**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to promote freedom from an accident hazard, the provision of hot coffee without verifying a safe temperature and/or ensuring the use of appropriate cups, for 3 of 5 residents reviewed for accidents, (#1, #4, and #5); and failed to prevent a burn injury for 1 of 3 residents reviewed for skin injuries, (#1), out of a total sample of 5 residents. The facility's failure to identify the untested temperature of hot coffee as a hazard which posed a risk for burns for residents with cognitive and/or physical impairments resulted in actual harm for resident #1 and placed all residents who received untested hot coffee at risk. Resident #1, a physically and cognitively impaired resident, received hot coffee in a Styrofoam cup and accidentally spilled the liquid on his leg. He suffered blisters and full-thickness skin loss, characteristics of second and third-degree burns, that placed him at risk for infection, a disfiguring scar, and decreased mobility. The resident required ongoing weekly assessments by a wound care specialist and daily dressing changes. Findings: 1. Review of the medical record revealed resident #1, an [AGE] year-old male, was admitted to the facility on [DATE]. His diagnoses included stroke with left side weakness and paralysis, left elbow contracture (shortening of the muscle that causes a stiff joint), arthritis of both knees, generalized muscle weakness, and a history of falling. Resident #1 was discharged to a nearby Skilled Nursing Facility (SNF) on 10/31/24 at his family's request. Review of the Minimum Data Set (MDS) Quarterly assessment with assessment reference date (ARD) of 9/25/24 revealed resident #1 had adequate hearing, used clear speech with distinct and intelligible words, was able to express his ideas and wants, and had clear comprehension of verbal communication. The resident had impaired vision and did not wear glasses. The document revealed resident #1 did not exhibit any hallucinations, disorganized thinking, or an altered level of consciousness during the look back period. He did not display any behavioral symptoms or reject evaluation or care that was necessary to achieve his goals for health and well-being. Resident #1 had functional limitation in range of motion of his arm and leg on one side and he used a wheelchair for mobility. The resident required set-up or clean-up assistance for eating and partial assistance for mobility and walking short distances. The MDS assessment revealed resident #1 had no pressure ulcers, wounds or skin problems, and he had pressure relieving devices for his bed and chair. Review of the medical record revealed resident #1 had a care plan for activities of daily living self-care performance deficit, initiated on 8/27/19. The interventions indicated he required the supervision of one staff after routine tray set up for eating and needed assistance with opening containers, cutting large items and opening and applying condiments. A care plan for the potential for impairment to skin integrity was initiated on 10/03/24. The document revealed resident #1 had blisters on the side and back of his left upper thigh. The interventions instructed nursing staff to monitor and document the location, size and treatment of the skin injury; report any abnormalities, signs of infection, or failure to heal to the physician; and re-direct behavior that could cause open wounds. Review of Weekly Skin Checks from July to September 2024 revealed resident #1 had no skin issues. The Weekly Skin Observation form dated 10/02/24 showed the resident had multiple blisters on the side and back of his left upper thigh. The document indicated the injuries included red open areas from popped blisters. Review of the Wound Care Specialist Advanced Practice Registered Nurse (APRN) Progress Note dated 10/02/24 revealed the provider saw resident #1 for initial evaluation of a left thigh wound with the context described as trauma, blister. The document indicated Wound #1 on the left posterior thigh was a full thickness trauma wound that measured 12.04 centimeters (cm) x 3.7 cm x 0.1 cm and had a scant amount of clear drainage. Wound #2 on the left lateral thigh was a partial thickness trauma wound that measured 1.9 cm x 2.5 cm x no measurable depth. The Wound Care Specialist APRN Progress Note revealed the provider next saw resident #1 on 10/16/24 for follow-up of his left thigh wound. Wound #1 was increased in size and measured 19.29 cm x 7.67 cm x 0.1 cm and had a moderate amount of clear drainage and 51 to 75% slough or soft, dead tissue. Wound #2 measured 1.7 cm x 2.5 cm x 0 cm and had 76 to 100% of eschar or hardened, dead tissue. Review of the Wound Care Specialist APRN Progress Note dated 10/23/24 revealed Wound #1 measured 15.31 cm x 5.61 cm x 0.1 cm and had moderate drainage. Wound #2 measured 1.01 cm x 2.33 cm x 0.1 cm. Both wounds were determined to be full thickness skin loss at that visit. A Progress Note dated 10/30/24 revealed Wound #1 measured 15 cm x 5.0 cm x 0.1 cm and had a moderate amount of clear drainage. Wound #2 measured 1.0 cm x 2.1 cm x 0 cm and was covered with eschar. On 11/01/24 at 2:19 PM, in a telephone