**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, Physician Assistant interview, Physician interview, and hospice staff interview the facility failed to notify the physician of bruising to Resident #2's right hip and thigh that was identified on 5/21/23 by Nursing Assistant (NA) #1 and Nurse #3 two days following a fall (5/19/23). The bruising continued through 5/31/23 and was accompanied by swelling. On 5/31/23 the resident also showed signs of pain. On 5/31/23 the resident was admitted to the hospital with a comminuted and angulated hip fracture (a comminuted fracture is when the bone is broken into more than two pieces, and an angulated fracture is where the ends of the bone fragments are at an angle to each other) and significant bruising from the right hip to thigh hip fracture. This was for one (Resident # 2) of seven residents reviewed for physician notification following falls with injury. The findings included: Resident # 2 was admitted to the facility on [DATE]. Resident # 2's significant change Minimum Data Set assessment, dated 3/7/23, coded the resident as moderately cognitively impaired. On 5/19/23 at 7:24 PM Nurse #1 noted the following in Resident # 2's record. The resident had been observed on the floor, was assessed for injuries with no apparent injuries found. Range of motion was performed on all extremities. A voice mail was left for the physician. Nurse #1 was interviewed on 6/29/23 at 2:30 PM and reported the following. Resident #2 had been at the nursing station when she fell on 5/19/23. No one had seen the resident fall, and she was called to assess the resident and found no signs of injury. The resident was transferred to the bed after the fall by pivoting her, and the resident transferred without any problems. She removed her clothes and did not find any bruises or injury. Following the date of 5/19/23 no one had mentioned to her that Resident #2 had a bruise on the days on which she cared for her. NA #1 was interviewed on 6/29/23 at 6:55 AM and reported the following. She had worked a double shift beginning on 5/20/23 on second shift and lasting until 5/21/23 at the end of third shift. The resident had no bruising during her check up until 6:00 AM. At that time, she saw a discolored, round reddish area on the right side of her leg. The resident did not complain of pain. She told Nurse #3. On 6/27/23 at 3:00 PM the Administrator and Corporate Nurse Consultant were interviewed and reported Resident # 2's bruise was first observed on 5/21/23 and assessed by Nurse #3. The facility presented an investigative file for Resident # 2's bruise and fracture, which included staff member's statements. Review of Nurse #3's statement, which was in the facility's investigative file, revealed on 5/21/23 the resident's NA (NA #1) had told him about the bruise. He assessed the bruise, found it to be dark red on her right thigh, and larger than his hand. Nurse #3 was interviewed on 6/27/23 at 4:50 PM and reported the following. It was close to the end of the shift when NA #1 reported a bruise on Resident #2's right thigh on 5/21/23. He assessed it, found it to be on the anterior part of her thigh and to be a large bruise. He thought it was related to her fall on 5/19/23. It was the first time he had seen it. Resident #2 was moving her legs and did not seem to be in pain. He took her vital signs to make sure it was not related to a bleeding problem and felt it should be something that should be monitored but did not tell the physician. The resident's vital signs were stable. The resident could not answer any questions related to the bruise. The facility's investigational summary indicated the following information for 5/22/23: - NA #6 observed a dark purple bruise to Resident's right hip during care and reported it to the nurse. He provided her incontinent care and transferred the resident via stand pivot. Resident #2 did now show signs of pain and her legs were straight. NA #6 was interviewed on 6/28/23 at 1:53 PM and reported the following. The resident seemed to bear weight on 5/22/23 when he transferred her. NA #6 recalled he talked to a nurse about the bruise. On 5/23/23 at 6:49 AM Nurse #2 noted in a nursing note that Resident #2 had a bruise to right hip/thigh. There was no notation of further assessment or that the physician was updated. On 5/23/23 Resident #2 was seen by her physician who noted the following. Patient noted to have a change in mental status. Patient is awake and alert and sitting up in wheelchair however appears glazed and withdrawn. Patient is less talkative and not reaching for things. She was unable to fully participate with OT [occupational therapy]. No acutes signs of pain to her arms and legs on passive range of motion. The physician further noted that she would order labs for the resident. The physician made no notation that she had been informed of a bruise to the resident's hip/thigh. The facility's investigational summary indicated the following information for 5/24/23 and 5/26/23: - 5/24/23: The resident was observed by the Physician Assistant (PA) at nursing station. Resident appeared lethargic and was leaning to the side. Resident was looking at PA but did not talk as she normally did. - 5/24/23: NA #7 noted at 11:00 PM resident was observed in bed awake with bruising noted to her right hip. She was unable to remember the color but remembered it was significant. There were no signs of pain. The bruise was reported to a nurse. - 5/26/23 indicated NA #6 observed bruise that was light purple with yellow on the front and darker purple towards the side. The bruise was similar in size as noted by NA on 5/22/23. Bruising again was reported to the nurse. On 5/26/23 at 6:52 AM Nurse #2 made a notation that Resident # 2 had a right thigh/hip bruise. There was no notation that the physician was updated. On 5/27/23 an admission Hospice Nurse electronically signed an admission assessment for Resident #2 for a start of service date on 5/25/23. The hospice nurse noted the following. Patient's right thigh, anterior and lateral are covered in black and blue bruises. The lateral portion of thigh/hip swelling about 1/3 the size of her left thigh. No interventions. No pain, anxiety or shortness of breath on exam. The hospice nurse noted the resident should be non-weight bearing on the hospice care plan. The facility's investigational summary indicated the following information for 5/28/23, 5/29/23, and 5/30/23: - 5/28/23: The NA noted a bruise on Resident #2's right thigh that was purple with yellowish colors. She did not report the bruise as she thought if most like came from a fall. - 5/29/23: An NA indicated a bruise was noted on Resident #2's right leg from her hip to her knee. Her right leg was bent with her knee towards the left side of the bed. There were no complaints of pain. - 5/30/23: At approximately 8:00 AM, NA #3 noted the resident's right leg was turned and bent with dark purple bruising from her hip to her thigh. NA #3 indicated he reported to the nurse who responded that the resident had fallen previously, and it probably took a while for the bruising to come up. NA #3 slowly straightened Resident #2's leg and then proceeded to provide bathing, incontinent care, and dressing. He then transferred Resident #2 via stand pivot transfer. The resident was noted to favor the right leg and she was leaning more to the left. Once seated in the wheelchair, NA #3 noted her right leg did not seem as if it was turned like it was before. There were no signs or symptoms of pain. - 5/30/23: At approximately 11:30 AM the Hospice NA took the resident to her room to lay her down. She positioned the chair next to the bed and then picked the resident up to move her to the bed. The Hospice NA indicated Resident #2 was able to bear some weight but stated she basically lifted the resident. The resident did not show any signs or symptoms of pain when transferred. Once in bed the Hospice NA noticed Resident #2's right leg was turned in and bent and her left leg was straight. She indicated she asked facility about Resident #2's leg and was informed by staff that she had fallen several days ago. NA #3 was interviewed on 6/28/23 at 2:35 PM and reported the following. When he first cared for her on the morning of 5/30/23, her right leg seemed to be in an awkward position when compared to the left. He took precautions and straightened it. It did not seem to cause her pain. When he pivoted her to the wheelchair, she seemed to put more weight on her left leg than her right leg. After she was in the wheelchair, he noticed she was leaning forward and that was the first day he had noted her to do that. Later a hospice NA came and put her in bed. He had talked to the nurse on the hall about her leg being bent. The Hospice NA was interviewed on 6/28/23 at 12:12 PM and reported the following. When she arrived, she found Resident #2 in her wheelchair, and she was leaning forward so that her head was facing downward. When she transferred Resident #2 on 5/30/23 she (the NA) did about 80% of the work. The resident did not bear all her weight. When she got Resident #2 back in bed, she noticed her leg was bent. It was bent so that the