**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and document review, the facility failed to thoroughly investigate injuries of unknown origin for 4 of 4 residents (R46, R18, R57, and 30) who had bruises where the injury was not witnessed, the resident could not explain the injury and the bruises were suspicious. The facility's pattern of failure to investigate injuries of unknown origin constituted an immediate jeopardy (IJ) situation. The IJ began on 3/26/24, when R46 was identified with a 2.4 centimeter (cm) x 2.6 cm inner thigh bruise and continued 3/27/24 when R18 was identified with a 7 cm x 5 cm facial bruise, 4/2/24 when R30 was identified with a 10 cm calf bruise, and 4/11/24 when R57 was identified with a 5.5 cm x 4 cm wrist bruise. The facility's system failure to identify suspicious injuries and thoroughly investigate injuries of unknown origin resulted in unverified rationale and lacked implementation of corrective action to protect resident from further sustaining injuries. The administrator, director of nursing (DON), executive director (ED) and administrative intern were notified of the IJ on 5/2/24 at 10:20 a.m. The facility implemented corrective action and the IJ was removed on 5/2/24 at 6:50 p.m. However, non-compliance remained at the lower scope and severity of E, which indicated no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: R46 R46's annual Minimum Data Set (MDS) dated [DATE], identified R46 had mild cognitive impairment and diagnoses which included non-traumatic brain dysfunction and dementia. On 4/30/24, review of health status note dated 3/26/24 at 8:08 a.m. revealed R46 was found sitting on the floor at 6:15 a.m. but was unable to recall what caused the fall. Licensed practical nurse (LPN)-E completed head to toe skin check and no injuries noted. During a telephone interview on 5/2/24 at 6:00 a.m., LPN-E explained he observed R46's head, neck, back, chest and all extremities on 3/26/24 at 8:08 a.m. and no bruises were noted at that time. Further review of the skin only evaluation dated 3/26/24 at 1:31 p.m., revealed registered nurse (RN)-D documented four new bruises noted on right forearm (4.5 cm x 4 cm), right lower arm (3.8 cm x 3.5 cm), right anterior elbow (3.8 cm x 3 cm) and right medial (inner) thigh (2.4 cm x 2.6 cm). It was unknown whether these bruises were the result of the fall in the morning on 3/26/24. Interview of RN-D on 4/20/24 at 4:15 p.m. revealed a nursing assistant asked her to look into the above bruises on 3/26/24 after R46 received a shower. RN-D did not know the cause of the right inner thigh bruise. On 5/1/24 at 2:30 p.m., interview of LPN-A, who completed an incident report related to a fall on 3/26/24, revealed she did not document the four new bruises were noted on 3/26/24 after a fall in the morning. When asked, LPN-A suspected R46 hit the grab bar or siderail during the fall from bed to floor causing the bruise on the right medial (inner) thigh. However, there was no evidence an investigation was done to rule out the root cause. On 5/1/24 at 2:40 p.m., interview of the director of nursing (DON) revealed she suspected the bruise on the right inner thigh was due to the use of Hoyer (full body mechanical lift) sling on 3/26/24 when lifting the resident up from the floor, however, there was no evidence an investigation was done to rule out the root cause. When asked, the DON did not know who operated the Hoyer lift on 3/26/24 to lift up R46. On 5/1/24 at 2:50 p.m., interview of the administrator revealed she was not aware of R46's inner thigh bruise. There was no evidence that the facility conducted a thorough investigation related to right inner thigh bruise, which was identified on 3/26/24. R18 During observation on 4/10/24, at approximately 8:30 a.m., R18 was observed seated in a Broda (reclining wheelchair) in the activity room. R18 had a fading purple bruise approximately two inches in diameter on the left side of R18's chin and neck area. R18 was unable to respond when questioned about the bruise. During interview on 4/10/24 at 12:11 p.m., family member (FM)-A stated R18 had sustained a large bruise on the left side of their chin/neck area; however, the facility was unable to explain to FM-A how the bruise occurred. R18's quarterly Minimum Data Set (MDS) dated [DATE] and annual MDS dated [DATE], identified R18 with severe cognitive impairment and diagnoses including dementia, Parkinson's disease, and anxiety disorder. The MDS also identified R18 as requiring substantial assistance with all activities of daily living. R18's Progress Note (nurses note) dated 3/27/24 at 6:00 a.m., indicated a night nursing assistant had reported a big bruise on the left side of chin. R18 was questioned if she had fallen or hit her face and reported no. R18's Progress Note dated 3/27/24 at 8:05 a.m., indicated