Deficiency Text Not Available

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Complaint #s NJ 163250, NJ 170219 Based on observation, interview, record review and review of other pertinent documents, it was determined that the facility failed to ensure a thorough and complete investigation was completed to determine the causal factor of injuries of unknown origin to ensure that resident abuse or neglect had not occurred for: a) a resident (Resident #150) who was found on 12/05/23, with an infected wound that required hospitalization on 12/05/23, and was diagnosed with osteomyelitis, and again observed during routine wound rounds on 12/19/23, with exposed bone and required transfer to the hospital on the same day, and was diagnosed with a acute fractures of the right proximal tibia and fibular diaphyses (two long thigh bones) on 12/19/23, b) an allegation of sexual abuse by Resident #94 that was reported to the Licensed Practical Nurse on 6/28/24 at 7:30 AM, the facility did not investigate the allegation until 7/1/24, c) and for a resident who had a history of being combative with care, reported new onset pain to the right hip/leg on 04/03/23, and was diagnosed with a comminuted mildly displaced fracture at the greater trochanter of the right hip on 04/07/23. This deficient practice occurred for 3 of 3 residents reviewed for abuse (Resident # 81 and #150, Resident #94). The deficient practice was as follows: Refer to F600K, F686G A) On 6/28/24, the surveyor reviewed the closed electronic medical record (EMR) for Resident #150. Review of the closed record revealed that Resident #150 was admitted to the facility with diagnoses which included but were not limited to; Benign prostatic hyperplasia, dementia in other diseases classified elsewhere and failure to thrive and dementia. According to the Annual Minimum Data Set (MDS), an assessment tool dated 8/7/23, Resident #150 was identified as having moderate cognitive impairment. Resident #150 scored 11 out of 15 on the Brief Interview for Mental Status (BIMS). Resident #150 was totally dependent on staff for all Activities of Daily Living (ADLs). On 07/02/24 at 11:30 AM, the surveyor reviewed all progress notes which revealed a 10/18/23 nurse's Skin Check note indicating that Resident #150 had a skin tear at the facility on the right anterior lower leg measuring 2 centimeters (cm) x 2 cm x 0.3 cm. The right hip was noted with an abscess measuring 2 cm x 2 cm x 0.2 cm. Interventions implemented for the wound were low air loss mattress, pillows between legs and bilateral heel booties. The wound had worsened and the facility did not document anything regarding the wound condition in the EMR. There was no documentation in the EMR that indicated the physician was made aware of the condition of the wound. Review of the Order Summary Report dated 11/2023, reflected an order dated 11/22/23, to cleanse the wound of the right anterior lower leg topically every day shift for wound, cleanse with acetic acid, do not scrub or use excessive force, pat dry, apply honey gel to wound, apply calcium alginate cut to size of wound base, cover with a bordered foam dressing. The right hip wound had an order, dated 11/29/23, to cleanse with acetic acid, do not scrub or use excessive force, pat dry, apply honey gel to wound, apply calcium alginate cut to size of wound base cover with a bordered foam dressing. The staff initialed the Treatment Administraation Record (TAR) from 12/1/23 to 12/5/23 indicating that the wound care was completed as ordered. On 12/05/23, at 21:15 [9:15 PM] Discharge Summary (6 days later0, for a Date of Discharge from the facility on 12/05/23 revealed Resident #150 . wound to right anterior lower leg is reclassified as Stage 4 pressure injury ., . purulent drainage and edema to the periwound. Unable to debride [remove dead tissue] due to the patient being severely contractive and combative. Recommend patient be sent to hospital for possible osteomyelitis. According to nursing notes, patient was admitted for wound infection. The Hospital record for Resident #150 for the Emergency Department to Hospital admission which began on 12/05/23 was obtained by the Department of Health (DOH) and revealed: Emergency Department (ED) Provider Note dated 12/05/23 at 11:00 PM revealed: -Initial Complaint: Patient presents with wound infection coming from rehab with a wound to RLE (right lower extremity with concern for infection + [positive] malodorous and oozing . Past medical history of dementia currently living in a nursing home with contractures patient with know wounds. Nonverbal and non-interactive. History and physical completed at the hospital upon admission on [DATE], revealed the following: History of failure to thrive, Parkinson disease, dementia, who presents from a Long Term Care Facility (name redacted) due to right lower leg wound with symptoms and signs of infection with need for debridement. Resident #150 was diagnosed with osteomyelitis. The surveyor reviewed the facility Progress notes from 12/1/23 to 12/05/23 and was unable to locate any documentation regarding the wound assessment entered by facility staff. Documentation regarding the wound was entered every Tuesday by the wound care team only. The hospital documentation revealed on 12/06/23, regarding the wound prior to discharge back to the facility on [DATE]. Right Hip Pressure Injury: Active present on admission. wound description Full Thickness Wound. wound length( cm) centimeter: 2.5 wound width (2.5 cm) wound depth (0.2 cm) Presure injury stage Stage 3( present on admission) Contributing Factors:Lower extremities contractures, urinary incontinence, decreased mobility. Bed/Mobility: 2 person assist to turn. Bowel/ Bladder: Condom Catheter. Interventions/ recommendations: Cleanse wound with Normal Saline,cover with Meplex Border small sacral foam dressing, change dressing every 3 days. Continue to turn and reposition every 2 hours using foam wedge to maintain side-lying position. The readmission History and Physical entered in the EMR by the facility physician on 12/08/23, indicated the following: Resident #150 was readmitted to LTC (Long Term Care Facility) after an acute hospitalization after presenting with right lower leg wound. Imaging revealed right tibial osteomyelitis. Resident #150 was started on an antibiotic which Resident #150 will complete on 12/15 and 12/16/23. Resident #150 was transferred back to the LTC facility in stable condition. On 06/28/24 at 10:30 AM, the surveyor interviewed the Unit Manager (UM) regarding the process for Resident #150's wound care as the resident was on the UM's unit. The UM stated that all preventative measures would be in place and daily rounds would also be completed to ensure preventative measures were in place. The surveyor asked about documentation related to Resident #150's wound and the UM confirmed there was no narrative documentation completed to monitor wound care and the staff would be responsible for initiating the treatment when it was applied to the wound. The UM had no additional information to provide. On 7/8/24 at 1:00 PM, the surveyor interviewed the wound care Nurse Practitioner (NP) via telephone who stated that during wound rounds she observed that the wound had a large amount of purulent (a symptom of infection aht oozes from a wound) drainage which was not documented or communicated to the wound team. Subsequenty, the NP stated Resident #150 was then transferred to the hospital on [DATE], and diagnosed with Osteomyelitis (inflammation of the bone caused by infection). Resident #150 was treated with broad spectrum antibiotic,Vancomycin and Zosyn for the infection. Resident #150 returned to the facility on [DATE]. On 07/08/24 at 1:10 PM, the Director of Nursing (DON) was interviewed regarding what were the expectations for wound care documentation for Resident #150. The DON stated upon review of Resident #150, she had not been working at the facility and there was no documentation for the wound other than what was already provided to the surveyor. - A Nursing Documentation Progress Note entered as a Late entry, dated 12/09/23 timed 06:12 and signed by a Licensed Practical Nurse (LPN) revealed Skin color is normal, Resident #150 is displaying the following signs and symptoms of infection; loss of appetite, fatigue, increased need for assistance with ADL's, new onset of change in level of consciousness. Resident #150 has an infection. There is heat (warmth) at the site of infection. There is redness (erythema at the site of infection.) There is swelling at the site of infection. There was no documented evidence that the above findings were communicated to the physician or the wound care team prior to 12/05/23. On 12/19/23, again during wound rounds, the wound care Nurse Practitioner identified, and documented, that Resident #150 required