knee was inward, and the bottom of her leg was outward. The bruise covered her hip and most of her upper thigh. She did not tell the facility nurse or the Hospice Nurse because NA #3 already knew about it. The facility's investigational summary indicated the following information for 5/31/23: - At approximately 11:00 AM the NA reported to the hall nurse that Resident #2 had a change in condition. While providing care it was noted NA that Resident #2 had bruising to her right hip and thigh and signs of pain to right hip. The nurse assessed the resident. The nurse observed purple bruising to the right hip and right thigh. Bruising showed signs of fading. Resident #2 was noted with facial grimacing and furrowing of eyebrows indicating pain. This nurse noted internal rotation of right hip. The PA was in the facility and was notified by the nurse to assess the resident. - The PA noted Resident #2 had progressive decline which included change in mental status, increased lethargy, and overall withdrawal. She was less engaged, not verbally responding to questions and had decreased oral intake. She was noted with moderate soft tissue swelling with significant bruising noted lateral aspect right thigh. The right leg was in an angulated position. Attempted to gently straighten leg and Resident #2 demonstrated discomfort by wincing. When questioned about pain there was no verbal response. On 5/31/23 the Physician Assistant saw Resident #2 and noted the following. Patient with significant swelling and bruising right hip history of fall on 5/19/23. She is wheelchair dependent, non-ambulatory patient seen lying in bed with right leg angulation highly suspicious for right hip fracture, stat x-ray of right hip was ordered however due to time delay in obtaining imaging decision was made to transfer to (hospital) for further evaluation. A review of hospital records for the date of 5/31/23 included a digital photograph of Resident # 2's hip and thigh which had become part of her hospital medical record. Review of the medical record photograph revealed the right hip was a yellowish color and the anterior thigh down to the knee was predominantly a dark purplish color. The hospital physician noted Resident # 2 had significant bruising in multiple stages of healing and internal rotation of right hip. An x-ray was completed showing a comminuted and severely angulated fracture of the right hip. (A comminuted fracture is when the bone is broken into more than two pieces, and an angulated fracture is where the ends of the bone fragments are at an angle to each other). Hospice services were continued for the resident, and she did not undergo surgery. According to the facility's schedules, following the time Resident #2's bruise had been found on 5/21/23, Nurse #2 had cared for Resident #2 on 5/21/23, 5/22/23. 5/23/23, 5/24/23, 5/25/23, 5/26/23, 5/27/23, 5/28/23, 5/29/23, and 5/30/23. Nurse #2 was interviewed on 6/28/23 at 6:44 AM and reported the following. She recalled another nurse telling her about the bruise and that the resident had fallen before it was found. She did not talk to the physician about the bruise because she thought a facility manager already knew about the bruise. She never saw that Resident #2's leg was deformed. The resident never appeared in pain when she cared for her, and her legs appeared symmetrical. When she had looked at the bruise, there was never any indication the resident's leg was fractured. According to the schedule sheets, Nurse #4 had cared for Resident #2 on 5/25/23, 5/26/23, 5/30/23, an 5/31/23. Nurse #4 was interviewed on 6/27/23 at 4:00 PM and again on 6/29/23 at 1:45 PM. Nurse #4 reported the following. The only way she knew about Resident #2's fall was because she had read the resident's record. When the NA told her on 5/30/23 she did not recall him saying anything about the resident's leg being bent. If he had done so, she would have told the Director of Nursing (DON) right away. It had also not been reported to her that Resident #2 was leaning in her wheelchair before they laid her back down on 5/30/23. She had been busy and not seen that herself. On 5/31/23 she was called into the room by a NA and Resident #2's hip looked like it was out of place. She immediately let the DON know and the Physician Assistant came in to look at her. It was validated with Nurse # 4that she had not spoken to the Physician or the Physician Assistant prior to 5/31/23 about the bruise or the leg being bent. The Physician Assistant (PA) was interviewed on 6/28/23 at 1:20 PM and reported the following. She is at the facility every Wednesday and the physician is at the facility every Tuesday and Friday. She had not been told of a bruise before 5/31/23. When she had been in the facility on the previous Wednesday (5/24/23, Resident # 2 just looked tired. The physician had seen her the previous day on 5/23/23 and they thought something metabolic might be occurring. Labs had been ordered. She was declining and placed on hospice that week. On Wednesday (5/31/23) she was in route to the facility when she received a call that her hip looked awkward. She ordered an x-ray while in route. When she arrived, she assessed Resident # 2 and found that while at rest, Resident # 2 appeared comfortable. With range of motion, she winced. The hip appeared angulated. The exact time the x-ray was to be completed could not be estimated, and therefore she talked to hospice and the decision to send her to the hospital was made. She knew Resident # 2 had fallen on 5/19/23 and no injury had been identified on that date, but felt something might have happened on 5/19/23 that progressed with time. Resident # 2's physician was interviewed on 6/29/23 at 4:00 PM and reported the following. On Tuesday (5/23/23) she had seen Resident # 2 because therapy had said she was not acting like herself. The resident was very out of it and was not reaching for things. She saw her at the nursing station. She was able to move her wheelchair. She (the physician) was aware Resident # 2 had fallen and checked her range of motion. The resident did not wince with range of motion. She had not been told anything about a bruise. If she had been notified of this, then she would have taken Resident # 2 back to her room, laid her down, and examined the bruise. On 5/23/23 Resident # 2 was not hospice yet, and she probably would have ordered an x-ray on that day also. Since she was not acting herself, she decided to order labs. Later, the resident became hospice because she had a long history of progressively declining. On 5/26/23 she did not see Resident # 2. The plan at that point was not to be aggressive with the resident's care. She had not been told anything about the bruise before 5/31/23. She had never known that hospice had recommended she be non-weight bearing. They did not get paperwork from hospice until after Resident # 2 was discharged from the facility. On 6/30/23 at 1:30 PM the facility Administrator was informed of immediate jeopardy. The Administrator presented a corrective action plan. - Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice. Resident #2 is alert to self. A Brief Interview for Mental Status (BIMS) score could not be obtained due to cognition. Diagnoses include but not limited to Progressive Supranuclear Ophthalmoplegia (unable to move eyes at will in all directions), history of Cerebral Infarction (stroke) affecting right side, Glaucoma (increased pressure behind the eyes), Convulsions (seizures), aphasia (difficulty communicating), Dysphagia (difficulty swallowing), Major Depressive Disorder, Dementia with behaviors, Abnormalities of gait and mobility (difficulty walking), history of repeated falls, Nontraumatic subarachnoid hemorrhage (bleeding on the brain not caused by injury), polyneuropathy (muscle and nerve pain), ataxia, (impaired balance), Fibromyalgia (muscle pain), displaced simple history of fracture of bone between hip and knee, history of fracture of nasal bones, Age-related Osteoporosis (weakening of bones) and Osteopenia (softening of the bones), Adult Failure to Thrive. On 5/19/23 at 1:20 pm, staff observed the resident on the floor. The nurse assessed the resident for injuries, and the resident could move all extremities with no apparent pain. After the resident was transferred to the chair, the nurse completed a head-to-toe assessment with no bruising noted. The nurse attempted to notify the on-call physician and left a voicemail. The nurse notified the resident representative of the fall. On 5/21/23 at 6:00 am, the Nursing Assistant (NA) observed a large bruise on the top inner thigh and notified the nurse. The nurse assessed the resident and noted a dark red bruise on the right thigh, larger than a hand. The physician was not notified of the newly identified bruise. On 5/23/23, the resident was seen by the physician for a change in mentation. The provider notes the resident was observed sitting up in a wheelchair by the nursing station with (1) No acute injuries noted from the fall on 5/19/23, (2) No signs of pain or discomfort, (3) No wincing on exam of arms, and legs (4) Resident manipulated wheelchair backward using both feet without complaints of