interview, resident #1's sister stated on 10/02/24, Registered Nurse (RN) B called to inform her she received change of shift report from the Director of Nursing (DON) regarding a skin issue on her brother's leg. The resident's sister stated RN B explained when she evaluated the area, there were two blisters on the left side of his thigh, but when she fully removed his pants, she discovered there was a large wound that extended from under his buttock down the back of his thigh. The resident's sister recalled she was told the area measured about eight inches and went down to the white meat. She stated she visited her brother a few days later and he informed her the injury was from spilling hot coffee on himself. She stated she was told the coffee was made on the unit at the nurses' station and provided in a Styrofoam cup. The resident's sister explained her brother had a stroke and as a result, his fingers were crooked. She stated he used a special spoon to eat and needed a cup with a handle as he had to place his fingers through the handle to hold it properly. Resident #1's sister stated the facility suggested her brother's injury was caused by his wheelchair. She expressed disbelief and explained her brother had propelled himself throughout the facility in his wheelchair for years and never had any skin issues. On 11/04/24 at 9:55 AM, the [NAME] 2 Unit Manager (UM) stated she learned about resident #1's wound in the daily clinical meeting on 10/02/24 when the DON informed the interdisciplinary team that he had a shearing-type wound on his leg. The UM explained she did not evaluate the skin concern that day, but one to two days later, Licensed Practical Nurse (LPN) A asked her to observe the area while she did resident #1's wound care and changed the dressing. The UM recalled the resident had two areas on the side of his thigh that appeared to be popped, draining blisters. She stated LPN A then showed her another wound on the back of resident #1's thigh that was between six and eight inches long and seeping fluid. The UM explained she was shocked, as the DON never mentioned the large wound on the back of his thigh, only that he had shearing on the side. The UM stated the areas did not have the appearance of typical shearing wounds. When asked about the cause of the wounds, the UM stated RN B informed her resident #1 said his coffee spilled. Shearing occurs when forces parallel to the skin stretch and distort internal tissue while there is downward pressure, leading to decreased blood flow and tissue death. Shearing forces contribute to pressure injuries (retrieved from www.merckmanuals.com/professional/dermatologic-disorders/pressure-injury/pressureinjuries#Etiology_v8381516 on 11/18/24). Burn wounds from heat sources such as scalding liquids raise the temperature of the skin and cause tissue death. The classification of burns depends on the depth and severity of penetration of the skin's surface. Second-degree or partial thickness burns involve the first two layers of skin. The burn site may be deep red and/or have blisters and a glossy appearance from leaking fluid, with possible loss of some skin. Third-degree burns penetrate the entire thickness of the skin and permanently destroy tissue. The burn site may appear white, (retrieved from www.hopkinsmedicine.org/health/conditions-and-diseases/burns on 11/18/24). Third degree burns can occur in two seconds with liquids of 148 degrees and in one second with liquids of 155 degrees (retrieved from the State Operations Manual Appendix PP - Guidance to Surveyors for Long Term Care Facilities on 11/18/24). On 11/04/24 at 10:08 AM, in a telephone interview, RN B recalled on the morning of 10/02/24, she received change of shift report from the DON, who told her resident #1 had blisters on his leg. She stated the DON asked her if she was aware of the skin injury. RN B explained she toileted resident #1 the day before and was certain his skin was intact with no blisters, abrasions, shearing, or any other skin issue on his legs. She stated the Wound Care Specialist APRN was in the facility that morning conducting weekly wound rounds, and she assessed resident #1's leg. RN B explained later that shift, she checked the resident's electronic medical record and discovered there was no documentation about the wound. She stated she completed a note regarding the change in condition and notified the Primary Care APRN and the resident's emergency contact, his sister. She then decided to check the resident's skin so she could complete an accurate Skin Observation note and was surprised to discover the areas were worse than described by the DON. She stated when she saw the extent of the wound on the back of resident #1's thigh, she asked the Primary Care APRN who was onsite, to assess the resident's wounds. On 11/04/24 at 10:31 AM, the Primary Care APRN confirmed she was in the facility on 10/02/24 and RN B asked her to assess resident #1. She stated his lateral thigh had a few popped blisters, but she did not remember seeing the wound on the back of the thigh. The Primary Care APRN recalled the Wound Nurse or the Wound Care Specialist APRN had already seen the resident earlier