**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff, Nurse Practitioner, Medical Director, and Radiologist interviews, the facility failed to protect a severely cognitively impaired resident from injury of unknown origin. On 3/18/23 nurse aide #1 observed bruising on Resident #22's left thigh and right fourth toe. On 3/20/23 Resident #22 was assessed by a nurse and found to have a bruise to her left thigh described as the size of a salad plate saucer and swollen knee. X-ray results revealed Resident #22 had a grossly displaced complex fracture of the left distal femur with angulation at the fracture site (the femur was broken in more than one place and the bone fragments were at an angle to each other). This was for one of one resident reviewed for an injury of unknown origin. The findings included: Resident #22 was admitted to the facility on [DATE] with diagnoses that included Tourette's disease (a nervous system disorder involving repetitive movements or unwanted sounds) cognitive communication deficit, abnormal posture, vascular dementia with behavioral disturbances, convulsions, and osteoporosis. The annual Minimum Data Set (MDS) assessment dated [DATE] showed Resident #22 was severely cognitively impaired, had unclear speech, and sometimes was able to understand others. The MDS showed Resident #22 required extensive assistance from two staff members for transfers and total assistance from one staff member for bathing. The MDS showed Resident #22 had not taken any anticoagulants, did not have any behaviors of refusing care, and did not have any physical/verbal behaviors directed at others. The MDS showed at the time of assessment, Resident #22 had not fallen in the previous six months. The care plan dated 1/8/23 showed Resident #22 had a focused area of socially inappropriate/disruptive behaviors of screaming out at times related to Tourette's disorder, a difficulty communicating, and at risk for falls with previous actual falls. Interventions included attempt to redirect as needed, use simple communications, assist with mobility at level resident requires, two persons assist with bathing, toileting, bed mobility, and transfers. A shower log and skin assessment sheet dated 3/18/23 (Saturday) showed Resident #22 had bruising on her left thigh and bruising on her right fourth toe. The shower sheet was signed by Nurse Aide #1 on 3/18/23 and the Unit Manager on 3/20/23. A nursing progress note written by Nurse #2 dated 3/20/23 read nurse aide was giving bath notice left knee was swollen. Physician was notified, order for left leg to be x-ray, writer called mobile x-ray mobile imagining. An x-ray dated 3/20/23 of Resident #22's left femur (thigh bone) showed osseous mineralization was decreased. This could reflect osteopenia (reduced bone mass lesser severity than osteoporosis) or osteoporosis (condition in which bones become brittle and fragile from a loss of tissue). The report also read Resident #22 had a grossly displaced complex fracture of the distal femur with angulation at the fracture site and soft tissue swelling. (the femur was broken in more than one place and the bone fragments were at an angle to each other). A Physician orders dated 3/20/23 showed an order to send Resident #22 to the emergency room for evaluation of a possible femur fracture. A nursing progress note written by the Unit Manager dated 3/20/23 read Resident sent to ER for further evaluation and treatment per MD for possible leg femur fracture. The emergency room physical assessment dated [DATE] read Left leg has obvious deformity. There is moderate swelling to left thigh with bruising. No additional obvious trauma on exam. Resident #22's vital signs were stable, and she was not in any distress. No known injury. Resident #22 showed signs of dementia, was alert, and moved her extremities spontaneously. The x-ray taken at the emergency room on 3/20/23 showed Resident #22 had a comminuted fracture (a fracture where the bone is broken in at least two places) that was reduced (a procedure used to set broken bones without cutting the skin open) in the emergency room and splinted after orthopedic surgery consultation. The facility was unable to provide the emergency room with information related to the cause of Resident #22's injuries. Resident #22 was admitted to the hospital on [DATE] with a diagnosis that included a closed fracture of the distal end of her left femur. (a fracture of the thigh bone above the knee). The resident was readmitted to the facility on [DATE]. An interview was conducted on 4/4/23 at 1:29 P.M. with Nurse Aide #2 who was assigned to Resident #22 on 3/20/23 for the 7 A.M. to the 7 P.M. shift. NA #2 indicated she was familiar with Resident #22. Resident #22 was unable to communicate with staff and rarely made her needs known. During the interview, NA #2 indicated Resident #22 was able to move her legs to hanging off the bed and sit up in the bed without assistance from staff. During the interview, NA #2 indicated she was assigned to work with Resident #22 on 3/17/23 during the 7 A.M. to 7 P.M. shift and had not observed Resident #22 to have any bruising. NA #2 indicated when she went to work on 3/20/23, she had not received a report that stated Resident #22 had a fall or any injury and Resident #22 behaved at her baseline with no indication she was in pain. NA#2 indicated when she went to Resident #22's room to provide her with a bed bath she noticed bruising that was light in color on her left thigh approximately the size of a salad plate saucer. NA #2 indicated when she reached over the side of the bed, NA #2 