pain (5) Cooperative, Frail, in no apparent distress, sitting up in a wheelchair, awake and alert, not speaking, appears withdrawn. A complete blood count (CBC), comprehensive metabolic panel (CMP), and urine/urine culture were ordered. On 5/25/23 the provider started an antibiotic for a possible urinary tract infection (UTI). On 5/25/23 at 6:33 pm, the resident was admitted to hospice services with a visit by the hospice nurse. From 5/21/23-5/30/23, multiple facility staff observed bruising to the resident's right thigh. Staff had not reported the bruising to the physician. However, the resident exhibited no complaints of pain or swelling during care nor stand and pivot transfers. On 5/31/23 at approximately 11:00 am, the NA reported to the hall nurse that the resident had bruising to the right hip and thigh and signs of pain to the right hip while providing care. The nurse assessed the resident and observed fading purple bruising to the right hip and thigh with internal rotation. The resident was noted with facial grimacing and furrowing of eyebrows indicating pain. The nurse notified the provider. The provider assessed the resident and ordered a STAT (immediately) x-ray. On 5/31/23 at 2:45 pm, the resident was transferred to the hospital by emergency services due to the length of time to obtain an in-house x-ray. The resident was admitted to the hospital with a diagnosis of a right femur fracture. The Administrator initiated an investigation for injury of unknown origin to include notification of police, Adult Protective Services (APS), and state reporting per facility protocol. -Address how the facility will identify other residents having the potential to be affected by the same deficient practice. On 5/31/23, the Unit Manager completed a 100% skin audit of residents to identify all residents with signs and symptoms of a fracture, new bruising, pain, and/or deformity of extremities. There were no additional concerns identified. On 6/2/23, the administrative nurses including the Minimum Data Set Nurse (MDS), Director of Nursing, Staff Development Coordinator (SDC) and Unit Managers completed an audit of all residents to determine if the resident was experiencing a change in condition, with no additional concerns identified. On 6/2/23, the administrative nurses including the Minimum Data Set Nurse (MDS), Director of Nursing, Staff Development Coordinator (SDC) and Unit Managers reviewed progress notes for the past 14 days to determine if a resident exhibited a change in condition, including signs/symptoms of a fracture, pain, or bruising, and ensure the practitioner was notified timely. The Director of Nursing will address all areas of concern identified during the audit, including the physician's notification for further instruction. The audit was completed by 6/8/23. - Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur. On 6/2/23, An in-service was initiated by the administrative nurses to include the Minimum Data Set Nurse (MDS), Director of Nursing, Staff Development Coordinator (SDC), and Unit Managers with all nurses regarding (1) Notification of Changes with emphasis on (a) a prompt complete assessment of a resident's slight or subtle changes with physician notification will ensure adequate management of the resident's acute illness or exacerbation of a chronic illness. (b) notification of physician with any change in resident condition to include but not limited to new bruising, pain, and deformity of extremity after a fall with documentation in the electronic record (2) Signs and Symptoms of a Fracture with emphasis on signs and symptoms of a fracture to include but not limited bruising, swelling over a bone or pain, assessment of the resident, and immediate notification of the physician with documentation in the electronic record. In-services will be completed by 6/8/23. After 6/8/23, any nurse who has not worked or received the in-service will receive it prior to the next scheduled work shift. All newly hired nurses will be in-service during orientation regarding Notification of Changes, and Signs and Symptoms of a fracture. - Indicate how the facility plans to monitor its performance to make sure that solutions are sustained; and Monitoring actions began on 5/31/23. 15 residents' charts, including charts of residents with recent falls, new or worsening bruising and residents receiving hospice services will be reviewed by the Unit Managers weekly x 4 weeks, then monthly x 1 month utilizing the Notification Audit Tool. This audit is to ensure the physician was notified of changes in condition and changes related to new bruising, pain, and deformity of extremities for further recommendations and to ensure the coordination of care with hospice services. The Unit Managers will address all areas of concern identified during the audit, including assessment of the resident, notification of the physician of changes, and staff re-training. The DON will review the Notification Audit Tool weekly x 4 weeks then monthly x 1 month to ensure all areas of concern are addressed. The DON will present the findings of the Notification Audit Tool to the Quality Assurance Performance Improvement (QAPI) committee, including but not limited to the Administrator, Director of Nursing, Maintenance Director, Dietary Manager, Activities Director, Social Worker, Therapy Director, and MDS Director and Medical Director monthly for 2 months. The QAPI Committee will meet monthly for 2 months to determine trends and/or issues that may need further interventions put into place and to determine the need for further frequency of monitoring. Date of corrective action completion: 6/9/23 The facility's corrective action plan was validated by the following. On 6/27/23 and beginning at 9:05 AM a tour of all facility halls was made. Multiple residents were interviewed at this time. The residents did not report any medical problems that had not been brought to the physician's attention and addressed. Multiple residents, who had sustained falls, were placed on a sample. There was documentation the physician had been notified of any injuries related to falls sustained by other sampled residents. The facility presented documentation they had completed their audits and inservices as noted in their corrective action plan. Multiple staff members were interviewed during the survey dates and validated they had attending inservice training as outlined in the facility's corrective action plan. On 6/30/23 the facility's correction date of 6/9/23 was validated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, Physician Assistant interview, Physician interview, and hospice staff interviews the facility failed to communicate effectively to ensure comprehensive assessment and care were provided to address bruising to Resident #2's right hip and thigh that was first identified on 5/21/23 by Nursing Assistant (NA) #1 and Nurse #3 two days following a fall (5/19/23). The facility continued to transfer the resident via stand pivot method with weight being placed on the right leg and on 5/30/23 NA #3 noted the resident's right leg was in an awkward position and he straightened it. The resident was admitted to the hospital on [DATE] with a comminuted and angulated hip fracture (a comminuted fracture is when the bone is broken into more than two pieces, and an angulated fracture is where the ends of the bone fragments are at an angle to each other) and significant bruising from the right hip to thigh. This was for one (Resident # 2) of seven residents reviewed for care following falls and injuries. The findings included: Resident #2 was admitted to the facility on [DATE]. The resident's diagnoses, in part, included supranuclear palsy (a progressive neurogenerative disease), stroke, polyneuropathy, dementia, aphasia (the loss of ability to comprehend and express speech due to brain damage), and ataxia (poor muscle control causing problems with balance and walking). Resident #2's significant change Minimum Data Set assessment, dated 3/7/23, coded the resident as moderately cognitively impaired and as needing extensive assistance with transfers and hygiene needs. She was not assessed to be ambulatory. The resident also was assessed to have a history of falls with major injury on the assessment. The resident was not on an anticoagulant. Resident #2's care plan, updated on 5/19/23, noted the resident had a history of falls with fracture. The care plan included multiple interventions which included but were not limited to keeping a fall mat by the resident's bed and encouraging her to be out of her room. On 5/19/23 at 7:24 PM Nurse #1 noted the following in Resident #2's record within a nursing note. The resident had been observed on the floor, was assessed for injuries with no apparent injuries found. Range of motion was performed on all extremities. A voice mail was left for the physician. Review of Nurse #1's statement, which was in the facility's investigative file, indicated she assessed Resident #2 following the 5/19/23 fall and the resident was able to move all her extremities without pain. She had removed the resident's clothes, examined her skin, and found no bruising on 5/19/23. Nurse #1 was interviewed on 6/29/23 at 2:30 PM and reported the following. Resident #2 had been at the nursing station when she fell on 5/19/23. No one had seen the resident fall, and she was called to assess the resident and found no signs of injury. The resident was transferred to the bed after the fall by pivoting her, and the resident transferred without any problems. She removed her clothes and did not find any bruises or injury. Following the date of 5/19/23 no one had mentioned to her that Resident #2 had a bruise on the days on which she cared for her. During an interview on 6/27/23 at 3:00 PM the Administrator and Corporate Nurse Consultant were interviewed and reported there was an investigative file for Resident #2 related to a bruise which was first observed on 5/21/23 and assessed by Nurse #3. The facility presented an investigative file which included staff member's statements. NA #1 was interviewed on 6/29/23 at 6:55 AM and reported the following. She had worked a double shift beginning on 5/20/23 on second shift and lasting until 5/21/23 at the end of third shift. The resident had no bruising during her check up until 6:00 AM. At that time, she saw a discolored, round reddish area on the right side of her leg. The resident did not complain of pain. She told Nurse #3. Review of Nurse #3's statement, which was in the facility's investigative file, revealed on 5/21/23 the resident's NA (NA #1) had told him about the bruise. He assessed the bruise, found it to be dark red on her right thigh, and larger than his hand. Nurse #3 was interviewed on 6/27/23 at 4:50 PM and reported the following. It was close to the end of the shift when NA #1 reported a bruise on Resident #2's right thigh on 5/21/23. He assessed it, found it to be on the anterior part of her thigh and to be a large bruise. He thought it was related to her fall on 5/19/23. It was the first time he had seen it. Resident #2 was moving her legs and did not seem to be in pain. He took her vital signs to make sure it was not related to a bleeding problem and felt it should be something that should be monitored but did not tell the physician. The resident's vital signs were stable. The resident could not answer any questions related to the bruise. The facility's investigational summary indicated the following information for 5/22/23: - NA #6 observed a dark purple bruise to Resident's right hip during care and reported it to the nurse. He provided her incontinent care and transferred the resident via stand pivot. Resident #2 did now show signs of pain and her legs were straight. NA #6 was interviewed on 6/28/23 at 1:53 PM and reported the following. The resident seemed to bear weight on 5/22/23 when he transferred her. He did recall that he had talked to a nurse about the bruise. According to the staffing schedule, NA #1 cared for Resident #2 again on 5/22/23 and 5/23/23. During the interview with NA # 1 on 6/29/23 at 6:55 AM NA # 1 reported during the times she cared for her, the resident liked to stretch out her leg and did not keep her leg in an awkward position. NA # 2 did not recall working with Resident # 2 following 5/23/23. On 5/23/23 at 6:49 AM Nurse #2 noted in a nursing note that Resident #2 had a bruise to right hip/thigh. There was no notation of further assessment or that the physician was updated. On 5/23/23 Resident #2 was seen by her physician who noted the following. Patient noted to have a change in mental status. Patient is awake and alert and sitting up in wheelchair however appears glazed and withdrawn. Patient is less talkative and not reaching for things. She was unable to fully participate with OT [occupational therapy]. No acutes signs of pain to her arms and legs on passive range of motion. The physician further noted that she would order labs for the resident. The facility's investigational summary indicated the following information for 5/24/23: - The resident was observed by the Physician Assistant (PA) at nursing station. Resident appeared lethargic and was leaning to the side. Resident was looking at PA but did not talk as she normally did. - NA #7 noted at 11:00 PM resident was observed in bed awake with bruising noted to her right hip. She was unable to remember the color but remembered it was significant. There were no signs of pain. The bruise was reported to a nurse. On 5/24/23 at 12:23 PM the Administrator made a notation in the progress notes that she had spoken to Resident #2's responsible party and he was interested in pursuing hospice services for Resident #2. On 5/25/23 at 6:33 PM the Administrator made a notation in the record in the progress notes that Resident #2 had been admitted to hospice services for cerebrovascular disease. On 5/26/23 at 6:52 AM Nurse #2 made a notation within a nursing note that Resident #2 had a right thigh/hip bruise. There was no notation of further assessment or that the physician was updated. The facility's investigational summary indicated the following information for 5/26/23. NA #6 observed bruise that was light purple with yellow on the front and darker purple towards the side. The bruise was similar in size as noted by NA on 5/22/23. Bruising again was reported to the nurse. During an interview with NA #6 on 6/28/23 at 1:53 PM he indicated he cared for Resident #2 on 5/26/23 and on that day she had a fever, and he was concerned about the bruise as well. Therefore, he did not get her up on 5/26/23. Her leg was straight, and he took care to push a brief up under her rather than turning her completely from side to side. The facility's investigational summary indicated the following information for 5/27/23 indicated NA #8 observed the bruise to Resident #2's right leg. Resident did not get out of the bed and was not eating like usual self. Resident #2's roommate informed NA # 8 that the resident had fallen. She indicated Resident #2's right leg seemed more bent and the left leg was straight. NA # 8 asked the resident if she was in pain and the resident did not respond. She indicated the resident did not move around in bed as usual. NA #8 had not reported the bruising or other changes due to being told the resident had fallen previously. On 5/27/23 an admission Hospice Nurse electronically signed an admission assessment for Resident #2 for a start of service date on 5/25/23. The Hospice Nurse noted the following. The resident was lethargic. Not oriented to person place, time, or situation. Aphasic. Makes eye contact at times but mostly stares into the distance. Right at the end of the visit she let out an audible, unintelligible sound. The Hospice Nurse further documented, Patient's right thigh, anterior and lateral are coved in black and blue bruises. The lateral portion of thigh/hip swelling about 1/3 the size of her left thigh. No interventions. No pain, anxiety or shortness of breath on exam. The Hospice Nurse noted the resident should be non-weight bearing on the hospice care plan. The Hospice Nurse, who had signed the admission hospice assessment on 5/27/23 was interviewed on 6/29/23 at 2:45 PM and reported the following. During her admission assessment, Resident #2 was in bed. Resident #2's right hip was swollen and 1/3 size larger than her left hip. She had a black and blue bruise which was on her hip, anterior thigh, and lateral thigh. She was not exhibiting pain or anxiety. She had reviewed the record and saw that Resident #2 had been seen by her facility physician with no further work up by the physician. She interpreted that to be that there was to be none since the resident was hospice. She had talked to Nurse #4 while in the facility. The facility's investigational summary indicated the following information for 5/28/23, 5/29/23, and 5/30/23: - 5/28/23: The NA noted a bruise on Resident #2's right thigh that was purple with yellowish colors. She did not report the bruise as she thought if most like came from a fall. - 5/29/23: An NA indicated a bruise was noted on Resident #2's right leg from her hip to her knee. Her right leg was bent with her knee towards the left side of the bed. There were no complaints of pain. - 5/30/23: At approximately 8:00 AM, NA #3 noted the resident's right leg was turned and bent with dark purple bruising from her hip to her thigh. NA #3 indicated he reported to the nurse who responded that the resident had fallen previously, and it probably took a while for the bruising to come up. NA #3 slowly straightened Resident #2's leg and then proceeded to provide bathing, incontinent care, and dressing. He then transferred Resident #2 via stand pivot transfer. The resident was noted to favor the right leg and she was leaning more to the left. Once seated in the wheelchair, NA #3 noted her right leg did not seem as if it was turned like it was before. There were no signs or symptoms of pain. - 5/30/23: At approximately 11:30 AM the Hospice NA took the resident to her room to lay her down. She positioned the chair next to the bed and then picked the resident up to move her to the bed. The Hospice NA indicated Resident #2 was able to bear some weight but stated she basically lifted the resident. The resident did not show any signs or symptoms of pain when transferred. Once