hospitalization because when she removed the dressing, the bone was exposed. Resident #150 was transferred to the hospital and diagnosed with fracture of the tibia and fibula. The facility provided an incident report dated 12/19/23, with the following: Nursing description: Noted during wound round protruding necrotic bone to right lower extremity. Due to deterioration, order obtained to send Resident #150 to hospital for evaluation. Immediate action taken: Assessed by wound care team Obtain order to send to Emergency Room Notify responsible party of changes. A note from the Interdisciplinary Care Team dated 12/19/23 timed 8:09 AM, relayed the following: Met to discuss recent deterioration to wound observed during wound rounds. Resident currently on low air loss mattress, wedge in place. Turns for pressure relief and daily wound rounds. New Interventions to include sent to hospital. The surveyor reviewed the hospital record from the hospitalization of 12/19/23, and the following were noted: -Comments: Right lower extremity: Contracture with flexion at the hip and knee. Significant wound on the anterior shin with exposed bone . -A 12/19/23 Hospital Radiology X-Ray report revealed Acute Fractures of the right proximal tibia and fibular diaphysis [right thigh long bones], additional clinical notes revealed, now presents 12/19 from the skilled nursing facility because of bone extruding through wound, as well as hematuria ([Urinary Catheter] inserted 12/17 for urinary retention) per hospital follow up with the facility the wound dressing was changed daily and the facility had no documentation regarding bone exposure and found during weekly wound observation, orthopedic plans for a Right aka [above the knee amputation] on 12/22. On 07/03/23 at 2:00 PM, in the presence of the survey team, the surveyor inquired to the DON regarding an investigation about the wound development and related to exposed bone. The DON stated she was not at the facility and that there was nothing else to provide. On 07/08/23 at 9:30 AM, during a telephone interview with the Resident #150's Representative (RR), she confirmed that Resident #150's leg could not be saved, Resident #150 had an amputation and was transferred to another LTC for aftercare. The RR also stated that she was not informed of any changes in the wound or any trauma. On 07/08/24 at 1:30 PM, the surveyor interviewed the physician in charge of the resident care at the LTC. The physician informed the surveyor that he was aware that Resident #150 having a chronic wound. The physician stated he not informed that Resident #150's bone was protruding, nor that Resident #150 sustained any trauma at the facility prior to being informed by the hospital that Resident #150 was admitted with fractures. B) On 6/28/24 at 7:30 AM, the surveyor entered Resident #94's room to observe the Medication Pass Administration with the Licensed Practical Nurse. The Nurse checked the resident's arm where the glucometer device was to read the Blood sugar. The resident was irritable and informed the LPN that another resident wandered in their room while they were sleeping, touched their feet, went with their hands under the cover and touched their genital area. Resident #94 identified the perpetrator as Resident #84 who resided in the next room. The LPN was about to exit the room, the surveyor asked the LPN if she heard Resident #94's concerns. The LPN confirmed that she heard Resident #94's concerns and stated, Management was already made aware. The surveyor continued with the Medication Administration and observed Resident #84 in the hallway near their room. On 6/28/24 at 10:30 AM, the surveyor returned to the North hallway and observed Resident #94 in bed. Resident #84 was observed in their room. On 6/28/24 at 12:15 PM, the surveyor reviewed Resident #94's electronic medical record (EMR) and noted that the incident regarding the alleged sexual abuse was not documented. The DON informed the survey team she came in at 6:30 AM and started the investigation, there was no documentation in the clinical record regarding the alleged sexual abuse. On 07/01/24 at 8:30 AM, the surveyor requested the investigation for the incident of 06/28/24. The Director of Nursing informed the surveyor that the allegation was reported to the New Jersey Department of Health (DOH). On 07/01/24 at 10:10 AM, the DON provided the investigation. The surveyor reviewed the investigation with the