observed Resident #22 to have a swollen knee. NA #2 reported the bruising to the assigned nurse. An interview was conducted on 4/4/23 at 2:02 P.M. with Nurse #2 who was assigned to Resident #22 on 3/20/23 for the 7 A.M. to the 7 P.M. shift. Nurse #2 indicated she had not received a report Resident #22 had a fall or another incident with injury. Nurse #2 indicated Resident #22 was sleeping when she arrived for her shift on 3/20/23 with no signs of she was in pain. During the interview, Nurse #2 indicated NA #2 reported Resident #22 had a bruise on her thigh, a bruise under her left leg by her knee, and an indentation above the left knee. Nurse #2 assessed Resident #22 and described the bruise under her leg at the knee as being about the size of a softball. The bruise was dark purple, red, with a little bit of tint on her thigh. Nurse #2 indicated the indentation at the left knee was only observed when the leg was looked at from the side. During the interview, Nurse #2 indicated she felt Resident #22 had a broken leg and reported the injury to the Unit Manager. Nurse #2 further indicated the x-ray technician reported to her, when Resident #2's left thigh was x-rayed, Resident #22 did not call out when her leg was repositioned. An interview was conducted on 4/4/23 at 1:16 P.M. with the Unit Manager. The Unit Manager indicated she was unaware Resident #22 had any bruising on her left thigh until 3/20/23 when Nurse #2 made her aware. The Unit Manager indicated herself and Nurse #2 went and assessed Resident #22. During the interview, the Unit Manager indicated Resident #22 was unable to verbalize what caused the bruise, so a head-to-toe assessment was completed with the following results: a bruise the size of a softball on the top of Resident #22's left thigh that appeared to be a newer bruise because it was not yellow, a bruise behind Resident #22's left knee, and a bruise on a toe. The Unit Manager indicated she does not recall which toe had a bruise. During the interview, the Unit Manager indicated Resident #22 was unable to verbalize pain but did not show any nonverbal signs of being in pain when she assessed her on 3/20/23. The Physician was notified, and a mobile x-ray was ordered. The Physician gave orders to send Resident #22 to the emergency room when the x-ray results showed a fracture. The Unit Manager indicated after Resident #22 went to the emergency room an investigation was started by the Administrator. An interview was conducted on 4/4/23 at 3:42 P.M. with the Director of Nursing (DON). During the interview, the DON indicated the morning Resident #22 went to the emergency room, the Unit Manager reported a bruise of unknown origin to herself and the Administrator. An interview was conducted on 4/5/23 at 10:09 A.M. with the Administrator. During the interview, the Administrator indicated he was made aware Resident #22 had a bruise on 3/20/23. The Administrator stated he went to Resident #22's room and observed a bruise that was a significant size of approximately 10-15 centimeters. The Administrator indicated the doctor was contacted, an x-ray was taken that showed a fracture, and the resident was sent to the emergency room. A telephone interview was conducted on 4/6/23 at 3:25 P.M. with the Nurse Practitioner (NP). The NP indicated she was in the building on 3/20/23 when she was alerted by nursing staff Resident #22 needed to be assessed for a bruise. The NP observed a large bruise on Resident #22's top to the side of her left thigh that appeared to be under 24 hours old based on the coloration and her leg was a little swollen. During the interview the NP indicated she felt Resident #22 had a possible fracture. The NP indicated the facility completed an investigation and it was determined the injury occurred due to a mechanical lift, Resident #22's combativeness, and Resident #22's weak bones. A telephone interview was conducted on 4/5/23 at 8:22 A.M. with the Medical Director. During the interview, the Medical Director indicated he was familiar with Resident #22 and had given orders to send her to the emergency room for evaluation for a femur fracture. The Medical Director indicated Resident #22 had advanced dementia, seizure activity, contractures, and was unable to straighten her legs. The Medical Director further indicated when staff used a mechanical lift to transfer Resident #22, the pressure points on her body were in different locations compared to a person who was not contracted. The Medical Director further indicated with Resident #22's weakened bones, the movement with the mechanical lift, and rolling back and forth during a shower, the bone may have become grossly displaced. During the interview, the Medical Director indicated he was unaware of Resident #22 having a fall prior to being taken to the emergency room on 3/20/23 for an evaluation. A telephone interview was conducted on 4/11/23 at 9:24 A.M. with Radiologist #1. During the interview, Radiologist #1 accessed Resident #22's electronic medical record and reviewed the x-rays of Resident #22's left femur (thigh bone) taken while she was in the emergency room. Radiologist #1 indicated the left thigh fracture was a recent fracture and had occurred approximately within a day or less from her hospitalization. The radiologist indicated Resident #22 had diminished bone mineralization which made her more prone to fractures. During the interview, Radiologist #1 indicated based off the severity of the break on the femur (thigh bone), the multiple fractures on the femur, the location of the break above the knee, he would guess the resident had