that day. She explained she later learned the injury was a burn from hot coffee. Review of the Primary Care APRN's Acute Care Progress Note dated 10/16/24 revealed resident #1's chief complaint was follow-up regarding a wound on his left posterior thigh. The document indicated the resident had a full thickness injury on the back of his left thigh, which according to the unit manager [name of UM], is a burn from coffee. On 11/04/24 at 11:44 AM, in a telephone interview, LPN A recalled she was assigned to care for resident #1 on the day following the discovery of his skin injury. She confirmed he had no prior skin issues. LPN A explained she was the night shift nurse and although the dressing change was scheduled for the day shift, she did it as the dressing was soiled from a large amount of dark-colored wound drainage. She recalled showing the wound to the UM who appeared shocked when she saw it as she thought it was just shearing. LPN A said, I asked him what happened, and he said he spilled coffee. LPN A stated the coffee cart from the kitchen arrived on the unit between 7:30 AM and 8:00 AM, but one of the other night nurses had a personal coffee maker that was used on the unit. On 11/04/24 at 12:43 PM, in a telephone interview, Certified Nursing Assistant (CNA) C confirmed he was regularly assigned to care for resident #1 on the night shift. He stated on the morning of 10/02/24, he was in the bathroom with the resident and noted he had skin sloughing on the back of his thigh. CNA C stated he immediately notified the assigned nurse, the DON. He acknowledged there was a coffee maker on the unit, but he did not know if someone provided resident #1 with hot coffee that day. On 11/04/24 at 1:29 PM, in a telephone interview, LPN D confirmed she provided a coffee maker and flavored creamers for use on the unit during the overnight shift. She explained there were residents who got up early, between 5:30 AM and 6:00 AM, and she normally brewed a pot of coffee at about 5:00 AM to accommodate them. She stated sometimes she even had to make two pots if they were all drinking it. LPN D said, It became almost a full-time job. She acknowledged neither she nor other staff checked the temperature of the coffee before they provided it to residents. She stated resident #1 usually got up at 6:30 AM and she routinely made his coffee early and left it in his room, to ensure it was ready for him. LPN D recalled on the morning of 10/02/24, at about 5:30 AM, she stood at her medication cart and heard the DON yell for help from resident #1's room. She stated CNA C ran into the room and she followed behind, but the DON looked out and said she didn't need her. LPN D explained she thought resident #1 fell as he often got up in the morning by himself, without calling for help. LPN D stated when she later asked CNA C what happened in resident #1's room, he acted like he did not know what she was talking about. LPN D verified resident #1 eventually told her he was burned that morning when he spilled hot coffee on himself. On 11/05/24 at 1:46 PM, in a telephone interview, CNA E stated about a day or two after the incident, she heard resident #1 was burned by hot coffee. She validated staff brewed coffee in the unit's pantry in the early morning. CNA E confirmed she observed LPN D distributing coffee to residents on many occasions. She verified LPN D usually made resident #1's coffee and left it on a table in his room. CNA E explained soon after this incident occurred, someone removed the coffee pot and staff were instructed not to give the residents hot liquids anymore. On 11/05/24 at 1:07 PM, in a telephone interview, the Wound Care Specialist APRN confirmed on 10/02/24, the DON approached her in the hallway and asked her to see resident #1 as he had a large blister on the back of his thigh. She stated she determined the wound was caused by trauma and surmised it could have been caused by constant rubbing on the seat of his wheelchair. The Wound Care Specialist APRN was informed resident #1 reported the wounds were the result of a hot coffee spill. She said, I am not 100% sure it was not a burn. It is a possibility that it is a burn injury and full thickness would be a third-degree burn. She expressed doubts that the resident would have tried to drink coffee that was hot enough to scald his leg. She added that she usually saw dietary staff arrive on the unit with coffee at about 7:30 AM while she was rounding. The Wound Care Specialist APRN was told residents on the unit received coffee prepared by staff at about 5:30 AM and safe temperatures were not verified before serving the hot liquid. She acknowledged she did not have access to that information at the time she assessed resident #1's wounds. On 11/04/24 at 4:15 PM, resident #1 confirmed an incident occurred before he was discharged from the facility to his current SNF. He pointed to his left thigh and said, I got burned with the coffee. Resident #1 explained he got coffee every morning from LPN D. He said, She makes it for me special, every morning. She knows how I like it. She's the best one. The resident recalled on that morning, he got out of bed by himself and sat in his