LPN-A met with R18 to evaluate the bruising to the left jaw/chin area. LPN-A noted some hardened swelling to jaw. R18 denied pain and did not allow an oral examination. LPN-A assessed R18 who was able to currently report the place and month to the staff. R18 denied intentional harm and reported they felt safe. R18's initial Incident Report dated 3/27/24, identified the bruise with no witnesses to an event which resulted in bruising. The completed investigation dated 4/2/24, identified the bruise as 7 cm by 5 cm on the left chin. The investigation indicated the nurse practitioner would assess the area and determine if the bruise could be dental in origin. The report further indicated the bruise may have also been due to R18's chin pressing against clavicle or shoulder as R18 had a history of resting their head in a dependent position. R18 was not displaying concerns with meal intake or pain at the time of the assessment. The conclusion of the investigation indicated Intentional harm is not suspected. R18's Geriatrics for Follow Up Nursing Home (nurse practitioner examination) dated 3/28/24, indicated R18 was seen due to possible dental issues resulting in a bruise to the left side of chin. R18 had a history of sleeping in a bent position leaning toward the left side with her head and chin nearly touching her shoulder. R18 denied pain and no pain was observed as she ate all her lunch. The nurse practitioner assessment identified the facial bruising of the left distal (lower) chin as of unknown etiology (cause) and differential (list of possible conditions that share the same symptoms) included trauma to jaw or dental concern of broken tooth, cavity, or abscess. The nurse practitioner indicated an abscess was unlikely due to no reports of pain or other infectious symptoms. During continuous observations on 4/11/24 from 8:05 a.m. to 9:00 a.m., R18 ate her breakfast meal without expressing any type of facial or dental pain. During interview on 4/11/24 at 9:54 a.m., LPN-B stated R18 had sustained a bruise from something in her mouth. LPN-B could not recall what had caused the bruise. During interview on 4/11/24 at 1:45 p.m., LPN-A stated injuries of unknown origin included physical injuries which were not witnessed, and the resident was not able to explain how the injury was obtained. LPN-A indicated she had been notified of R18's facial bruise on 3/28/24, and due to the location, LPN-A had determined the bruise was consistent with a dental issue. LPN-A verified R18 had last been evaluated by a dentist in January of 2024 and had not expressed any type of dental concerns from the time of the evaluation to 4/11/24. LPN-A stated due to the location of the bruise, LPN-A determined the cause would be dental. When asked if LPN-A had interviewed any staff or completed any type of investigation to rule out alternative possibilities such as abuse, LPN-A confirmed the facility had not interviewed any of the direct care staff or investigated the bruise as a potential abuse or as an injury sustained during the provision of care. During interview of 4/11/24 at 2:31 p.m. RN-A confirmed a facial bruise which was 7 cm x 5 cm of unknown origin would be considered suspicious. The staff should have reported the bruise and investigated the origin to decide if the bruise was sustained due to abuse or inappropriate provision of care. RN-A confirmed the bruise was not investigated. During interview on 4/11/24 at 2:57 p.m., the administrator stated the bruise had been discussed as a dental concern and none of the staff identified the bruise as a possible injury of unknown origin or abuse. Upon review of the bruise, the administrator confirmed the facial bruise should have been investigated to ensure abuse had not occurred. During telephone interview on 4/19/24 at 9:53 a.m., LPN-A stated R18 frequently bent her neck and had her chin positioned next to her left side of the body. LPN-A had interviewed R18 on 3/27/24, and R18 was orientated to self, place (the name of the facility) and the month only. R18 denied being fearful of any staff members thus LPN-A had documented, no intentional harm and reported that [R18] felt safe. LPN-A had not performed any investigation to rule out potential abuse, or inappropriate care causing the bruising. During telephone interview on 4/19/24 at 10:08 a.m., the DON stated the facility felt the bruise was due to a dental concern and the facility had not completed any type of investigation to determine the origin of the bruise. During telephone interview on 4/19/24 at 10:40 a.m., LPN-A stated they had completed an abnormal involuntary movement scale (AIMS) on 3/26/24, (the day before the bruise was identified) which included observation of R18's face. At that time R18 did not have any type of facial bruising at the time of the assessment. In addition, LPN-A