**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record review, and facility policy review, the facility failed to notify the Physician or the Resident Representative (RR) when a resident was observed to have bruising, edema, and pain to her left thigh and vaginal area, until the following day when she was diagnosed with a femoral fracture for one (1) of six (6) sampled residents. Resident #1. Findings include: A review of the facility's policy, Notification of Change in a Resident's Condition or Status, revised 8/2/22, revealed, Policy Statement: Our facility shall promptly notify the resident, his or her Attending Physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status .Policy Interpretation and Implementation .1. The nurse will notify the resident's Attending Physician or physician on call when there has been .b. discovery of injuries of an unknown source .4. Unless otherwise instructed by the resident, a nurse will notify the resident's representative when: a. The resident is involved in any accident or incident that results in an injury including injuries of an unknown source . A record review of the facility's investigation which included the,Alleged Abuse Incident Report dated 11/3/23, revealed on 10/28/23 at approximately 1:45 PM, License Practical Nurse (LPN) #1 reported to Registered Nurse (RN) #2 Supervisor that Resident #1 had bruising to the left thigh and vaginal area with swelling and pain. On 10/29/23 at approximately 7:30 AM, the assigned RN/Supervisor #1 observed Resident #1 bruising to the left thigh and groin area, with swelling and pain, notified her physician, and transferred Resident #1 to the local emergency room (ER). Record review of a handwritten statement from Certified Nursing Assistant (CNA) #1, dated 10/29/23, revealed on 10/28/23 at about 1:30 PM, that CNA #1 noticed a large bruise on Resident #1's vagina and she informed LPN #1. CNA #1 and LPN #1 discovered another bruise on the bottom of her labia. A record review of the Progress Notes revealed a Nurses Note, dated 10/28/23 at 1:45 PM, signed by LPN #1, revealed, alerted to resident's room. upon exam bruising was noted to vaginal area, and left thigh. painful to touch. Swelling noted to upper left thigh. shift supervisor notified of resident's condition . There was no documentation indicating the RR or the Physician were notified of the bruising or pain on 10/28/23. A record review of the Progress Notes revealed a Nurses Note, dated 10/29/23 at 8:21 AM, signed by RN #1, revealed, Alerted by (Proper Name) LPN #1 about bruising on resident's vagina and left hip. While putting resident's head of bed down to view the area, the resident began to cry out in pain. (Proper Name) Director of Nursing (DON) notified of situation. Dr. (Proper Name) aware. New orders given to send to ER for further evaluation. A record review of the hospital record, with an admission date of 10/29/23, revealed, Resident #1 was presented to the hospital with a left leg injury. Emergency Department (ED) workup was significant for left proximal femur fracture. The Physical Exam revealed Resident #1 had diffuse bruising at various stages of healing to left lower extremity and expected tenderness to left lower extremity. The Assessment/Plan revealed the ED nursing staff filed an elder abuse report and pain medications were ordered. On 2/6/24 at 11:17 AM, during a phone interview with LPN #1, he confirmed that on 10/28/23, around 1:00 PM, he was called to Resident #1's room by CNA #1 and was made aware of the residents bruising of the left groin and vaginal area. He stated Resident #1 was non-verbal, had facial grimacing, and was in pain. LPN #1 confirmed he did not notify the Medical Provider or the RR regarding the resident's bruises or pain on 10/28/23. On 2/6/23 at 11:27 AM, during a phone conversation with RN #2, she confirmed that on 10/28/23 after lunch, LPN #1 informed her of Resident #1 bruising to the left groin area. RN #2 confirmed she did not assess the resident. She passed the situation off to the night shift but could not remember the nurse's name. RN #2 confirmed that she did not notify the physician or the RR on 10/28/23 about the resident's condition. On 2/7/24 at 10:11 AM, during an interview with the DON, she confirmed that the physician and the RR should have been notified of Resident #1's bruises and pain. She explained it was the facility's policy to notify the Medical Director and the RR of any changes with the residents and she expected the nursing staff to follow the facility's policy. On 2/7/24 at 2:49 PM, in an interview with the Administrator, he confirmed that on 10/28/23 the facility did not follow the facility's policy regarding notification of a change in a resident's condition. The Administrator stated that he expected the facility staff to follow the policy and notify the physician and the RR. During an interview on 2/8/24 at 12:00 PM, with the Medical Director, he confirmed the facility did not contact him or provide him with any information on Resident #1's bruising of the left leg and perineal area on 10/28/23. He said he expected the facility to notify him of any change in a resident's condition. Record review of the admission Record revealed the facility admitted Resident #1 on 6/14/2016 and she had current diagnoses including Alzheimer's Disease and Vascular Dementia. Record review of the annual Minimum Data Set (MDS) with an Assessment Reference Date of 8/30/23, revealed Resident #1 required a staff interview for mental status and her cognition was severely impaired. Based on the facility's implementation of corrective actions on 11/2/23, the State Agency (SA) determined the deficiency to be Past Non-Compliance (PNC). The deficiency was corrected as of 11/3/23, before the SA's entrance on 2/5/24. Validation: On 2/8/23, the SA validated through staff interviews, record review, and facility policy review the facility began an investigation on 10/29/23. The SA validated through staff interview and record review of the sign in sheet and meeting minutes that an emergency Quality Assurance Performance Improvement (QAPI) meeting with all required staff was held on 10/31/23 at 9:15 AM. The DON, Medical Provider, and Social Services Director attended the QAPI meeting to discuss the situation regarding abuse and neglect, including investigation and reporting