wheelchair. He demonstrated how he reached across his body with his right hand and grasped the white Styrofoam cup. He brought his arm back towards his chest and showed how the cup of coffee tipped and spilled down the left side of his thigh and under his left leg. Resident #1 stated he then went to the bathroom to remove his clothes, and the DON found him there. He confirmed CNA C entered the room soon afterward. On 11/05/24 at 4:11 PM, the UM at resident #1's current SNF stated he completed the admission assessment on 10/31/24. Joint review of the document revealed the resident was admitted with a burn wound to the rear left thigh. The UM recalled he received the information from the resident and his family. He verified resident #1 clearly stated the etiology of the wound and although his speech was sometimes soft and a little slow, he was able to communicate well, make his needs known, and easily participate in conversation. The UM showed the resident's current Brief Interview for Mental Status (BIMS) Evaluation tool which had a score of 8/15, indicating moderate cognitive impairment. The UM explained he was also the facility's Wound Care Nurse and once informed the wound was a burn, he realized the orders from the previous facility were more appropriate for a pressure-type wound, not a burn, so he obtained new physician orders. 2. Review of the medical record revealed resident #4, a [AGE] year-old male, was admitted to the facility on [DATE] with diagnoses including stroke with right side weakness and paralysis, difficulty walking, and seizures. The MDS Quarterly assessment with ARD of 8/22/24 revealed resident #4 had a BIMS score of 15/15 which indicated he was cognitively intact. The resident used a walker for mobility. Resident #4 had a care plan for physical mobility deficits related to a stroke with right sided weakness, initiated on 3/05/24. The interventions indicated the resident was able to ambulate with a rolling walker. A care plan for risk for falls related to stroke with right sided weakness, seizures, and a history of falling was initiated on 3/07/24. The interventions instructed staff to anticipate and meet the resident's needs and reorient him regarding safety reminders. On 11/05/24 at 10:31 AM, resident #4 confirmed he was one of the residents who received coffee early in the mornings before the kitchen was open. He explained LPN D was a great nurse as she made coffee for the residents who were up early. Resident #4 stated his routine was to go to the nurses' station and LPN D would pour the hot coffee into his cup. He pointed to a personal stainless steel insulated cup that was in a cup holder attached to his walker. Resident #4 explained LPN D even bought cup holders for some residents so they would not have to carry the hot coffee. The resident shared that LPN D no longer provided hot coffee since the incident that involved a resident #1 who was burned when he spilled hot coffee on himself. Resident #4 said, He hardly had use of his hands. He has a really rough time holding things sometimes. He was in his room when it happened. He told me about it the next day. 3. Review of the medical record revealed resident #5, a [AGE] year-old male, was re-admitted to the facility on [DATE] with diagnoses including stroke with left side weakness and paralysis, repeated falls, generalized muscle weakness, chronic pain, and left foot drop. The MDS Quarterly assessment with ARD of 8/09/24 revealed resident #5 had a BIMS score of 12 which indicated moderate cognitive impairment. He required set-up assistance for eating and supervision or touching assistance for mobility. Resident #5 had limitation in functional range of motion of one leg and used a wheelchair. Resident #5 had a care plan for activities of daily living self-care performance deficit related to left side paralysis following a stroke, impaired mobility and balance, and a history of falling, revised on 2/21/24. The interventions included set-up assistance of one staff member before eating. A care plan for risk for falls, revised on 5/29/24, revealed resident #5 had gait and balance problems, left side weakness, poor trunk control, and poor safety awareness. The goals included minimizing the risks of incidents and injury. The interventions instructed nursing staff to anticipate and meet his needs and therapy staff were to evaluate for wheelchair modifications as indicated. On 11/05/24 at 10:25 AM, resident #5 verified he was one of the residents who received early morning cups of coffee from LPN D. He explained he was a retired roofer, and for many years he woke up at about 4:30 AM to go to work. The resident stated he still could not sleep later than that. Resident #5 described the cup as white Styrofoam with a lid. When asked about the temperature of the coffee, he said, I've got to let it sit to cool it off a little before I can drink it. On 11/04/24 at 12:02 PM, the Dietary Manager stated the facility's process to ensure safety and prevent burns was to check the temperatures of all food and beverages in the kitchen before the items were served to residents. He explained after temperatures were checked, coffee and hot water for tea were poured