stated R18 was to be transferred by one staff and a gait belt. During telephone interview on 4/19/24 at 11:15 a.m., RN-C stated NA-E reported R18 had facial bruising on 3/27/26 at 6:00 a.m. and RN-C assessed R18 by looking into her mouth, R18 denied pain but did wince when the area was touched. R18 denied any type of maltreatment. RN-C completed the facility incident report. During telephone interview on 4/19/24 at 11:22 a.m., NA-F stated R18 transferred with two staff members and did not require any type of additional assistive devices. According to NA-F, R18 was not resistive to cares and NA-F was unaware of how R18 had sustained the bruise. During telephone interview on 4/19/24 at 11:36 a.m., NA-G stated R18 required assistance with transfers which included one staff member. NA-G stated they frequently would assist R18 by placing one arm under R18's shoulder/neck area and one under R18's buttocks/thighs. NA-G would then pick up R18 from the reclining chair and place them into bed or vice versa. NA-G stated they did not have any type of problems with the transfer as R18 was small in stature and did not weigh very much. R18 was not resistive during the transfers and R18's body did not touch NA-G's body during the transfer. NA-G stated they were not aware any other staff members transferring R18 like this, but it worked well for them. NA-G denied any instance in which they had difficulties transferring R18 such as near miss falls or quick sudden adjustments while positioned in their arms. During telephone interview on 4/19/24 at 2:36 p.m., NA-H stated R18 transferred with assistance of two staff members. R18 was not resistive to transfers and was able to stand, pivot and sit on the bed or chair without difficulties. NA-H denied R18 having difficulties or resistive behaviors during transfers. During telephone interview on 4/19/24 at 2:46 p.m., NA-E stated R18 required two staff for transfers. R18 was not resistive to cares. NA-E had reported the facial bruising to the nursing staff the morning of 3/27/24. During the night, the staff did not turn the overhead lights on until R18 was ready to get out of bed. During the night, R18 received incontinence cares via light from the bathroom or hallway. The main overhead light was not turned on until 3:00 - 5:00 a.m. At that time R18 was noted to have facial bruising which was reported to the nursing staff. NA-E unaware of how R18 would have sustained facial bruising. On 4/19/24 at 3:00 p.m. the DON, administrator and LPN-A were interviewed. The DON stated the cares for each resident were communicated to the staff members via a [NAME] system (written notes), on the Tasks section of the electronic medical record and on the resident care plans. The staff members were to transfer R18 with assistance of two staff as directed by the care plan. The nursing staff supervised the direct care staff to ensure they were following the resident care plans. The DON, administrator and LPN-A were informed of the discrepancies between the transfers styles utilized by the staff: one person transfer, two-person transfer and full body lift without a mechanical lift with arm under neck/shoulder and other under buttocks. The DON confirmed a potential for personal injury for a resident transferred being picked up. The DON stated if the facility had been aware of the discrepancies of transfer styles, they may have approached the facial bruising that R18 sustained differently. The DON verified the facility had not completed any type of investigation of R18's bruise of unknown origin since the SA interviewed staff members on 4/11/24. During a follow-up interview on May 1, 2024, at 12:40 pm, LPN-A explained that if the IDT (Interdisciplinary Team) found the extent and location of bruises suspicious in cases of unknown origin injuries, they were considered reportable. LPN-A conducted an investigation into the left facial bruising of R18 on 3/27/24 and completed a summary on 4/2/24. However, LPN-A stated that she had not interviewed any staff and added, There is no other documentation of investigations prior to my summary on 4/2/24, in the incident report. Whatever I have in the progress notes, is all I have. When asked what actions the facility took in response to R18's injury of unknown origin, LPN-A said, I notified the Nurse Practitioner to assess the resident for dental issues. LPN-A explained that the extent and location of a bruise determined if it should be considered an injury of unknown origin as reportable and that no formal tool was utilized to investigate the root causes of incidents that included bruises and injuries of unknown origin. During a follow-up interview on 5/1/24 at 1:44 p.m., the DON clarified LPN-A was responsible for collecting information and not assessing a resident. The DON expected LPN-A to promptly complete her investigation