**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure nursing staff effectively notified the physician of a resident's injury for 1 (Resident #1) of 3 (Resident #1, Resident #2, and Resident #3) sampled residents. This deficient practice resulted in an immediate jeopardy for Resident #1 on Friday, 10/13/2023 at 7:30 p.m., when S5LPN noted Resident #1's right arm tucked behind her back. She observed the resident's whimpering and her right arm was swollen and puffy. S5LPN notified S9MD's office via fax at approximately 10:30 p.m. that same evening when the physician's office was closed and would have remained closed and not staffed for the weekend. On Monday, 10/16/2023 at 7:11 a.m. S3LPN observed the injury, notified the doctor by phone and sent the resident to the hospital for evaluation and treatment where she was diagnosed with a fracture of the right arm. The facility implemented corrective actions and was in substantial compliance on 10/16/2023 prior to the State Agency's investigation on 11/08/2023; thus, it was determined to be a Past Noncompliance citation. Findings: Review of the facility's policy for Change in Resident Medical Status revealed the following: A facility must immediately inform the resident; consult with the resident's physician when there is a significant change in the resident's physical, mental or psychological status. A significant change is defined as a major decline or improvement in the resident's status that will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions, is not self-limiting. Review of Resident #1's clinical record revealed the resident was admitted on [DATE] with diagnoses to included, but not limited to, Hemiplegia and Hemiparesis following Cerebral Infarction affecting Right Dominant Side, Dementia without Behavioral Disturbance, Cognitive Communication Deficit, Generalized Muscle Weakness, and Specified Disorders of Bone Density and Structure. Review of Resident #1's MDS (Minimum Data Set, a standardized health status assessment) with ARD (Assessment Reference Date) of 08/08/2023 (prior to injury) revealed Resident #1 had a BIMS (Brief Interview for Mental Status) score of 8 which indicated the resident to be mildly impaired. The MDS also revealed Resident #1 was dependent of staff for her functional status. Section GG, titled Functional Abilities and Goals, indicated the resident had impairment on one side of the upper extremity. Further review revealed she was not on a scheduled pain medication regimen nor was receiving as needed pain medication. Review of Resident #1's MDS (Minimum Data Set, a standardized health status assessment) with ARD (Assessment Reference Date) of 10/16/2023 (after injury) revealed Resident #1 had a BIMS (Brief Interview for Mental Status) score of 8 which indicated the resident to be mildly impaired. The MDS also revealed Resident #1 was dependent of staff for her functional status. Section GG, titled Functional Abilities and Goals, indicated the resident had impairment on one side of the upper extremity. Further review revealed the resident had occasional pain and received as needed pain medications. Review of Resident #1's Care Pan included the following, in part: Date initiated: 01/22/2021. ADL Function-bed mobility, transfers, locomotion requires total assistance. Goal: Resident will have needs met through next review. Approach: assist resident with turning and repositioning in bed and observe for and notify MD as needed for any joint pain and/or discomfort. Date initiated: 01/22/2021. Health Condition-resident has a diagnosis of hemiplegia/hemiparesis-CVA with right hemi (hemiparesis - one sided muscle weakness). Goal: Resident will have all needs met through next review. Approach: notify MD of any complications and assist resident with ADL's as needed. Date initiated: 01/22/2021. Resident is at risk for pain related to diagnosis of CVA (Cerebrovascular Accident) with hemi to right side. Goal: Resident will not have any unrelieved pain through next review. Approach: administer meds as ordered, notify MD of any unrelieved pain, and observe onset, location, severity, and duration of pain. Date initiated: 10/16/2023. Health condition-resident has a diagnosis of osteopenia. Goal: resident will have no complications through next review. Approach: notify MD of any unrelieved pain/discomfort. Review of Resident #1 Nurses Notes revealed the following: 10/13/2023 10:00 p.m. Right arm and hand swollen and red. Resident repositioned off of arm. Tylenol given for pain. Doctor faxed and waiting for response. Sore noted to elbow area of right arm. Signed by S5LPN. 10/16.2023 7:11 a.m. During morning rounds, resident noted in bed with eyes open and crying. Resident complaining of severe pain to right arm. Assessment completed. Severe swelling noted to right mid arm. Right elbow dark red scab noted with red, light purple and yellow discoloration noted. Right arm warm to touch .Vital signs stable . 