of abuse and neglect. The QAPI members also discussed ethics and communication, perineal care, notification of changes, mechanical lift and transfer safety, care plans, and [NAME] following the incident. The QAPI meeting concluded that the Plan of Correction was to in-service all staff, suspend the CNA, and conduct body audits on all residents. The QA Committee reviewed all related policies and procedures with no changes recommended. The SA validated through staff interview and record review of the in-service sign-in sheets that in-services with all staff conducted by the Administrator and the DON began on 10/29/23 regarding abuse and neglect, investigating and reporting abuse and neglect, ethics, communication, perineal care, notification of changes, mechanical lift and transfer safety, care plan, and [NAME]. No staff were allowed to work until they received the in-service training. The SA validated through staff interview and record review that the DON conducted Resident mechanical lift/transfer assessments on all residents on 11/1/23 and ensured all were up-to-date and care planned accordingly. The SA validated through staff interview and record review that on 11/1/23 through 11/2/23, the DON completed new pain assessments for all residents and updated the care plan accordingly. The SA validated through staff interview and record review that the DON completed body audits on 10/29/23 through 10/31/23 on all current residents. The SA validated through staff interview and record review, for monitoring purposes, all nurses and CNAs completed a lift skill observation. The SA validated through staff interview and record review, for monitoring purposes, Transfer Audits were completed by the nurse two (2) times per day until 12/31/23. The SA validated through staff interview and record review, for monitoring purposes, weekly body audits are completed by nurses on all residents. The SA validated that the facility reported the incident to the SA and the Attorney General Office (AGO) on 10/29/23.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record review, and facility policy review, the facility failed to protect the resident's right to be free from neglect as evidenced by Resident #1, who was observed to have bruising, edema, and pain to her left thigh and vaginal area, did not receive care or treatment until the following day when she was diagnosed with a femoral fracture for one (1) of six (6) sampled residents. Resident #1. Findings included: A review of the facility's policy, Abuse Prevention Program, reviewed July 2019, revealed, Policy Statement: Our residents have the right to be free from abuse, neglect . A review of the facility's policy, Compliance with Reporting Allegation of Abuse/Neglect/Exploitation, dated 10/10/22, revealed, .Compliance Guidelines .Identification: The facility will identify events, occurrences, patterns and trends that may constitute: a. Neglect: Failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress . A record review of the facility's investigation which included the,Alleged Abuse Incident Report dated 11/3/23, revealed that on 10/28/23 at approximately 1:45 PM, License Practical Nurse (LPN) #1 reported to Registered Nurse (RN) #2 Supervisor that Resident #1 had bruising to the left thigh and vaginal area with swelling and pain. On 10/29/23 at approximately 7:30 AM, the assigned RN/Supervisor #1 observed Resident #1 bruising to the left thigh and groin area, with swelling and pain, notified her physician, and transferred Resident #1 to the local emergency room. Record review of a handwritten statement from Certified Nursing Assistant (CNA) #1, dated 10/29/23, revealed on 10/28/23 at about 1:30 PM, that CNA #1 noticed a large bruise on Resident #1's vagina and she informed LPN #1. CNA #1 and LPN #1 discovered another bruise on the bottom of her labia. A record review of the Progress Notes revealed a Nurses Note, dated 10/28/23 at 1:45 PM, signed by LPN #1, revealed, alerted to resident's room. upon exam bruising was noted to vaginal area, and left thigh. painful to touch. Swelling noted to upper left thigh. shift supervisor notified of resident's condition . Record review of a handwritten statement from LPN #1, undated, revealed on 10/28/23 at approximately 1:30 PM, he was called to Resident #1's room and was made aware of bruising to the groin/perineal care. There was old bruising noted to the vagina/major labia and inner left thigh. The resident was showing no signs or symptoms of distress or pain at this time. Shift supervisor was notified of the resident's condition. Report on resident's condition was given at shift change. On the following morning, 10/29/23, it was noted that the resident's left leg was visually displaced and that she was complaining of pain with movement. A record review of a handwritten statement from RN #2, dated 10/30/23, revealed LPN #1 told her that the CNA said Resident #1 had an injury and he was going to write a report. The resident had a bruise and hematoma that they noticed on Saturday afternoon (10/28/23) and RN #2 did not go down and look at it. A record view of the Progress Notes revealed a Nurses Note, dated 10/29/23 at 8:21 AM, signed by RN #1, revealed, Alerted by (Proper Name) LPN #1 about bruising on resident's vagina and left hip. While putting resident's head of bed down to view the area, the resident began to cry out in pain. (Proper Name) Director of Nursing (DON) notified of situation. Dr. (Proper Name) aware. New orders given to send to ER for further evaluation. A record review of the hospital records,including the History and Physical and Progress notes, with an admission date of 10/29/23, revealed Resident #1 presented to the hospital with a left leg injury. Emergency Department (ED) workup was significant for left proximal femur fracture. The Physical Exam revealed Resident #1 had diffuse bruising at various stages of healing to left lower extremity and expected tenderness to left lower extremity. Patient withdraws to pain. The Assessment/Plan revealed the ED nursing staff filed an elder abuse report and pain medications were ordered. On 2/6/24 at 11:17 AM, during a phone conversation with LPN #1, he confirmed that on 10/28/23, around 1:00 PM, he was called to Resident #1's room by Certified Nurse Assistant (CNA) #1 and was made aware of the residents bruising of