Based on observation, staff and resident interviews, record review, and facility policy review, the facility failed to ensure a resident's right to be free from abuse including involuntary seclusion, verbal abuse and unreasonable confinement by staff members physically restraining a resident for one (1) of three (3) residents sampled. Resident #1. Findings include: Record review of facility policy titled, Abuse, Neglect and Exploitation, dated 3/17/23, revealed, It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect , 'Abuse' means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish, which can include staff to resident abuse . Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. 'Verbal Abuse' means the use of oral, written or gestured communication or sounds that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance regardless of their age, ability to comprehend, or disability .Involuntary Seclusion refers to the separation of a resident from .his/her room .against the resident's will . During an interview with the Administrator on 11/20/24 at 9:15 AM, it was revealed that the incident occurred on 10/30/24 around 6:00 PM and was reported by Resident #3 to the Administrator the next morning on 10/31/24. She stated after viewing the video footage and interviewing residents and staff, it was determined that the resident was confined to her chair and made to stay in the lobby area and was not allowed to go to the bathroom by two staff members. An interview with Resident #3 on 11/20/24 at 12:25 PM, revealed she was in the lobby area when this incident occurred between Resident #1 and Registered Nurse (RN) #1 and Licensed Practical Nurse (LPN) #1. She stated Resident #1 needed to go to the bathroom and LPN #1 held her in the chair and yelled at her and told her to stay in the chair and that she was not leaving. Then, RN #1 wrapped her arms around resident from behind and held her in the chair. They yelled at her and were telling her that they were going to send her out to the hospital. Resident #1 was moving a lot and trying to get them to let her go. Resident #3 stated, That really hurt me to see them treat her that way. I had to get out of there because I couldn't watch that. An interview with Resident #2 on 11/20/24 at 12:40 PM, revealed he also witnessed this incident in the lobby, and he reported it the next day. He stated it started when the resident told LPN #1 that she needed to go to her room to go to the bathroom, but LPN #1 told her she had just gone and not done anything, so she was not going back and to stay in her chair. The resident moved her chair towards the door several times, but LPN #1 brought her back to the lobby area each time. LPN #1 told another staff member to close the doors that led from the lobby to the hallway so Resident #1 could not leave. He stated LPN #1 took the resident's hands and held them together in front of the resident and tried to hold her arms on the resident's chest to keep her in her chair. She yelled at the resident to sit down, she was not going to her room, she was going to be sent out, and she was tired of her doing this. At that point, RN #1 came and held the resident from behind with her arms wrapped around the resident's shoulders and the resident's arms were crossed and she held her arms. The resident tried to get them to let go of her and go to the bathroom. He stated it was awful to watch, and he had never seen anything like that before with these nurses or other staff and both of these nurses seemed irritated, and the situation was out of control. An observation and interview with Resident #1 on 11/20/24 at 3:00 PM, revealed the resident sitting in her recliner in her room drinking water from her cup with jerky and uncoordinated movements. Resident #1 had a diagnosis of Huntington's disease; therefore she was extremely difficult to understand, but she continued to repeat each statement until she was understood. She stated she was in the lobby area and needed to go to the bathroom, but LPN #1 would not take her since she had just been. She attempted to propel herself to her room, but LPN #1 stopped her and pushed her back into the lobby. LPN #1 held her in the chair and yelled at her saying she was not going to her room, and she was getting sent to the hospital. Then, RN #1 held her from behind while she was sitting in her chair and would not allow her to move. She stated she had the right to go to the bathroom and to be held down was wrong and she did not like being treated that way. She denied any physical injury but stated she was emotionally bothered, and this made her angry and upset that they did this to her. She stated that the nurses sent her to the emergency room (ER) and she told the doctor in the ER that nothing was wrong with her that she just needed to go to the bathroom and they wouldn't allow her too. The resident confirmed that she was returned to the facility later that evening. During a phone interview on 11/20/24 at 3:45 PM, LPN #1 she stated Resident #1 was in the lobby area and was taken to the bathroom by a Certified Nursing Assistant (CNA) #5 and within a few minutes, she stated she needed to go to the bathroom again. CNA #5 was with another resident, and she informed Resident #1 that it would be a few minutes and the CNA would be back to take her to the bathroom. She stated the resident tried to propel herself to her room and she told her she could not go back by herself due to the risk of a fall. She stated Resident #1 got mad and was hitting and pushing and tried to throw herself out of the chair and she did hold her in the chair to keep her safe. She stated a resident does have the