**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record review, and policy review, the facility failed to protect the resident's right to be free from neglect related to not ensuring a safe transfer from a wheelchair to a bed for one resident (Resident #2) of three sampled residents requiring staff assistance with a mechanical lift for transfers. This failure created a situation where the resident fell from the mechanical lift to the floor, causing injuries resulting in transfer to a higher level of care for treatment. Findings included: Review of Resident #2's nurse progress notes dated 4/22/2025 at 6:23 p.m. and authored by Staff A, Licensed Practical Nurse (LPN), revealed the following Nursing Note: Writer was notified by [Certified Nursing Assistant] CNA that [Resident #2] was on floor. CNA came and informed me that another CNA stated she couldn't reach to hook sling up and when said CNA went to raise [name brand of full body mechanical lift], she didn't know that she wasn't hooked up properly and resident fell out of sling. Upon entering room, [Resident #2] was observed laying [sic] face down with on [sic] head pressed against leg of [name brand] mechanical lift, blood was observed on face and floor. Resident [#2] was crying out loud. Nurse immediately called for help and proceeded to call 911 due topositioning [sic] of [Resident #2]. Staff was informed not to touch resident, wait for [Emergency Medical Technician] EMT. [Medical Doctor] MD notified, [Director of Clinical Services] DCS notified, family notified. Resident sent out to ER [Emergency Room] for eval[uation] and [treatment]. On 5/6/2025 at 10:10 a.m., an interview was conducted with Staff A, LPN. She revealed she was called to Resident #2's room on 4/22/2025 and found Resident #2 lying on the floor beside the mechanical lift. Staff A, LPN confirmed Resident #2 is a two person mechanical lift transfer and she was being transferred from a chair to the bed with the assistance from Staff B, CNA and Staff C, CNA. Staff A, LPN revealed Resident #2 fell from the mechanical sling to the floor and had head injuries. She noted the sling was loose or drooping, but couldn't recall whether all the loops were properly secured in the lift. Review of the facility's Adverse Incident Log revealed a documented incident dated 4/23/2025. It was noted an incident involving Resident #2 occurred resulting in Neglect. This incident was reviewed with the Nursing Home Administrator (NHA), Director of Clinical [NAME] (DCS), and the Regional Nursing Consultant (RNC). Through review of the facility's investigation, it was found on 4/22/2025 at approximately 4:15 p.m., Resident #2 was in her room being assisted out from her wheelchair and to her bed via a mechanical lift with Staff B, CNA and Staff C, CNA present. While Resident #2 was hoisted up approximately two feet from the wheelchair, she slid forward and off the mechanical lift sling, to the floor. The NHA and DCS both revealed Resident #2 had a head laceration and the primary physician ordered Resident #2 to the hospital for treatment. The NHA revealed Resident #2 did not return to the facility from the hospital. The NHA revealed the following as a result from their investigation: Staff B, CNA and Staff C, CNA reported to Resident #2's room to transfer her from her wheelchair to the bed with using a mechanical lift. Resident #2 was lying on the blue fabric sling and was ready to be lifted from the wheelchair with the mechanical lift. Staff C, CNA positioned herself directly behind the head of Resident #2's wheelchair as Staff B, CNA pushed the mechanical lift toward Resident #2's wheelchair. Staff C, CNA hooked the sling straps over the two front hooks and Staff B, CNA failed to appropriately hook the two back sling straps to the back hooks. When Staff B, CNA used the mechanical remote control to lift the resident, she was lifted approximately two feet in the air from the wheelchair and started to fidget. The NHA revealed at that point the back straps were not hooked in and while the resident was fidgeting, the straps on the right side of the resident fell off, resulting in Resident #2 falling forward and out from the sling to the floor. The NHA confirmed if the back straps were properly hooked into place, the mechanical lift transfer would not have failed and the resident would not have fallen to the floor. The NHA revealed Resident #2 received a head injury as a result from the fall from the mechanical lift due to poor judgement from both Staff B, CNA and Staff C, CNA, who did not utilize the mechanical lift's standard operating procedure. The NHA confirmed both Staff B, CNA and Staff C, CNA did not ensure the mechanical lift straps were fully secured to the hooks to ensure a safe transfer and both staff members were terminated. The NHA said he had his staff inspect the mechanical lift and sling in question and found there was nothing to indicate equipment faulty. He expressed he had a mechanical lift maintenance company look at the machine and the sling and that company found there had not been any faults with them. Review of Resident #2's medical record revealed she was admitted to the facility on [DATE] and discharged to hospital with no return on 4/22/2025. Review of Resident #2's Minimum Data Set (MDS) Quarterly assessment dated [DATE], revealed under the Activities of Daily Living (ADL) section - Impairment one side to both upper and lower extremities, chair/bed, bed/chair transfers = Dependent on staff. Review of Resident #2's care plans with a next review date 5/28/2025 revealed the following: - ADL/Mobility - Decline in function mobility and self-care requiring assist and rehab interventions due to limitations associated with multiple falls/multiple fx (fracture) (prior to admission), with interventions in place to include but not limited to: mechanical lift with transfers assistance x 2. On 5/6/2025 during the 7 a.m. to 3 p.m. (7-3) shift, Staff D, CNA, Staff E, CNA, and Staff F, CNA revealed anytime a resident required a transfer from bed to chair or from chair to bed should be done with a mechanical lift and there are always to be two staff members; one who operates the lift and one at standby next to the resident for support. Staff D, CNA, Staff E, CNA, and Staff F, CNA noted the four straps of the lift sling must be hooked appropriately so they don't slip off machine. On 5/6/2025 during the 7-3 shift nurses Staff A, LPN and Staff G, LPN were interviewed. Staff A, LPN and Staff G, LPN revealed they conduct rounds throughout the shift and look at how staff are caring for their assigned residents. Staff A, LPN and Staff G, LPN revealed they ensure the mechanical lifts are charged and always ready for use and when staff use the lifts, there are always two staff members in the room during the transfer. Review of the facility's Nursing Procedures Manual - Transfer Techniques dated 7/2023, revealed the following: Purpose: To safely transfer a guest/resident while minimizing the risk of injury to the guest/resident and caregiver. Procedure: 1. Review any special precautions or approaches to take when transferring a guest/resident. Obtain assistance as needed and utilize a gait belt, as indicated. 