into containers for service. He confirmed hot coffee and tea should be served in diner-type plastic cups with a handle and covered with a plastic lid. The Dietary Manager stated the facility's maximum allowed temperature for hot liquids was 145 degrees Fahrenheit. He verified kitchen staff arrived at 6:00 AM so it should not be possible for residents to get coffee earlier. According to the National Coffee Association the optimal temperature for brewing coffee is approximately 200 degrees Fahrenheit and the preferred serving temperature is between 140 and 155 degrees Fahrenheit (retrieved from www.ncausa.org on 11/18/24). Review of the facility's policy and procedure for Hot Liquids, updated on 7/29/24, revealed residents would receive hot liquids at a palatable temperature that would not burn the skin if spilled. The guidelines indicated coffee would be brewed at the recommended temperature and leave the kitchen at a temperature between 140 and 158 degrees. The policy revealed coffee served to residents outside of mealtimes should be checked to ensure the temperature was not above 145 degrees and it should never be served in Styrofoam cups.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to initiate an investigation for injury of unknown origin after a diagnosis of left tibial fracture was identified in the hospital for 1 of 3 residents reviewed for abuse/neglect of a total sample of 45 residents, (#71). Findings: Resident #71 was admitted to the facility on [DATE] and readmitted from an acute care hospital on 2/3/21 with new diagnoses including unspecified fracture of upper end of left tibia, subsequent encounter for closed fracture with routine healing, urinary tract infection, muscle weakness, lack of coordination and left knee pain. Her prior diagnoses included dementia, polyarthritis and history of falls. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] (pre-hospitalization) indicated resident #71 had a Brief Interview for Mental Status (BIMS) of 11 that indicated moderate cognitive impairment. She was assessed to require supervision for bed mobility, transfers, walking in room and corridor, locomotion on and off the unit, dressing, toilet use, personal hygiene and bathing. Resident #71 was not steady but able to stabilize without staff assistance when moving from seated to standing position, walking, turning around, moving on and off toilet and surface to surface transfers (transfer between bed, chair or wheelchair). She required 1 person assist with toilet use and required set up or supervision for all other activities. Review of a nursing progress note dated 1/29/21 at 11:32 PM, read, Patient was leaning heavily to one side in wheelchair and verbally not making sense. Two CNAs (Certified Nursing Assistant) brought to my attention that she gets up and goes around the building. I assessed the patient while in bed and patient could not answer questions correctly. Another nurse confirmed that this was not her normal and that I should send her out for further evaluation. I obtained vital signs which were within normal range. I contacted the right persons and family. Daughter stated she would not be able to go visit her in the hospital but wanted to be updated on her status .Emergency unit arrived and they assessed patient who they stated the patient was answering back correctly and vital signs were stable for them .transported patient to .medical system (hospital). Review of the hospital Emergency Department (ED) record dated 1/29/21 read, presents to .ED with c/o (complaints of) left knee pain and swelling x 1 day. Patient is poor historian and d/t (due to) dementia her cognition kind of waxes and wanes .Patient denies falling/trauma to the left lower extremity .CT (computed tomography)of left knee with acute mildly comminuted fracture through intercondylar eminence and medial tibial plateau .received .IV (intravenous) Dilaudid (narcotic pain medication) .knee immobilizer. The hospital record revealed that resident #71 was admitted on [DATE] and the history and physical read, Assessment and Plan: Pleasant 86 yo (year old) F (female) who presents with the following, acute comminuted fracture, intercondylar eminence and medial tibial plateau, acute microcytic anemia, UTI (urinary tract infection) and elevated D-Dimer (indicates may be blot clot). Plan .keep immobilizer, .PT/OT (physical and occupational therapy) with instructions for no weight bearing on left leg . Review of the facility nursing progress note dated 1/30/21 at 9:31 AM read, Pt (patient) was sent to hospital at approx. 