a fall. The radiologist further stated an aggressive amount of force from a fall, or a car accident was required for this type of fracture, and it was an unusual fracture to have occurred in a mechanical lift. The Administrator was notified of the Immediate Jeopardy on 4/6/23 at 5:00 P.M. The facility provided a corrective action plan on 4/8/23 which alleged a date of completion of 3/25/23. The corrective action plan indicated: The root cause analysis identified that the alleged noncompliance resulted from the failure of the facility to ensure each resident is free from injury of unknown origin for one resident #22. The RCA identified that an employee failed to use the mechanical lift properly per facility mechanical lift policy and procedures. Resident #22 have fragile bones resulting from decreased osseous mineralization that reflect osteopenia and osteoporosis. The RCA concluded that due to Resident #22 condition of osteopenia it is most likely that the sustained fractures resulted from an improper use of the mechanical lift by nursing aide #1 on 3/18/2023. The RCA concluded that the extent of resident #22 injuries is related to resident #22 medical condition and improper use of the mechanical lift. On 3/25/2023, Nursing assistant #1 was immediately suspended to allow further investigation of the allegation of abuse/neglect of Resident #22. Nurse #1 assessed Resident #22 on 03/20/2023 and notified the attending physician who ordered an X ray of the Resident #22 leg. Unit Coordinator #1 spoke to Xray technician who completed the Xray and received a preliminary result that resident had a fracture. Unit Coordinator contacted the Attending Physician who ordered resident to be sent to emergency room for evaluation and treatment. The Unit Coordinator #1 notified the resident's responsible party of the change in condition as well as transfer to the emergency room on 3/20/2023. On 03/25/2023, Director of Nursing completed a one-on-one re-education for Nursing Aide #1 on the importance of having assistance when using mechanical lift. The Director of Nursing also re-educated Nurse Aide #1 on 3/25/2023 on the abuse prohibition policy and procedures to include, but not limited to, ensuring each resident remains free from injuries of unknown sources. Resident #22 was readmitted on [DATE]. Resident #22 was reassessed by MDS Coordinator #1, and the care plan was revised to include measures for pain management and two person's assistance with ADLs, and the use of two persons assistance with mechanical lift. How the facility will identify other residents having the potential to be affected by the same deficient practice: 100% interview of all residents in the facility who are alert and oriented completed by assistant Director of Nursing, Staff Development Coordinator, Unit Coordinator #1 and/or MDS Coordinator on 3/25/23 to identify any other resident with an allegation of abuse/neglect. No other resident voiced any allegation of abuse/neglect. Findings of this audit are documented on a resident abuse interview tool located in the facility compliance binder. 100% audit of current resident's medical diagnosis completed by assistant director of Nursing, Staff Development Coordinator, MDS Coordinator #1, Unit Coordinator #1, and/or MDS Coordinator #2 on 03/25/2023, to identify any other resident with diagnosis of osteopenia and or osteoporosis and assure each resident has a care plan with intervention such as use two persons for transfer, to minimize risk for pathological and/or spontaneous fractures. Findings of this audit are documented on a care plan ADL audit tool located in the facility compliance binder. MDS Coordinator #1 and/or MDS Coordinator #2 on 03/25/2025, assure each resident has an Assistance of Daily Living (ADL) care plan that indicates the amount of assistance required during ADL care to include the use of mechanical lifts. Findings of this audit are documented on a care plan ADL audit tool located in the facility compliance binder. 100% audit of all incident reports written in the last 30 days completed on March 25, 2023, by Director of Nursing, Unit coordinator #1, and/or Unit manager #2 to identify any other incident of injury of unknown source. No other injuries of unknown sources identified. Findings of this audit are documented on an Incident report audit tool located in the facility compliance binder. 100% audit of all current resident's shower sheets for the last 30 days was completed on 03/25/2023 by Director of Nursing, MDS Coordinator #1, MDS coordinator #2, Unit coordinator #1, and/or Unit Manager #2 to identify any other documentation of an injury of unknown source further investigation. No other injuries of unknown sources were identified. Findings of this audit are documented on shower sheets audit tool located in the facility compliance binder. Measures will be put into place or systemic changes made to ensure that the deficient practice will not recur: Effective 03/25/2023, facility will ensure all remains free from abuse, neglect, misappropriation of resident property, and exploitation, to include be free from injuries of unknown source. Effective 03/25/2023 facility employees follow the company abuse prohibition policy and procedures, and policy and procedures when using mechanical lift to ensure each resident remains free from abuse to include injuries of unknown source. At least two employees are present when using a mechanical lift from 3/25/2023. Effective 03/25/2023, all new residents have a bed mobility assessment completed on admission, quarterly, and with any changes in their bed