**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and facility document and policy review, the facility failed to prevent a fire in a kitchen near residents. Specifically, kitchen staff placed plastic and foam containers in an oven on the second and third floor kitchens of Cottage B, causing the containers to melt and excessive smoke to [NAME] out of the oven into an area near residents.It was determined the facility's non-compliance with one or more requirements of participation caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The Immediate Jeopardy (IJ) was related to 483.25(d)(1) (Accidents).The IJ began on 06/23/2025 at 11:46 AM when Food Service Worker (FSW) #24 placed five plastic containers and one foam to-go container holding food for a lunch meal into an oven set to the warm setting on the second floor of Cottage B. FSW #24 then proceeded to deliver the lunch meal to the third floor of Cottage B. There was then a strong smell of burnt plastic in the living area on the second floor of Cottage B. Certified Nurse Aide (CNA) #33 opened the oven, and smoke billowed out into the kitchen and common area where residents were sitting. CNA #33 then turned the oven off and opened the door to the outdoor balcony to air out the living area of the second floor. An observation on 06/23/2025 at 12:05 PM revealed two burnt and melted foam to-go containers sitting on a countertop in the kitchen on the third floor of Cottage B.The Administrator (ADM) and Community Executive Director (ED) were notified of the IJ and provided the IJ template on 06/23/2025 at 5:49 PM. A Removal Plan was requested. The Removal Plan was accepted by the state survey agency on 06/27/2025 at 11:01 PM. The IJ was determined to be removed on 06/29/2025 at 7:00 PM after the survey team performed onsite verification that the Removal Plan had been implemented. Noncompliance remained at the lower scope and severity of E that was not immediate jeopardy for F689.Additional findings were identified related to Residents #36, #92, #77, and #53. Specifically, Resident #36 suffered a right femur fracture when staff provided care and a thorough investigation was not conducted, Resident #92 suffered a fall and the facility did not investigate for the root cause of the fall, Resident #77 was assessed to need a sit-to-stand lift for transfers when one was not available for staff to use, and Resident #53 was found outside of the facility, gone for an unknown period of time.Findings included:1. A facility policy titled, Fire Safety, dated 08/01/2012, indicated, It is the policy of this facility to insure [sic] that equipment is in compliance with applicable state and local regulations regarding fire safety.An owner's manual provided by the facility staff titled, Direct Air Convection Built-In Electric Wall Oven, revised in May 2024, indicated Do not store or use flammable materials in or near an oven, including paper, plastic, pot holders, linens, wall coverings, curtains, drapes and gasoline or other flammable vapors and liquids.Product specifications provided by facility staff, dated 06/23/2025, indicated the foam to-go containers should be stored at temperatures from 55 to 90 degrees Fahrenheit (F) and the plastic deli containers maximum storage temperature was 212 degrees F.An observation on 06/23/2025 at 11:46 AM revealed double ovens in the kitchen on the second floor of Cottage B. The observation revealed both ovens were dirty with crusty black lumps on the bottom of the ovens and inside the doors. Further observation revealed FSW #24 placed five small plastic containers and one foam to-go container holding food for the lunch meal directly on metal racks in an oven. During an interview at that time, FSW #24 stated that foam and plastic containers could go in the oven to keep the food warm.An observation on 06/23/2025 at 11:55 AM, revealed a strong smell of burnt plastic in the kitchen second floor. The observation revealed CNA #33 opened the oven, and smoke billowed out into the kitchen and common area where residents were sitting. The observation revealed CNA #33 pulled the food out of the oven and opened the door to the outdoor balcony to air out the living area of the second floor.An observation on 06/23/2025 at 12:05 PM revealed two burnt and melted foam to-go containers sitting on a countertop in the kitchen on the third floor of Cottage B.During an interview on 06/29/2025 at 11:04 AM, CNA #27, who was on the third floor on 06/23/2025, stated she witnessed FSW #24 place the plastic and foam to-go containers into the oven, she knew they should not have been in the oven, but by the time she