7AM verbal order received to transfer resident to ER for evaluation and treatment related to right arm edema, pain and discoloration. Signed by S3LPN. Further review of nurse's notes for the resident revealed that there were no notes regarding the resident's injury or additional attempts to notify a physician after Friday, 10/13/2023 at 10:00 p.m. until Monday, 10/16/2023 at 7:11 a.m. when S3LPN assessed the injury, notified the doctor and sent the resident to the hospital for evaluation and treatment. Review of Resident #1's hospital medical records revealed the attending physician, S10MD (Medical Doctor), noted on the resident's disposition: obvious area of ecchymosis (bruising) and the patient moans with pain upon palpation (physical exam). CT (cat scan) of the upper extremity for pain in the right arm revealed an acute transverse distal humeral (upper arm bone) fracture .additional non-displaced fracture through the base of the olecranon (part of the elbow) process suspected. On 11/06/2023 at 2:00 p.m., an observation was made of the resident sitting in her wheelchair in the hallway. She was pleasant and smiled when spoken to but did not answer any questions, only smiled. There was no evidence or outward displays of pain or discomfort observed. On 11/08/2023 at 10:40 a.m., an observation was made of the resident lying in her bed. Resident is awake and alert but did not communicate verbally. Resident is noted lying on left side with her right arm in a soft cast and elevated on a pillow. Resident did not demonstrate any outward signs or symptoms of pain or discomfort An interview was conducted on 11/06/2023 at 3:00 p.m. with S4CNA (Certified Nursing Assistant). She confirmed she cared for the resident on the evening of Friday, 10/13/2023. She stated when she initiated care, Resident #1's right arm was lying across her abdomen and stated this is when she noticed the discoloration and swelling of the resident's right arm. She then notified S5LPN (Licensed Practical Nurse) immediately and they elevated Resident #1's arm using a wedge after they changed the resident's bedding. She confirmed the resident had bruising to the right arm along with redness. An interview was conducted on 11/06/2023 at 3:15 p.m. with S5LPN who worked the 2:00 pm to 10:00 pm shift on 10/13/2023. She reported that on 10/13/2023 around 6:30 p.m. - 7:00 p.m., S4CNA notified her that Resident #1's right arm was red and crying in pain. S5LPN stated that when she entered the room, Resident #1's right elbow was tucked under her back and that resident's right arm was swollen and puffy and thought that it was caused by her being on the arm for an undetermined amount of time. She denied seeing any bruising at that time. She reported that the resident was whimpering but did not continue to cry or whimper after she was left alone. She stated that she did not immediately notify the doctor and continued to administer medications. She reported that when she did notify the doctor, it was by fax but should have called instead due to it being after normal business hours on a Friday evening. A phone interview was conducted on 11/07/2023 at 1:15 p.m. with S6LPN who worked the night shift (10:00 pm to 6:00 a.m.) on 10/13/2023 and cared for Resident #1. She confirmed that S5LPN told her Resident #1's right arm was red, swollen, painful, and that the doctor had been notified. She stated she never received any communication from the doctor and never followed up with any doctor regarding the resident's arm during her shift. She reported that she communicated the residents' change of condition to the oncoming nurse (S7LPN) at the end of her shift. A phone interview was conducted on 11/07/2023 at 2:12 p.m. with S7LPN. She established that she worked double shifts (from 6:00 a.m. to 10:00 p.m.) on both 10/14/2023 and 10/15/2023 and cared for Resident #1. She attested that upon her first assessment of the resident on 10/14/2023 at 8:00 a.m., the resident's right arm was swollen and had some mild, yellow discoloration. She verified that she had received information about Resident #1's arm from S6LPN and that the doctor had been notified. She stated that she did not clarify if the doctor had called or responded to the notification. She confirmed that had she known that the physician was only faxed about the resident's arm, she would have called him for a follow up. An interview was conducted on 11/06/2023 at 1:45 p.m. with S3LPN. She stated she was first notified by S8CNA that Resident #1's right arm was swollen, red and she was crying in pain on Monday, 10/16/2023 at 7:11 a.m. Upon her assessment she noted yellow, blue, green and purple bruising to the