right to fall but she felt that it was her responsibility to keep that from happening if she could. She stated she should not have yelled at the resident or held her when she did not want to be held, but she did this to keep her safe, not to be malicious or mean. She stated she wished the situation had been handled differently, but she just did not want her to fall. LPN #1 confirmed that she was terminated from the facility related to this incident. A phone interview with CNA #1 on 11/20/24 at 4:05 PM, revealed she came up on the situation and the resident was yelling that she had to go to the bathroom and RN #1 was holding her from behind. CNA #1 did not witness the resident hitting or kicking but said it appeared to her that she was trying to free herself from being held. She stated she was shocked to see this and did not know what to think about it. During a phone interview with RN #2 on 11/20/24 at 4:15 PM, it was revealed that she and RN #1 were having shift report in the office, and they heard a big commotion and yelling so they went out to see what was happening. She stated LPN #1 said the resident was kicking and hitting and she needed help to hold her in her chair, so RN #1 put her arms around her from behind her to keep her from falling from the chair. She heard LPN #1 yelling at the resident that they were going to send her out and to sit down or you are going to fall. She felt they were trying to keep her safe and she did not think they meant for things to be that loud and out of control. A phone interview with CNA #2 on 11/20/24 at 4:45 PM revealed she had come into the lobby area and the lobby doors were closed and she heard the resident yelling that she needed to go to the bathroom and LPN #1 told her that she had just been to the bathroom and did not need to go again. She stated LPN #1 also cussed and yelled at the resident to calm down and she was not going to put up with this sh*t and that she was being sent out. CNA #2 observed that the resident was not combative but appeared to be trying to get loose from being held. She stated RN #1 was behind the resident and had her arms wrapped around her shoulders. She stated a CNA #3 came up and was holding her hands and talking calmly to the resident and the resident calmed down and RN #1 released her hold. She stated she had never seen anything like that, and the resident did not deserve for her caregivers to treat her that way in her home. During a phone interview on 11/21/24 at 9:45 AM, CNA #3 revealed the lobby doors were closed and when she walked through, she saw RN #1 holding the resident like a bear hug from behind and RN #1 said the resident had been hitting and kicking. RN #1 asked her to hold the resident's hands so she gently placed her hands over the resident's hands, and talked calmly to her and she calmed down and RN #1 released her hold on her. She stated the ambulance came and she was taken to the hospital. A phone interview with RN #1 on 11/21/24 at 10:00 AM revealed on the evening of the incident, she and the day nurse were in the office for shift change report and they heard a commotion and yelling in the lobby area. She and the day shift nurse went into the lobby area and heard LPN #1 and Resident #1 yelling loudly and LPN #1 told Resident #1 that she needed to calm down and she was going to be sent out to the hospital. LPN #1 told her the resident had been hitting and slapping all day and she asked her to help hold her in the chair so she would not fall out while she did the paperwork for the hospital transfer. She held her from behind around her shoulders like a bear hug to keep her from falling out of the chair and the resident tried to get loose. She stated the resident had a history of fighting and attacking staff and had been to the emergency room before for this. The resident told her she needed to go to the bathroom to poop but LPN #1 said she had already been and did not do anything. CNA #3 came and held her hands and talked to her and she calmed down and she stated she released the bear hug hold on her. The ambulance arrived and she was assisted onto the gurney and was taken to the hospital. She stated with the information she had received, her first concern was to keep this resident and others safe. She stated she made a judgement call based on the information she had received and in hindsight, the situation should have been handled differently and she should not have held her in her chair. She stated when she was in the situation, all she could think of was what to do to prevent a harmful fall. RN#1 confirmed that she resigned from the facility, prior to the facility terminating her. A phone interview with CNA #4 on 11/21/24 at 10:08 AM, revealed that she and CNA #1 came into the lobby and heard the commotion. RN #1 was holding the resident from behind and CNA #3 walked over to talk to the resident. She stated RN #1 and LPN #1 were screaming to sit down and you're not going anywhere. The resident yelled out and tried to get loose, but she did not see the resident kick or hit. As the resident calmed down and got quiet, she said she just needed to go to the bathroom. The ambulance arrived and she was taken to the hospital. An interview with RN #3 on 11/21/24 at 10:20 AM, revealed she had worked day shift and Resident #1 was agitated. After she ate her dinner in the dining room, she was taken to the lobby area. She stated LPN #1 was trying to calm her down and stated to the resident, We're not doing this and that she is Going to send her out. She stated she did not see the part of the incident where the resident was being held, but she knew the nurses and she did not believe they meant