the left groin and vaginal area. He stated Resident #1 was non-verbal, had facial grimacing, and was in pain. LPN #1 notified RN #2, who was the facility supervisor of Resident #1's bruising, and she informed him to complete an incident report. LPN #1 confirmed that he did not follow up with RN #2 to ensure the resident was assessed by the RN on 10/28/23. On 10/29/23 at approximately 7:00 AM, LPN #1 reported the bruising to RN #1. RN #1 assessed the resident and immediately called the Medical Director, the Director of Nursing (DON), and the ambulance for transfer to the hospital. LPN #1 confirmed that he should have provided more care to Resident #1 on 10/28/23 but was following the chain of command. On 2/6/23 at 11:27 AM, during a phone conversation with RN #2, she confirmed that on 10/28/23 after lunch, LPN #1 informed her of Resident #1 bruising to the left groin area. RN #2 confirmed she did not assess the resident. She passed the situation off to the night shift but could not remember the nurse's name. RN #2 stated it was the facility's policy to report bruising of the vaginal area to the DON and Medical Director and that she did not report or assess the resident. On 2/6/24 at 11:35 AM, during a phone interview with CNA #1, she stated on 10/28/23 at approximately 1:30 PM, when changing Resident #1's brief, she observed a large orange and black bruise between her legs and groin area on the left side. The resident's leg was cocked out a little, which was not normal for the resident because she normally kept her legs closed together very tight. She stated that she notified LPN #1. On 2/6/24 at 11:41 AM, during a phone interview with RN #1, she confirmed on 10/29/23 at 7:24 AM, LPN #1 requested she assess Resident #1's peri-area related to bruising and swelling. She observed yellow and black bruising to her left groin and leg. RN #1 notified the DON, Medical Director, and called the local ambulance. The resident was transferred out of the facility by a local ambulance and brought to the local hospital. On 2/7/24 at 10:11 AM, during an interview with the DON, she confirmed that on 10/29/23 at approximately 8:00 AM, she received a call from RN #1 stating that Resident #1 had bruising to her left hip, pubic area, and upper pelvic area. The DON stated that on 10/29/23 at approximately 12:20 PM, she entered the facility and began her investigation. However, she did not observe the resident or the bruising because the resident had already been transferred to the hospital. The DON revealed the facility did not follow the abuse and neglect policy because the RN should have assessed the resident and reported her findings to the Medical Director and the DON on 10/28/24 when the bruising was observed by facility staff. On 2/7/24 at 2:49 PM, in an interview with the Administrator, he confirmed that on 10/28/23 the facility did not follow the abuse or neglect policy. He stated that Resident #1 should have been assessed by RN #2 on 10/28/23 and she should have reported the bruising to the Medical Director and the DON. On 2/8/24 at 12:00 PM, during an interview with the Medical Director, he confirmed the facility did not contact him or provide him with any information on Resident #1's bruising of the left leg and perineal area on 10/28/23. He said he expected the facility to notify him of any change in a resident's condition. Record review of the admission Record revealed the facility admitted Resident #1 on 6/14/2016 and she had current diagnoses including Alzheimer's Disease and Vascular Dementia. Record review of the annual Minimum Data Set (MDS) with an Assessment Reference Date of 8/30/23, revealed Resident #1 required a staff interview for mental status and her cognition was severely impaired. Based on the facility's implementation of corrective actions on 11/2/23, the State Agency (SA) determined the deficiency to be Past Non-Compliance (PNC). The deficiency was corrected as of 11/3/23, before the SA's entrance on 2/5/24. Validation: On 2/8/23, the SA validated through staff interviews, record review, and facility policy review the facility began an investigation on 10/29/23. The SA validated through staff interview and record review of the sign in sheet and meeting minutes that an emergency Quality Assurance Performance Improvement (QAPI) meeting with all required staff was held on 10/31/23 at 9:15 AM. The DON, Medical Provider, and Social Services Director attended the QAPI meeting to discuss the situation regarding abuse and neglect, including investigation and reporting of abuse and neglect. The QAPI members also discussed ethics and communication, perineal care, notification of changes, mechanical lift and transfer safety, care plans, and [NAME] following the incident. The QAPI meeting concluded that the Plan of Correction was to in-service all staff, suspend the CNA, and conduct body audits on all residents. The QA Committee reviewed all related policies and procedures with no changes recommended. The SA validated through staff interview and record review of the in-service sign-in sheets that in-services with all staff conducted by the Administrator and the DON began on 10/29/23 regarding abuse and neglect, investigating and reporting abuse and neglect, ethics, communication, perineal care, notification of changes, mechanical lift and transfer safety, care plan, and [NAME]. No staff were allowed to work until they received the in-service training. The SA validated through staff interview and record review that the DON conducted Resident mechanical lift/transfer assessments on all residents on 11/1/23 and ensured all were up-to-date and care planned accordingly. The SA validated through staff interview and record review that on 11/1/23 through 11/2/23, the DON completed new pain assessments for all residents and updated the care plan accordingly. The SA validated through staff interview and record review that the DON completed body audits on 10/29/23 through 10/31/23 on all current residents. The SA validated through staff interview and record review, for monitoring purposes, all nurses and CNAs completed a lift skill observation. The SA validated through staff interview and record review, for monitoring purposes, Transfer Audits were completed by the nurse two (2) times per day until 12/31/23. The SA validated through staff interview and record review, for monitoring purposes, weekly body audits are completed by nurses on all residents. The SA validated that the facility reported the incident to the SA and the Attorney General Office (AGO) on 10/29/23.