removed them from the oven they had already started melting.During an interview on 06/23/2025 at 4:05 PM, the Executive Chef stated the kitchen staff prepared food in the main kitchen located in the main building and then sent it to Cottage A and Cottage B in metal steam table pans, plastic deli containers, and individual meals in foam to-go containers. The Executive Chef further stated if the plastic containers holding the food for the residents in the cottages melted, then the ovens must have been on the wrong setting because they could withstand being reheated to 200 to 250 degrees F. Per the Executive Chef, the foam to-go containers were not designed to be put in an oven and should not have been in the oven at all. The Executive Chef further stated the plastic deli containers' maximum storage temperature was 212 degrees F and the foam to-go containers' storage temperature should be 55 to 90 degrees F per the product's specifications.During an interview on 06/28/2025 at 2:34 PM, the Director of Nursing Services (DNS) stated she expected staff to know how to operate the oven and to know what temperature to set the oven to when using it. The DNS further stated she expected staff to monitor the oven when in use for fire safety, and plastic and foam were not appropriate materials to use in the oven.During an interview on 06/28/2025 at 3:15 PM, the ADM stated he expected staff to keep the residents safe by having practices that met the safety requirements for fire prevention.On 06/28/2025 at 2:30 PM a Removal Plan was submitted by the facility and accepted by the State Agency. It read as follows: F689: Free from Accident Hazards/Supervision/Devices: Food placed in ovens in Cottages in plastic and Styrofoam [sic] containers which were not considered appropriate for the oven. Plastic overheated and created smoke on 2nd floor of Cottage B.1. Administrator and Maintenance Director were notified on 06/23/2025 at 12:15 p.m. by Nurse of containers placed in the oven which caused smoke.2. The ovens on the second and third floors of Cottage B were disabled by the Maintenance Director on 06/23/2025 at 8:05 p.m. The ovens were locked out/tagged out until assessed/repaired by Maintenance or an outside technician.3. Fire Safety re-education was initiated with [the facility's name] skilled nursing facility team members, nurses, aides, therapy, housekeepers and dietary, on 06/23/2025 by the Administrator/DNS or designee. An inservice [sic] was completed for all team members on not placing non cookware items on the stove top or in oven, no plastic or Styrofoam in the oven when heating/warming food and policy on fire safety. New hires will be educated by the Director of Clinical Orientation during orientation, and center does not utilize agency in the center.4. The Administrator or designee will monitor to ensure there are no inappropriate containers placed in the ovens for each meal for one week, five meals per week on each floor for four weeks then monthly for three months. Results will be reported at the monthly QAPI [Quality Assurance and Performance Improvement] for follow-up as needed.The immediacy of the IJ was removed on 6/23/25.On 06/28/2025 at 2:30 PM, the facility provided a Removal plan and was accepted by the State Survey Agency. Noncompliance remained at the lower scope and severity of E.Onsite Verification of Removal Plan:The IJ was removed on 06/29/2025 at 7:00 PM after the survey team performed onsite verification that the Removal Plan had been implemented. The survey team verified that the ADM and Maintenance Director were notified of the containers placed in the oven, which caused smoke. The survey team verified the ovens on the second and third floor of Cottage B were disabled by the Maintenance Supervisor. The ovens were locked out and tagged out until they were assessed and repaired by an outside technician. The completion of staff education related to fire safety was reviewed and verified by the survey team through interviews. The survey team reviewed and verified audit plans through interview with the ADM.2. A facility policy titled, [Facility Name] Event Communication Pathway, dated January 2021, revealed the section titled, Key Components of Investigation, included, Once the immediate threat has been removed and all patients/residents are safe initiate a thorough investigation. Key components of an investigation - Detailed description of the event/allegation (objective and factual) - Assessment of patient/resident and description of any injury - Interview summaries of all pertinent parties (the interviewer completes the summary, the interviewee signs