in bed the Hospice NA noticed Resident #2's right leg was turned in and bent and her left leg was straight. She indicated she asked facility about Resident #2's leg and was informed by staff that she had fallen several days ago. Review of the facility's investigative file revealed NA #3 had been assigned to care for Resident #2 on the 7:00 AM to 3:00 PM shift on 5/30/23. The following information appeared in NA #3's statement. When he was bathing and dressing the resident, her right leg was turned and bent. There was dark purple bruising from her hip to her thigh. He told Resident #2's nurse who in turn told him Resident #2 had fallen and it probably took a while for the bruising to come up. He then slowly straightened Resident #2's leg and proceeded with care. When he transferred her to the chair, she seemed to be favoring her right leg and leaning more to her left. He took her to the nursing station to sit and later that morning noticed she was leaning forward in her wheelchair. The hospice NA came and placed her in the bed. NA #3 was interviewed on 6/28/23 at 2:35 PM and reported the following. When he first cared for her on the morning of 5/30/23, her right leg seemed to be in an awkward position when compared to the left. He took precautions and straightened it. It did not seem to cause her pain. When he pivoted her to the wheelchair, she seemed to put more weight on her left leg than her right leg. After she was in the wheelchair, he noticed she was leaning forward and that was the first day he had noted her to do that. Later a hospice NA came and put her in bed. He had talked to the nurse on the hall about her leg being in an awkward position, and he felt sure the nurse had checked her. Review of the facility's investigative file revealed a statement from the Hospice NA who had cared for Resident #2 on 5/30/23. The statement read, On 5/30/23 I got to the facility around 10:30 AM. [Resident #2] was sitting at the nurse's station bent over with her eyes open. I asked [NA #2] about her care and whether she always leaned like that. She told me that [Resident #2] was a pivot transfer and that she did not always lean like that. The hospice nurse was also at the nurse's station at this time and did not say anything about her care. I asked if I should leave her there or lay her down. I took her to the room to lay her down. I positioned her chair next to the bed and then picked her up to move her to the bed. (Resident #2) was able to bear some weight, but I basically lifted her. [Resident #2] did not show any signs and symptoms of pain when I transferred her. I then held her and lifted her legs into the bed while turning her. I noticed her right leg was turned in and bent and her left leg was straight. I went and got [NA#3] to help pull her up in bed. When we got her pants off, I saw a bruise on her right leg from her hip to her knee. I asked [NA # 3] about her leg and he told me that she had fallen several days ago. The Hospice NA was interviewed on 6/28/23 at 12:12 PM and reported the following. When she arrived, she found Resident #2 in her wheelchair, and she was leaning forward so that her head was facing downward. When she transferred Resident #2 on 5/30/23 she (the NA) did about 80% of the work. The resident did not bear all her weight. When she got Resident #2 back in bed, she noticed her leg was bent. It was bent so that the knee was inward, and the bottom of her leg was outward. The bruise covered her hip and most of her upper thigh. She did not tell the facility nurse or the Hospice Nurse because NA #3 already knew about it. The facility's investigational summary indicated the following information for 5/31/23: - At approximately 11:00 AM the NA reported to the hall nurse that Resident #2 had a change in condition. While providing care it was noted by NA that Resident #2 had bruising to her right hip and thigh and signs of pain to right hip. The nurse assessed the resident. The nurse observed purple bruising to the right hip and right thigh. Bruising showed signs of fading. Resident #2 was noted with facial grimacing and furrowing of eyebrows indicating pain. This nurse noted internal rotation of right hip. The PA was in the facility and was notified by the nurse to assess the resident. - The PA noted Resident #2 had progressive decline which included change in mental status, increased lethargy, and overall withdrawal. She was less engaged, not verbally responding to questions and had decreased oral intake. She was noted with moderate soft tissue swelling with significant bruising noted lateral aspect right thigh. The right leg was in an angulated position. Attempted to gently straighten leg and Resident #2 demonstrated discomfort by wincing. When questioned about pain there was no verbal response. On 5/31/23 the Physician Assistant saw Resident #2 and noted the following. Patient with significant swelling and bruising right hip history of fall on 5/19/23. She is wheelchair dependent, non-ambulatory patient seen lying in bed with right leg angulation highly suspicious for right hip fracture, stat x-ray of right hip was ordered however due to time delay in obtaining imaging decision was made to transfer to (hospital) for further evaluation. The Physician Assistant (PA) was interviewed on 6/28/23 at 1:20 PM and reported the following. She was at the facility every Wednesday and the physician was at the facility every Tuesday and Friday. She had not been told of a bruise before 5/31/23. When she had been in the facility on the previous Wednesday (5/24/23), Resident #2 just looked tired. The physician had seen her the previous day on 5/23/23 and they thought something metabolic might be occurring. Labs had been ordered. She was declining and placed on hospice that week. On Wednesday (5/31/23) she was in route to the facility when she received a call that the resident's hip looked awkward. She ordered an x-ray while in route. When she arrived, she assessed Resident #2 and found that while at rest, Resident #2 appeared comfortable. With range of motion, she winced. The hip appeared angulated. The exact time the x-ray was to be completed could not be estimated, and therefore she talked to hospice and the decision to send her to the hospital was made. She knew Resident #2 had fallen on 5/19/23 and no injury had been identified on that date, but felt something might have happened on 5/19/23 that progressed with time. A review of hospital records for the date of 5/31/23 included a digital photograph of Resident #2's hip and thigh which had become part of her hospital medical record. Review of the medical record photograph revealed the right hip was a yellowish color and the anterior thigh down to the knee was predominantly a dark purplish color. The hospital physician noted Resident #2 had significant bruising in multiple stages of healing and internal rotation of right hip. An x-ray was completed showing a comminuted and severely angulated fracture of the right hip. (A comminuted fracture is when the bone is broken into more than two pieces, and an angulated fracture is where the ends of the bone fragments are at an angle to each other). Hospice services were continued for the resident, and she did not undergo surgery. According to the facility's schedules, following the time Resident #2's bruise had been found on 5/21/23, Nurse #2 had cared for Resident #2 on 5/21/23, 5/22/23. 5/23/23, 5/24/23, 5/25/23, 5/26/23, 5/27/23, 5/28/23, 5/29/23, and 5/30/23. Nurse #2 was interviewed on 6/28/23 at 6:44 AM and reported the following. She recalled another nurse telling her about the bruise and that the resident had fallen before it was found. She did not talk to the physician about the bruise because she thought a facility manager already knew about the bruise. She never saw that Resident #2's leg was deformed. The resident never appeared in pain when she cared for her, and her legs appeared symmetrical. When she had looked at the bruise, there was never any indication the resident's leg was fractured. Review of Nurse #1's statement revealed the following. She worked with Resident #2 on 5/22/23, 5/28/23, and 5/29/23. Nurse #1 was interviewed on 6/29/23 at 2:30 PM and reported no one had mentioned to her that Resident #2 had a bruise on the days on which she cared for her (5/22/23, 5/28/23, 5/29/23). According to schedule sheets, NA #2 had cared for Resident #2 on 5/20/23, 5/23/23, 5/25/23 and 5/29/23 on the 7:00 AM to 3:00 PM shift. NA #2 was interviewed on 6/28/23 at 10:45 AM and reported the following. She thought it was around the time she was assigned to care for Resident #2 on 5/23/23 that the resident had a big, dark, blue bruise. It covered most of the top of her thigh. She asked another NA about the bruise, and they told her Resident #2 had fallen. She did not talk to a nurse about it. Resident #2 moved her leg okay, and she could stand and pivot the same as she usually did. She did not seem to be in pain, and the bruise was the only thing that seemed different about her. According to schedule sheets, Nurse #4 had cared for Resident #2 on 5/25/23, 5/26/23, 5/30/23, and 5/31/23. A review of the facility's investigative file revealed