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record review, and facility policy review, the facility failed to report an injury of unknown origin within two (2) hours when facility staff observed a Resident who had bruising, edema, and pain to her left thigh and vaginal area for one (1) of six (6) sampled residents. Resident #1 Findings include: A review of the facility policy, Abuse Investigation and Reporting, revised July 2019, revealed Policy Statement: .All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source (abuse) shall be promptly reported to local, state and federal agencies (as defined by current regulations) . A review of the facility's policy, Compliance with Reporting Allegations of Abuse/Neglect/Exploitation, dated 10/10/22, revealed, Policy: It is the policy of this facility to report all allegations of abuse .injuries of unknown sources .are reported immediately to the Administrator of the facility and to other appropriate agencies in accordance with current state and federal regulations within prescribed timeframe's .Compliance Guidelines .Identification: The facility will identify events, occurrences, patterns and trends that may constitute .4. Identification .d. Injuries of unknown source: Includes circumstances when both the following conditions are met; i. The source of the injury was not observed by any person or could not be explained by the resident. ii. The injury is suspicious because of the extent of the injury, location of the injury . A record review of the facility's investigation which included the,Alleged Abuse Incident Report dated 11/3/23, revealed that on 10/28/23 at approximately 1:45 PM, License Practical Nurse (LPN) #1 reported to Registered Nurse (RN) #2 Supervisor that Resident #1 had bruising to the left thigh and vaginal area with swelling and pain. On 10/29/23 at approximately 7:30 AM, the assigned RN/Supervisor #1 observed Resident #1 bruising to the left thigh and groin area, with swelling and pain, notified her physician, and transferred Resident #1 to the local emergency room. The Date of Alleged Incident documented as 10/28/23 and indicated the date and time of first report to the SA was 10/29/23 at 12:24 PM. Record review of a handwritten statement from Certified Nursing Assistant (CNA) #1, dated 10/29/23, revealed on 10/28/23 at about 1:30 PM, that CNA #1 noticed a large bruise on Resident #1's vagina and she informed LPN #1. She and LPN #1 discovered another bruise on the bottom of her labia. During a phone interview on 2/6/24 at 11:17 AM, LPN #1 confirmed on 10/28/23, around 1:00 PM, he was called to Resident #1's room by CNA #1 and was made aware of the residents bruising of the left groin and vaginal area. He stated Resident #1 was non-verbal, had facial grimacing, and was in pain. LPN #1 notified RN #2, who was the facility supervisor, of Resident #1's bruising, and she informed him to complete an incident report. He confirmed that he did not notify the Administrator or the DON of the resident's bruising, swelling, and pain. He stated he followed his chain of command. During a phone interview on 2/6/23 at 11:27 AM, RN #2 confirmed on 10/28/23 after lunch, LPN #1 informed her of Resident #1 bruising to the left groin area. RN #2 confirmed she did not assess the resident. She passed the situation off to the night shift but could not remember the nurse's name. RN #2 stated it was the facility's policy to report bruising of the vaginal area to the DON and Medical Director and that she did not report or assess the resident. On 2/7/24 at 10:11 AM, during an interview with the DON, she confirmed that the facility staff first observed the bruising on Resident #1's left groin and perineal area on 10/28/23, but they did not report the injury of unknown origin until 10/29/23 at approximately 8:00 AM, which was more than two (2) hours after the injuries were observed. On 2/7/24 at 2:49 PM, in an interview with the Administrator, he confirmed that on 10/28/23, Resident #1 sustained an injury. He stated that although the facility staff were aware, the DON or himself was not aware of the injury until 10/29/23. On 10/29/24 at approximately 11:30 AM, the DON notified him of the incident and then it was reported to the SA on 10/29/23 at 12:24 PM. He stated that it should have been reported within two (2) hours of it occurring on 10/28/23. Record review of the admission Record revealed the facility admitted Resident #1 on 6/14/2016 and she had current diagnoses including Alzheimer's Disease and Vascular Dementia. Based on the facility's implementation of corrective actions on 11/2/23, the State Agency (SA) determined the deficiency to be Past Non-Compliance (PNC). The deficiency was corrected as of 11/3/23, before the SA's entrance on 2/5/24. Validation: On 2/8/23, the SA validated through staff interviews, record review, and facility policy review the facility began an investigation on 10/29/23. The SA validated through staff interview and record review of the sign in sheet and meeting minutes that an emergency Quality Assurance Performance Improvement (QAPI) meeting with all required staff was held on 10/31/23 at 9:15 AM. The DON, Medical Provider, and Social Services Director attended the QAPI meeting to discuss the situation regarding abuse and neglect, including investigation and reporting of abuse and neglect. The QAPI members also discussed ethics and communication, perineal care, notification of changes, mechanical lift and transfer safety, care plans, and [NAME] following the incident. The QAPI meeting concluded that the Plan of Correction was to in-service all staff, suspend the CNA, and conduct body audits on all residents. The QA Committee reviewed all related policies and procedures with no changes recommended. The SA validated through staff interview and record review of the in-service sign-in sheets that in-services with all staff conducted by the Administrator and the DON began on 10/29/23 regarding abuse and neglect, investigating and reporting abuse and neglect, ethics, communication, perineal care, notification of changes, mechanical lift and transfer safety, care plan, and [NAME]. No