confirmation of facts) - Immediate protection initiated - Relevant causal/contributing factors and observations - Specific interventions to prevent reoccurrence - Summary of the outcome/investigative findings - Any pertinent monitoring/follow up.An admission Record indicated the facility admitted Resident #36 on 10/03/2022. According to the admission Record, the resident had a medical history that included diagnoses of senile degeneration of the brain, osteoarthritis, a periprosthetic fracture around the internal prosthetic right hip joint (a break in the bone around the internal right hip prosthetic) (onset date 12/12/2024), and encounter for orthopedic aftercare (onset date 12/12/2024).An annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/16/2025, revealed Resident #36 had severe impairment in cognitive skills for daily decision-making and had a short-term and long-term memory problem per a Staff Assessment of Mental Status (SAMS). The MDS indicated Resident #36 was dependent on staff with rolling left and right when in bed. The MDS indicated Resident #36 received hospice care while a resident.Resident #36's Care Plan Report, included a focus area initiated on 12/04/2023, that indicated the resident had a self-care deficit related to decreased functional abilities, fluctuating self-performance, and impaired cognition, with a history of a periprosthetic fracture around the internal prosthetic right hip joint. Interventions directed staff to allow adequate time with tasks (initiated 12/04/2023) and to provide all the effort with tasks including rolling to the left and right (initiated 01/30/2025). Resident #36's Care Plan Report, included a focus area initiated on 02/29/2024, and revised on 04/24/2025, that indicated the resident needed pain management and monitoring related to osteoarthritis, polyneuropathy, a history of transient ischemic attacks, and a history of periprosthetic fracture around the internal prosthetic right hip joint. Interventions directed staff to administer pain medication as ordered; provide dim lighting/quiet environment; evaluate and establish level of pain on numeric scale/evaluation tool; evaluate characteristics and frequency/pattern of pain; evaluate what made the pain worse; reposition as needed; and ensure rest.Resident #36's Order Recap [Recapitulation] Report, for the timeframe from 11/01/2024 through 06/30/2025, included an order dated 09/04/2024 for tramadol HCL (tramadol hydrochloride, an opioid agonist to treat moderate to severe pain) 100 milligrams (mg) every four hours as needed for pain related to osteoarthritis; the order had an end date of 12/12/2024. The Order Recap Report included an order dated 12/01/2023 for acetaminophen (a pain reliever) 1000 mg three times a day for pain; the order had an end date of 12/12/2024.Resident #36's 12/2024 Medication Administration Record [MAR], revealed staff documented that the resident received tramadol HCL100 mg on 12/06/2024 at 6:20 AM for a pain level of 5 (on a pain scale of 0-10, with 10 being the worst possible pain), and it was effective. The MAR revealed staff documented that the resident received tramadol HCL100 mg on 12/06/2024 at 2:38 PM for a pain level of 8, and it was effective. The MAR revealed staff documented that the resident received acetaminophen 1000 mg on 12/06/2024 at 9:00 AM for a pain level of 6 and at 2:00 PM for a pain level of 8.Resident 36's Weights and Vitals Summary, indicated that on 12/05/2024 the resident's pain level was rated 0 at 10:58 AM, 3:05 PM, 10:47 PM, and 10:49 PM, and the resident's pain level was rated 5 on 12/06/2024 at 6:20 AM. Resident #36's hospice Visit Note Report, dated 12/06/2024, indicated a family member and Licensed Practical Nurse (LPN) #6 notified the hospice services that Resident #36 had severe pain in their right leg and requested a visit. The note revealed LPN #6 stated staff had left Resident #36 in bed due to hip pain, with no reports of a fall prior to the onset of pain. The note indicated the hospice nurse assessed Resident #36's right leg and noted the leg to be shortened and rotated with swelling to the thigh and no discoloration. The note indicated the hospice physician was notified, and the facility staff received an order to obtain an x-ray of Resident #36's right pelvis, hip, and femur. The note indicated Resident #36 received tramadol at 6:30 AM and 10:30 AM, and Tylenol (an analgesic, pain reliever) at 9:00 AM. The note indicated the hospice nurse visit began at 12:48 PM on 12/06/2024.A nursing Progress Notes, dated 12/06/2024 at 4:27 PM, indicated Resident #36 appeared to be in severe pain and was