resident's right outer arm (elbow area) spreading to the inner arm (elbow crease area) and also noted a skin tear to the outer elbow. She stated she attempted to perform an assessment but the resident would not allow her manipulate the arm due to pain. She verified that she immediately phoned the doctor to report her assessment, followed by phoning the ambulance services, the resident's family, S2DON, and finally the hospital to give a report. An interview was conducted on 11/06/2023 at 2:30 p.m. with S2DON (Director of Nursing). She confirmed that S3LPN notified her of Resident's #1's condition and that the resident was being transferred to the hospital for evaluation and treatment. S2DON confirmed that the physician should have been contacted by phone as opposed to fax for Resident #1. An interview was conducted on 11/08/2023 at 11:00 a.m. with S9MD. He confirmed that there is no one in his office after hours or on weekends to monitor faxes and confirmed his office hours are Monday -Friday, 8:00 a.m. - 5:00 p.m. S9MD confirmed, that if a resident demonstrated new onset extremity pain, swelling, tenderness, discoloration and/or temperature changes, he or the on-call physician should have been notified by phone, not fax. Interviews with multiple nursing and CNA staff verified that they were in-serviced and corroborated that the facility was conducting pain monitoring, ADL monitoring, MD notification monitoring, and abuse/neglect monitoring as per the corrective action plan. An interview was conducted on 11/08/2023 at 1:05 p.m. with S1ADM. She stated that the initial QA monitoring performed on Monday, 10/16/2023 resulted in the facility being in compliance with the exception of Resident #1's reported incident. She verified that the monitoring will continue weekly for another 2 months or longer if any negative outcomes are discovered. The facility implemented the following actions beginning Monday, 10/16/2023 to correct the deficient practice that occurred on 10/13/2023: 1. S2DON and S1ADM immediately opened an investigation into the injury of unknown origin. 2. On 11/16/2023, S1ADM and S2DON conducted staff re-education with all staff on the following: Proper assessment for Pain and Notification to MD, Pain Scales, Abuse Neglect Injury of Unknown Origin, ADL care & Transfers per lift status and care plan, Any and all PRN medications administered must be entered into AHT, Change of status of residents should be documented every shift and reported to physician and responsible party. 3. Monitoring performed by DON or Designee. Monitoring consists of accurate ADL care, accurate pain assessment, MD notification as needed, abuse/neglect/injury of unknown origin.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for 1 (#1) of 3 (#1, #2 and #3) sampled residents. The facility failed to ensure nursing staff: 1. effectively communicated a change in Resident #1's condition to a physician and 2. intervene by following up with the physician after the identified a change in condition for Resident #1 when she continued to display signs of injury and pain. This deficient practice resulted in an immediate jeopardy for Resident #1 on Friday, 10/13/2023 at 7:30 p.m., when S5LPN noted Resident #1's right arm tucked behind her back. She observed the resident whimpering and her right arm was swollen and puffy. S5LPN notified S9MD's office via fax at approximately 10:30 p.m. that same evening when the physician's office was closed and would have remained closed and not staffed for the weekend. Nursing staff verbalized the resident's arm was red and swollen and displayed signs of pain yet failed to assess and administer medication for pain or implement any interventions to address the resident's injury. On Monday, 10/16/2023 at 7:11 a.m. S3LPN observed the resident crying in pain due to her arm injury, notified the doctor by phone and sent the resident to the hospital for evaluation and treatment where she was diagnosed with a fracture of the right arm. The facility implemented corrective actions and was in substantial compliance on 10/16/2023 prior to the State Agency's investigation on 11/08/2023; thus, it was determined to be a Past Noncompliance citation. Findings: Review of the facility's policy for Change in Resident Medical Status revealed the following: A facility must immediately inform the resident; consult with the resident's physician when there is a significant change in the resident's physical, mental or psychological status. A significant change is defined as a major decline or improvement in the resident's status that will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions, is not self-limiting .A facility must immediately inform the resident; consult with the resident's physician and notify, consistent with his or her authority, the resident