staff were allowed to work until they received the in-service training. The SA validated through staff interview and record review that the DON conducted Resident mechanical lift/transfer assessments on all residents on 11/1/23 and ensured all were up-to-date and care planned accordingly. The SA validated through staff interview and record review that on 11/1/23 through 11/2/23, the DON completed new pain assessments for all residents and updated the care plan accordingly. The SA validated through staff interview and record review that the DON completed body audits on 10/29/23 through 10/31/23 on all current residents. The SA validated through staff interview and record review, for monitoring purposes, all nurses and CNAs completed a lift skill observation. The SA validated through staff interview and record review, for monitoring purposes, Transfer Audits were completed by the nurse two (2) times per day until 12/31/23. The SA validated through staff interview and record review, for monitoring purposes, weekly body audits are completed by nurses on all residents. The SA validated that the facility reported the incident to the SA and the Attorney General Office (AGO) on 10/29/23.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record review, and facility policy review, the facility failed to implement care plan approaches or interventions related to pain and resident transfers for one (1) of six (6) residents reviewed for care plans. Resident #1. Findings Include: Record review of the facility's Comprehensive Care Plans policy, revised 8/24/22, revealed, .It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights .to meet a resident's medical, nursing .needs that are identified in the resident's comprehensive assessment .Policy Explanation and Compliance Guidelines .3. The comprehensive care plan will describe .a. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being . Record review of the Order Summary Report with active orders as of 11/20/23, revealed Resident #1 had a Physician Order, dated 8/1/2019 for Acetaminophen Tablet 500 MG (milligrams) Give two (2) tablet by mouth every 6 hours as needed for .pain . Record review of the electronic Medication Administration Record (eMAR) for October 2023 revealed there was no documentation that Resident #1 received pain medication in October. A record review of the Comprehensive Care Plan for Resident #1 revealed a Problem of Resident is at risk for pain . with Interventions/Tasks initiated on 8/1/2019 of Administer pain medications per order .and a Problem of The resident has an ADL (Activities of Daily Living) self-care performance deficit .with interventions/Tasks initiated on 10/1/2019 of Transfer: The resident requires Total Mechanical Lift with 2 staff assistance for transfers. A record review of the Progress Notes revealed a Nurses Note, dated 10/28/23 at 1:45 PM, signed by Licensed Practical Nurse (LPN) #1, revealed, alerted to resident's room. upon exam bruising was noted to vaginal area, and left thigh. painful to touch . There was no documentation that pain was addressed in the nurses note. A record review of the hospital records, with an admission date of 10/29/23, revealed, Resident #1 presented to the hospital with a left leg injury. Emergency Department (ED) workup was significant for left proximal femur fracture. The Physical Exam revealed Resident #1 had diffuse bruising at various stages of healing to left lower extremity and expected tenderness to left lower extremity. The Assessment/Plan revealed the ED nursing staff filed an elder abuse report and pain medications were ordered. On 2/6/24 at 11:17 AM, during a phone interview with LPN #1, he confirmed on 10/28/23 he did not follow Resident #1's care plan related to pain. LPN #1 stated Resident #1 demonstrated she was in pain because she had facial grimacing. LPN #1 stated he gave Resident #1 Acetaminophen, but he failed to provide any documentation regarding administering the medication. On 2/7/24 at 10:11 AM, during an interview with the Director of Nursing (DON), she confirmed that Certified Nursing Assistant (CNA) #2 did not follow the care plan when she transferred Resident #1 with the mechanical lift and did not have assistance from another staff member as per the video surveillance evidence. The DON confirmed care plan interventions were not implemented regarding pain when LPN #1 observed Resident #1 to be in pain on 10/28/23. The DON explained that care plans were in place for the staff to use to take care of the residents and she expected the staff at the facility to follow care plan interventions on the residents. On 2/8/24 at 11:19 AM, during an interview with Minimum Data Set (MDS)/RN, she confirmed that care plans provided a detailed and effective personalized outline of the care that is to be provided to the residents. It was her expectation that the staff follow the care plans on residents to ensure consistency in the nursing care of the residents. Record review of the admission Record revealed the facility admitted Resident #1 on 6/14/2016 and she had current diagnoses including Alzheimer's Disease and Vascular Dementia. Record review of the annual Minimum Data Set (MDS) with an Assessment Reference Date of 8/30/23, revealed Resident #1 required a staff interview for mental status and her cognition was severely impaired. Further review revealed she required extensive assistance with two person physical assist with transfers. Based on the facility's implementation of corrective actions on 11/2/23, the State Agency (SA) determined the deficiency to be Past Non-Compliance (PNC). The deficiency was corrected as of 11/3/23, before the SA's entrance on 2/5/24. Validation: On 2/8/23, the SA validated through staff interviews, record review, and facility policy review the facility began an investigation on 10/29/23. The SA validated through staff interview and record review of the sign in sheet and meeting minutes that an emergency Quality Assurance Performance Improvement (QAPI) meeting with all required staff was held on 10/31/23 at 9:15 AM. The DON, Medical Provider, and Social Services Director attended the QAPI meeting to discuss the situation regarding abuse and neglect, including investigation and reporting of abuse and neglect. The QAPI members also discussed ethics and communication, perineal care, notification