DON and noted the LPN's statement was not included. The investigation did not reflect Resident #94's statement made on 6/28/24 at 7:30 AM, in the presence of the surveyor. The surveyor again asked the DON for the LPN's statement which was not included in the investigation. The DON stated that she would provide the statement later. On 07/01/24 at 10:30 AM, a follow-up interview in the presence of two surveyors was conducted with the LPN confirmed that Resident #94 reported being violated. She stated that Resident #94 reported that Resident #84 touched them in a homosexual way. The LPN added that was Resident #84's perception. On 07/01/24 at 12:30 PM, the survey team met with the LNHA and the DON and requested the investigation for the alleged sexual abuse reported to the LPN on 6/28/24 at 7:30 AM. Both indicated that they were not aware of the allegation of sexual abuse. The DON stated that she was only made aware that Resident #84 touched Resident #94's feet. She reported to the facility at 6:30 AM on 06/28/24, and started the investigation. A note entered by the Social Worker (SW) on 6/28/24 at 6:35 PM, revealed that the SW met with Resident #94, and Resident #94 was able to explain what had happened. There was no documentation regarding being touched inappropriately. On 07/01/24 at 1:27 PM, the surveyor interviewed the SW again regarding the allegation of sexul abuse by Resident #94. The surveyor, in the presence of the survey team, asked if the SW was aware. The SW stated, just now, she was made aware of it. The surveyor asked if the SW spoke with the nurse who heard the allegation and the SW stated she was not told about the nurse who overheard the allegation of inappropriate touching unit today. The surveyor asked if the SW interviewed Resident #94 and she stated, not yet. The surveyor asked if the allegation was considered abuse and the SW stated, it is abuse and the surveyor asked why? The SW stated, if somebody touches you without your consent that is abuse, and stated, there are many types of abuse, and confirmed that Resident #84 wandered. On 7/01/24 at 1:30 PM, the surveyor reviewed the facility's policy on abuse, neglect and misappropriation. Under Reporting/ Response: The facility will have written procedure that include: Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement applicable) within specified timeframe: a. Immediately, but no later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or b. Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. Assuring that reporters are free from retaliation or reprisal; Promoting a culture of safety and open communication in the work environment prohibiting retaliation against any employee who reports a suspicion of a crime., This facility will post a conspicuous notice of employee rights including the right to file a complaint with the State Survey Agency if the employee believe the facility has retaliated against him/her for reporting a suspected crime and how to file a complaint. The administrator will follow up with government agencies during business hours, to confirm the initial report was received, and to report results of the investigation when final within 5 working days of the incident, as required by state agencies. C) A Reportable Event Record/Report (RER) was received by the Department of Health (DOH) on 04/06/2023 regarding Resident #81 which revealed: Date of Event: 04/06/2023, Time of Event: 11:10 AM. 1. Narrative: At 11:10 AM on 04/06/23, notified that a 3 cm (centimeter) linear bruise noted to R (right) hip on Monday 04/04/2023. Resident has advanced stage dementia and does not speak English. Resident does ambulate without assistance at times in room. Resident has a Dx. (diagnosis) osteopenia and osteoarthritis. 3. Resident was assessed for further injuries and no further injuries were noted. X-rays were completed for R hip, R femur, and R knee and were negative for fractures. Ultrasounds were completed for R hip and were negative fractures. CT (CAT Scan) has been ordered for the site. Statements are being collected from staff from the past 72 hours. On 06/27/24 at 1:01 PM, Resident #81 observed in a recliner chair in the room. On 07/01/24 at 8:54 AM, the surveyor reviewed the requested completed investigation and supporting documents related to the RER for Resident #81 that were provided by the Director of Nursing (DON). The DON confirmed the documents provided were all the documents