representative when there is an accident involving the resident which results in injury and has the potential requiring physician intervention . Review of the facility's policy for Pain Screen and Management revealed the following: .all residents have the right to treatment for pain .non-communicative residents are assess by observation on nonverbal behavior .A pain screen is completed when a resident has a new onset of pain, a new type of pain, new pain medication or treatment, or when a resident has not experienced an acceptable level of pain relief .when documenting regarding pain, the following elements should be addressed: date and time of onset, location of pain, character, severity, alleviate factors, exacerbation factors, treatments and medication, responses . Review of Resident #1's clinical record revealed the resident was admitted on [DATE] with diagnoses to included, but not limited to, Hemiplegia and Hemiparesis following Cerebral Infarction affecting Right Dominant Side, Dementia without Behavioral Disturbance, Cognitive Communication Deficit, Generalized Muscle Weakness, and Specified Disorders of Bone Density and Structure. Review of Resident #1's MDS (Minimum Data Set, a standardized health status assessment) with ARD (Assessment Reference Date) of 08/08/2023 (prior to injury) revealed Resident #1 had a BIMS (Brief Interview for Mental Status) score of 8 which indicated the resident to be mildly impaired. The MDS also revealed Resident #1 was dependent of staff for her functional status. Section GG, titled Functional Abilities and Goals, indicated the resident had impairment on one side of the upper extremity. Further review revealed she was not on a scheduled pain medication regimen nor was receiving as needed pain medication. Review of Resident #1's MDS (Minimum Data Set, a standardized health status assessment) with ARD (Assessment Reference Date) of 10/16/2023 (after injury) revealed Resident #1 had a BIMS (Brief Interview for Mental Status) score of 8 which indicated the resident to be mildly impaired. The MDS also revealed Resident #1 was dependent of staff for her functional status. Section GG, titled Functional Abilities and Goals, indicated the resident had impairment on one side of the upper extremity. Further review revealed the resident had occasional pain and received as needed pain medications. Review of Resident #1's Care Pan included the following, in part: Date initiated: 01/22/2021. ADL Function-bed mobility, transfers, locomotion requires total assistance. Goal: Resident will have needs met through next review. Approach: assist resident with turning and repositioning in bed and observe for and notify MD as needed for any joint pain and/or discomfort. Date initiated: 01/22/2021. Health Condition-resident has a diagnosis of hemiplegia/hemiparesis-CVA with right hemi (hemiparesis - one sided muscle weakness). Goal: Resident will have all needs met through next review. Approach: notify MD of any complications and assist resident with ADL's as needed. Date initiated: 01/22/2021. Resident is at risk for pain related to diagnosis of CVA (Cerebrovascular Accident) with hemi to right side. Goal: Resident will not have any unrelieved pain through next review. Approach: administer meds as ordered, notify MD of any unrelieved pain, and observe onset, location, severity, and duration of pain. Date initiated: 10/16/2023. Health condition-resident has a diagnosis of osteopenia. Goal: resident will have no complications through next review. Approach: notify MD of any unrelieved pain/discomfort. Review of Resident #1's October 2023 MAR (Medication Administration Record) revealed the following: -Monitor for edema every shift: Day shift: 10/13/2023 was documented as trace. 10/14/2023 & 10/15/2023 was documented as none. Evening shift: 10/13/2023, 10/14/2023 & 10/15/2023 was documented as no. Night shift: 10/13/2023, 10/14/2023 & 10/15/2023 was documented as no. -Observe for s/s abnormal bleeding/bruising every shift. All shifts for 10/13/2023, 10/14/2023 and 10/15/2023 were answered as no. Further review revealed that the Tylenol S7LPN documented as administered in her nurse's note dated and timed 10/13/2023 at 10:00 p.m. was not reflected on the resident's MAR nor were there any additional doses documented by any other staff from 10/13/2023 to 10/15/2023. Review of Resident #1 Nurses Notes revealed the following: 10/13/2023 10:00 p.m. Right arm and hand swollen and red. Resident repositioned off of arm. Tylenol given for pain. Doctor faxed and waiting for response. Sore noted to elbow area of right arm. Signed by S5LPN. 10/16/2023 7:11 a.m. During morning rounds, resident noted in bed with eyes open and crying. Resident complaining of severe pain to right arm. Assessment completed. Severe swelling noted to right mid arm. Right elbow dark red scab noted with red, light purple and yellow discoloration noted. Right arm warm to touch .Vital signs stable . 