of R18's left chin bruise within the five-day window and document all investigations in the progress notes and facility incident report. The DON expected LPN-A to interview the staff that worked at the time of R18's incident on 3/27/24 and prior to 3/27/24. The DON stated, I was notified of the incident via text message on 3/27/24 at 7:41 a.m., and I did not see or assess R18. The DON also indicated that no formal tool was utilized to thoroughly investigate the root causes of incidents. When asked what actions were taken to protect R18 from further incurring a bruise, the DON stated, I do not know. Further, the DON indicated that there was no abuse and neglect training conducted between when the incident occurred on 3/26/24 until the date of the interview on 5/1/24. During a follow-up interview on 5/1/24 at 2:53 p.m., the administrator stated LPN-A had collected and summarized all the information regarding R18's left facial bruising on 3/27/24 in the facility's internal incident report. When asked who was responsible for investigating allegations of abuse and/or injuries of unknown origin, the administrator replied that it depended on who and that she primarily served as a contact person. The administrator also acknowledged R18's left facial bruising could have been considered suspicious due to its location, but it was not deemed reportable [by the facility]. Furthermore, the administrator revealed that no formal tool was utilized to investigate the root causes of incidents, and it was based on their practical knowledge. Finally, when asked if R18's left facial bruising was suspicious, the administrator responded, I was not worried. R57 R57's significant change MDS dated [DATE], identified R57 was severely cognitively impaired and had diagnoses which included Alzheimer's disease and dementia. R57's progress note (PN) dated 4/11/24, authored by LPN-B, identified LPN-B was notified by aide of a bruise to R57's wrist. LPN-B assessed the bruise and noted a 5.5 x 4 cm bruise around R57's left wrist. LPN-B notified LPN-A. R57 was unable to state how she obtained the bruise. R57's PN dated 4/11/24, authored by LPN-A, identified LPN-A interviewed R57 regarding the bruise. R57 stated she did not know how she obtained the bruise, did not know it was there, and might have bumped it on something. R57's incident report dated 4/11/24, included the information from LPN-B and LPN-A's progress notes in the nursing description of the incident. Predisposing environmental factors were identified as none. Predisposing physiological factors were identified as confused, fragile skin, history of falls and impaired memory. There were no predisposing situation factors identified. The report identified no witnesses found. The report included the text of R57's PN dated 4/19/24 which identified the investigation of the incident. R57 was noted to have bruising to left wrist. R57 was interviewed regarding bruising and denied intentional harm and reported she felt safe. R57 was happy/laughing during interview, mood pleasant and outgoing. R57 was unsure how bruise occurred but stated that she might have bumped it on something. R57 used a Broda chair (a tilt in space positioning chair) when out of bed and frequently was seated at tables in common area, occasionally attempted to exit chair/stand independently. The report indicated bruise likely occurred due to unintentional contact between extremity and furniture or fixture, such as table. During interview on 4/30/24 at 1:56 p.m., LPN-B reviewed R57's electronic medical record and stated she thought the bruise to R57's wrist wrapped around part of the wrist but was not sure if it was the inner or outer portion of the wrist. The bruise curved but did not go around the entire wrist. It did not look like anyone had grabbed her but with any bruises to the wrist she liked to be sure to update the manager so they could look at it. She did not identify the bruise to be suspicious. During interview on 4/30/24 at 2:14 p.m., NA-A stated she had worked with R57 on 4/10/24 and had not noticed any bruising on that day. She worked with R57 again on 4/11/24 and in the morning noticed black/purple bruises on the top of both of R57's wrists that were approximately the size of a walnut. They almost looked like thumb marks. She notified LPN-B of the bruises. During follow-up interview on 4/30/24 at 2:44 p.m., LPN-B stated she didn't recall bruises on both of R57's wrists. She had only looked at one bruise. During interview on 5/1/24 at 12:40 p.m., LPN-A stated in general if someone had a skin injury or bruise, she would evaluate the bruise, interview the resident, and interview the team. She checked for resident pain, looked at the injury and looked for potential causes of the bruise such as use of blood thinner, combative behaviors or resident known health