3. Assemble equipment, as needed, in the guest/resident room. 5. Complete transfer, as indicated and review Transfer Basics in this procedure. 6. Document any observations made during transfers. Observations may include, but are not limited to: - Refusal of transfer. - Changes in clinical condition. - Complaints of pain or discomfort. - Guest/resident level of participation in transferring. - Guest/resident response. Review of the manufacturer's manual for the mechanical full body lift used by the facility revealed the following under Patient Lifting: 7.1.1 Positioning the Lift for use: . 1. Press the Legs Open button on the hand control to open the legs of the patient lift to maximum. 2. Position the patient lift using the steering handle. 3. Press the Boom Down button on the handle control to lower the boom for easy attachment of the sling. 7.1.2 Attaching Slings to the Lift 1 . Place the straps of the sling over the hooks on the hanger bar. 2 . Match the corresponding colors on each side of the sling for an even lift of the patient. 7.2 Lifting/Moving the Patient: Do not lock the rear casters of the patient lift when lifting an individual. Locking the rear casters could cause the patient lift to tip and endanger the patient and assistants. Do not move the patient if the sling is not properly connected to the hooks of the hanger bar. When the sling is elevated a few inches off the stationary surface and before moving the patient, check again to make sure the sling is properly connected to the hooks of the hanger bar. If any attachments are not properly in place, lower the patient back onto the stationary surface and correct this problem; otherwise, injury or damage may occur. Do not use slings and patient lifts from different manufacturers. [Manufacturer name] slings are made specifically for use with [manufacturer name] patient lifts. Injury or damage may occur. Review of the facility's policy titled Abuse, Neglect, Exploitation and Misappropriation, last revision date of 9/2023, revealed the following: Policy: The center recognizes each resident's right to be free from abuse, neglect, and exploitation (ANE), misappropriation of resident property. This includes, but is not limited to, freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's symptoms. Neglect: Neglect is defined in statute 483.5 is the failure of the center, its team members or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. This occurs when the center was aware of or should have been aware of goods or services that the resident(s) required but the center failed to provide them resulting in or may result in physical harm, pain, mental anguish, or emotional distress. This does not mean that all services must be provided by the center but that the center is responsible to ensure that the residents receives the necessary/required services. Goods and services fall into categories. Those categories are structures and processes and individual. 3. Employee Obligation: All employees have a duty to respect the rights of all residents, to treat them with dignity and to prevent others from violating the resident's rights. Any employee who witnesses or has knowledge of an act of abuse or an allegation of abuse, neglect, exploitation, or mistreatment, including injuries of unknown origin or misappropriation of resident property, is obligated to report such information immediately.

Based on observations, interviews, and record review the facility failed to protect the right to be free from neglect related to pain management, contracture management, activities of daily living (ADL) care, and seating systems for one resident (#91) out of 38 total sampled residents. Findings included: On 9/7/24 at 3:31 p.m., Resident #91 was lying in bed with bilateral upper extremities contracted. No palm guards or splints were observed on the resident or in the room. No wheelchair or seating system was observed in the room. Her fingernails extended approximately ½ inch past the tips of her fingers with debris underneath and she had hair growth on her chin. The resident stated she didn't know if the staff could clip her nails, but she would like them shorter. (Photographic evidence obtained with resident consent). Review of the admission Record showed Resident #91 was admitted in April of 2024 with diagnoses to include nontraumatic intracerebral hemorrhage, moyamoya disease, adult failure to thrive, unspecified dementia moderate without behavioral/psychotic/or mood disturbance, contracture of muscle right and left lower leg, and type II diabetes mellitus. Review of Resident #91's Minimum Data Set (MDS) assessment for a significant change, dated 7/15/24, showed a Brief Interview for Mental Status (BIMS) score of 13, indicating intact cognition. The MDS showed the resident had upper and lower extremity impairment on both sides, used a manual wheelchair, and was dependent on a helper for eating, hygiene, bathing, and dressing. The assessment showed the resident was at risk of developing pressure ulcers/injuries and had a pressure reducing device for her chair. The assessment showed physical therapy (PT) was started and ended on 5/21/24 and occupational therapy (OT) started and ended on 5/20/24. Review of Resident #91's care plan showed a focus area of potential for pain related to stage III pressure ulcer (resolved on 7/11/24) and contractures of left and right lower extremities. Initiated on 7/2/24 and revised on 9/9/24. Interventions included administer and monitor for effectiveness and for possible side effects of pain