7AM verbal order received to transfer resident to ER for evaluation and treatment related to right arm edema, pain and discoloration. Signed by S3LPN. Further review of nurse's notes for the resident revealed that there were no notes regarding the resident's injury, pain, or additional attempts to notify a physician after Friday, 10/13/2023 at 10:00 p.m. until Monday, 10/16/2023 at 7:11 a.m. when S3LPN assessed the injury, notified the doctor and sent the resident to the hospital for evaluation and treatment. Review of Resident #1's hospital medical records revealed the attending physician, S10MD (Medical Doctor), noted on the resident's disposition: obvious area of ecchymosis (bruising) and the patient moans with pain upon palpation (physical exam). CT (cat scan) of the upper extremity for pain in the right arm revealed an acute transverse distal humeral (upper arm bone) fracture .additional non-displaced fracture through the base of the olecranon (part of the elbow) process suspected. On 11/06/2023 at 2:00 p.m., an observation was made of the resident sitting in her wheelchair in the hallway. She was pleasant and smiled when spoken to but did not answer any questions, only smiled. There was no evidence or outward displays of pain or discomfort observed. On 11/08/2023 at 10:40 a.m., an observation was made of the resident lying in her bed. Resident is awake and alert but did not communicate verbally. Resident is noted lying on left side with her right arm in a soft cast and elevated on a pillow. Resident did not demonstrate any outward signs or symptoms of pain or discomfort An interview was conducted on 11/06/2023 at 3:00 p.m. with S4CNA (Certified Nursing Assistant). She confirmed she cared for the resident on the evening of Friday, 10/13/2023. She stated when she initiated care, Resident #1's right arm was lying across her abdomen and stated this is when she noticed the discoloration and swelling of the resident's right arm. She then notified S5LPN (Licensed Practical Nurse) immediately and they elevated Resident #1's arm using a wedge after they changed the resident's bedding. She confirmed the resident had bruising to the right arm along with redness. An attempt for a follow-up interview with S4CNA was made on 11/08/2023 at 10:15 a.m. but was unsuccessful. An interview was conducted on 11/06/2023 at 3:15 p.m. with S5LPN who worked the 2:00 pm to 10:00 pm shift on 10/13/2023. She reported that on 10/13/2023 around 6:30 p.m. - 7:00 p.m., S4CNA notified her that Resident #1's right arm was red and crying in pain. S5LPN stated that when she entered the room, Resident #1's right elbow was tucked under her back and that resident's right arm was swollen and puffy and thought that it was caused by her being on the arm for an undetermined amount of time. She denied seeing any bruising at that time. She reported that the resident was whimpering but did not continue to cry or whimper after she was left alone. She stated that she did not immediately notify the doctor and continued to administer medications to other residents. She reported that when she did notify the doctor, it was by fax but should have called instead due to it being after normal business hours on a Friday evening. A phone interview was conducted on 11/07/2023 at 1:15 p.m. with S6LPN who worked the night shift (10:00 pm to 6:00 a.m.) on 10/13/2023 and cared for Resident #1. She confirmed that S5LPN told her Resident #1's right arm was red, swollen, painful, and that the doctor had been notified. She stated she never received any communication from the doctor and never followed up with any doctor regarding the resident's arm during her shift. She reported that she communicated the resident's change of condition to the oncoming nurse (S7LPN) at the end of her shift. A phone interview was conducted on 11/07/2023 at 2:12 p.m. with S7LPN. She established that she worked double shifts (from 6:00 a.m. to 10:00 p.m.) on both 10/14/2023 and 10/15/2023 and cared for Resident #1. S7LPN stated that the resident cannot move or reposition herself. She attested that upon her first assessment of the resident on 10/14/2023 at 8:00 a.m., the resident's right arm was swollen and had some mild yellow discoloration. She verified that she had received information about Resident #1's arm from S6LPN and that the doctor had been notified but did not clarify if the doctor had called or responded to the notification. She stated she first assessed the resident at around 8:00 a.m. on 10/14/2023 when she administered medications to the resident. She stated the resident's right arm was swollen and had some mild yellow discoloration but saw nothing immediately alarming. She