to cause her harm. Interview with CNA #5 on 11/21/24 at 3:45 PM revealed this was a hard situation to witness. She stated the resident was held in her chair by RN #1 and LPN #1 was cussing and yelling and telling her they were going to send her out to the hospital. She stated the resident was not fighting but was trying to get out of their grip. She stated it seemed like the nurses were frustrated and it turned into a bad situation. During an interview on 11/21/24 at 11:40 AM, the Director of Nursing (DON) stated they were notified of the incident by a resident the day after it occurred. She stated they watched the video and interviewed staff and residents. Resident #1 was cognitive and had the right to go where she wanted to go and no one would want a resident to fall, but a resident has that right. She stated Resident #1 was physically restrained and was kept from going where she wanted to go and doing what she wanted to do, therefore her rights were violated. She stated this incident was troubling to watch on the video and in the time frame they kept her from doing what she chose, the staff could have taken her to the bathroom. She confirmed the resident was verbally abused and was secluded to remain in the chair and was held in the chair by a staff member to prevent her from going to the bathroom. During an interview on 11/21/24 at 1:45 PM, the Administrator confirmed the resident was cognitive and had the right to make decisions on what she wanted to do and the resident was upset and angry that the staff confined her and kept her from going to the bathroom. She confirmed this violated her rights and that physical restraining of a resident is part of abuse and involuntary seclusion. On observation of the video with the Administrator on 11/20/24 at 1:40 PM, revealed on 10/30/24 at 6:01 PM, the resident was brought into the lobby. LPN #1 spoke to the resident at approximately 6:03 PM, then redirected her to the lobby in front of the TV at approximately 6:04 and 6:05 PM. At approximately 6:06 PM, a CNA took the resident to the restroom just outside the lobby area and returned to the lobby at approximately 6:14 PM. At approximately 6:20 PM, LPN #1 approached resident again and spoke to her and then about 6:21 LPN #1 redirected her back to the same area. At approximately 6:22 PM, Resident #1 began to roll herself backwards and LPN #1 approached and rolled her beside the exit area to B hall and the double doors were closed and LPN #1 appeared to speak with resident and touched her to keep her in place in her chair. At approximately 6:25 PM, RN #1 approached LPN #1 and resident and it appeared they talked and then RN #1 began to hold resident from behind. At 6:30 PM, while RN #1 was still holding resident, CNA #3 approached the resident and appeared to be speaking to the resident, RN #1, or both. At approximately 6:32 PM CNA #3 appeared to lay her hands over the top of Resident's hands and RN #1 released the resident. At approximately 6:33 PM, Emergency Medical Technicians arrived, and the resident was taken to the hospital by ambulance. The video verified the resident was not allowed to leave the lobby area by LPN #1 and then was held in her chair for almost eight (8) minutes by RN #1 and was not allowed to move from the area. The video verified what the witnesses had stated during their interviews to the State Agency (SA). The video did not have audio but from all the interviews and from the mannerisms of the staff in question it was determined there was yelling in part of this incident captured on the video footage. Record review of ER notes dated 10/30/24 revealed, .presents to the Emergency Department (ED) from the nursing facility due to aggression. Patient is alert and oriented times (x) 4 and states that she just wanted to go to the bathroom, and no one helped her. Record review of Resident #1's admission Record revealed the facility admitted the resident on 1/7/21 with diagnoses that included Huntington's Disease. Record review of Resident #1's Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 10/29/24 revealed the resident had a Brief Interview for Mental Status (BIMS) score of 12 which indicated the resident had moderate cognitive impairment. Record review of Resident #2's admission Record revealed the facility admitted the resident on 5/28/21. Record review of Resident #2's MDS with ARD of 11/8/24 revealed the resident had a BIMS score of 15 which indicated the resident was cognitively intact. Record review of Resident #3's admission Record revealed the facility admitted the resident on 12/28/20. Record review of Resident #3's MDS with ARD of 9/24/24 revealed the resident had a BIMS score of 15 which indicated the resident was cognitively intact.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, record review and facility policy review the facility failed to develop and implement a person-centered care plan for residents requiring assistance with Activities of Daily Living (ADL) (Residents #4, #6, #27, and #35), a resident requiring assistance with transfers using a lift (Resident #53), a resident with a diagnosis of Post-Traumatic Stress Disorder (Resident #47), and a resident requiring dental services and ADLs, (Resident #34) for seven (7) of 19 resident care plans reviewed. Findings included: Review of the facility policy titled, Comprehensive Care Plans with a revision date of 3/10/23, revealed, it is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. Resident #6 Record review of Resident #6's care plan revealed the resident's need for assistance with ADL's related to Hemiplegia resulting from a car accident. Interventions related to the care plan