2230 (11:30 PM) last night. Daughter called the facility trying to find out why she was sent and if she was being admitted . This writer spoke with . ED, pt is being admitted for UTI, anemia, elevated D-Dimer and left knee fracture. Daughter notified. A review of the facility abuse and incident logs did not show that an investigation for injury of unknown origin had been initiated until brought to the Executive Directors/Abuse Coordinator attention by surveyor on 3/19/21, 7 weeks after the facility became aware of resident's left knee fracture. Review of the facility's Abuse, Neglect, Exploitation and Misappropriation Policies and Procedures with revision date of 11/28/17 read, It is inherent in the nature and dignity of each resident at the center that he/she be afforded basic human rights, including the right to be free from abuse, neglect, mistreatment .The management of the facility recognizes these rights and hereby establishes the following statements, policies, and procedures to protect these rights and to establish disciplinary policy, which results in the fair and timely treatment of occurrence of resident abuse .Neglect .Failure to take precautionary measures to protect the health and safety of the resident .Training .Employee Obligation .Any employee, who witnesses or has knowledge of an act of abuse or an allegation of abuse, neglect .including injuries of unknown source .Is obligated to report such information immediately, but no later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or no later than 24 hours .Preliminary Investigation .An incident report shall be filed by the individual in charge who received the report .Investigation: The abuse Coordinator and/or Director of Clinical Services shall take statements from the victim, the suspect(s) and all possible witnesses including all other employees in the vicinity of alleged abuse .Reporting/Response: Any employee or contracted service provider who witnesses or has knowledge of an act of abuse .including injuries of unknown source .to a resident, is obligated to report such information immediately .Once an allegation of abuse is reported, the Executive Director, as the abuse coordinator, is responsible for ensuring that reporting is completed timely .a full investigation in order to obtain a clear picture of what actually happened . On 3/15/21 at 11:15 AM, resident #71 was observed lying in bed. She was oriented to person and place and was complaining of pain. She pressed the call light and the Activities Director (AD) came into the room and said she thought the resident's nurse had given her something earlier for pain and she would let the nurse know the resident was still in pain. On 3/15/21 at 11:40 AM, Licensed Practical Nurse (LPN) B said he had given resident #71 Tramadol approximately 30 minutes ago and that he had just checked on her and she was still in pain. He said he planned to call the physician if the medication was still not effective after 60 minutes. Resident #71 was ordered Tylenol pre-hospitalization and Tramadol was initiated after she returned to the facility post hospitalization. Tramadol is an oral medication that is used to help relieve ongoing moderate to moderately severe pain. Tramadol is similar to opioid (narcotic) analgesics. It works in the brain to change how your body feels and responds to pain. (www.rxlist.com) Review of the resident's Medication Administration Records (MAR) from January 2021 to present date 3/19/21 noted that prior to hospitalization, 1/29/21 the resident had not required any pain medication. Upon return from the hospital on 2/3/21 she had been given Tramadol 7 times. On 3/19/21 at 10 AM, the Regional Registered Nurse (RN) stated, It was the perfect storm and we missed doing an abuse investigation for resident #71 regarding hospitalization and new fracture of left knee. She said the MDS coordinator reviewed the medical record when the resident returned to the facility from the hospital, spoke to staff and no one reported a fall. She added their normal process regarding resident with an injury of unknown origin was to initiate an investigation right away and complete an immediate report to the Agency for Healthcare Administration. She acknowledged this was not done. On 3/19/21 at 10:30 AM, the MDS coordinator said after the resident returned to the facility post hospitalization, she received therapy for pain/swelling of the left knee and decreased mobility. Prior to her going out to the ER (emergency room) on 1/29/21, the nursing staff thought she had a stroke as she did not have any pain. It surprised us when we found out she was having pain in the ER. The MDS coordinator said she spoke with the floor nurse who sent her out to hospital on 1/29/21 and found out that by the time the EMTs (Emergency Medical Technician) arrived at the facility, the resident was making more sense talking to them. The MDS coordinator said they discussed resident #71 at the morning meeting on 2/5/21 after she came back from the hospital (2/3/21) and could not remember the name of the staff person who reviewed her hospital record. They said she had a fracture to her left knee. We reviewed her chart and questioned if she fell and she had not. The MDS coordinator verified resident #71 had a new fracture. The MDS coordinator said there was no discussion at the meeting regarding initiating an allegation for an injury of unknown origin. She said she assumed an investigation was already done by the Director of Clinical Services (DCS). The MDS Coordinator verified no one asked her to interview the staff on the resident's unit. She said she asked the staff if resident #71 had any falls so that she could complete the significant change MDS assessment dated [DATE]. She verbalized the MDS assessment was initiated as the resident had