medication, consultation as needed for PT, OT, mental health, make a referral to resident's physician to consider premedicating for pain prior to treatments to optimize participation, notify the resident's physician if they do not state/demonstrate relief or reduction of pain after one hour of receiving the first intervention, observe and report to nurse: signs and symptoms of pain, worsening of pain, observe for non-verbal behavior cues of pain, and report changes in pain location/type frequency/intensity to physician. There is no mention of the contractures of the left and right upper extremities. On 9/8/24 at 1:44 p.m., Resident #91 was lying flat in her bed with a left tilt. The resident was quiet while lying still. When she attempted to move her right hand and arm, she screamed out. The resident said she was in pain and needed something. When asked if she had any splints, guards, or anything for her contracted hands, she said she did not but would like something to help. The resident would not volunteer information but would answer questions if directly asked. The resident's nails remained untrimmed and dirty. An interview was conducted on 9/8/24 at 1:46 p.m. with Staff L, Licensed Practical Nurse (LPN). The nurse was informed Resident #91 yelled out, and vocalized she was in pain, and had requested something to help. Staff L said all the resident had ordered was Tylenol, and she didn't know if it would help. She said Resident #91 yelling out when she moved is her norm [normal]. Review of Resident #91's physician orders showed an active order for Tylenol 325 mg x 2 tablets every 4 hours as needed for mild to moderate pain. No other medications were ordered for pain control. There was an order dated 4/4/24 for a Pain Management consult as needed. An interview was conducted on 9/8/24 at 2:13 p.m. with a family member of Resident #91. The family member said when Resident #91 was admitted her left hand was contracted and now both hands and feet are. The family member stated Resident #91 only had a couple days of therapy when she was first admitted , and the therapist said there was no sense in giving the resident therapy. The family member said they were concerned about the resident having sores, that the wound care nurse said were related to the resident sweating a lot. The family member said Resident #91's roommate was always turning the temperature up in the room and making Resident #91 hot. The family member said a few days ago staff told her they would work on moving the resident to a new room, but they also said that a month ago. The family member said she didn't know why the resident's nails were not being cared for; they were long and dirty. The family member said social services told her they were getting a special chair that has a high back and reclines, but the resident was always in bed on her back. The family member said they had never seen Resident #91 in a different position. The family member said Resident #91 can get confused and will not speak up, but if she is asked something, she will answer. An interview was conducted on 9/8/24 at 3:07 p.m. with Staff P, Certified Nursing Assistant (CNA). She said Resident #91 normally screams anytime she was moved. She said when the resident was changed, the resident screams. When the CNAs roll her one way she screams when they roll her back. She said they do put positioning pillows under her. Staff P said she had never seen Resident #91 out of bed. She said every resident should have a wheelchair, but Resident #91 does not. Upon entering Resident #91's room the roommate asked Staff P to turn the temperature up in the room. Staff P was observed going to Resident #91 who was lying in the bed on her back. The CNA attempted to extend the 3rd digit on the resident's right hand from a closed fist. When she did, Resident #91 screamed out in pain and an unpleasant odor was emitted from the resident's hand. The resident's fingers were unable to be extended out without the resident crying out in pain. Staff P said the aides are not able to get a washcloth in the resident's hand to clean it. An interview was conducted on 9/9/24 at 10:06 a.m. with Staff O, CNA. She said she regularly cares for Resident #91 on the day shift, on weekdays. Staff O said when she turned the resident, the resident would say she was in pain and screamed out. Staff O said she was the CNA that provided showers/bed baths to Resident #91. She said, to be honest, I don't really do nail. I can't see very well. She added she did not want to clip the resident's skin and hurt her. Staff O said Resident #91 does not have a wheelchair, and she stays in her bed all the time. A follow-up interview and observation on 9/9/24 at 12:19 p.m. was conducted with Staff O, CNA with Staff Q, CNA assisting. Staff O was observed trying to move Resident #91's fingers, the resident grimaced and moaned in pain. Staff O said she can not clean under the resident's finger, she just tried to get cream under them. Staff Q was surprised the resident had nothing for her hands and said she needs a carrot. Resident #91 had pressure relieving boots on bilateral feet, the CNA was observed removing the boots and a strong odor was present. The plantar aspect (soles) of the resident's bilateral feet were dry, cracked and skin sloughed off onto the bed when the boots were removed. Both feet were in a dorsiflexed position (backward bending) and had significant edema (swelling) that was non-blanchable to the CNA's touch. Resident #91 also had an open area of the posterior (calf) side of her right lower leg that had no dressing. According to Pisces Health a carrot hand contracture orthosis kit painlessly positions the fingers away from the palm to protect the skin from excessive moisture, pressure, and the risk of nail puncture injuries while helping to prevent bacteria build up and unpleasant odors. (Accessed on 9/16/24 at https://www.pisceshealth.com/original-carrot-blue-one-size) An interview was conducted on 9/9/24 at 9:41 a.m. with Staff G, LPN. She said Resident #91 did not really ask for things and if you asked her a question, she could not give a definite answer. Staff G said she believed the resident had a wheelchair, but she doesn't know where the CNAs put it. She said the resident does scream out in pain and would still scream out in pain after she took Tylenol but not as bad as when she had no