issues. She looked at the extent, location, resident statements about the injury, and team member voiced concerns to help determine if an injury was suspicious. Injuries of unknown cause would be suspicious if the injury was in an area such as a breast or if it was like a handprint for example. The investigation was documented in the incident report and progress notes, however she did not keep details of the investigation such as interviews, unless the incident was determined to be reportable to the SA. She gathered information and brought the incidents to leadership for a decision as to what needed to occur going forward such as a report to the SA, further investigation etc. Incidents were also discussed at the interdisciplinary team (IDT) meetings which occurred twice daily. The meetings were informal, and no notes were taken. She did not utilize a formal tool such as root-cause analysis to conduct the investigation or analyze the incidents. During interview on 5/1/24 at 1:44 p.m., the DON verified the facility did not use a formal tool for the investigation of incidents. However, stated if an incident was determined to be reportable to the SA, they did use some rudimentary tools to help document the investigation that were not required for use with non-reportable incidents. The facility did not record why an incident was determined not to be reportable. A bruise would be reported related to the circumstances around the bruise such as location, suspicion such as sexual assault or a handprint. The size the bruise would be a factor as well. She would expect LPN-A to gather information related to devices used, knowledge of the resident and to interview staff working at the time. The facility had recently changed their process related to incidents from their previous use of written witness statements to their electronic medical record system which was paperless. She stated they probably have some work to do on their process. During interview on 5/1/24 at 2:52 p.m. the administrator stated they were the contact person for all abuse and neglect reportable concerns, and she reviewed all incidents in the electronic medical record. If an incident was reportable, they would interview all other residents to ensure residents were safe. They would also assess the affected resident and take into consideration predisposing factors and risk factors. If any of these factors were off they would report the incident. She would at times expect the investigation of incidents to include interviews of staff. During interview on 5/1/24 at 4:04 p.m., RN-E recalled seeing a purple/reddish bruise on the inner side of R57's wrist. She was not sure how R57 obtained the bruise and noted it was reported by the day shift nurse. During interview on 5/2/24 at 7:51 a.m., LPN-A identified she investigated R57's bruise. She stated although the progress note indicated the bruise was around R57's wrist, the bruise curved around the inner left wrist but did not encircle the wrist. R57 believed she may have bumped it on something. She sat in a Broda chair at the table most of her day and would push herself from the armrests to move the chair and try to stand/transfer. It looked like more of an edge of table bump. LPN-A stated she had spoken extensively with LPN-B regarding the bruise but could not specifically remember if she had spoken with NA-A. She had no further documentation of her investigation such as interviews and she had not considered the bruise suspicious. LPN-A stated NA-A's description of bruises that looked like thumb marks would have prompted a full investigation, however LPN-A stated It didn't, I saw it. R57's record lacked documentation regarding the right wrist. During interview on 5/2/24 at approximately 8:00 a.m., the DON indicated she was aware of R57's bruise and had signed off on the incident report. There was no report of the area looking like a thumb mark, but such a report should have initiated an investigation and report to the SA. R30 R30's quarterly MDS dated [DATE], identified R30 had severe cognitive impairment and diagnoses which included Alzheimer's disease, dementia, and anemia. The MDS also identified R30 had no hallucinations or delusions and did not exhibit any physical, verbal or other behavioral symptoms during the look back period. Interview and observation of R30 on 4/30/24 at 3:50 p.m., revealed the resident was alert but oriented to person only. The resident reported leaving the facility and planning to move back to the United States. On 4/30/24, review of a nursing progress note dated 4/30/2024 at 10:05 p.m., revealed R30's family reported to RN-C a bruise was noted on resident's left lower extremity. RN-C assessed and documented that a bruise of 4 inches (10 cm) was noted from the resident's left middle calf to left foot. When asked, R30 was unable to recall. RN-C