a new fracture and she needed to complete the assessment which addressed falls. She noted she spoke to staff on 2/5/21 but did not document the names of the nurse or Certified Nursing Assistant (CNA) who were on duty as she was not conducting an investigation. She did not recall if the DCS was present at the morning meeting along with the Case Manager and other managers. The MDS Coordinator validated resident #71 had a significant change in her condition as a result of the new fracture. She said the resident had declined functionally in her Activities of Daily Living (ADL). She acknowledged prior to hospitalization, the resident was able to transfer herself from the bed to the wheelchair with stand by assistance of staff. Post hospitalization she required staff to provide weight bearing assistance. If resident #71 had a fall she would not be able to get up on her own. She said she assumed the DCS did an investigation as this was a fracture of unknown origin which should always be investigated. She then stated, next time I may have to prod people to do their job. Review of the significant change in status MDS assessment dated [DATE] (post-hospitalization), indicated the resident's BIMS was now 10 indicating moderate cognitive impairment. She previously required supervision only but now required 1 person extensive assistance for bed mobility, transfers, locomotion on the unit, dressing, toilet use, and personal hygiene. Resident #71 was now totally dependent with bathing, was not steady and only able to stabilize with staff assistance when moving from seated to standing position, moving on and off toilet and surface to surface transfers (transfer between bed and chair or wheelchair). On 3/19/21 at 11:24 AM, the Case Manager (CM) said she was present at the morning meeting on 2/5/21. She could not recall if they signed in for the meetings at that time or who the DCS was. She remembered she attended the morning meeting on 2/4/21 and was led to believe the resident's fracture was of an indeterminate age and was not acute. She said an acute fracture or injury of unknown origin would be investigated by the Administrator and DCS. She said if she knew the resident had an acute fracture, she would have reported to the DCS and an investigation would have been initiated by her. The CM said she knew resident #71 well as she saw her daily during room rounds. She noted the resident was alert with confusion and may not have remembered if she had fallen. If she had fallen, she would not have been able to get back up. The resident was able to get around independently with her wheelchair prehospitalization. The CM acknowledged that if the investigation was done timely, it would have been more accurate as some of the staff that worked in January 2021 no longer worked at the facility. On 3/19/21 at 12 PM, resident #71 self-propelled in wheelchair in her room. She was talkative and pleasant. She said she was in the hospital due to her knee. She could not recall how her left knee was fractured and added she had to wear an elastic type brace when she came back to the facility. She could not remember if she had any falls. On 3/19/21 at 12:08 PM, a telephone interview was conducted with resident #71's daughter. She said that she and her sister had questions about their mother's fractured knee. The daughter went on to say their mother had dementia and could not tell them what happened. She noted the first week after the fracture, the facility said they did not know anything about it. The facility just said she was complaining of her knee hurting and had a UTI. The daughter said her mother did not try to get out of her chair on her own and had concerns she may have fallen. She added the facility had a lot of staff turnover and used agency staff. She said if the staff were rough, her mother would not report it because she felt, the less said the better. On 3/19/21 at 12:58 PM, LPN A acknowledged she was the nurse who spoke with resident #71's daughter by phone the morning of 1/30/21. She noted the resident had been transferred to the hospital the night before. She said the daughter called her on 1/30/21 because she could not get answers from the hospital. She stated she called the hospital and was informed the resident was admitted to the hospital with left knee fracture. The LPN noted the hospital made it sound as if it was not a new fracture. LPN A said she informed the resident's daughter and the Unit Manager (UM) of the fracture. LPN A then said, if she had known that it was an acute fracture she would have tried to figure out what happened. She would have spoken to the staff to see if the resident fell and would have documented the acute fracture in the medical record. LPN A verified the resident was able to get herself in/out of bed and was independently mobile in her wheelchair prior to hospitalization. When she came back from the hospital, she was put on the observation unit for 2 weeks and had new order of Tramadol for pain. She had to stay in her room for 2 weeks due to Corona Virus Disease 2019 quarantine procedures for new or re-admissions. On 3/19/21 at 1:26 PM, the UM said she started working at the facility on 1/25/21. She