a statement from Nurse #4 which noted the following information. A hospice nurse had not talked to her about Resident #2's bruise. She had never been told in report about a bruise or a fall. She had read in the resident's record about a fall. On 5/30/23 an NA told her Resident #2 had a bruise and she told him it was probably due to the fall. She did not assess the bruise that day. On 5/31/23 two NAs came to her and reported Resident #2's hip looked swollen and as if it was out of socket. She reported this to the physician and the Director of Nursing. Nurse #4 was interviewed on 6/27/23 at 4:00 PM and again on 6/29/23 at 1:45 PM. Nurse #4 reported the following. The only way she knew about the fall was because she had read the resident's record. When the NA told her on 5/30/23 she did not recall him saying anything about the resident's leg being bent. If he had done so, she would have told the Director of Nursing (DON) right away. It had also not been reported to her that Resident #2 was leaning in her wheelchair before they laid her back down on 5/30/23. She had been busy and not seen that herself. On 5/31/23 she was called into the room by a NA and Resident #2's hip looked like it was out of place. She immediately let the DON know and the Physician Assistant came in to look at her. She did not seem to be in a lot of pain. Interview with the Director of Nursing on 6/30/23 at 12:46 PM revealed none of her staff had reported Resident #2's bruise to her before the morning of 5/31/23. Resident #2's physician was interviewed on 6/29/23 at 4:00 PM and reported the following. Typically, Resident #2 could transfer with assistance, but she was non-ambulatory. She had some unusual spontaneous movements due to her neurological disease, but her legs were normally straight. On Tuesday (5/23/23) she had seen Resident #2 because therapy had said she was not acting like herself. The resident was very out of it and was not reaching for things. She saw her at the nursing station. She was able to move her wheelchair. She (the physician) was aware Resident #2 had fallen and checked her range of motion. The resident did not wince with range of motion. She had not been told anything about a bruise. If she had been notified of this, then she would have taken Resident #2 back to her room, laid her down, and examined the bruise. On 5/23/23 Resident #2 was not hospice yet, and she probably would have ordered an x-ray on that day also. Since she was not acting herself, she decided to order labs. Later, the resident became hospice because she had a long history of progressively declining. On 5/26/23 (the Friday she was routinely in the facility) she did not see Resident #2. The plan at that point was not to be aggressive with the resident's care. She had not been told anything about the bruise before 5/31/23. She had never known that hospice had recommended she be non-weight bearing. They did not get paperwork from hospice until after Resident #2 was discharged from the facility. Interview with the Administrator on 6/30/23 at 11:40 AM revealed the facility received nothing from hospice related to their concern about Resident #2's hip or the hospice nurse's admission assessment until after Resident #2 was discharged from them. On 6/30/23 at 1:30 PM the facility Administrator was informed of immediate jeopardy. The Administrator presented a corrective action plan. - Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice. Resident #2 is alert to self. A Brief Interview for Mental Status (BIMS) score could not be obtained due to cognition. Diagnoses include but not limited to Progressive Supranuclear Ophthalmoplegia (unable to move eyes at will in all directions), history of Cerebral Infarction (stroke) affecting right side, Glaucoma (increased pressure behind the eyes), Convulsions (seizures), aphasia (difficulty communicating), Dysphagia (difficulty swallowing), Major Depressive Disorder, Dementia with behaviors, Abnormalities of gait and mobility (difficulty walking), history of repeated falls, Nontraumatic subarachnoid hemorrhage (bleeding on the brain not caused by injury), polyneuropathy (muscle and nerve pain), ataxia, (impaired balance), Fibromyalgia (muscle pain), displaced simple history of fracture of bone between hip and knee, history of fracture of nasal bones, Age-related Osteoporosis (weakening of bones) and Osteopenia (softening of the bones), Adult Failure to Thrive. On 5/19/23 at 1:20 pm, staff observed the resident on the floor. The nurse assessed the resident for injuries, and the resident could move all extremities with no apparent pain. After the resident was transferred to the chair, the nurse completed a head-to-toe assessment with no bruising noted. The nurse attempted to notify the on-call physician and left a voicemail. The nurse notified the resident representative of the fall. On 5/21/23 at 6:00 am, the Nursing Assistant (NA) observed a large bruise on the top inner thigh and notified the nurse. The nurse assessed the resident and noted a dark red bruise on the right thigh, larger than a hand. The physician was not notified of the newly identified bruise. On 5/23/23, the resident was seen by the physician for a change in mentation. The provider notes the resident was observed sitting up in a wheelchair by the nursing station with (1) No acute injuries noted from the fall on 5/19/23, (2) No signs of pain or discomfort, (3) No wincing on exam of arms, and legs (4) Resident manipulated wheelchair backward using both feet without complaints of pain (5) Cooperative, Frail, in no apparent distress, sitting up in a wheelchair, awake and alert, not speaking, appears withdrawn. A complete blood count (CBC), comprehensive metabolic panel (CMP), and urine/urine culture were ordered. On 5/25/23 the provider started an antibiotic for a possible urinary tract infection (UTI). On 5/25/23 at 6:33 pm, the resident was admitted to hospice services with a visit by the hospice nurse. From 5/21/23-5/30/23, multiple facility staff observed bruising to the resident's right thigh. Staff had not reported the bruising to the physician. However, the resident exhibited no complaints of pain or swelling during care nor stand and pivot transfers. On 5/31/23 at approximately 11:00 am, the NA reported to the hall nurse that the resident had bruising to the right hip and thigh and signs of pain to the right hip while providing care. The nurse assessed the resident and observed fading purple bruising to the right hip and thigh with internal rotation. The resident was noted with facial grimacing and furrowing of eyebrows indicating pain. The nurse notified the provider. The provider assessed the resident and ordered a STAT (immediately) x-ray. On 5/31/23 at 2:45 pm, the resident was transferred to the hospital by emergency services due to the length of time to obtain an in-house x-ray. The resident was admitted to the hospital with a diagnosis of a right femur fracture. The Administrator initiated an investigation for injury of unknown origin to include notification of police, Adult Protective Services (APS), and state reporting per facility protocol. - Address how the facility will identify other residents having the potential to be affected by the same deficient practice. On 5/31/23, the Unit Manager completed a 100% skin audit of residents to identify all residents with signs and symptoms of a fracture, new bruising, pain, and/or deformity of extremities. There were no additional concerns identified. On 6/2/23, the administrative nurses including the Minimum Data Set Nurse (MDS), Director of Nursing, Staff Development Coordinator (SDC) and Unit Managers completed an audit of all residents to determine if the resident was experiencing a change in condition, with no additional concerns identified. On 6/2/23, the administrative nurses including the Minimum Data Set Nurse (MDS), Director of Nursing, Staff Development Coordinator (SDC) and Unit Managers reviewed progress notes for the past 14 days to determine if a resident exhibited a change in condition, including signs/symptoms of a fracture, pain, or bruising, and ensure the practitioner was notified timely. The Director of Nursing will address all areas of concern identified during the audit, including the physician's notification for further instruction. The audit was completed by 6/8/23. On 6/6/23, the Administrator, Medical Director and Director of Nursing reviewed with the Hospice Director all residents currently receiving hospice services to identify any concerns or changes in condition that had not been previously addressed. No additional concerns were identified. - Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur. On 6/6/23, the Administrator, Medical Director and Director of Nursing met with Hospice Director regarding communication and timely reporting of resident acute changes. Beginning 6/7/23, all Hospice personnel will exit with the Unit Manager, Director of Nursing and/or Administrator following each visit to the facility to provide an update for any concerns or resident changes in condition. On 6/2/23, An in-service was initiated by the administrative nurses to include the Minimum Data Set Nurse (MDS), Director of Nursing, Staff Development Coordinator (SDC), and Unit Managers with all nurses regarding (1) Notification of Changes with emphasis on (a) a prompt complete assessment of a resident's slight or subtle changes with physician notification will ensure adequate management of the resident's acute illness or exacerbation of a chronic illness. (b) notification of physician with any change in resident condition to include but not limited to new bruising, pain, and deformity of extremity after a fall with documentation in the electronic record (2) Signs and Symptoms of a Fracture with emphasis on signs and symptoms of a fracture to include but not limited bruising, swelling over a bone or pain, assessment of the resident, and immediate notification of the physician with documentation in the electronic record. In-services will be completed by 6/8/23. After 6/8/23, any nurse who has not worked or received the in-service will receive it prior to the next scheduled work shift. All newly hired nurses will be in-service during orientation regarding Notification of Changes, and Signs and Symptoms of a fracture. - Indicate how the facility plans to monitor its performance to make sure that solutions are sustained; and Monitoring actions began on 5/31/23. 