medicated with tramadol 100 mg per their PRN (pro re nata, as-needed) order. The Progress Notes indicated that upon assessment, Resident #36's right hip was swollen, very painful to touch, and the top part of the hip was larger than the bottom half. The Progress Notes indicated the nurse reached out to hospice staff, the hospice nurse came to the facility to assess the resident, and the hospice physician ordered an x-ray immediately. The Progress Notes indicated the x-ray results revealed a right femur fracture. The Progress Notes indicated the hospice physician was notified and then ordered Resident #36 to be sent to the emergency room for an evaluation. The Progress Notes indicated Resident #36's family was at bedside during that time. Resident #36's Radiology Interpretation, dated 12/06/2024 at 12:59 PM, indicated the resident had a right hip arthroplasty with displaced periprosthetic fracture at the subtrochanteric (upper area of the femur) femur with decreased osseous mineralization. The record revealed, This could reflect osteopenia or osteoporosis, in the correct clinical context.A facility incident report dated 12/06/2024 at 4:17 PM, indicated Resident #36 appeared to be in severe pain and was medicated with tramadol 100 mg per a PRN order. The report indicated that upon assessment, Resident #36's right hip appeared to be swollen, very painful to touch, and the top part of the hip was larger than the bottom half. The report indicated Resident #36 was unable to describe what occurred, and the resident's pain level was 8. The report indicated the physician was notified on 12/06/2024 at 1:23 PM. Resident #36's hospital Discharge Summaries, dated 12/12/2024, indicated the resident presented to the emergency room with right hip periprosthetic hip fracture. The summaries indicated that per the facility's records, Resident #36's sitter arrived at the facility on 12/06/2024 and was told by facility staff that the resident should not be transferred from the bed to the wheelchair due to hip pain. The summaries indicated that upon assessment, Resident #36's hip was found to be painful and swollen. The summaries indicated that due to the proximity of the fracture to the hardware, Resident #36 was transferred to another hospital for surgical repair. On 06/24/2025 at 1:58 PM, Family Member (FM #76), Resident #36's family member, stated they arrived at the facility on the day of the incident at about 8:00 to 8:30 AM after the sitter called them. FM #76 stated there was no urgency from staff that the staff thought anything was wrong, and the ambulance was not provided until 2:30 PM to 3:00 PM. FM #76 stated they met with the facility, and the facility said they were sorry and that the incident was not handled properly. FM #76 stated they thought the facility had notes, but there was no outcome from the investigation. FM #76 stated they did not know if Resident #36's bones were so brittle the bones could not stay attached to the prothesis, or if something happened.During an interview on 06/24/2025 at 3:03 PM, Hospice Nurse #42 stated a hospice nurse visited the resident on 12/06/2024 due to Resident #36's pain in the right leg. Hospice Nurse #42 stated Family Member #76 notified the hospice case manager, and LPN #6 called as well. Hospice Nurse #42 stated hospice services ordered an x-ray which revealed a right femur fracture. During an interview on 06/25/2025 at 8:12 AM, Resident #36's sitter, Sitter #72, stated they came in on the morning of 12/06/2024 around 7:15 AM, and the facility staff told the sitter not to get Resident #36 up because the resident's side hurt and was swollen. Sitter #72 stated they notified the family of Resident #36's condition because the resident's hip looked broken. Sitter #72 stated they asked a CNA to have a nurse look at Resident #36 and for some pain medication for the resident. Sitter #72 stated staff revealed they had administered pain medication to Resident #36 at 6:30 AM that morning. Sitter #72 stated at 8:30 AM they asked for pain medication again for Resident #36, and the resident was given Tylenol. Sitter #72 stated a family member notified the hospice nurse who then came and obtained an x-ray of Resident #36's right hip. During an interview on 06/25/2025 at 9:02 AM, LPN #6 stated Registered Nurse (RN) #7 gave her report (information sharing between shifts) on the morning of 12/06/2024, informing her that Resident #36's hip was red and painful to touch, but RN #7 had not notified anyone including hospice staff. LPN #6 stated she then assessed Resident #36, found the resident's hip bruised and painful to touch, and contacted the