medication for pain. Staff G said Resident #91 did not have any palm guards or splints. An interview was conducted on 9/9/24 at 10:29 a.m. with the Wound Care Nurse. She said Resident #91 gets blisters on her skin from moisture. She said the resident's roommate like the air conditioning off and Resident #91 sweats a lot. Staff G heard staff were working on changing roommate, but she did not know where that stood. The Wound Care Nurse said Resident #91 cried out when she was turned or moved. She said she felt like the resident was a little fearful and anticipates turning, and she yells out. The Wound Care Nurse said the resident had contractures on both arms that caused her pain, and she believed the resident only had Tylenol to take for the pain. An interview was conducted on 9/9/24 at 12:23 p.m. with the Director of Nursing (DON). She reviewed Resident #91's record and said she had not been seen by pain management or podiatry, only her primary care provider had seen her. An interview was conducted on 9/9/24 at 2:44 p.m. with the Social Services Director (SSD) and Social Services Assistant (SSA). They both said they knew Resident #91's roommate wanted a room change because of the temperature differences between the two, but no one told them about Resident #91 having issues with sweating and that causing problems. The SSD and SSA said they did not know Resident #91 or the family wanted a room change. They also said they had not spoken to the family regarding any wheelchair or special chair for the resident. Review of an OT evaluation for Resident #91, dated 4/5/24 showed, Patient demonstrates poor rehab potential at this time. Patient presents with BUE [bilateral upper extremity] multiple deformities secondary to her medical condition and extremely painful upon movement. The evaluation noted the resident had a pain level of 4 out of 10 at rest and an 8 out of 10 with movement. The pain with movement was described as gnawing and excruciating. It showed the pain limited the resident's functional abilities. The resident was not reviewed for OT again until 5/20/24 at re-admission after a hospital stay. Again, no skilled OT intervention was indicated. A pain level of 8 out of 10 on movement was noted and described as heavy, sharp, stabbing, and shooting. Review of a PT evaluation dated 4/5/24 showed Resident #91 demonstrated impaired cognition and extremely low activity tolerance when very limited passive range of motion (PROM) was provided on B (bilateral) knee. It showed the resident was not an appropriate candidate for skilled therapy. The evaluation noted Resident #91 had a pain level of 10 out of 10 with movement and it limited her functional activity. It showed pain interventions were unknown. The resident was not reviewed for PT again until 5/20/24 at re-admission after a hospital stay. Again, no skilled PT intervention was indicated. A pain level of 9 out of 10 on movement was noted. The impressions showed While therapist very slowly slightly moved pt's [patient's] LE [lower extremity] to perform PROM on B knees/B hips: pt screamed and asked to stop. An interview was conducted on 9/9/24 at 11:49 a.m. with the Director of Rehabilitation (DOR) and the Director of Operations for Rehab. The DOR said every resident admitted gets scheduled for an OT, PT and speech therapy (ST) evaluation. She said it is not often they do not pick up a new admission for therapy services. She said if a resident cannot tolerate the therapy evaluations, they would communicate with nursing and do the evaluations at a later time. The DOR said if a resident cannot tolerate touch, they discuss with nursing to see what medication the resident could possibly take. The modalities the therapy department had available to address pain include electrical stimulation (ESTIM), ultrasound, and diathermy. The DOR said they try to screen all resident's quarterly for therapy, and anytime nursing puts in a referral for a therapy screen. The DOR reviewed Resident #91's medical record. She said in April when they did the therapy screen, the resident could not tolerate passive range of motion. She said therapy should have communicated with nursing to see if there was anything going on medication wise and that would have been documented. The DOR confirmed there was no documentation of therapy communicating with nursing regarding Resident #91's pain. She said she did not see anything in the medical record that would contradict the modalities the therapy department had to address pain and those would have been a plausible program to trial with Resident #91. After reviewing the medical record, she said Resident #91 did not get screened at her quarterly review, only on admission in April 2024 and re-admission in May 2024. She stated, I cannot tell you why she wasn't screened on the quarterly unless something didn't trigger it. The DOR said without the therapy screens, therapy would not know the resident needed contracture management. She said nursing could also put in a referral for contracture management, and therapy had not received any referrals for this resident. The DOR said at the time of the therapy evaluations the resident could not tolerate any range of motion therefore, she was not evaluated for a wheelchair. She said Resident #91 would have probably received a high back or broda chair. She said the resident did not have any chair and did not recall ever seeing the resident out of bed. She said during the therapy evaluation for Resident #91, the resident asked them to stop due to the pain. The DOR said there was no documentation that a conversation had taken place with nursing related to the resident's pain. The DOR said therapy could have tried something like splints or palm guards to see if the resident could tolerate anything. The DOR said nothing had been attempted with Resident #91 and contracture management was not addressed. An interview was conducted on 9/9/24 at 1:37 p.m. with Resident #91's primary care Nurse Practitioner (NP). The NP said when she has seen Resident #91, the resident was typically lying still and not in pain. She said she had tried to talk to the nurses but did not get a lot of information from them. She said no one communicated to her the resident was having pain with movement or that she had pain during her therapy screen and was not getting therapy. The NP said she was under the assumption