did not remember attending the morning meeting the week of 2/4/21 when the resident returned from the hospital. She did not remember any conversations regarding resident #71 having an acute fracture. She said the resident had increased pain due to the fracture and received Tramadol for pain. On 3/19/21 at 1:36 PM, the Physical Therapist (PT) said resident #71 received therapy from 2/4/21 to 2/24/21 due to fractured left knee. He said the resident returned from the hospital with left knee brace. She was guarded due to the pain and would not straighten her leg. He noted the resident was non weight bearing (NWB) when she returned from the hospital and was still presently NWB with the left leg. He noted she had poor cognition and it was challenging to do therapy as she needed frequent repeat instructions. He verbalized the resident could not get out of bed when she returned to the facility. We were doing the initial therapy with her in the bed for the first week. Prior to hospitalization, she could get out of bed by herself, bear weight both legs, get herself into the wheelchair, scoot, pivot with right leg into the chair. She could take herself to the bathroom and wheel self around the building. He said he completed the physical therapy evaluation when she returned from the hospital on 2/4/21. She was total care with everything at that time. He said he could not get her out of bed for therapy due to pain and treatments were done in bed for positioning and range of motion. He noted therapy got her out of bed 6 days after she returned, on 2/10/21 with maximum assistance and NWB to left leg. He said she was discharged from therapy services on 2/24/21 because of her insurance. He added that transfers were still difficult for her. On 3/19/21 at 2:20 PM, Certified Nursing Assistant (CNA) F said that prior to hospitalization, the resident could get herself into the wheelchair from bed, go the bathroom on her own, and bathe herself while sitting on the toilet. She stated she needed help with dressing and could wheel self around the building. When she got back from the hospital, she was on the observation unit for 2 weeks. CNA F said that when the resident returned to her usual unit she could not turn in bed and now needed 2 staff to help her with everything. She said that since the resident is NWB to left lower leg, it takes 2 staff to bathe/turn her in bed, get her into the wheelchair and assist her onto the toilet. She can wheel herself in the wheelchair but all other ADLs except for eating require 2 staff. On 3/19/21 at 3:11 PM, an interview was conducted with the Executive Director (ED) and DCS. The ED said they had clinical meetings at about 9:00 AM which consisted of nurse leadership. After this meeting, morning meetings were held consisting of the entire leadership team. The ED said they would have discussed resident #71 at both meetings as the resident had returned from the hospital. He said the DCS was not at the clinical meeting on 2/4/21. The DCS said she was not aware that resident #71 had diagnosis of acute fracture left lower extremity until it was brought to their attention by the surveyor this morning. The DCS stated no one looked at resident #71's hospital record until this morning and they were not aware she had an acute fracture. They thought something was wrong with her knee. The DCS said their usual practice was to review the hospital record at the clinical meeting, and they should have reviewed resident #71 when she came back to the facility. The DCS said they should not have assumed it was an old injury. They noted that since an investigation of the fracture had not occurred when it was discovered 7 weeks ago, it was unlikely the facility would be able to obtain a clear picture of what actually happened. They acknowledged the facility utilized agency staff and had turn over in their management staff. Some of the staff involved in the care of resident #71 no longer worked at the facility and were not available for interview during the survey. On 3/19/21 at 3:46 PM, the attending physician said he was not aware resident #71 had an acute fracture and that he would need to review the records. He acknowledged the facility staff should have investigated the acute fracture/injury of unknown origin and reviewed the hospital records upon her return to the facility. Although the facility indicated they were not aware of resident #71 having new diagnosis of acute fracture (left knee) they listed left tibial fracture on several of her care plans. The resident's plan of care initiated on 2/21/21 for pain medication included diagnosis of left tibial fracture. Plan of care revised on 2/4/21 for potential for pain included diagnosis of left upper tibia fracture. The following care plans reviewed by the facility on 3/3/21 for ADL self-care performance deficit, alteration in musculoskeletal status, potential for pressure injury and functional bladder incontinence also included diagnosis of left tibia fracture with impaired weight bearing. Review of the Facility Assessment Tool, dated, 8/18/17, revealed the facility was competent to provide care and services for residents with diagnoses of dementia and fractures.