hospice nurse requesting a stat (statim, immediately) x-ray. LPN #6 stated the hospice nurse then came to the facility and obtained an x-ray that revealed a femur fracture. LPN #6 stated they then contacted the management team notifying them of the fracture. LPN #6 stated the Community ED had interviewed her about the incident. During an interview on 06/26/2025 at 7:24 AM, the Community ED stated Resident #36's fracture was not reported to the state because when staff turned the resident the morning of 12/06/2024, they heard a pop, so the fracture was of known origin. The Community ED stated she did not see her file about the incident and did not know who the staff member was that repositioned Resident #36 at the time. The Community ED stated she did not know why the night shift did not notify hospice or get an x-ray, did not know who was on the night shift, but would have talked with everyone who worked that shift to see what happened. The Community ED stated the incident occurred during the overnight shift and was reported to the oncoming shift, who notified hospice and the physician to get an x-ray. The Community ED stated Resident #36 had osteoporosis. By the time of the survey exit, no investigation of the incident had been presented to the surveyors. On 06/26/2025 at 7:41 AM, the Ombudsman stated the facility had a care plan meeting with the family after the event, and the care plan meeting did not go well as the Community ED was unable to be there and the interim Director of Nursing Services (DNS) at that time did not really know any specifics. The Ombudsman stated the Community ED did an investigation, but the family was frustrated as findings were not communicated well and were ambiguous. The Ombudsman stated the interim DNS was supposed to do an investigation that day but did not, and there were unresolved issues about a nurse being unable to get to Resident #36 due to being on another floor and uncertainty about Resident #36's foot being caught in a bed rail.During an interview on 06/26/2025 at 9:35 AM, RN #7 stated CNA #46 notified her that when she changed Resident #36's brief, the resident was in pain, and RN #7 told the next shift's nurse that Resident #36 was in pain and to notify the physician that morning. RN #7 stated no incidents occurred on her shift that could have led to the fracture, and she gave Resident #36 pain medication. RN #7 stated that she did not remember if she completed an incident report or entered a nurse note. RN #7 stated the incident occurred later in her shift and the next shift was about to start, so she gave the responsibility to the following shift. RN #7 stated she had three floors of residents to handle, to give medications to, and she told the next shift of the incident.During an interview on 06/26/2025 at 10:50 AM, CNA #46 stated that when she provided care to Resident #36 the morning of 12/06/2024, she turned the resident onto their right side and the resident moaned, made sounds like they were in pain, and grimaced. CNA #46 stated she did not know what was going on with Resident #36 because no incident occurred on her shift, and she did not want to make the resident's pain any worse, so she notified the nurse to assess the resident. CNA #46 stated she did not hear a pop, and Resident #36 did not fall or hit anything when moved during care, but was in pain that was not normal for her. During an interview on 06/26/2025 at 11:47 AM, RN #9 stated she asked some CNAs who took care of Resident #36 on 12/05/2024 if the resident was in pain when put to bed or if the resident was acting differently that night, but there was nothing reported. RN #9 stated they were surprised to learn of Resident #36's femur fracture because no incident occurred with the resident on her shift. RN #9 stated when there was an injury of unknown origin, an investigation into what happened should be done.During an interview on 06/27/2025 at 10:56 AM, Medical Director (MD) #5 stated with severe osteopenia just turning Resident #36 in the bed could cause a fracture. MD #5 stated without knowing how severe Resident #36's osteopenia was it was hard to speculate on exactly what happened, and there was no definitive cause. During an interview on 06/28/2025 at 9:53 AM, the DNS stated she expected staff to be trained in safe turning and repositioning of residents to prevent any injuries when caring for the residents. During an interview on 06/28/2025 at 12:09 PM, the ADM stated he expected staff to be trained to turn and reposition residents per their policy to prevent accidents. The ADM stated for any incident staff needed to inform the nurse, an