and the family member believed R30 bumped the left foot on something. On 5/1/24, review of the facility incident report dated 4/11/24, revealed LPN-A documented R30 self-propels in a wheelchair around the unit and receives anticoagulant therapy. At times, the resident kicks out or strikes out at caregivers. LPN-A documented Bruising likely occurred due to resident striking left foot on, unintentionally or while attempting to kick out. There was no incident on 4/2/24 which might contribute to the bruise on left calf and left foot. On 5/1/24 at 2:30 p.m., interview of LPN-A revealed he/she reported the bruise to the administrator and DON on their routine interdisciplinary team (IDT) meetings. The IDT meetings ran twice a day. LPN-A stated no further action was taken after the meeting. However, LPN-A did not recall the date of the meeting. Further review of Respond History related to Behavior Monitoring and Intervention dated on 4/2/24 and the nursing progress note dated 4/2/24, revealed R30 did not have any behavior issue which might contribute to the bruise as a result of kicking or bumping. It is unknown how R30 might kick or bump at the front causing a bruise on the left middle calf and foot and which object might pose a risk to R30 causing future bruising. There was no thorough investigation completed to rule out the root cause. Interview of RN-C on 5/1/24 at 4 p.m., revealed a purple bruise was first noted on the top of left foot and left shin on 4/2/24 in the evening, which is inconsistent with the skin assessment he/she documented on 4/2/24. See F684. The Facility Responsibilities for Reporting Allegations policy dated 9/2022, directed an injury should be classified as an injury of unknown source when all of the following criteria are met: · The source of the injury was not observed by any person; and · The source of the injury could not be explained by the resident; and · The injury is suspicious because of: o The extent of the injury, or o The location of the injury (e.g., the injury is located in an area not generally vulnerable to trauma), or o The number of injuries observed at one particular point in time, or o The incidence of injuries over time The Abuse, Neglect, Exploitation, or Misappropriation - Reporting and Investigating policy dated 9/2022 directed upon receiving any allegations of abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source, the administrator is responsible for determining what actions (if any) are needed for the protection of residents. The policy also directs the individual conducting the investigation at minimum: a. reviews the documentation and evidence; b. reviews the resident's medical record to determine the resident's physical and cognitive status at the time of the incident and since the incident; c. observes the alleged victim, including his or her interactions with staff and other residents; d. interviews the person(s) reporting the incident; e. interviews any witnesses to the incident; f. interviews the resident (as medically appropriate) or the resident's representative; g. interviews the resident's attending physician as needed to determine the resident's condition; h. interviews staff members (on all shifts) who have had contact with the resident during the period of the alleged incident; i. interviews the resident's roommate, family members, and visitors; j. interviews other residents to whom the accused employee provides care or services; k. reviews all events leading up to the alleged incident; and l. documents the investigation completely and thoroughly. The immediate jeopardy that began on 3/26/24, was removed on 5/2/24, at 6:50 p.m., when the facility conducted interviews with all interviewable residents regarding their perception of safety in the facility and completed a physical assessment of all residents to identify any injuries of unknown origin. Nursing leadership, including the facility unit managers, DON and administrator were educated on investigating injuries of unknown origin by the facility's regional director of health services. The facility's policy regarding injuries of unknown source was reviewed and all staff were educated on identification of injuries of unknown source. The administrator will monitor compliance daily to ensure complete investigation practices are followed and will complete an audit of incidents of unknown source or bruising for four weeks. Any identified concerns will be addressed immediately and if trends or patterns are identified, the facility will conduct an ad-hoc Quality Assurance and Performance Improvement meeting to address any additional interventions needed to ensure compliance. However, non-compliance remained at the lower scope and severity of an E, which indicated no actual harm with potential for more than minimal harm that is not immediate jeopardy.