mobility status, by the nurse on duty. This is reviewed in the daily clinical meeting and be documented on the facility medical records under the comprehensive care plan. Any resident who requires mechanical lift has a care plan for two persons assistance with the mechanical lift. Effective 03/25/2023, the facility clinical team to include the Director of Nursing, Assistant Director of Nursing, Unit Coordinator #1 and/or Unit Coordinator #2 revised the process of reviewing all new admits/readmits in a daily clinical meeting and include the provision for bed mobility assessment to ensure it is completed and documented in electronic medical records, presence of osteopenia and/or osteoporosis, and ensure appropriate care plan is in place. Any discrepancies identified are corrected promptly. Finding of this systemic change is documented on the daily clinical meeting report form located on the daily clinical meeting binder. 100% education of all current staff to include full-time, part-time, employees from contracted staffing agencies company, and as needed employees completed by the Director of Nursing, Assistant Director of Nursing, and/or Unit Coordinators (#1, #2). The emphasis of this education includes but not limited to, the importance of completing bed mobility assessment on admission, quarterly and with changes of bed mobility status. Staff education also focused on facility abuse prohibition policy and procedures. and the requirements to use two persons assistance when using mechanical lifts at all times. This education was completed by 03/25/2023. Any staff members not educated 03/25/2023 is not allowed to work until educated. This education is now provided annually and has been added to the new hire orientation for all new employees including agency employees effective 03/25/2023. How the facility plans to monitor its performance to make sure that solutions are sustained: Effective 03/25/2023, the Director of Nursing, Assistant Director of Nursing, MDS Coordinators (#1, #2), Unit Coordinators (#1, #2), and/or Weekend Supervisor complete abuse prohibition monitoring process. This monitoring process is accomplished by observing residents to ensure employees are providing services in the facility that assure each resident is free from abuse and neglect, and to provide an environment that is free from accidents and hazards. The monitoring process is accomplished by observing five randomly selected staff when using the mechanical lift to ensure two people are present when using the lift. This monitoring process will be completed daily for two weeks, weekly for two more weeks, then monthly for three months, or until the pattern of compliance is established. Any negative findings are addressed promptly. This monitoring process is documented on a Mechanical lift use monitoring tool located in the facility compliance binder. Effective 03/25/2023, the Director of Nursing, Assistant Director of Nursing, Unit Coordinators (#1, #2), and/or Weekend Supervisor review all new admissions for the last 24 hours or from last clinical meeting to ensure that a bed mobility assessment has been completed, a diagnosis or osteopenia/osteoporosis has been identified (if any) and plan or care developed to include intervention such as two people assistance with transfers when to minimize risk if injuries. Any negative findings are corrected promptly. This monitoring process is completed daily for two weeks, weekly for two more weeks, then monthly for three months or until the pattern of compliance is maintained. Findings of this monitoring process will be documented on the bed mobility assessment tool for new residents located in the facility compliance binder. Effective 03/25/2023, the Director of Nursing, Assistant Director of Nursing, Unit Coordinators (#1, #2), and/or Weekend Supervisor complete incident/accident monitoring process. This monitoring process will be accomplished by reviewing all skin assessments and shower sheets completed for the last 24 hours or from last clinical meeting to ensure that any identified injuries of unknown source has been assessed by a nurse and being addressed promptly. Any negative findings are corrected promptly. This monitoring process is completed daily for two weeks, weekly for two more weeks, then monthly for three months or until the pattern of compliance is maintained. Findings of this monitoring process are documented on the Skin assessments audit tool located in the facility compliance binder. Effective 03/25/2023, the Director of Nursing and/or Assistant Director of Nursing report findings of this monitoring process to the facility Quality Assurance and Performance Improvement Committee (QAPI), for recommendations and/or modifications, monthly for three months, or until the pattern of compliance is archived. Date of Completion: 3/25/23 The facility provided a corrective action plan for the incident that happened on 3/18/23 with a completion date of 3/25/23. The onsite validation was conducted on 4/10/23. Staff from different departments and who worked different shifts were interviewed and verified they had received training in using two people when transferring residents in a mechanical lift. Alert and oriented residents were interviewed who indicated they had been asked if they had been abused by staff and the residents had no concerns. A review was completed of the audit logs that included the educational information provided to staff during the in-service and a review of in-service staff sign-in logs. The in-service logs were reviewed, staff names were randomly selected and verified to have received training. The audit of resident medical diagnoses, care plan to include two staff for transfer with a mechanical lift, the shower sheets and incident reports were verified to have been completed and no additional unreported injuries were identified. A review of the monitoring tool revealed staff had completed daily monitoring of shower sheets and incident reports. The QAPI plans to include this monitoring in their next meeting. The facility's compliance date was validated as 3/26/23.