assessment was needed, and at times an x-ray was needed.3. A facility policy titled, Falls Prevention, dated April 2024, indicated, Purpose: To establish a process that identifies risk and interventions to mitigate the occurrence of falls. The section titled Post Fall revealed, The risk event is initiated to capture a detailed description of the event, vital signs, witness statements, and notification of the NP/MD [Nurse Practitioner/Medical Doctor] and RP [Responsible Party]. The risk event prompts completion of the nurse progress notes and the Post Fall Analysis (PFA), and The PFA is completed to develop all appropriate interventions, record the care plan review, record notification of caregivers of new intervention and documentation of the IDT [Interdisciplinary Team] decision making process to prevent future falls. The policy also indicated, The IDT reviews post fall investigation and summarizes the team recommendations for interventions.An admission Record revealed the facility admitted Resident #92 on 05/20/2025. According to the admission Record, the resident had a medical history that included diagnoses of aftercare following surgery for neoplasm; malignant neoplasm of the mouth; malignant neoplasm of the hard palate; malignant neoplasm of the head, face and neck; depression; gastrostomy status; hypertension; and dysphagia. According to the admission Record Resident #92 was discharged to the hospital on [DATE].An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/26/2025, revealed Resident #92 had a Brief Interview for Mental Status (BIMS) score of 11, which indicated the resident had moderate cognitive impairment. The MDS indicated Resident #92 had no falls in the last month prior to admission, no fractures related to a fall in the six months prior to admission, and no falls since admission.Resident #92's Care Plan Report, included a focus area revised 05/22/2025, that indicated the resident was at risk for falls related to a new environment and medication use. Interventions initiated on 05/22/2025 directed staff to keep the bed in low position, the call light and personal items available and in reach, the environment well-lit and free from clutter, to observe for side effects of medications, and provide orientation to the new room and roommate.A facility document titled Incidents by Incident Type, dated 06/25/2025, indicated Resident #92 had a fall incident on 06/02/2025 at 6:20 AM.Resident #92's, Post Fall Review, dated 06/03/2025, revealed the resident had an unwitnessed fall from the bed to the floor on 06/02/2025. The Post Fall Review revealed Resident #92 had no apparent injury, had a headache, was holding their head, and was sent to the hospital for an evaluation.During a phone interview on 06/24/2025 at 3:31 PM, Family Member (FM) #73, Resident #92's family member, indicated staff refused to go into Resident #92's room to take care of the resident's needs. FM #73 stated the Director of Nursing Services (DNS) told her the resident fell out of bed during the night shift while a sitter sat outside the resident's room with the door closed due to the resident having a Clostridium difficile (C. diff, a bacteria,) infection. FM #73 stated Resident #92 fell on [DATE], went to the hospital, and stayed a week with diagnoses of pneumonia, urinary tract infection, and atrial fibrillation. FM #73 stated Resident #92 went to a different skilled nursing facility after discharge from the hospital. During an interview on 06/27/2025 at 10:39 AM, Director of Clinical Operations (DCO) #26 stated the Post Fall Review was the only documentation the facility was able to find related to Resident #92's fall on 06/02/2025. During an interview on 06/27/2025 at 2:57 PM, DNS stated her expectation was that staff document, report, and investigate all falls. The DNS stated her expectation was that a Post Fall Review was completed in the electronic medical record documenting new interventions for each fall. The DNS stated there was no documentation in Resident #92's progress notes about the fall on 06/02/2025. The DNS stated that a nurse called her to report Resident #92's fall, but the nurse did not complete the Post Fall Review, so she completed it herself. The DNS stated Resident #92 had a sitter, who was sitting outside the resident's room with the door closed when the resident fell out of bed. The DNS confirmed she did not do an investigation into the cause of the Resident #92's fall, because the resident did not return to the facility. 