the resident had been getting PT and nursing did not tell her the resident was not. The NP said on June 20, 2024, she assessed the resident, and a family member was present. The family member mentioned that having only Tylenol was not enough to help the resident. The NP said she ordered Tramadol at that time. The NP reviewed Resident #91's medical record. In her system she was able to see the Tramadol had been ordered; however, it never showed up in the facility's system. The NP reviewed the facility's system and confirmed the Tramadol was not in the system as an active, completed, or discontinued order and the Medication Administration Record (MAR) did not show the resident had been administered Tramadol. The NP said she doesn't know what went wrong because the two systems crossed over. Review of Resident #91's progress notes showed the following: 6/20/24 Provider note from the primary care NP The family member reported she has complained of pain and is unsure that Tylenol is helping. The plan showed Continue to monitor for pain and provide pain relief with p.r.n. [as needed] Tylenol and restarted tramadol. Review of Resident #91's June 2024 physician orders showed Tylenol 325 mg x 2 tablets every 4 hours as needed for mild to moderate pain. There were no other orders related to pain control. Review of Resident #91's progress note also revealed a note dated 7/9/24 showing during a care plan meeting the resident's family member discussed wanting to see the resident out of bed in a chair 2-3 times a week. An interview was conducted on 9/9/24 at 3:25 p.m. with the DON. She said if Resident #91 was not able to do her therapy evaluations due to pain, it should have been reported to nursing so it could be passed along to the primary care provider. The DON said she had not been aware of the family having concerns about Resident #91's pain control in June 2024. She said she did not know what happened with the Tramadol order for the NP, and nurses do not review the doctor's notes. The DON said she was not aware of anyone that reviewed the doctor's plan for the residents' unless the unit managers did. She said her expectation would have been for the nurses to have notified the physician and obtained orders for pain medication and pain management to see the resident, if it was appropriate. The DON said it was not acceptable for Resident #91 to scream in pain when she was changed. She said the resident cannot tolerate being out of bed due to the fact she cannot be moved because of her discomfort. The DON said staff had not tried to get the resident out of bed because therapy couldn't complete the evaluation, and she had not been screened for a wheelchair. The DON said she was not a part of the care plan meeting in July 2024 and did not know there was a discussion with the family about wanting the resident out of bed 2-3 times a week. The DON reported the CNAs should be trimming Resident #91's fingernails when they do baths. She also said nursing could have put in a podiatry consult or a provider could have put it in. A follow-up interview was conducted on 9/10/24 at 2:38 p.m. with Resident #91. The resident was lying in bed. She said when she moved her pain level was usually 8 out of 10. When asked about being moved from the bed to shower chair she said, that didn't feel good. Review of a facility policy titled Abuse, Neglect, Exploitation, and Misappropriation, revised September 2023, showed the following: Policy: the center recognizes each resident's right to be free from abuse, neglect, and exploitation (ANE), misappropriation of resident property. This includes, but it is not limited to, freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's symptoms. This includes the centers identification of residents whose personal histories render them at risk for abusing other residents, and development of intervention strategies to prevent occurrences, observing for changes that would trigger abusive behavior, reassessment of the interventions on a regular basis. The center will not employ or otherwise engage individuals who have been found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law; having a finding entered into the State nurse aide registry concerning abuse, neglect, exploitation, mistreatment of residents or misappropriation of their property or have a disciplinary action in effect against his or her professional license by a state licensure body as a result of a finding of abuse, neglect, exploitation, misappropriation of property or mistreatment. This center reports suspicions of crimes committed against a resident of this center in accordance with section 1150B of the Social Security Act to at least one law enforcement agency and the State Survey Agency . Neglect Neglect as defined in statute 483.5 is the failure of the center, its team members or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. This occurs when the center was aware of or should have been aware of goods or services that the resident(s) required but the center failed to provide them resulting in or may result in physical harm, pain, mental anguish or emotional distress. This does not mean that all services must be provided by the center but that the center is responsible to ensure that the resident receives the necessary/required services. Goods and services fall into categories. Those categories are structures and processes and individual . Review of a facility procedure, dated 07/2023, titled Nail Care (Fingernails) showed: Purpose: To prevent infection and promote healthy fingernails. 16. Provide nail care according to guest/resident preferences and need. 17. Notify the physician of any changes or concerns with nails or surrounding skin.