15 residents' charts, including charts of residents with recent falls, new or worsening bruising and residents receiving hospice services will be reviewed by the Unit Managers weekly x 4 weeks, then monthly x 1 month utilizing the Notification Audit Tool. This audit is to ensure the physician was notified of changes in condition and changes related to new bruising, pain, and deformity of extremities for further recommendations and to ensure the coordination[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of manufacturer's instructions, and staff interviews, the facility failed to ensure securement was according to manufacturer's recommendations to provide a safe van transport. Resident #50 slid out of a reclined high back wheelchair into a seated position on the floor of the van with his legs extended in front of him and the seatbelt was above his head. Resident #50 alerted the transportation driver he had fallen. The transportation driver stopped the van in the center turning lane of a well-traveled road in the afternoon with the hazard lights on and lifted the Resident back into the high back wheelchair in a bear hug motion. The transportation driver proceeded to take Resident #50 to his appointment, failing to report the incident to the facility. Resident #50 was not assessed for injuries from the incident until later in the day; Resident #50 complained of a bruise to the right under arm, a left forearm bruise, and right ankle pain. This was for 1 of 11 residents reviewed for supervision to prevent accidents. This incident had the high likelihood of serious harm, injury or death. Findings included: Review of 4-point wheelchair securement system's use and care manual not dated found on the manufacture's website included the following information: ensure shoulder and lap belts are adjusted as firmly as possible, but consistent with user comfort. Resident #50 was admitted to the facility on [DATE] with cumulative diagnoses that included stroke and peripheral vascular disease (PVD). Review of physician orders revealed that 50 milligrams (mg) of Tramadol HCl powder every 6 hours as needed for pain was ordered on 2/3/23. Review of physician orders revealed that 650 mg of Tylenol three times daily as needed for pain was ordered on 2/7/23. Resident #50's admission Minimum Data Set (MDS) dated [DATE] indicated he was moderately cognitively impaired. Resident #50 required the assistance of two staff members with transfers and was unable to walk. He had a wheelchair for mobility. Review of an incident report dated 3/2/23 and completed by the Unit Manager revealed that on 3/2/23 the transportation driver stated Resident #50 slid out of the wheelchair on the transportation van during transport to an outside appointment. The report indicated a complete body assessment was performed on Resident #50 with no injuries noted, and he was provided pain medicine. A skin inspection dated 3/2/23 was reviewed and revealed Resident #50 included, in part, the following new skin conditions: a bruise to the right under arm, a left forearm bruise, and right ankle pain. Nurse's progress note written by the Unit Manager dated 3/2/23 at 3:27 PM showed Resident #50 complained of right leg pain. The Medical Director (MD) was notified and ordered immediate x-rays. As needed pain medication was provided to Resident #50. Review of Resident #50's Medication Administration Records (MAR) for March 2023 showed he received Tylenol 650 milligrams (mg) ordered for severe pain on 3/2/23 at 8:00 PM for a pain level of 3 on a 0-10 pain scale where 0 is no pain and 10 is the highest pain level. Resident #50 also received tramadol on 3/2/23 for a pain level of 2 on a 0-10 pain scale. On 3/3/23, Resident #50 received Tylenol at 8:00 AM for a pain level of 3 and received tramadol on 3/3/23 for a pain level of 4. Nurse's progress note written by the Unit Manager dated 3/2/23 at 5:30 PM revealed the mobile x-ray company was contacted. Nurse's progress note written by the Unit Manager dated 3/2/23 at 5:46 PM showed Resident #50 refused to go to the emergency room (ER) for evaluation. An interview was conducted with the Unit Manager on 7/5/23 at 11:47 AM. She revealed Resident #50 went out for a scheduled appointment on 3/2/23, and when he returned to the facility, he told another staff member (name unknown) that he had slid out of his wheelchair in the van. The Unit Manager stated she then notified the Administrator and performed a skin assessment with no visible injuries. She notified the MD as well who had requested for him to be sent to hospital, but he refused. Resident #50 denied any pain or discomfort and appeared nervous after the incident. Physician order dated 3/2/23 showed x-rays were ordered for the left/right hips, left thigh, right/left knees, and left/right lower legs. Review of the x-ray results for the pelvis (both hips) dated 3/2/23 showed Resident #50 had no acute fractures or dislocation. Review of the x-ray results for the right/left knees, left thigh, and right/left lower legs dated 3/3/23 showed Resident #50 had no acute fractures or dislocation. MD note dated 3/3/23 showed Resident #50 was evaluated by the MD after he slid out from the wheelchair while on the transportation van. Resident #50 had complained of left knee pain and was offered to go to the hospital, but he declined. X-rays were ordered and performed in the facility. The note indicated Resident #50 had a small bruise noted on the right side of his forehead and bruising to his leg (no indication of which side). An interview was attempted with the MD, but she was unavailable during the investigation. Review of an investigation summary report created by the Administrator dated 3/3/23 showed at 1:05 PM Resident #50's high back wheelchair was in a reclined position at approximately a 45-degree angle. The shoulder strap did not fit snug to the resident due to the wheelchair being reclined, and the transportation driver did not sit Resident #50 upright in the wheelchair. During transport at 1:30 PM, the transportation driver heard Resident #50 say I'm down. At 1:31 PM, the transportation driver stopped the van in the middle lane of a busy road and applied the hazard lights. Resident #50 was at the base of the footrests with his back against the front of the wheelchair and his legs extended out in front. The transportation driver lifted him back into his wheelchair and continued to the appointment destination. At 2:45 PM, the transportation driver returned to the facility, returned Resident #50 to his room, and did not notify anyone of the incident on the van. At 3:00 PM, the Administrator, previous Director of Nursing (DON), and the Unit Manager met with the resident and his family to discuss the appointment. Resident #50 told them he slid out of his wheelchair on the van during transport. He was assessed for injuries with none noted. The Administrator called the transportation driver immediately to return to the facility. A reenactment of the incident was performed to show exactly what had occurred. There were not any other witnesses. At 3:30 PM, the Administrator ceased all future transportation appointments for the day and utilized an outside transportation company for any further travel. At 4:30 PM, the transportation driver returned to the facility, was provided education on reporting of incidents, and was suspended pending the investigation. A witness statement given by the transportation driver on 3/2/23 showed that Resident #50 was in a reclined position during transport and remained in a reclined position during transport. A witness statement given by Nurse Aide (NA) #4 read on 3/2/23 at 11:30 AM Resident #50 was adjusted in a high back wheelchair to a slightly reclined position. At approximately 12:00 PM, he was picked up for transport. Resident #50 was discharged from the facility on 3/28/23 and unable to be reached for an interview. The transportation