4. A facility policy titled, Lift 4 Care-Safe 4 All, dated 02/2023, revealed the section titled, Purpose, included, To provide team members guidance with assisting residents to safely reposition or transfer. The policy revealed the section titled, Guideline, included, 2. A licensed healthcare provider must complete a lift evaluation for every resident upon admission, readmission or with any change of condition. The lift evaluation will assist in establishing the resident's independence or the need for assistance during repositioning or transfers. The evaluation will also assist in determining sling size if appropriate and/or the number of team members required to assist during transfer or repositioning. Documentation of the lift evaluation must be completed in the resident's [electronic] chart, and communication of the lift evaluation findings must be documented in the care plan, caregiver guide or Kardex. The policy also indicated, 4. The sit-to-stand lift should be used for residents who can bear at least 25% weight on one or both legs, have the ability to follow simple commands, have upper torso and body strength and able to grip with one or both hands. Further review revealed, 7. In order to maintain residents' safety, residents should be lifted or transferred by the lift and sling which is deemed appropriate after the lift evaluation is completed. There should be no interchanging of lifts and slings.An admission Record indicated the facility admitted Resident #77 on 11/21/2024. According to the admission Record, the resident had a medical history that included late onset Alzheimer's disease, abnormal posture, generalized muscle weakness, and lack of coordination.A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/14/2025, revealed Resident #77 had a Brief Interview for Mental Status (BIMS) score of 3, which indicated the resident had severe cognitive impairment. The MDS indicated the resident was dependent on staff for chair/bed-to-chair transfers, going from the sitting to standing position, and tub/shower transfers.Resident #77's Care Plan Report, included a focus area initiated 11/22/2024, that indicated the resident had a physical functioning deficit with transfers. The care plan instructed staff to use the total mechanical lift with a large green sling and the EZ Way (type of sit-to-stand lift) Burgandy Large Sling. Both of these interventions were resolved on 01/09/2025. New interventions were implemented on 07/02/2025 that instructed the staff to use the sit-to-stand lift with the medium yellow sling, and physical therapy was to work with the resident to ensure safety with the sit-to-stand lift.Resident #77's Care Plan Report included a focus area initiated 04/11/2025, that indicated the resident had a self-care deficit related to impaired cognition/dementia. Interventions directed staff to provide all effort with transfers from the chair to the bed and tub and shower transfers since the resident was dependent on staff.Resident #77's Lift Transfer Evaluation (EZ Way), dated 11/22/2024, indicated the resident had a physical functioning deficit with transfers and required assistance of the EZ Way (sit-to-stand) lift with a large burgundy sling for weights of 190-320 pounds.Resident #77's Lift Transfer Evaluation (ARJO Maxi Sky Lift), dated 11/22/2024, indicated the resident had a physical functioning deficit with transfers and required assistance of the total mechanical lift with the large green sling for weights of 154-264 pounds.Resident #77's Progress Notes revealed a Clinical Health Status Evaluation note dated 11/21/2024 that indicated the resident transferred with the use of a sit-to-stand lift.Resident #77's Lift Transfer Evaluation (Hillrom/LIKO Ceiling Lift), dated 01/09/2025, indicated the resident transferred with a transfer/walking belt and one team member.Resident #77's Care Plan Report was updated to resolve the use of the lifts but did not reflect the use of the transfer/walking belt and one team member for transfers.Resident #77's Progress Notes revealed a Weekly Nurses Note dated 03/01/2025 that indicated the resident used a sit-to-stand lift for transfers.During an interview on 07/17/2025 at 3:10 PM, Registered Nurse (RN) #1 stated if a resident had been assessed and determined to need a lift for transfers, then it would not be safe to transfer a resident manually. She stated she thought Resident #77 was a 2-to-3-person transfer, but she was not sure and would have to check with the certified nursing assistants (CNAs).During a telephone interview on 07/18/2025 at 9:59 AM, RN #36 stated she thought Resident #77 could transfer with maximum assistance but thought the facility was requiring them to use lifts to get residents out of bed.During an interview on 07/1