included fingernail care daily (if needed) and to check nail length and trim and clean as necessary. Record review of care plan revealed there were no interventions in place for shaving. On 8/8/23 at 2:30 PM, an observation and interview with Resident #6 revealed long and bushy facial hair on his face, chin, mustache, under the chin and jaws, on lower cheeks, and neck. He stated he liked having a mustache and a goatee, but he prefers to be clean-shaven on the rest of his face and neck. His fingernails were noted to be long, approximately 1/3 inch from the nailbed and he stated he would like for his fingernails and toenails to be trimmed since they were too long. He stated he had mentioned these things to someone on staff, but he was unsure who that was and stated he needed the staff's assistance at this time, but hoped he could eventually do these things independently. An interview with the Minimum Data Set (MDS) Registered Nurse (RN) on 8/9/23 at 4:10 PM, stated the care plan should reflect the needs of the residents and the care on the care plan is transferred to the [NAME] so the staff will know what care is required. She confirmed the facility failed to follow the care plan for the fingernail care daily (as needed) and to check nail length and trim and clean nails as necessary. The facility also failed to develop a person-centered care plan for the resident's preference for mustache/goatee and otherwise a clean-shaven face. An interview with the Director of Nursing (DON) on 8/10/23 at 9:40 AM, revealed the resident is cognitive and able to make his requests known. She stated his care plan should be reflective of his preferences and his preferences should be honored and confirmed the facility failed to do that when he was not groomed the way he preferred. Record review of Resident #6's admission Record revealed the resident was admitted to the facility on [DATE]. His diagnoses included Hemiplegia, Personal History of Traumatic Brain Injury, Lesion of Ulnar Nerve, Left Upper Limb, Chronic Pain, Unilateral Primary Osteoarthritis of Left Knee. Record review of MDS with Assessment Reference Date (ARD) of 5/25/23, revealed a Brief Interview of Mental Status (BIMS) of 15 indicating resident was cognitively intact. Resident #53 Record review of Care Plan with an onset date of 3/27/23, revealed the resident needed assistance with ADL care and for transfers she was listed as Transfer: the resident is totally dependent on 2 (two) staff for transferring and the resident requires Mechanical Lift ([NAME]) with 2 staff assistance for transfers. Record review of Care Plan with review start date of 6/30/23, revealed the resident needed assistance with ADL care and for transfers she was listed as Transfer: the resident requires Mechanical Lift ([NAME]) with 2 staff assistance for transfers. Record review of Physician's Order dated 6/16/23, revealed an order for x-ray of left shoulder related to acute pain. Record review of Patient Results of left shoulder x-ray from local hospital dated 6/16/23, revealed, Findings: Bone - There is a nondisplaced fracture involving the neck of the left humerus. There is no definite dislocation identified. There is mild angulation of the humeral head laterally. Intact AC joint. The MDS Registered Nurse (RN) revealed in an interview on 8/10/23 at 8:45 AM, the resident was care planned for a total lift for transfers and it was changed to a sit to stand lift, and after her shoulder incident, she was changed back to a total lift. She printed off the previous care plans and noted on the care plans, only the Vander-Lift (full body lift) was listed for transfers. She stated that the Vera Lift (sit to stand lift) had to be on the care plan at some point since she could see a resolved date for the Vera Lift after the resident's incident. She stated she is unable to locate the care plan that listed the sit-to-stand lift in the system, but she can see that it was resolved. An interview with the Director of Nursing (DON) on 8/10/23 at 9:10 AM, revealed the full body lift was currently being used, but for a period the sit-to-stand lift was being used. When asked about the care plan indicating the full body lift was to be used for transfers, she responded that she is uncertain why that one is listed since she had been using the sit-to-stand lift and was able to bear some weight and was doing well with transfers. She pulled the most recent lift assessment dated [DATE] and it revealed the resident required a Vander-Lift or other full mechanical lift which is a full body lift and not a sit to stand lift. She stated the residents are assessed annually for the type of lift required. She confirmed the most recent assessment determined the need for the total lift, and at the time of the resident's injury, the wrong lift was used for her transfer. She confirmed the care plan was inaccurately developed for a brief time frame of the resident's stay and it was not being implemented properly since only a full body lift should have been used according to this resident's lift assessment. During an interview with MDS RN and DON on 8/10/23 at 10:30 AM, the MDS RN revealed that after reviewing the Care Plan and [NAME] for this resident, she had determined that at some point between 4/15/23 and 5/15/23, the Vera Lift (sit to stand lift) was added to the care plan since it shows up on the [NAME]. She stated the information on the [NAME] comes from the Care Plan, so it had to be added to the Care Plan for it to trigger on the [NAME]. She stated from what can be determined on the [NAME]/Care Plan, it appears that the sit-to-stand lift was added on 5/5/23 and removed on 6/16/23 (after the