stated that the resident never gave any cues of pain and therefore never administered pain medications. She stated that she did not assess the resident's range of motion or pulse because it was her paralyzed side and only visually inspected it. S7LPN stated that because she worked double weekend shifts, she never faxed a doctor to report changes in a resident's condition because no one would be in the office. She always called the on-call physician if needed. She confirmed that had she known that the physician was only faxed about the resident's arm, she would have called him for a follow up. She verified that she gave report to the oncoming nurse (S11LPN) that the resident's right arm was red, swollen, and that the physician had been contacted. An interview was conducted on 11/06/2023 at 1:45 p.m. with S3LPN. She stated she was first notified by S8CNA that Resident #1's right arm was swollen, red and she was crying in pain on Monday, 10/16/2023 at 7:11 a.m. Upon her assessment she noted yellow, blue, green and purple bruising to the resident's right outer arm (elbow area) spreading to the inner arm (elbow crease area) and also noted a skin tear to the outer elbow. She stated she attempted to perform an assessment but the resident would not allow her manipulate the arm due to pain. She verified that she immediately phoned the doctor to report her assessment, followed by phoning the ambulance services, the resident's family, S2DON, and finally the hospital to give a report. An interview was conducted on 11/06/2023 at 2:30 p.m. with S2DON (Director of Nursing). She confirmed that S3LPN notified her of Resident's #1's condition and that the resident was being transferred to the hospital for evaluation and treatment. S2DON confirmed that the physician should have been contacted by phone as opposed to fax when Resident #1's arm first appeared red and swollen on 10/13/2023. S2DON confirmed that the nurses had not documented bruising on this resident as listed on her MAR. She then reviewed resident's nurse's notes and confirmed that the only documentation the resident's injury was at the time of discovery on 10/13/2023 and again at the time the resident was sent to the hospital on [DATE]. She stated that that there was no evidence of monitoring for or assessment of the resident's injury for 3 days. She viewed nurse's note on 10/13/2023 by S7LPN at the time of initial discovery and stated that it failed to reflect that the resident had a full assessment of the right arm (including range of motion, pulse, capillary refill, hand grasps). An interview was conducted on 11/06/2023 at 4:20 pm with S2DON and S1ADM. S2DON reviewed the resident's plan of care for pain and agreed that the resident should have had pain monitoring especially because of the injury. She was unable to produce any evidence/documentation that staff had assessed and monitored the resident's pain. at this An interview was conducted on 11/08/2023 at 11:00 a.m. with S9MD. He confirmed that there is no one in his office after hours or on weekends to monitor faxes and confirmed his office hours are Monday -Friday, 8:00 a.m. - 5:00 p.m. S9MD confirmed, that if a resident demonstrated new onset extremity pain, swelling, tenderness, discoloration and/or temperature changes, he or the on-call physician should have been notified by phone, not fax. Interviews with multiple nursing and CNA staff verified that they were in-serviced and corroborated that the facility was conducting pain monitoring, ADL monitoring, MD notification monitoring, and abuse/neglect monitoring as per the corrective action plan. An interview was conducted on 11/08/2023 at 1:05 p.m. with S1ADM. She stated that the initial QA monitoring performed on Monday, 10/16/2023 resulted in the facility being in compliance with the exception of Resident #1's reported incident. She verified that the monitoring will continue weekly for another 2 months or longer if any negative outcomes are discovered. The facility implemented the following actions beginning Monday, 10/16/2023 to correct the deficient practice that occurred on 10/13/2023: 1. S2DON and S1ADM immediately opened an investigation into the injury of unknown origin. 2. On 11/16/2023, S1ADM and S2DON conducted staff re-education with all staff on the following: Proper assessment for Pain and Notification to MD, Pain Scales, Abuse Neglect Injury of Unknown Origin, ADL care & Transfers per lift status and care plan, Any and all PRN medications administered must be entered into AHT, Change of status of residents should be documented every shift and reported to physician and responsible party. 3. Monitoring performed by DON or Designee. Monitoring consists of accurate ADL care, accurate pain assessment, MD notification as needed, abuse/neglect/injury of unknown origin.