that were part of the the completed investigation for the RER. A review of Resident #81's electronic medical record revealed: - The Quarterly Minimum Data Set, dated [DATE], revealed that the function status section indicated Resident #81 required Extensive assistance of one staff for toileting, transferring, bed mobility and transfer. -A Nursing Quarterly Evaluation, Effective 04/02/23, documented by a Licensed Practical Nurse (LPN); E. Mood/Behavior: C. Resistive During Care and D. Combative was checked; Skin condition #4, a. Skin is Intact; Activity: Degree of Physical Activity, Walks Occasionally: Walks occasionally during day, but for very short distances, with or without assistance. Spends majority of each shift in bed or chair. The Pain Evaluation revealed: A. Evaluation 1. Manner of expressing pain: a. Verbal 2. Ask resident: Have you had pain or hurting at any time in the last 5 days? 0. No 3. Ask resident: How much of the time have you experienced pain or hurting over the last 5 days? 9. Unable to answer 4. Ask resident: Over the past 5 days, has pain made it hard for you to sleep at night? 0. No 5. Ask resident: Over the past 5 days, have you limited your day-to-day activities because of pain? 0. No 11. Pain is Rated by: a. Numeric Rating Scale 11a. Numeric Rating Scale (00-10) Ask resident: Please rate your worst pain over the last 5 days on a zero to ten scale, with zero being no pain and ten as the worst pain you can imagine. (Show resident 00-10 pain scale). Enter two-digit response. Enter 99 if unable to answer. 0 -4/2/2023 08:58 Nursing Evaluation Note (Structured Progress Note) Late Entry, The resident is oriented to person. The resident is confused. Speech is clear. The resident speaks/understands Italian. The resident is resistive during care. The resident is combative. The resident takes antidepressant medication. The resident has no evidence of delirium. Fall Risk Score: 14.0 Fall Risk Category: High Risk for Fall 4/3/2023 11:56 Nursing Late Entry: Note Text: Resident was noted in AM (morning) with pain to right hip/leg. Resident was having difficulty walking. Nursing examined resident she was noted with edema to b/l LE (bilateral lower extremity), no redness or bruising was seen. Nursing informed Family, [Doctor], Director/NP [Nurse Practitioner]. Order placed for Xray of right hip, right femur, right Tib [tibula] and Fib [fibula] and right ankle. Results were negative for fracture. However, resident was still having pain. Resident family did not want sent to ER for CT [CAT] scan. Follow up Xray's ordered for the AM. PRN pain medication administered. A 4/6/2023 07:05, Nursing Note Text: 11 to 7 skilled nurses note: resident was in [their] chair resting at beginning of shift, able to assist resident to lay down with some degree of difficulty, resident favoring right hip/leg, c/o of pain, they slept through most of the night with occasional outbursts of talking and light moaning, we were able to perform morning care and able to get resident into bathroom to toilet, also resident allowed me to apply ace wraps to b/l [bilateral] lower legs. will continue to monitor 4/6/2023 14:21 INTERACT SBAR (Situation, Background, Assessment, Summary- utilized with change in condition), Summary for Providers Situation: The Change In Condition/s reported on this CIC Evaluation are/were: Other change in condition Resident/Patient is in the facility for: Long Term Care Primary Diagnosis is: COVID-19 UNSPECIFIED DEMENTIA, UNSPECIFIED SEVERITY, WITHOUT BEHAVIORAL DISTURBANCE, PSYCHOTIC DISTURBANCE, MOOD DISTURBANCE, AND ANXIETY M15.9 POLYOSTEOARTHRITIS, UNSPECIFIED LOCALIZED SWELLING, MASS AND LUMP, LOWER LIMB, BILATERAL OTHER SPECIFIED PERSONAL RISK FACTORS, NOT ELSEWHERE CLASSIFIED Relevant medical history is: Dementia Resident/Patient had the following medications changes in the past week: Outcomes of Physical Assessment: Positive findings reported on the resident/patient evaluation for this change in condition were: - Functional Status Evaluation: Needs more assistance with ADLs Decreased mobility - Skin Status Evaluation: Discoloration - Pain Status Evaluation: Does the resident/patient have pain? Yes Nursing observations, evaluation, and recommendations are: Resident was noted on 4/3/23 with pain to right hip, no redness or bruising seen at this time. On 4/6/23 Resident was noted with continued pain and 3 cm linear Brusie to right hip. Xrays completed