incident involving the fracture of the left humerus), and the full lift was put in on 1/5/22 and was never removed. The DON confirmed the most recent assessment was for a total lift, so, the total lift should have been the one used. Record review of Resident #53's admission Record revealed the resident was admitted to the facility on [DATE] with diagnoses included Wedge Compression Fracture of first and second Lumbar Vertebra, Hypertension, Cerebrovascular Disease, Muscle Weakness, Moderate Protein-Calorie Malnutrition, and Paroxysmal Atrial Fibrillation. Record review of Resident #53's MDS with ARD of 6/20/23, revealed a BIMS of nine (9) indicating the resident is mildly cognitively impaired. Resident #4 Record review of Resident #4's care plans revealed a care plan indicating the resident needed assistance with bathing. An observation on 08/08/23 at 11:25 AM revealed that Resident #4 was sitting up in her wheelchair in the dining area with approximately 10 gray hairs in random areas of the chin and cheeks that were approximately 1 inch long. In an observation and interview on 8/8/23 at 4:30 PM with Certified Nurse Assistant (CNA) #11 confirmed that Resident #4 had several long hairs on her chin and cheeks that needed to be removed. She revealed she is unsure if she is supposed to shave the resident or use a tweezer to remove the hairs. She revealed that facial hair removal should occur when the resident gets a bath and that she does not recall being told which way to remove facial hair on female residents and has not ask, but admitted it needed to be removed. An interview on 8/9/23 at 4:20 PM with the DON confirmed that females should have facial hair removed during their bath unless they refuse, and that CNA's have been taught that. She confirmed that the residents care plan regarding ADL assistance had not been implemented properly. Record review of Resident #4's admission Record revealed the resident was admitted to the facility on [DATE] with medical diagnoses that included Dementia and Need for Assistance with Personal Care. Record review of Resident #4's MDS with an ARD of 5/17/23 revealed in Section C a BIMS score of 04, which indicated the resident is severely cognitively impaired. This review revealed in Section G that the resident needed assistance from staff to complete Personal Hygiene and 'Bathing. Resident #47 Record review of Resident #47's medical diagnoses revealed an admitting diagnosis of Post Traumatic Stress Disorder (PTSD). Record review of Resident #47's care plans revealed the resident did not have a care plan regarding PTSD. During an interview on 8/9/23 at 11:45 AM with the MDS RN revealed that she is responsible for doing most all the care plans. She revealed that she discovered a few weeks ago that the resident had a diagnosis of PTSD even though she had been the one to code that diagnosis on the resident's MDS. She confirmed that she realized it was on her admitting diagnoses and stated, but that was just a history. She confirmed that the resident did not have a care plan regarding PTSD but should have and that she did not actually do this resident's care plans but sees now that she should have gone back and checked the record. When asked if she knew what triggered the resident's PTSD, she stated No. She confirmed that care plans direct care to make sure the resident gets all the care they need. When asked if a care plan would have helped the staff to know what triggers the resident she stated, Yes. On 8/9/23 at 1:36 PM, interview with the Licensed Social Worker (LSW) revealed that a care plan lays out the specific care provided for the residents. She confirmed that the resident needed a PTSD care plan. On 8/9/23 at 2:18 PM, interview with the DON stated that she did not realize that the resident had a diagnosis of PTSD on admission to the facility and confirmed that the resident should have had a care plan to address this diagnosis. Record review of Resident #47's admission Record revealed the resident was admitted to the facility on [DATE] with medical diagnoses that included PTSD. Record review of Resident #47's MDS with an ARD of 5/4/23 revealed in Section I that the resident had a diagnosis of PTSD and in Section C a BIMS of 11, which indicated the resident is moderately cognitively impaired. Resident #27 Record review of Resident #27's care plan revealed the Resident needs assistance with ADL related to (r/t) Dementia and physical limitations. Fingernail Care Daily (if needed) and (Resident's name) is to be gotten out of bed daily and dressed and brought out of her room. An observation on 08/08/23 at 10:50 AM, revealed Resident #27 was lying in bed with fingernails on bilateral hands were approximately one-half (1/2) inch long and jagged past the fingertips and a brown substance was under the nails. An observation and interview on 08/08/23 at 3:10 PM the DON confirmed that the nails were long and jagged and had a brown substance under her nails and it appeared as if they hadn't been cleaned in a while. In an interview on 08/09/23 at 4:00 PM with RN #1 revealed the resident has a special wheelchair for her, but we don't get her up every day, it's usually about two or three times a week. The SA inquired about Resident #27's ADL care plan and RN #1 confirmed after pulling the CNA [NAME] that the resident is to be gotten out of bed daily and dressed and brought out of the room. RN #1 revealed I didn't know that was in her plan of care. RN #1 revealed the aides must click on it every day and document whether she was gotten up or not. An interview on 08/09/23 at 4:15 PM, with CNA #3 confirmed the plan of care was not being followed regarding