facility nurse reported the resident had pain with transfers and positioning. There was no evidence the facility had Hospice care plan for the resident reflecting pain management, positioning or contracture issues. Further review of Resident #49's progress notes, including physician's notes dated 01/01/22 to 04/12/22 revealed no evidence or mention of contractures. From 04/04/22 to 04/08/22 during the annual survey random intermittent observations made revealed during every observation the resident was in bed with his legs observed to be pulled up at the hip level toward his chest. On 04/06/22 at 2:55 P.M. interview with Therapy Coordinator #130 revealed the resident had been in Hospice for over two years and had not received any therapy services or quarterly screenings during that time period. On 04/08/22 at 2:28 P.M. Resident #49 was observed in bed lying on his side. The resident's legs were observed to be contracted up to his waist. On 04/08/22 at 2:30 P.M. interview with State Tested Nursing Assistant (STNA) #720 revealed the resident's contractures had worsened in the last year. The STNA reported the resident was not on any type of restorative program and did not use any type of splinting devices because he was on Hospice. During the interview, the STNA confirmed the resident's legs would not straighten/extend out and they had been drawn up to his waist for a while. The STNA confirmed Hospice had to change size of briefs (to a larger size) because it was difficult to put the briefs on due to the resident's contractions. On 04/08/22 at 3:38 P.M. interview with Registered Nurse (RN) #850 verified Resident #49 was admitted to the facility on [DATE] with no functional impairment or range of motion impaired. The RN confirmed Hospice documented the resident was badly contracted in their note on 12/28/21. RN #850 confirmed according to the resident's medical record there was no evidence the resident had been provided any restorative nursing services including range of motion services to prevent or address the development of contractures and limitations in functional ability since 06/13/20. RN #850 confirmed the resident was not currently receiving any type of ROM services. Resident #49 sustained increased pain and decreased functional mobility related to the lack of services being provided. Review of the facility policy titled Range of Motion, dated 01/01/21 revealed the facility in collaboration with the medical director, director of nursing and as appropriate physical/occupational consultant shall establish and utilize a systematic approach for prevention of decline in range of motion, including the assessment, appropriate care planning, and preventive care. Range of motion (such as current extent of movement of his/her joints and the identification of limitation) would be assessed on admission/readmission, quarterly and upon a significant change. Review of facility policy titled Restorative Nursing Programs, dated 01/01/21 revealed residents could benefit from a restorative program to prevent contractures. 5. Review of Resident #59's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including quadriplegia C5-C7, convulsions, neurogenic bowel, mood disorder, major depressive disorder, morbid obesity, post-traumatic stress disorder with mixed anxiety and depressed mood, hearing loss, impacted teeth and hypokalemia. Review of Resident #59's admission Minimum Data Set (MDS) 3.0 assessment, dated 12/30/2021 revealed the resident had clear speech, understands others, made self-understood and her cognition was intact. Resident #59 had minimum depression, no indicators of psychosis, no behaviors and did not reject care. Resident #59 required extensive staff assistance from staff for bed mobility, was dependent on two staff to transfer,