on 4/3/23 and 4/4/23 no fracture noted, CT [CAT scan] recommended, Venous Doppler on 4/4/23 neg [negative] for DVT [deep vein thrombosis- blood clot] . CT set for 4/723. Family does not want resident to be sent out to ER (Emergency Room) at this time. Continue to monitor and pain management in place. On 07/01/24 at 8:54 AM, the surveyor reviewed the requested Investigation provided by the Director of Nursing (DON) that was related to the RER for Resident #81. The DON confirmed the documents provided was the completed investigation and revealed the following: Description of Event: At 11:10 AM on 04/06/2023, notified that a 3 cm [centimeter] linear bruise was noted to right hip when APN [nurse practitioner] during exam. Resident was noted with new pain to the right hip on Monday 4/4/2023. Resident has advanced stage dementia and does not speak English. The Resident does ambulate without assistance at times in the room. Resident has a DX: osteoarthritis. Action: Full body assessment completed on residents with no other injuries noted; Investigation immediately initiated . Resident's Pertinent Medical Data: Alert and oriented to self with a Brief Interview for Mental Status 99 [severe cognitive impairment]. Resident is an extensive assist with all Activities of Daily Living. Diagnosis: Dementia, polyosteorathritis, hypokalemia, hypertension. Events Preceding Incident: Resident demonstrated new pain to the right hip area Monday 4/3/2023 . Statement Summary: At 11:10 AM on 04/06/23, notified that a 3 cm linear bruise was noted to right hip when APN was doing exam. Resident was noted with new pain to the right hip on Monday 04/04/2023. [This contradicted the documented information in the Events Preceding Incident section and the medical record]. Resident has advanced stage dementia and does not speak English. The resident does ambulate without assistance at times in the room. Resident was interviewed with daughter's assistance in translation. Resident stated that they fell but was unable to elaborate due to advanced dementia level. An investigation was initiated, and statements were gathered from all staff that were assigned to resident from Sunday 04/02/23 until 04/06/2023. No fall was reported . Conclusions: The IDC [Interdisciplinary Team] met to discuss and review the incident and has determined that the cause of the bruise was caused by an unwitnessed fall. A reasonable person would conclude that this was isolated incident and no abuse or neglect occurred. There was no intent to cause any harm. Investigational summary completed by: [DON]. A review of the attached statements revealed the following 13 Witness Statements: -Incident Date: [Left Blank], Type of Incident [Left Blank], Please provide a written description of what you observed section: I [name toileted [Resident] on Sunday 04/02/2023 and did not complain of any pain.; Name, Title /Relation to Resident: Signed, Certified Nurse Aide and [Date: Blank]. -Incident Date: 4/2/23, Type of Incident [Left Blank], Incident time- 11-7 shift; Please provide a written description of what you observed section: No falls or incidents occurred during my shift. Resident slept through the night with no [signs/symptoms] of pain or discomfort. Name, Title /Relation to Resident: Signed, LPN and Date: 04/2/23. -Incident Date: [Blank]; Type of Incident Skin Bruise, Please provide a written description of what you observed section: I did not see any bruise or Resident on my shift on 04/03/23, 3-11, Name, Title /Relation to Resident: Signed, [No Title and Date: Blank]. -Incident Date: 4/6; Type of Incident Bruise; Please provide a written description of what you observed section: I cared for resident on 4/4 and I did not see any bruising on resident's hip; Name, Title /Relation to Resident: Signed, [No Title and Date: Blank]. -Date: 04/04/23; Incident Date: [Left Blank]; Type of Incident Skin, Please provide a written description of what you observed section: I cared for resident on 04/04/23. No new skin change was reported. Resident in stable condition. Name, Title /Relation to Resident: Signed, [Licensed Practical Nurse (LPN) and Date: 04/04/23]. -Incident Date: 4/6/23; Type of Incident Bruise; Please provide a written description of what you observed section: I cared for resident on 4/4 and I did not see any bruising on resident's hip; Name, Title /Relation to Resident: Signed, [No Title and Date: Blank]. -Incident Date: 4/6/23; Type