getting the resident up daily. She revealed I didn't know it was in there. An interview on 08/09/23 at 4:35 PM, the DON confirmed Resident #27's care plan regarding nail care and getting the resident out of bed daily was not followed and it should have been. She revealed she wasn't aware of Resident #27 being out of bed daily but confirmed it was on the CNA's [NAME]. An interview on 08/10/23 at 10:30 AM, with CNA #4 revealed she did document that she got Resident #27 up yesterday, but I documented in error and did not get her up. She revealed she wasn't aware that the resident needed to be up every day but confirmed that it did show up on the [NAME] to be signed off daily. An interview on 08/10/23 at 10:40 AM, with CNA #5 revealed I think the last time she got up was sometime last week we haven't been getting her up every day. A record review of Resident #27's admission Record revealed the resident was admitted to the facility on [DATE] with diagnoses that include Metabolic Encephalopathy, Unspecified Dementia, Peripheral Vascular Disease, and Generalized Anxiety Disorder. Record review of the MDS with an ARD of 07/20/23, revealed the resident is rarely/never understood which indicated the resident has severe cognitive impairment. Resident #34 A record review of the care plan for Resident #34, date initiated 7/10/23, revealed Focus: The resident needs assistance with ADL r/t (related to ) stroke .Interventions: BATHING/SHOWERING: The resident is totally dependent on 1 staff for bathing. Check nail length and trim and clean as necessary .PERSONAL HYGIENE/ORAL CARE: The resident requires extensive assistance of 1 staff with personal hygiene and oral care . An observation on 8/08/23 at 2:18 PM, of Resident # 34 revealed long nails that measured approximately 3/8 inch in length from the tip of the fingers, with a brown substance underneath and raised brown patches on his tongue. An overpowering putrid (rotten) odor was present inside the room. The residents' teeth were observed to be in bad condition, with dark brown/black color to all the teeth and red, inflamed gums. An observation and interview with the DON on 8/08/23 at 3:20 PM, confirmed that Resident #34 had long dirty fingers nails, and raised brown patches on his tongue and it appeared that he had not received oral or nail care lately. An interview on 8/10/23 at 9:45 AM, with the MDS nurse confirmed that there was not a care plan developed for the resident's dental condition and that the staff was not aware of the problem with his teeth. She confirmed that the staff did not follow the care plan for cleaning and trimming the residents' nails and stated, If it's on there to be done, they are supposed to do it. She acknowledged nail care was part of the standard care the aides should provide. Record review of the Order Summary Report revealed an order dated 6/21/23, NPO (nothing by mouth) diet tube feeding texture related to Cerebral Infarction, Dysphagia. Also revealed an order dated 6/21/23, Enteral Feed Order every day and night shift Clean mouth with swabs. Record review of the admission Record revealed Resident # 34 was admitted to the facility on [DATE] with medical diagnoses that included Cerebral Infarction, Unspecified Dementia, Dysphagia, Hemiplegia and Hemiparesis Affecting Right Dominant Side and Gastrostomy Status. Review of the MDS with an ARD date of 6/27/23 revealed under section G, Resident #34 required total dependence for personal hygiene. Resident #35 Record review of Resident #35's care plans revealed, under, BATHING/SHOWERING: The resident requires extensive assist from 1 staff with bathing. Check nail length and trim and clean as necessary. HE HAS REQUESTED TO HAVE A SHOWER DAILY. An observation and interview on 08/08/23 at 11:07 AM, revealed Resident #35 stated that the facility was not bathing him but once a week. The resident revealed his bath day was yesterday, but he did not get one. The resident stated, I want my nails cut too. Observed long nails on both hands that measured approximately 3/8 inch in length. An observation and interview on 8/8/23 at 3:25 PM, with RN #2 confirmed that Resident #35 had long nails and it could cause skin injury. RN # 2 asked Resident #35 if he got a shower yesterday, and the resident replied, No, I didn't. She revealed that the resident was a diabetic, so she would have to cut his nails. An interview with the DON on 8/09/23 at 11:30 AM, revealed she had spoken with the aide assigned to the resident to give him a shower on Monday. She confirmed that the aide did not give the resident a shower. An interview with the DON on 8/9/23 at 11:32 AM, revealed she was not aware that Resident #35 was care planned for a daily shower. She stated, I didn't know. She confirmed that the resident had not been receiving daily showers routinely and agreed that the care plan was not followed. An interview with the MDS Nurse on 8/10/23 at 9:45 AM, revealed that the staff did not follow the care plan by not giving the resident a daily shower or provide needed nail care. She confirmed that the ADL had not applicable (N/A) documented, which revealed a daily shower had not been done. Record review of the August ADL bathing task for Resident #35 revealed under 8/01/23, 8/03/23, 8/04/23, 8/06/27, 8/07/23, and 8/08/23, Not Applicable (N/A) was checked indicating the resident did not receive a daily shower. Record review of the admission Record revealed that Resident #35 was admitted to the facility on [DATE] with medical diagnoses that included Type 2 Diabetes Mellitus, Major Depressive Disorder, Gastro-Esophageal Reflux Disease, Acquired Absence of Left Leg Below Knee and Acquired Absence of Right Leg Above Knee. Record review of the MDS with an ARD of 7/12/23 revealed under section C a BIMS score of 10, indicating Resident # 35 is moderately cognitively impaired. Also revealed under section G, the resident requires one-person physical assist with personal hygiene and is totally dependent for bathing.