Based on observations, interviews, and record review the facility failed to ensure pain was managed for one resident (#91) out of three residents reviewed for pain out of a total sample of 38 residents. Findings included: On 9/7/24 at 3:31 p.m., Resident #91 lying in bed with bilateral upper extremities contracted. No palm guards or splints were observed on the resident or in the room. No wheelchair or seating system was observed in the room. Her fingernails extended approximately ½ inch past the tips of her fingers with debris underneath. The resident stated she didn't know if the staff could clip her nails, but she would like them shorter. (Photographic evidence obtained with resident consent). On 9/8/24 at 1:44 p.m., Resident #91 was lying flat in her bed with a left tilt. The resident was quiet while lying still. When she attempted to move her right hand and arm, she screamed out. The resident said she was in pain and needed something. When asked if she had any splints, guards, or anything for her contracted hands, she said she did not but would like something to help. The resident would not volunteer information but would answer questions if directly asked. An interview was conducted on 9/8/24 at 2:13 p.m. with a family member of Resident #91. The family member said when Resident #91 was admitted her left hand was contracted and now both hands and feet are. The family member stated Resident #91 only had a couple days of therapy when she was first admitted , and the therapist said there was no sense in giving the resident therapy. The family member said they were concerned about the resident having sores, that the wound care nurse said were related to the resident sweating a lot. The family member said she didn't know why the resident's nails were not being cared for; they were long and dirty. The family member said social services told her they were getting a special chair that has a high back and reclines, but the resident was always in bed on her back. The family member said they had never seen Resident #91 in a different position. The family member said Resident #91 can get confused and will not speak up, but if she is asked something, she will answer. A follow-up interview was conducted on 9/10/24 at 2:38 p.m. with Resident #91. The resident was lying in bed. She said when she moved her pain level was usually 8 out of 10. When asked about being moved from the bed to shower chair she said, that didn't feel good. Review of the admission Record showed Resident #91 was admitted in April of 2024 with diagnoses to include nontraumatic intracerebral hemorrhage, moyamoya disease, adult failure to thrive, unspecified dementia moderate without behavioral/psychotic/or mood disturbance, contracture of muscle right and left lower leg, and type II diabetes mellitus. Review of Resident #91's Minimum Data Set (MDS) assessment for a significant change, dated 7/15/24, showed a Brief Interview for Mental Status (BIMS) score of 13, indicating intact cognition. The MDS showed the resident had upper and lower extremity impairment on both sides and was dependent on a helper for activities of daily living (ADL's). The assessment showed in the last 5 days (7/10/24 to 7/15/24) the resident was not on a scheduled pain medication regimen, had not received PRN (as needed) pain medication, and non-medication intervention for pain was provided. The pain assessment interview was conducted with the resident, but she was marked as unable to answer yes or no to pain presence. The staff assessment for pain or possible pain during the last 5 days (7/10/24 to 7/15/24) revealed none of the following had been observed or documented for Resident #91: non-verbal sounds of pain (crying, whining, gasping, moaning or groaning), vocal complaints of pain, facial expressions of pain, or protective body movements or posture. The assessment showed physical therapy (PT) was started and ended on 5/21/24 and occupational therapy (OT) started and ended on 5/20/24. Review of Resident #91's care plan showed a focus area of potential for pain related to stage III pressure ulcer (resolved on 7/11/24) and contractures of left and right lower extremities. Initiated on 7/2/24 and revised on 9/9/24. Interventions included administer and monitor for effectiveness and for possible side effects of pain medication, consultation as needed for PT, OT, mental health, make a referral to resident's physician to consider pre-medicating for pain prior to treatments to optimize participation, notify the resident's physician if they do not state/demonstrate relief or reduction of pain after one hour of receiving the first intervention, observe and report to nurse: signs and symptoms of pain, worsening of pain, observe for non-verbal behavior cues of pain, and report changes in pain location/type frequency/intensity to physician. There is no mention of the contractures of the left and right upper extremities. An interview was conducted on 9/8/24 at 1:46 p.m. with Staff L, Licensed Practical Nurse (LPN). The nurse was informed Resident #91 yelled out, and vocalized she was in pain, and had requested something to help. Staff L said all the resident had ordered was Tylenol, and she didn't know if it would help. She said Resident #91 yelling out when she moved is her norm [normal]. Review of Resident #91's physician orders showed an active order for Tylenol 325 mg x 2 tablets every 4 hours as needed for mild to moderate pain. No other medications were ordered for pain control. There was an order dated 4/4/24 for a Pain Management consult as needed. An interview was conducted on 9/8/24 at 3:07 p.m. with Staff P, Certified Nursing Assistant (CNA). She said Resident #91 normally screams anytime she was moved. She said when the resident was changed, the resident screams. When the CNAs roll her one way she screams when they roll her back. She said they do put positioning pillows under her. Staff P said she had never seen Resident #91 out of bed. She said every resident should have a wheelchair, but Resident #91 does not. Staff P was observed going to Resident #91 who was lying in the bed on her back. The CNA attempted to extend the 3rd digit on the resident's right hand from a closed fist. When she did, Resident #91 screamed out in pain and an unpleasant odor was emitted from the resident's hand. The resident's fingers were unable to be extended out without the resident crying out in pain. Staff P said the aides are not able to get a washcloth in the resident's hand to clean it. An interview was conducted on 9/9/24 at 10:06 a.m. with Staff O, CNA. She said she regularly cares for Resident #91 on the day shift, on weekdays. Staff O said when she turned the resident, the resident would say she was in pain and screamed out. Staff O said she was the CNA that provided showers/bed baths to Resident #91. She said, to be honest, I don't really do nail. I can't see very well. She added she did not want to clip the resident's skin and hurt her. Staff O said Resident #91 does not have a wheelchair, and she stays in her bed all the