of changes, mechanical lift and transfer safety, care plans, and [NAME] following the incident. The QAPI meeting concluded that the Plan of Correction was to in-service all staff, suspend the CNA, and conduct body audits on all residents. The QA Committee reviewed all related policies and procedures with no changes recommended. The SA validated through staff interview and record review of the in-service sign-in sheets that in-services with all staff conducted by the Administrator and the DON began on 10/29/23 regarding abuse and neglect, investigating and reporting abuse and neglect, ethics, communication, perineal care, notification of changes, mechanical lift and transfer safety, care plan, and [NAME]. No staff were allowed to work until they received the in-service training. The SA validated through staff interview and record review that the DON conducted Resident mechanical lift/transfer assessments on all residents on 11/1/23 and ensured all were up-to-date and care planned accordingly. The SA validated through staff interview and record review that on 11/1/23 through 11/2/23, the DON completed new pain assessments for all residents and updated the care plan accordingly. The SA validated through staff interview and record review that the DON completed body audits on 10/29/23 through 10/31/23 on all current residents. The SA validated through staff interview and record review, for monitoring purposes, all nurses and CNAs completed a lift skill observation. The SA validated through staff interview and record review, for monitoring purposes, Transfer Audits were completed by the nurse two (2) times per day until 12/31/23. The SA validated through staff interview and record review, for monitoring purposes, weekly body audits are completed by nurses on all residents. The SA validated that the facility reported the incident to the SA and the Attorney General Office (AGO) on 10/29/23.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, interviews, and facility policy review, the facility failed to ensure a resident was free of accidents and/or hazards when a staff member transferred a resident using a mechanical lift without two (2) people to assist for one (1) of six (6) sampled residents. Resident #1 Findings include: Record review of the facility's Safe Transfer and Lifting of Residents policy, revised 8/2/22, revealed, .In order to protect the safety and well-being of .residents, and to promote quality care, this facility uses appropriate techniques and devices to lift and move residents .Policy Interpretation and Implementation .VI. Procedure for transferring resident with full body lift .f. Ensure 2nd person is assisting . A record review of the facility's investigation which included the,Alleged Abuse Incident Report dated 11/3/23, revealed that on 10/28/23 at approximately 1:45 PM, License Practical Nurse (LPN) #1 reported to Registered Nurse (RN) #2 Supervisor that Resident #1 had bruising to the left thigh and vaginal area with swelling and pain. On 10/29/23 at approximately 7:30 AM, the assigned RN/Supervisor #1 observed Resident #1 bruising to the left thigh and groin area, with swelling and pain, notified her physician, and transferred Resident #1 to the local emergency room. The investigation revealed during camera review, 10/28/23 at 6:42 AM, Certified Nursing Assistant (CNA) #2 pushed Resident #1 out of her room in a Geri-chair and her left leg was not crossed over her right as per her normal routine. A record review of the Progress Notes revealed a Nurses Note, dated 10/28/23 at 1:45 PM, signed by LPN #1, revealed, alerted to resident's room. upon exam bruising was noted to vaginal area, and left thigh. painful to touch. Swelling noted to upper left thigh. shift supervisor notified of resident's condition . Record review of a handwritten statement from LPN #1, undated, revealed on 10/28/23 at approximately 1:30 PM, he was called to Resident #1's room and was made aware of bruising to the groin/perineal care. There was old bruising noted to the vagina/major labia and inner left thigh. The resident was showing no signs or symptoms of distress or pain at this time. Shift supervisor was notified of the resident's condition. Report on resident's condition was given at shift change. On the following morning, 10/29/23, it was noted that the resident's left leg was visually displaced and that she was complaining of pain with movement. A record review of a handwritten statement from RN #2, dated 10/30/23, revealed LPN #1 told her that the CNA said Resident #1 had an injury and he was going to write a report. The resident had a bruise and hematoma that they noticed on Saturday afternoon (10/28/23) and RN #2 did not go down and look at it. A record view of the Progress Notes revealed a Nurses Note, dated 10/29/23 at 8:21 AM, signed by RN #1, revealed, Alerted by (Proper Name) LPN #1 about bruising on resident's vagina and left hip. While putting resident's head of bed down to view the area, the resident began to cry out in pain. (Proper Name) Director of Nurses(DON) notified of situation. Dr. (Proper Name) aware. New orders given to send to ER for further evaluation. A record review of the hospital records including the History and Physical and Progress Notes, with an admission date of 10/29/23, revealed Resident #1 presented to the hospital with a left leg injury. Emergency Department (ED) workup was significant for left proximal femur fracture. The Physical Exam revealed Resident #1 had diffuse bruising at various stages of healing to left lower extremity and expected tenderness to left lower extremity. The Assessment/Plan revealed the ED nursing staff filed an elder abuse report and pain medications were ordered. Record review of the Employee Termination Report, dated 11/3/23, revealed CNA #2 was discharged from employment with the facility due to Violation of Lift Policy. On 2/6/24 at 11:17 AM, during a phone interview with LPN #1, he confirmed that on 10/28/23, around 1:00 PM, he was called to Resident #1's room by Certified Nurse Assistant (CNA) #1 and was made aware of the residents bruising of the left groin and vaginal area. He stated Resident #1 was non-verbal, had facial grimacing, and was in pain. LPN #1 notified RN #2, who was the facility supervisor, of Resident #1's bruising, and she informed him to complete an incident report. On 