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interviews, nurse practitioner, and medical director interview, the facility failed to have a nurse assess a severely cognitively impaired resident (Resident #22) when an injury of unknown origin was discovered. On 3/18/23 nurse aide (NA) #1 did not report new bruising to Resident #22's left thigh and right fourth toe. On 3/20/23 Resident #22 was observed to have a bruise to her left thigh described as the size of a salad plate saucer and swollen knee. These findings were reported to Nurse #2 who assessed Resident #22. X-ray results revealed Resident #22 had a grossly displaced complex fracture of the left distal femur with angulation at the fracture site (the femur was broken in more than one place and the bone fragments were at an angle to each other). This was for 1 of 1 resident reviewed for an injury of unknown origin. The findings included: Resident #22 was admitted to the facility on [DATE] with diagnoses that included Tourette's disease (a nervous system disorder involving repetitive movements or unwanted sounds) cognitive communication deficit, abnormal posture, vascular dementia with behavioral disturbances, convulsions, and osteoporosis. The annual Minimum Data Set (MDS) assessment dated [DATE] showed Resident #22 was severely cognitively impaired, had unclear speech, and sometimes was able to understand others. The MDS showed Resident #22 required extensive assistance from two staff members for transfers and total assistance from one staff member for bathing. The MDS showed Resident #22 had not taken any anticoagulants, did not have any behaviors of refusing care, and did not have any physical/verbal behaviors directed at others. The care plan dated 1/8/23 showed Resident #22 had a focused area of socially inappropriate/disruptive behaviors of screaming out at times related to Tourette's disorder and a difficulty communicating. Interventions included attempt to redirect as needed and use simple communications. A shower log and skin assessment sheet dated 3/15/23 showed Resident #22 had no documented bruises on her skin. The shower sheet was signed by Nurse Aide #1 on 3/15/23 and the Unit Manager on 3/16/23. A shower log and skin assessment sheet dated 3/18/23 (Saturday) showed Resident #22 had bruising on her left thigh and bruising on her right fourth toe. The shower sheet was signed by Nurse Aide #1 on 3/18/23 and the Unit Manager on 3/20/23. Review of facility records showed no shift report sheet dated 3/18/23 from the 7 P.M. to 7 A.M. shift. The shift report listed each resident on an assignment. The shift report was used by staff to document changes in a resident's care reported from previous shifts and that occurred during their shift, in addition the sheet showed resident's glucose blood sugar results for sliding scale insulin to be administered. Review of a nursing progress note written by Nurse #2 dated 3/20/23 read nurse aide was giving bath notice left knee was swollen. Physician was notified, order for left leg to be x-ray, writer called mobile x-ray mobile imagining. Review of an x-ray dated 3/20/23 of Resident #22's left femur (thigh bone) showed osseous mineralization was decreased. This could reflect osteopenia (reduced bone mass lesser severity than osteoporosis) or osteoporosis (condition in which bones become brittle and fragile from a loss of tissue). The report also read Resident #22 had a grossly displaced complex fracture of the distal femur with angulation at the fracture site and soft tissue swelling. (the femur was broken in more than one place and the bone fragments were at an angle to each other). Review of physician orders dated 3/20/23 showed an order to send Resident #22 to the emergency department for evaluation of a possible femur fracture. Review of a nursing progress note written by the Unit Manager dated 3/20/23 read Resident sent to ER for further evaluation and treatment per MD for possible leg femur fracture. Review of the hospital physical assessment dated [DATE] read Left leg has obvious deformity. There is moderate swelling to left thigh with bruising. No additional obvious trauma on exam. Resident #22's vital signs were stable, and she was not in any distress. Resident #22 showed signs of dementia, was alert, and moved her extremities spontaneously. The x-ray taken at the hospital on 3/20/23 showed Resident #22 had a comminuted fracture (a fracture where the bone is broken in at least two places) that was reduced (a procedure used to set broken bones without cutting the skin open) in the emergency room and splinted after orthopedic surgery consultation. Resident #22 was admitted to the hospital on [DATE] with diagnosis that included closed fracture of distal end of left femur. (a fracture of the thigh bone above the knee). The resident was readmitted to the facility on [DATE]. A telephone interview was conducted on 4/4/23 at 2:32 P.M. with NA #1 who was assigned Resident #22 on 3/18/23 and 3/19/23 during the 7 P.M. to 7 A.M. shift. During the interview, NA #1 indicated when she gave Resident #22 a bed bath on 