time. A follow-up interview and observation on 9/9/24 at 12:19 p.m. was conducted with Staff O, CNA with Staff Q, CNA assisting. Staff O was observed trying to move Resident #91's fingers, the resident grimaced and moaned in pain. Staff O said she can not clean under the resident's finger, she just tried to get cream under them. Staff Q was surprised the resident had nothing for her hands and said she needs a carrot. Resident #91 had pressure relieving boots on bilateral feet, the CNA was observed removing the boots. The plantar aspect (soles) of the resident's bilateral feet were dry, cracked and skin sloughed off onto the bed when the boots were removed. Both feet were in a dorsiflexed position (backward bending) and had significant edema (swelling) that was non-blanchable to the CNA's touch. Resident #91 also had an open area of the posterior (calf) side of her right lower leg that had no dressing. According to Pisces Health a carrot hand contracture orthosis kit painlessly positions the fingers away from the palm to protect the skin from excessive moisture, pressure, and the risk of nail puncture injuries while helping to prevent bacteria build up and unpleasant odors. (Accessed on 9/16/24 at https://www.pisceshealth.com/original-carrot-blue-one-size) An interview was conducted on 9/9/24 at 9:41 a.m. with Staff G, LPN. She said Resident #91 did not really ask for things and if you asked her a question she couldn't give a definite answer. Staff G said she believed the resident had a wheelchair, but she doesn't know where the CNAs put it. She said the resident does scream out in pain and would still scream out in pain after she took Tylenol but not as bad as when she had nothing. Staff G said Resident #91 did not have any palm guards or splints. An interview was conducted on 9/9/24 at 10:29 a.m. with the Wound Care Nurse. She said Resident #91 gets blisters on her skin from moisture. She said the resident's roommate like the air conditioning off and Resident #91 sweats a lot. The Wound Care Nurse said Resident #91 cried out when she was turned or moved. She said she felt like the resident was a little fearful and anticipates turning, and she yells out. The Wound Care Nurse said the resident had contractures on both arms that caused her pain, and she believed the resident only had Tylenol to take for the pain. An interview was conducted on 9/9/24 at 12:23 p.m. with the Director of Nursing (DON). She reviewed Resident #91's record and confirmed the resident she had not been seen by pain management. Review of an OT evaluation for Resident #91, dated 4/5/24 showed, Patient demonstrates poor rehab potential at this time. Patient presents with BUE [bilateral upper extremity] multiple deformities secondary to her medical condition and extremely painful upon movement. The evaluation noted the resident had a pain level of 4 out of 10 at rest and an 8 out of 10 with movement. The pain with movement was described as gnawing and excruciating. It showed the pain limited the resident's functional abilities. The resident was not reviewed for OT again until 5/20/24 at re-admission after a hospital stay. Again, no skilled OT intervention was indicated. A pain level of 8 out of 10 on movement was noted and described as heavy, sharp, stabbing, and shooting. Review of a PT evaluation dated 4/5/24 showed Resident #91 demonstrated impaired cognition and extremely low activity tolerance when very limited passive range of motion (PROM) was provided on B (bilateral) knee. It showed the resident was not an appropriate candidate for skilled therapy. The evaluation noted Resident #91 had a pain level of 10 out of 10 with movement, and it limited her functional activity. It showed pain interventions were unknown. The resident was not reviewed for PT again until 5/20/24 at re-admission after a hospital stay. Again, no skilled PT intervention was indicated. A pain level of 9 out of 10 on movement was noted. The impressions showed While therapist very slowly slightly moved pt's [patient's] LE [lower extremity] to perform PROM on B knees/B hips: pt [patient] screamed and asked to stop. An interview was conducted on 9/9/24 at 11:49 a.m. with the Director of Rehabilitation (DOR) and the Director of Operations for Rehab. The DOR said if a resident cannot tolerate the therapy evaluations, they would communicate with nursing and do the evaluations at a later time. The DOR said if a resident cannot tolerate touch, they discuss with nursing to see what medication the resident could possibly take. The modalities the therapy department had available to address pain included electrical stimulation (ESTIM), ultrasound, and diathermy. The DOR said they try to screen all resident's quarterly for therapy and anytime nursing puts in a referral for a therapy screening. The DOR reviewed Resident #91's medical record. She said in April when they did the therapy screen, the resident could not tolerate passive range of motion. She said therapy should have communicated with nursing to see if there was anything going on medication wise and that would have been documented. The DOR confirmed there was no documentation of therapy communicating with nursing regarding Resident #91's pain. She said she did not see anything in the medical record that would contradict the modalities the therapy department had to address pain and those would have been a plausible program to trial with Resident #91. After reviewing the medical record, she said Resident #91 did not get screened at her quarterly review, only on admission in April 2024 and re-admission in May 2024. She stated, I cannot tell you why she wasn't screened on the quarterly unless something didn't trigger it. The DOR said without the therapy screens, therapy would not know the resident needed contracture management. She said nursing can put in a referral for contracture management, and therapy had not received any referrals for Resident #91. The DOR said at the time of the therapy evaluations the resident could not tolerate any range of motion therefore she was not evaluated for a wheelchair. She said Resident #91 would have probably gotten a high back or broda chair. She said the resident did not have any chair, and she did not recall ever seeing her out of bed. She said during the therapy evaluation for Resident #91, the resident asked them to stop due to the pain. The DOR said there was