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident and staff interview, record review, and facility policy review, the facility failed to ensure a resident was free from accidents during a lift transfer by using the inappropriate lift for one (1) of 19 residents reviewed for investigations. Resident #53 Findings include: Record review of facility policy titled Modified Lifting Policy undated, revealed, (Proper name of nursing home) will provide a safe work environment for patient care areas by providing and requiring the use of safety materials, equipment and training designed to prevent personnel and patient injury. The policy also revealed, 1. Staff will follow the documented lifting protocol deemed appropriate for each resident. 2. Staff will utilize proper transfer/lifting/assistance procedures for each resident to include use of mechanical transfer devices or other lifting equipment or devices and by applying proper body mechanics. Record review of Physician's Order dated 6/16/23, revealed an order for x-ray of left shoulder related to acute pain. Record review of Patient Results of left shoulder x-ray from local hospital dated 6/16/23, revealed, Findings: Bone - There is a nondisplaced fracture involving the neck of the left humerus. There is no definite dislocation identified. There is mild angulation of the humeral head laterally. Intact AC joint. Record review of hospital records dated 6/16/23, revealed, [AGE] year-old female who presents from local nursing facility due to a humeral fracture. Patient says she was being helped to bed and she may have slipped somewhat but there is no significant fall or trauma. She has pain to her left shoulder with any attempts at movement. Denies any other complaints. Hospital records also revealed the aftercare instructions as Humerus Fracture, treated with immobilization. An interview on 8/8/23 at 11:55 AM, with Resident #53 revealed the staff was assisting her from her chair to her bed and their feet got twisted and she fell. Stated she was taken to the hospital due to a broken left arm but did not have to have surgery. She stated she wore a sling while it healed. An interview on 8/9/23 at 3:00 PM, with Resident #53 revealed she did not fall to the floor with this incident, but when she was on the stand-up lift, she stumbled when transferring to the bed. She stated she had pain in her arm, and she was given Tylenol. An interview with the Minimum Data Set (MDS) Registered Nurse (RN) on 8/10/23 at 8:45 AM, revealed the resident was care planned for a full body total lift for transfers and it was changed to a sit to stand lift, and after her shoulder incident, she was changed back to a total lift. She printed off the previous care plans and noted on the care plans, only the Vander-Lift (full body lift) was listed for transfers. She stated that the Vera Lift (sit to stand lift) had to be on the care plan at some point since she could see a resolved date for the Vera Lift after the resident's incident. She stated she is unable to locate the care plan that listed the sit-to-stand lift in the system. An interview with the Director of Nursing (DON) on 8/10/23 at 9:10 AM, revealed the resident was being transferred from her chair to the bed in a sit-to-stand lift by two (2) staff members and when the resident was placed in bed, she complained of her left arm and stated she had pain. She confirmed she investigated the incident and sent the information into the State Agency (SA) and from what she was able to determine the resident had a diagnosis of osteoporosis and it could have been a spontaneous type fracture. She was unable to determine any other cause of the injury. She stated the full body lift was now being used, but at that time she had been assessed for a sit-to-stand lift. When asked about that the care plan indicated that the full body lift was to be used for transfers, she responded that she is uncertain why that one is listed since she had been using the sit-to-stand lift and was able to bear some weight and was doing well with transfers. She pulled the assessment dated [DATE] and it revealed the resident required a full body lift/Vander-Lift or other full mechanical lift and not a sit to stand lift. She stated she looked for another assessment or documentation for the change in lift type, but she was unable to find where another assessment was done. She stated the residents are assessed annually for the type of lift required. She confirmed the most recent assessment determined the need for the total lift, and at the time of the resident's injury, the wrong lift was used for her transfer. An interview with Minimum Data Set (MDS) Registered Nurse (RN) and the DON on 8/10/23 at 10:30 AM, revealed that after reviewing the Care Plan and [NAME] for this resident, she had determined that at some point between 4/15/23 and 5/15/23, the Vera Lift (sit to stand lift) was added to the care plan since it shows up on the [NAME]. She stated the information on the [NAME] comes from the Care Plan, so it had to be added to the Care Plan for it to trigger on the [NAME]. She stated from what can be determined on the [NAME]/Care Plan, it appears that the sit-to-stand lift was added on 5/5/23 and removed on 6/16/23 (after the incident), and the full lift was put in on 1/5/22 and was never removed. The MDS RN stated she does not