3/18/23, she observed bruising on Resident #22's left thigh, under her left knee, and on her fourth toe. NA #1 indicated Resident #22 did not appear to have a deformed leg. NA #1 stated she reported the bruising on Resident #22 to Medication Aide #2 and continued to provide Resident #22 with care throughout the rest of the shift. NA #1 indicated there was no change in Resident #22's behaviors from her baseline. During the interview, NA #1 indicated the previous shift had not reported any bruising on Resident #22. A follow up telephone interview was conducted with NA #1 on 4/6/23 at 11:19 A.M. During the interview, NA #1 indicated the skin conditions she observed on Resident #22 were immediately reported to Medication Aide #2 when she observed them. NA #1 described the bruise she observed on Resident #22's knee as a yellow bruise in the middle of Resident #22's knee, about the width of a number two pencil from the eraser to where it says two on the side of the pencil that curved with the natural curve of the knee. During the interview, NA #1 was unable to describe the length of the bruise on Resident #22's left knee. NA #1 indicated she completed the shower sheet and put the sheet in the shower book at the nurses' station for review. NA #1 indicated Resident #22's bruising was not reported to the assigned nurse on duty. During the interview, NA #1 indicated she had been educated prior to this date to report changes to both the medication aide and the assigned nurse. NA #1 did not indicate the appearance of Resident #22's bruise on 3/19/23. A telephone interview was conducted on 4/4/23 at 3:06 P.M. with Medication Aide #2 assigned Resident #22 on 3/18/23 and 3/19/23 during the 7 P.M. to 7 A.M. shift. During the interview, the Medication Aide indicated when nurse aide #1 went into Resident #22's room to provide incontinence care to Resident #22, she observed a bruise on Resident #22's fourth toe and the back of her left knee. Medication Aide #2 indicated NA #1 reported the bruises to her at that time. Medication Aide #2 indicated the bruising appeared purple and dark in color and she thought the bruises were old. During the interview, Medication Aide #2 stated she wrote down the location of the bruises on a piece of paper and gave the paper to Nurse #1. The Medication Aide #2 indicated she had not received a report Resident #22 had a fall or another incident and was unsure what had caused the bruising. A follow up telephone interview was conducted on 4/6/23 at 11:37 A.M. with Medication Aide #2. During the interview, the Medication Aide indicated when she observed the bruises on Resident #22, she wrote the information down on a 24-hour shift report. The Medication Aide was unsure what time she handed the report to Nurse #1. The Medication Aide observed Resident #22 to have two bruises, a bruise on the top of the right fourth toe and a bruise on the back of the knee. During the interview, Medication Aide #2 indicated Resident #22 had to be turned onto her side to observe the bruise on her left knee. Medication Aide #2 was unable to describe the size and appearance of the bruise and stated she was not sure how to measure bruises. Medication [NAME] #2 was unable to recall if she verbally told the nurse about Resident #22's bruising. A telephone interview was conducted on 4/5/23 at 4:21 P.M. with Nurse #1 who was the nurse overseeing the Medication Aide on 3/18/23. During the interview, Nurse #1 indicated when a nurse aide completed a resident's shower, the nurse aide used the shower sheet paperwork to document any changes in the resident's skin. The shower sheet was then provided to the assigned nurse with any changes in the resident's skin for the nurse to complete an assessment of the resident. Nurse #1 indicated she did not receive a report on 3/18/23 about any changes in Resident #22's skin. Nurse #1 further indicated had she received a report, she would have assessed Resident #22's skin. A follow up interview was conducted on 4/6/23 at 11:45 A.M. with Nurse #1. During the interview, Nurse #1 indicated at approximately 6:30 A.M. on 3/19/23, Medication Aide #2, assigned to Resident #22, gave her a scratch sheet of paper. The paper had the residents assigned to Medication Aide #2's blood glucose results, to include Resident #22's blood glucose results. Nurse #1 indicated she did not see any changes in Resident #22's skin written on the sheet. During the interview, Nurse #1 indicated no one during the shift verbally told her about any bruises on Resident #22's skin. An interview was conducted on 4/5/23 at 4:29 P.M. with NA #3 who was assigned Resident #22 on 3/19/23 for the 7 A.M. to 7 P.M. shift. During the interview NA #3 indicated she had not worked with Resident #22 long and she does not recall Resident #22 to have a bruise. NA #3 indicated nothing about Resident #22 having a bruise was given during the shift report and had she observed a bruise on Resident #22, she would have immediately reported the mark to her assigned nurse. An interview was conducted on 4/4/23 at 1:29 P.M. with Nurse Aide #2 who was assigned to Resident #22 on 3/20/23 for the 7 A.M. to the 7 P.M. shift. NA #2 indicated she had not received a report Resident #22 had a fall or any injury. When she went to Resident #22's room to provide her with a bed bath she noticed bruising that was light in color on her left thigh approximately the size of a salad plate saucer. NA #2 indicated when she reached over the side of the bed, NA #2 observed Resident #22 to have a swollen knee. NA #2 reported the bruising to the assigned nurse. An interview was conducted