2/6/24 at 11:35 AM, during a phone interview with CNA #1, she stated on 10/28/23 at approximately 1:30 PM, when changing Resident #1's brief, she observed a large orange and black bruise between her legs and groin area on the left side. The resident's leg was cocked out a little, which was not normal for the resident because she normally kept her legs closed together very tight. She stated that she notified LPN #1. On 2/6/24 at 11:41 AM, during a phone interview with RN #1, she confirmed on 10/29/23 at 7:24 AM, LPN #1 requested she assess Resident #1's peri-area related to bruising and swelling. She observed yellow and black bruising to her left groin and leg. RN #1 notified the DON, Medical Director, and called the local ambulance. The resident was transferred out of the facility by a local ambulance and brought to the local hospital. On 2/7/24 at 10:11 AM, during an interview with the DON, she confirmed that on 10/28/23, Resident #1 had bruising of her left groin and peri-area with leg swelling. The DON stated the injury that Resident #1 sustained could have been caused by a CNA performing a transfer with mechanical lift by herself with no other staff assistance. The DON revealed that according to the video surveillance, CNA #2 entered and exited the resident's room alone, with the mechanical lift. The CNA was placed on suspension and terminated following the investigation. On 2/7/24 at 2:49 PM, in an interview with the Administrator, he confirmed he observed the video surveillance, and on 10/28/23, CNA #2 entered Resident #1's room at approximately 6:00 AM alone with the mechanical lift. CNA #2 exited about 15 minutes later with Resident #1. The Administrator stated the facility could not determine the exact cause of the injury following the investigation but that it was likely caused by the night shift CNA on 10/28/23. CNA #2 was suspended pending investigation and then terminated. Record review of the admission Record revealed the facility admitted Resident #1 on 6/14/2016 and she had current diagnoses including Alzheimer's Disease and Vascular Dementia. Record review of the annual Minimum Data Set (MDS) with an Assessment Reference Date of 8/30/23, revealed Resident #1 required a staff interview for mental status and her cognition was severely impaired. Based on the facility's implementation of corrective actions on 11/2/23, the State Agency (SA) determined the deficiency to be Past Non-Compliance (PNC). The deficiency was corrected as of 11/3/23, before the SA's entrance on 2/5/24. Validation: On 2/8/23, the SA validated through staff interviews, record review, and facility policy review the facility began an investigation on 10/29/23. The SA validated through staff interview and record review of the sign in sheet and meeting minutes that an emergency Quality Assurance Performance Improvement (QAPI) meeting with all required staff was held on 10/31/23 at 9:15 AM. The DON, Medical Provider, and Social Services Director attended the QAPI meeting to discuss the situation regarding abuse and neglect, including investigation and reporting of abuse and neglect. The QAPI members also discussed ethics and communication, perineal care, notification of changes, mechanical lift and transfer safety, care plans, and [NAME] following the incident. The QAPI meeting concluded that the Plan of Correction was to in-service all staff, suspend the CNA, and conduct body audits on all residents. The QAPI Committee reviewed all related policies and procedures with no changes recommended. The SA validated through staff interview and record review of the in-service sign-in sheets that in-services with all staff conducted by the Administrator and the DON began on 10/29/23 regarding abuse and neglect, investigating and reporting abuse and neglect, ethics, communication, perineal care, notification of changes, mechanical lift and transfer safety, care plan, and [NAME]. No staff were allowed to work until they received the in-service training. The SA validated through staff interview and record review that the DON conducted Resident mechanical lift/transfer assessments on all residents on 11/1/23 and ensured all were up-to-date and care planned accordingly. The SA validated through staff interview and record review that on 11/1/23 through 11/2/23, the DON completed new pain assessments for all residents and updated the care plan accordingly. The SA validated through staff interview and record review that the DON completed body audits on 10/29/23 through 10/31/23 on all current residents. The SA validated through staff interview and record review, for monitoring purposes, all nurses and CNAs completed a lift skill observation. The SA validated through staff interview and record review, for monitoring purposes, Transfer Audits were completed by the nurse two (2) times per day until 12/31/23. The SA validated through staff interview and record review, for monitoring purposes, weekly body audits are completed by nurses on all residents. The SA validated that the facility reported the incident to the SA and the Attorney General Office (AGO) on 10/29/23.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and facility policy review, the facility failed to ensure pain management was provided to a resident when the resident was observed with bruising, edema, and pain to the left thigh and vaginal area, and was subsequently diagnosed with a femoral fracture for (1) of six (6) residents reviewed for pain. Resident #1. Findings include: Record review of the facility's policy, Pain Assessment and Management, revised 8/2/22, revealed, .The purposes of this procedure are to help the staff identify pain in the resident, and to develop interventions that are consistent with the resident's goals and needs and that address the underlying causes of pain .6. Assess the resident's pain and consequences of pain at least each shift for acute pain or significant changes . A record review of the facility's investigation which included the,Alleged Abuse Incident Report dated 11/3/23, revealed on 10/28/23 at approximately 1:45 PM, License Practical Nurse (LPN) #1 reported to Registered Nurse (RN) #2 Supervisor that Resident #1 had bruising to the left thigh and vaginal area with swelling and pain. A record review of the Progress Notes revealed a Nurses Note, dated 10/28/23 at 1:45 PM, authored by