know why she added this lift, and it could have been a system error or improperly entered information. The DON stated she is not sure how far back the use of the sit/stand lift was being used, but she knew it was being used for a while before the injury occurred. The DON confirmed the most recent assessment was for a total lift, so, the total lift should have been the one used. She stated when the lift was changed from the full lift to the sit-to-stand lift, no assessment was done to ensure safety for the resident. She confirmed that prior to changing a resident to a more independent type of transfer device, an assessment should have been done to ensure the resident would be safe using this for transfers and the facility failed to do this assessment. An interview with Certified Nursing Assistant (CNA) #9 on 8/10/23 at 10:40 AM, revealed she had worked at the facility for about one and a half years and has worked with this resident often. She stated the staff use the [NAME] to determine what lift to use, and this resident had the sit to stand lift listed. She stated that the resident was now using the full body lift for transfers. A phone interview with CNA #8 on 8/10/23 at 10:45 AM, revealed she was working with the resident when this incident occurred. She stated this was the first time she had worked with this resident. She stated she and another CNA used the sit-to-stand lift to transfer the resident from the chair to the bed that evening. She stated she wondered why the stand-up lift was being used since her left arm was weak. She stated they placed the resident in her bed and after she was lying down, the resident stated her left arm was hurting and would like some Tylenol. The nurse gave Tylenol, and her pain was eased. She stated she was unaware of anything that occurred during the transfer that would have caused an injury, but the next day an x-ray was done and showed a fracture. She stated the facility had trained her on lift use and she had done this job for 15 years. She confirmed that the resident's [NAME] showed to use a sit-to-stand lift. During an interview on 8/10/23 at 10:40 AM, the Administrator confirmed the facility failed to use the lift the resident was assessed for. She confirmed the resident had an injury but could not confirm it was from the lift. Record review of Transfer/Lift Assessment dated 12/21/22, for Resident #53 revealed, Instructions - An assessment should be made prior to each task if the resident has a varying level of ability due to medical reasons, fatigue, medications, etc. When in doubt, assume the patient cannot assist in the transfer/repositioning. Section A of assessment revealed, Ability to assist with transfer/positioning - The resident's level of assistance can best be described as - Dependent: resident requires more than 50% assistance by staff or is unpredictable in the amount of assistance offered. Section B of assessment revealed, Weight Bearing - Can the resident bear weight? No. Section C of the assessment revealed, Upper Extremity Strength - Does the resident have upper extremity strength to support his/her weight during transfer? No. Section G of the assessment revealed, Care Plan - After completing assessment, indicate transfer/repositioning needs below: How does the patient transfer to and from bed-chair, chair toilet, chair-chair, etc. - Vander-Lift or other full mechanical lift - one or two person assist. Record review of Care Plan History revealed on 1/5/22, the [NAME] (full body) lift was listed. On 5/5/23, the Vera (sit-to-stand lift) was listed. On 6/16/20, the Vera Lift was resolved. Record review of Care Plan with review start date of 3/27/23, revealed the resident needed assistance with Activities of Daily Living (ADL) care and for transfers she was listed as Transfer: the resident is totally dependent on 2 staff for transferring and, the resident requires Mechanical Lift ([NAME]) with 2 staff assistance for transfers. Record review of [NAME] Report for each month from 12/15/23 - 4/15/23, revealed, Transfer: the resident is totally dependent on 2 staff for transferring and Transferring: the resident requires Mechanical Lift ([NAME]) with 2 staff assistance for transfers. Record review of [NAME] Report dated 5/15/23 and 6/15/23 revealed, Transfer: the resident is totally dependent on 2 staff for transferring and Transferring: the resident requires Mechanical Lift (Vera) with 1 or 2 staff assistance for transfers. Record review of Care Plan with review start date of 6/30/23, revealed the resident needed assistance with Activities of Daily Living (ADL) care and for transfers she was listed as Transfer: the resident requires Mechanical Lift ([NAME]) with 2 staff assistance for transfers. Record review of Electronic Medication Administration Record for June 2023 revealed the resident received the nightly dose of Tylenol on 6/15/23. The resident received the as needed dose of Tylenol on 6/16/23 at 5:11 AM and on 6/17/23 at 2:36 AM. The resident received her night dose of Tylenol each night but did not receive the as needed Tylenol any other time during the month of June. Record review of Resident #53's admission Record revealed the resident was admitted to the facility on [DATE]. Diagnoses included Wedge Compression Fracture of first and second Lumbar Vertebra, Hypertension, Cerebrovascular Disease, Muscle Weakness, Moderate Protein-Calorie Malnutrition, and Paroxysmal Atrial Fibrillation. Record review of Resident #53's Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 6/20/23, revealed a Brief Interview for Mental Status (BIMS) score of nine (9) which indicated the resident is moderately cognitively impaired.