on 4/4/23 at 2:02 P.M. with Nurse #2 who was assigned to Resident #22 on 3/20/23 for the 7 A.M. to the 7 P.M. shift. Nurse #2 indicated she had not received a report Resident #22 had a fall or another incident with injury. Nurse #2 indicated Resident #22 was sleeping when she arrived for her shift on 3/20/23 with no calling out or moaning. During the interview, Nurse #2 indicated NA #2 reported Resident #22 had a bruise on her thigh, a bruise under her left leg by her knee, and an indentation above the left knee. Nurse #2 assessed Resident #22 and described the bruise under her leg at the knee as being about the size of a softball. The bruise was dark purple, red, with a little bit of tint on her thigh. Nurse #2 indicated the indentation at the left knee was only observed when the leg was looked at from the side. During the interview, Nurse #2 indicated she felt Resident #22 had a broken leg and reported the injury to the Unit Manager. Nurse #2 further indicated the x-ray technician reported to her, when Resident #2's left thigh was x-rayed, Resident #22 did not call out when her leg was repositioned. An interview was conducted on 4/4/23 at 1:16 P.M. with the Unit Manager. The Unit Manager indicated she was unaware Resident #22 had any bruising on her left thigh until 3/20/23 when Nurse #2 made her aware. The Unit Manger indicated herself and Nurse #2 went and assessed Resident #22. During the interview, the Unit Manger indicated Resident #22 was unable to verbalize what caused the bruise, so a head-to-toe assessment was completed with the following results: a bruise the size of a softball on the top of Resident #22's left thigh that appeared to be a newer bruise because it was not yellow, a bruise behind Resident #22's left knee, and a bruise on a toe. The Unit Manager indicated she does not recall which toe had a bruise. During the interview, the Unit Manager indicated Resident #22 was unable to verbalize pain but did not show any nonverbal signs of being in pain when she assessed her on 3/20/23. The physician was notified, and a mobile x-ray was ordered. The Physician gave orders to send Resident #22 to the hospital when the x-ray results showed a fracture. The Unit Manager indicated on 3/18/22 staff should have reported the bruise on Resident #22's thigh to the nurse that worked that shift. A telephone interview was conducted on 4/6/23 at 3:25 P.M. with the Nurse Practitioner (NP). The NP indicated she was in the building on 3/20/23 when she was alerted by nursing staff Resident #22 needed to be assessed for a bruise. The NP observed a large bruise on Resident #22's top to the side of her left thigh that appeared to be under 24 hours old based on the coloration and her leg was a little swollen. During the interview the NP indicated she felt Resident #22 had a possible fracture. The NP indicated the facility completed an investigation and it was determined the injury occurred due to a mechanical lift, Resident #22's combativeness, and Resident #22's weak bones. A telephone interview was conducted on 4/5/23 at 8:22 A.M. with the Medical Director. During the interview, the Medical Director indicated he was made aware Resident #22 had a bruise on her left thigh on 3/20/23. The Medical Director indicated an x-ray was ordered and it was discovered Resident #22 had a fracture. During the interview, the Medical Director indicated Resident #22 was severely demented and unable to express to staff the cause of her bruise. The facility completed an investigation and determined the improper use of a mechanical lift and the repositioning of the resident during her bath had caused the injury. An interview was conducted with the Director of Nursing (DON) on 4/4/23 at 3:42 P.M. During the interview, the DON indicated the Unit Manager reported the bruise on Resident #22's left thigh to herself and the Administrator. When the facility was made aware of the bruise, an investigation was immediately started. The DON indicated staff should have reported the bruise to herself or the Administrator when it was discovered over the weekend, and she is unsure why staff had not reported the injury when it was first discovered. The Administrator was notified of the Immediate Jeopardy on 4/6/23 at 5:00 P.M. The facility provided a corrective action plan on 4/8/23 which alleged a date of completion of 3/25/23. The corrective action plan indicated: The root cause analysis identified that the alleged noncompliance resulted from the failure of the facility staff (nurse aide #1) to report an injury of unknown source to a nurse on 3/18/2023 for further assessment and plan of care. Resident #22 injury was assessed by a nurse on 3/20/2023. How corrective action will be accomplished for those residents found to have been affected by the deficient practice. On 3/25/2023, Nursing assistant #1 was immediately suspended to allow further investigation of the allegation of abuse/neglect of Resident #22. Nurse #1 assessed Resident #22 on 03/20/2023 and notified the attending physician who ordered an X ray of resident #22's leg. Unit coordinator #1 spoke to Xray technician who completed the Xray and received a preliminary result that resident had a fracture. Unit coordinator #1 contacted the Attending physician who ordered resident #22 to be sent to hospital for evaluation and treatment. The unit coordinator notified resident #22 responsible party of the change in condition as well as transfer to the hospital on 3/20/2023. On 03/25/2023, Director of nursing completed a one-on-one education with nursing assistant #1 on the importance of reporting any incident, accident, or any injuries to a nurse on duty for further evaluation and treatment. How the facility will identify other residents having the potential to be affected by the same deficient practice: 100% audit of all incident reports written in the last 30 days completed on March 25, 2023, by Director of Nursing, Unit coordinator #1, and/or Unit manager #2 to identify any other incident or injury not reported to a nurse on time. No other injuries and/or incidents/accidents identified as not reported to a nurse for proper follow ups. Findings of this audit are documented on an incident report audit tool located in the facility compliance binder. 