no documentation that a conversation had taken place with nursing related to the resident's pain. The DOR said therapy could have tried something like splints or palm guards to see if the resident could tolerate anything. The DOR said nothing had been attempted with Resident #91 and contracture management was not addressed. During an interview on 9/9/24 at 1:37 p.m. with Resident #91's primary care Nurse Practitioner (NP) it was revealed that when she sees Resident #91, the resident was typically lying still and not in pain. The NP said she had tried to talk to the nurses but did not get a lot of information from them. She said no one communicated to her the resident was having pain with movement or that she had pain during her therapy screen and was not getting therapy. The NP said she was under the assumption the resident had been getting PT and nursing did not tell her the resident was not. The NP said on June 20, 2024, she assessed the resident, and a family member was present. The family member mentioned that having only Tylenol was not enough to help the resident. The NP said she ordered Tramadol at that time. The NP reviewed Resident #91's medical record. In the NP's electronic record system she was able to see the Tramadol had been ordered; however, it never showed up in the facility's electronic system. The NP reviewed the facility's system and confirmed the Tramadol was not in the system as an active, completed, or discontinued order and the Medication Administration Record (MAR) did not show the resident had been administered Tramadol. The NP said she doesn't know what went wrong because the two systems cross over one another. Review of Resident #91's 6/20/24 provider note from the primary care NP revealed the family member reported she [Resident #91] has complained of pain and is unsure that Tylenol is helping. The plan showed Continue to monitor for pain and provide pain relief with p.r.n. [as needed] Tylenol and restarted tramadol. Review of Resident #91's June 2024 physician orders showed Tylenol 325 mg x 2 tablets every 4 hours as needed for mild to moderate pain. There were no other orders related to pain control. Review of Resident #91's progress note also revealed a note dated 7/9/24 showing during a care plan meeting the resident's family member discussed wanting to see the resident out of bed in a chair 2-3 times a week. An interview was conducted on 9/9/24 at 3:25 p.m. with the DON. She said if Resident #91 was not able to do her therapy evaluations due to pain, it should have been reported to nursing so it could be passed along to the primary care provider. The DON said she had not been aware of the family having concerns about Resident #91's pain control in June 2024. She said she did not know what happened with the Tramadol order for the NP, and nurses do not review the doctor's notes. The DON said she was not aware of anyone that reviewed the doctor's plan for the residents' unless the unit managers did. She said her expectation would have been for the nurses to have notified the physician and obtained orders for pain medication and pain management to see the resident, if it was appropriate. The DON said it was not acceptable for Resident #91 to scream in pain when she was changed. She said the resident cannot tolerate being out of bed due to the fact she cannot be moved because of her discomfort. The DON said staff had not tried to get the resident out of bed because therapy couldn't complete the evaluation, and she had not been screened for a wheelchair. The DON said she was not a part of the care plan meeting in July 2024 and did not know there was a discussion with the family about wanting the resident out of bed 2-3 times a week. The DON reported the CNAs should be trimming Resident #91's fingernails when they do baths. She also said nursing could have put in a podiatry consult or a provider could have put it in. Review of a facility policy titled Pain assessment and Management, dated 1/1/20, showed the following: Recognition and Management of Pain- in order to help a resident attain or maintain his or her highest practicable level of well-being and to prevent or manage pain, the facility, to the extent possible: -Recognizes when the resident is experiencing pain and identify circumstances when pain can be anticipated. -Evaluate the existing pain on a scale from 0-10 with 10 being the worst. -Manages or prevents pain, consistent with the comprehensive assessment and plan of care, current professional standards of practice, and the resident's goals and preferences. Strategies for the prevention and management of pain may include but are not limited to the following: -Assessing the potential for pain, recognizing the onset, presence and duration of pain, and assessing the characteristics of pain; -Addressing/treating the underlying causes of the pain, to the extent possible; -Developing and implementing both non-pharmacological and pharmacological interventions/approaches to pain management, depending on factors such as whether the pain is episodic, continuous, or both; -Identifying and using specific strategies for preventing or minimizing different levels or sources of pain or pain-related symptoms based on the resident-specific assessment, preferences and choices, a pertinent clinical rationale, and the resident's goals and; using pain medications judiciously to balance the resident's desired level of pain relief with the avoidance of unacceptable adverse consequences; -Monitoring appropriately for effectiveness and/or adverse consequences (e.g., constipation, sedation) including defining how and when to monitor the resident's symptoms and degree of pain relief; and -Modifying the approaches, as necessary. -Identifying target signs and symptoms (including verbal reports and nonverbal indicators from the resident) and using standardized assessment tools can help the interdisciplinary team evaluate the resident's pain and responses to interventions and determine whether the care plan should be revised,: -If pain has not been adequately controlled, it may be necessary to reconsider the current approaches and revise or supplement them as indicated; or -if pain has resolved or there is no longer an indication or need for pain medication, the facility works with the practitioner to discontinue or taper (as needed to prevent withdrawal symptoms) analgesics.