LPN #1, revealed, alerted to resident's room. upon exam bruising was noted to vaginal area, and left thigh. painful to touch . There was no documentation that pain was addressed in the nurses note. A record review of the hospital records which included the History and Physical and Progress Notes, with an admission date of 10/29/23, revealed Resident #1 presented to the hospital with a left leg injury. Emergency Department (ED) workup was significant for left proximal femur fracture. The Physical Exam revealed Resident #1 had diffuse bruising at various stages of healing to left lower extremity and expected tenderness to left lower extremity. The Assessment/Plan revealed the ED nursing staff filed an elder abuse report and pain medications were ordered. Record review of the Order Summary Report with active orders as of 11/20/23, revealed Resident #1 had a Physician Order, dated 8/1/2019 for Acetaminophen Tablet 500 MG (milligrams) Give two (2) tablet by mouth every 6 hours as needed for .pain . Record review of the electronic Medication Administration Record (eMAR) for October 2023 revealed there was no documentation that Resident #1 received pain medication in October. Record review of the Order Summary Report with active orders as of 11/20/23 revealed a physician order dated 11/1/23 Morphine Sulfate (concentrate) solution 20 MG/ML (milliliter) give 0.5 ml by mouth every 2 hours as need for .PAIN. Record review of the November 2023 MAR revealed Resident #1 had documented pain levels 14 times that ranged from four (4) to eight (8) from 11/1/23 through 11/14/23 and had received Morphine Sulfate 14 times in November after her diagnosis of a left femur fracture on 10/29/23. On 2/6/24 at 11:17 AM, during a phone interview with LPN #1, he confirmed he was notified that Resident #1 had bruising to her left leg and groin area. LPN #1 stated Resident #1 demonstrated she was in pain because she had facial grimacing. LPN #1 stated he gave Resident #1 Acetaminophen, but he failed to provide any documentation regarding administering the medication. On 2/7/24 at 10:11 AM, during an interview with the Director of Nursing (DON), she confirmed that on 10/28/23, RN #2 should have assessed Resident #1 because she had demonstrated she was in pain due to her facial grimaces. She explained that Resident #1 rarely demonstrated pain. The DON confirmed Resident #1 was prescribed Acetaminophen Tablets and there was no documentation that it was administered in October 2023. She reported that RN #2 and LPN #1 did not follow the facility's policy on pain assessment and management for Resident #1 and she expected the staff to follow the policy. On 2/7/24 at 2:49 PM, in an interview with the Administrator, he confirmed that on 10/28/23, the facility did not follow the pain policy and should have medicated Resident #1 for pain. He expected the staff to follow the policy and procedures of the facility. On 2/8/24 at 12:00 PM, during an interview with the Medical Director, he confirmed the facility did not provide him with any information on Resident #1's pain on 10/28/23. He stated he expected the facility to notify him of residents' acute pain. Record review of the admission Record revealed the facility admitted Resident #1 on 6/14/2016 and she had current diagnoses including Alzheimer's Disease and Vascular Dementia. Record review of the annual Minimum Data Set (MDS) with an Assessment Reference Date of 8/30/23, revealed Resident #1 required a staff interview for mental status and her cognition was severely impaired. Based on the facility's implementation of corrective actions on 11/2/23, the State Agency (SA) determined the deficiency to be Past Non-Compliance (PNC). The deficiency was corrected as of 11/3/23, before the SA's entrance on 2/5/24. Validation: On 2/8/23, the SA validated through staff interviews, record review, and facility policy review the facility began an investigation on 10/29/23. The SA validated through staff interview and record review of the sign in sheet and meeting minutes that an emergency Quality Assurance Performance Improvement (QAPI) meeting with all required staff was held on 10/31/23 at 9:15 AM. The DON, Medical Provider, and Social Services Director attended the QAPI meeting to discuss the situation regarding abuse and neglect, including investigation and reporting of abuse and neglect. The QAPI members also discussed ethics and communication, perineal care, notification of changes, mechanical lift and transfer safety, care plans, and [NAME] following the incident. The QAPI meeting concluded that the Plan of Correction was to in-service all staff, suspend the CNA, and conduct body audits on all residents. The QA Committee reviewed all related policies and procedures with no changes recommended. The SA validated through staff interview and record review of the in-service sign-in sheets that in-services with all staff conducted by the Administrator and the DON began on 10/29/23 regarding abuse and neglect, investigating and reporting abuse and neglect, ethics, communication, perineal care, notification of changes, mechanical lift and transfer safety, care plan, and [NAME]. No staff were allowed to work until they received the in-service training. The SA validated through staff interview and record review that the DON conducted Resident mechanical lift/transfer assessments on all residents on 11/1/23 and ensured all were up-to-date and care planned accordingly. The SA validated through staff interview and record review that on 11/1/23 through 11/2/23, the DON completed new pain assessments for all residents and updated the care plan accordingly. The SA validated through staff interview and record review that the DON completed body audits on 10/29/23 through 10/31/23 on all current residents. The SA validated through staff interview and record review, for monitoring purposes, all nurses and CNAs completed a lift skill observation. The SA validated through staff interview and record review, for monitoring purposes, Transfer Audits were completed by the nurse two (2) times per day until 12/31/23. The SA validated through staff interview and record review, for monitoring purposes, weekly body audits are completed by nurses on all residents. The SA validated that the facility reported the incident to the SA and the Attorney General Office (AGO) on 10/29/23.