100% audit of all current resident's shower sheets for the last 30 days was completed on 03/25/2023 by Director of Nursing, MDS Coordinator #1, MDS coordinator #2, Unit coordinator #1, and/or Unit manager #2 to identify any other documentation of an injury that was not reported to a nurse for proper assessment. No other injuries were identified as not reported to a nurse for proper follow-up. Findings of this audit are documented on shower sheets audit tool located in the facility compliance binder. Measures will be put into place or systemic changes made to ensure that the deficient practice will not recur: Effective 03/25/2023, facility ensures each residents receives quality of care and treatment based on the comprehensive assessment of a resident and in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices, including but not limited to ensuring any injury of a resident is reported to a nurse for proper assessment and follow ups. Effective 03/25/2023 facility employees follow the company policy and procedures, when observing/identifying any injury to a resident, by notifying the nurse on duty for proper assessment and follow ups. Effective 3/25/2023 and moving forward nurse on duty assess any reported injury and document findings on each resident's medical records. 100% education of all current staff to include full time, part time, employees from contracted staffing agencies company, and as needed nursing employees were completed by the Director of Nursing, Assistant Director of Nursing, Staff development coordinator, and/or Unit Coordinators (#1, #2). The emphasis of this education includes but is not limited to, the importance of reporting any incident/accident to a nurse on duty for proper assessment and follow-ups. This education was completed by 03/25/2023. Any staff members not educated on 03/25/2023, was not allowed to work until educated. This education will be provided annually and is added to the new hire orientation for all new employees effective 03/25/2023. How the facility plans to monitor its performance to make sure that solutions are sustained. Effective 03/25/2023, the Director of Nursing, Assistant Director of Nursing, MDS coordinators (#1, #2) and/or Unit Coordinators (#1, #2) have been completing quality of care monitoring process. This monitoring process is accomplished by reviewing all skin assessments and shower sheets completed for the last 24 hours or from last clinical meeting to ensure that any identified injuries has been assessed by a nurse and being addressed promptly. Any negative findings are corrected promptly. This monitoring process has been completed daily Monday through Friday for two weeks, weekly for two more weeks, then monthly for three months or until the pattern of compliance is maintained. Findings of this monitoring process are documented on the Skin assessments audit tool located in the facility compliance binder. Effective 03/25/2023, the weekend nurse supervisor completes quality of care monitoring process. This monitoring process is accomplished by reviewing all skin assessments and shower sheets completed for the last 24 hours to ensure that any identified injuries have been assessed by a nurse and addressed promptly. Any negative findings are corrected promptly. This monitoring process is completed every Saturday, and Sunday for two weeks, weekly for two more weeks, then monthly for three months or until the pattern of compliance is maintained. Findings of this monitoring process will be documented on the Skin assessments audit tool located in the facility compliance binder. Effective 03/25/2023, the Director of Nursing and/or Assistant Director of Nursing report findings of this monitoring process to the facility Quality Assurance and Performance Improvement Committee (QAPI), for recommendations and/or modifications, monthly for three months, or until the pattern of compliance is archived. Date of Completion: 3/25/23 The facility provided a corrective action plan for the incident that happened on 3/18/23 with a completion date of 3/25/23. The onsite validation process was completed on 4/10/23. Staff from different departments and who worked different shifts were interviewed and verified they had received training to immediately report injuries to a nurse. A review was completed of the audit logs that included the educational information provided to staff during the in-service and a review of in-service staff sign in logs. The in-service logs were reviewed, staff names were randomly selected and verified to have received training. The audit of the shower sheets and incident reports were verified to have been completed and no additional unreported injuries were identified. A review of the monitoring tool revealed staff had completed daily monitoring of shower sheets and incident reports. The QAPI plans to include this monitoring in their next meeting. The facility's compliance date was validated as 3/26/23.