of Incident Bruise; Please provide a written description of what you observed section: I cared for resident on 4/5 and I did not see any bruising on resident's hip; Name, Title /Relation to Resident: Signed, [No Title and Date: Blank]. -Incident Date: 4/6/23; Type of Incident Bruise, Please provide a written description of what you observed section: No one brought to this writer's attention of any skin issues on the shift Name, Title /Relation to Resident: Signed, [No Title] and Date: 07/18/23 [Three months after incident]. -Incident Date: 4/6; Type of Incident Bruise, Please provide a written description of what you observed section: I was not informed of any skin issue on the shift. Name, Title /Relation to Resident: Signed, [No Title and Date: Blank]. -Incident Date: 4/6; Type of Incident Bruise Right Hip, Please provide a written description of what you observed section: Was not aware of said discoloration to hip or it was not reported during this shift staff. Name, Title /Relation to Resident: Signed, LPN Date: 04/06/23. -Incident Date: 4/6; Type of Incident Bruise Right Hip, Please provide a written description of what you observed section: I was not informed that resident had a bruise nor did I see a skin alteration to residents right hip. Name, Title /Relation to Resident: Signed, LPN, Date: [undated]. -Incident Date: 4/6; Type of Incident Bruise Right Hip, Please provide a written description of what you observed section: I did not notice any bruise on the resident right hip during care. Name, Title /Relation to Resident: Signed, [No Title and Date: Blank]. -Incident Date: 4/6/23; Type of Incident Bruise Right Hip, Please provide a written description of what you observed section: I care for the Resident today 04/06/23 I notice a small bruise to the right hip I notify the unit manager and nurse immediately informed. CNA Name, Date: Blank]. -Incident Date: 4/6/23; Type of Incident Bruise Right Hip, Please provide a written description of what you observed section: I care for the Resident today 04/06/23 I notice a small bruise to the right hip I notify the unit manager and nurse immediately informed. CNA Name, Date: Blank. -Incident Date: 4/6/23; Type of Incident Bruise, Please provide a written description of what you observed section: I was informed this shift by NP that resident had a bruise on right hip. I am unaware of how/when this happened. Name, Title /Relation to Resident: Signed, [No Title and Date: 04/06/23]. On 07/03/24 at 1:43 PM, the surveyor interviewed the DON in the presence of the survey team. The surveyor asked what would be completed when a new symptom would occur with a resident as Resident #81 had new complaint of pain to the right leg on 4/3/23 and was diagnosed with a hip fracture on 4/7/23. The DON stated typically the nurse would call the physician, regarding a change in condition would occur and notify family. The surveyor asked when the resident presented with new pain on 4/3 was that when the investigation began. The DON stated, typically I go back from when baseline changed and collect statements for 72 hours prior. The surveyor showed the DON the statements had missing dates and they did not go back 72 hours from 4/3/23. The DON stated the Unit Manager (UM) would obtain the statements and they were responsible for interviewing staff. The surveyor asked how abuse/neglect was ruled out and the DON did not offer a response. The surveyor asked the DON who was responsible for reviewing the investigation and she stated she reviewed it. The surveyor requested a timeline of events leading up to Resident #81's fracture. On 7/8/24 at 8:30 AM, the facility offered a one paged document which revealed on 04/02/23, a physician documented there was no pain changes. On 04/03/23, nursing noted new pain to right hip at 11:00 AM, Tylenol was administered and was ineffective. During the investigation, the [family] was able to obtain some information of the cause of the fracture. The resident's [family] stated that the resident stated they fell and could not get any additional information. There was no statement from the family, no documentation regarding the alleged fall and interviewing staff related to a fall, no additional statements were provided. On 07/08/24 at 3:09 PM, the Licensed Nursing Home Administrator (LNHA) provided a one page document which included a paragraph that the facility investigated the fracture appropria[TRUNCATED]