driver's witness statement dated 3/2/23 read: I was transporting Resident #50 to his medical appointment. He was in a high back wheelchair in a reclined position. The wheelchair remained in a reclined position during transport. The seatbelt was secured around Resident #50's waist with straps beneath the arm rest. Resident #50 reported the seat belt position was comfortable. He was secured at the base of the wheelchair. During transport, Resident #50 yelled out I'm down. I looked in the rear-view mirror. At that time, I was getting off highway 440. I stopped the van in the middle lane - hazards were applied. I went to the back of the van to see what was going on. Resident #50 was noted to have slid out of his wheelchair: his back was against the wheelchair and his bottom rested on the footrests. Both legs were extended out in front of his body. Resident #50 did not report he was in pain. I pulled him back up into the wheelchair. Once back in the wheelchair, I proceeded to take Resident #50 to his appointment, which was rescheduled. I returned him to the facility with still no reports of pain. The transportation driver could not be reached for an interview because a contact phone number was not available, and he no longer worked at the facility. An interview was conducted with NA #4 on 3/2/23 at 4:07 PM. She revealed that if Resident #50 sat up straight in the high back wheelchair, then he would slide out of the chair. On 3/2/23, NA #4 indicated that Resident #50 was just slightly reclined, not even halfway in his wheelchair prior to transport. An interview was conducted with Nurse #5 on 7/5/23 at 12:53 PM, who was assigned to Resident #50 on 3/2/23 from 7:00 AM - 7:00 PM; however, she could not recall the details of Resident #50 or the events on 3/2/23. An interview was conducted on 7/5/23 at 11:50 A.M. with the Nurse Consultant. During the interview, the Nurse Consultant indicated that although the investigation summary noted Resident #50 was reclined at a 45-degree angle during transport, he was in fact reclined only slightly (15 degrees at the most). An interview was conducted on 7/5/23 at 4:33 PM. During the interview, the Administrator indicated the transportation driver could have secured Resident #50 more safely and should have reported the incident to management immediately. Resident #50 told her on 3/2/23 that he had a seat belt on and slid from the wheelchair to the footrest of the wheelchair. No injuries were noted, and immediate x-rays were performed immediately following the incident with no injuries noted. Resident #50 declined to go to the hospital for evaluation. He told the Administrator that the transportation driver stopped the van and assisted the resident back into the wheelchair then continued to the scheduled appointment. On 7/5/2023 at 4:15 P.M., the facility's Administrator was informed of the immediate jeopardy. The facility provided the following corrective action plan with a completion date of 3/8/22: Resident #50 is alert and oriented with a Brief Interview of Mental Status (BIM) of 10. Diagnosis include Diabetes, hypertension (high blood pressure), Chronic Obstructive Pulmonary Disease (inflammation of the lungs that reduces air flow) , Ischemic Cardiomyopathy ( enlarged heart), history of heart attack, Anemia, Cerebral Infarction (stroke), Coronary Artery Disease (blockage of major blood vessels), Hyperlipidemia (high levels of lipids/fat in the blood), Peripheral Artery Disease (narrowing blood vessels that reduces blood flow), deep vein thrombosis (blood clot), Hemiplegia (paralysis) and hemiparesis (partial weakness) affecting left side, and Aneurysm (ruptured blood vessel). Per the driver's report, on 3/2/2023, at approximately 11:00 am, the transportation driver arrived at the facility to transport resident to a medical appointment. The transportation driver lowered and secured the wheelchair ramp onto the ground. The transportation driver entered the facility and assisted Resident #50 by high back wheelchair onto the van wheelchair lift. The high back wheelchair was in a reclined position. The driver backed the wheelchair and resident onto the lift and into the van. The transportation driver secured the wheelchair/resident in the van by locking the brakes and placing/tightening the back-floor straps around the frame of the wheelchair on the back right and sides. The transportation driver then secured the front floor straps around the front frame of the wheelchair and tightened the straps. The transportation driver then placed the seat belt with the shoulder strap hooked to the lap belt through the arms of the wheelchair and fastened it around the resident waist. The shoulder strap did not fit snugly to the resident due to the wheelchair being reclined. The transportation driver did not sit the resident upright in the chair. At approximately 1:30 pm, the transportation driver heard the resident yell, I'm down. At 1:31 pm, the transportation driver stopped the van in the center turning lane of a well-traveled roadway with his hazard lights on. Upon entering the back of the van, the resident was positioned at the base of the footrests, with the resident's back against the front of the wheelchair, the resident's bottom was positioned on the leg rests, and the resident legs were extended in front of the resident. The seatbelt was positioned at the top of the resident's head. The transportation driver unbuckled the seatbelt and placed the resident back in the wheelchair. The resident denied pain or injury and was transported to the appointment. On 3/2/23, during a discussion with the resident, resident representative, Administrator, and Registered Nurse (RN) Unit Manager, Resident #50 reported he slid out of a wheelchair while being transported in the van. The Administrator immediately initiated an investigation. The Director of Nursing (DON) and Unit Manager assessed the resident with no identified concerns. The resident declined to go to the emergency room for further evaluation. The Medical Director was notified of the incident on the van. On 3/2/23, the van driver was suspended by the Administrator pending investigation. On 3/2/23, at approximately 3:30pm, the facility Administrator stopped all resident wheelchair transport utilizing the facility's van. An alternate contracted van transport company was utilized until education and return demonstration could be completed with the facility van transport driver. On 3/2/23 a root cause analysis was completed to identify root cause for van driver not securing a snug fit of the shoulder strap per manufacturer guidelines and why he did not immediately report to the facility and call Emergency Management Services. The transportation driver was trained on securing a resident during transport, as well as what to do if resident had fall on van. Training was performed 12/3/21, which included stopping van, putting hazard lights on, not moving the resident, notifying Emergency Medical Services (EMS) and the facility. Resident #50 utilized a mechanical lift for transfers with the assistance of one. Resident #50 had therapy assessment completed on 2/3/23 that indicated resident was appropriate to transfer into upright wheelchair. On 3/2/23, the Social Worker (SW) initiated resident questionnaires with all alert and oriented residents regarding medical transport to include: Do you have any concerns related to medical transport? If yes, please explain. There were no additional concerns identified. On 3/2/23, The DON and Unit Manager completed an audit of all incident reports for the past 30 days. This audit was to identify any other incidents during medical transport. There were no additional identified areas of concern. On 3/2/23, the van including straps was inspected by the Maintenance Assistant with no identified concerns. - Actions taken to alter the process or system failure to prevent a serious adverse outcome for occurring or recurring. On 3/2/23, the Administrator completed an in-service with the van driver regarding prompt notification to the facility regarding van incidents, procedure for van incidents, proper positioning of resident on van, and securing residents on van. The transportation driver was the only driver employed by the facility at the time of the event. The sister facility transportation driver is responsible for training newly hired facility van drivers to include return demonstration. On 3/7/23, a sister facility transportation driver completed training with return demonstration with the facility's van transport driver, Unit Manager, Housekeeping Supervisor, and the Maintenance Assistant on how to properly secure a resident during medical transport. The manufacturer's video was utilized for reviewing the appropriate technique of securing resident for medical transport. This in-service also included emphasis on (1) never position the lap belt over the abdominal area, over the wheelchair armrests, through the wheelchair arm rests or with the belt assembly twisted and (2) ensuring wheelchairs are not reclined during transport. - The procedure for monitoring the plan of correction. Monitoring actions began on 3/2/23. The Director of Nursing, Unit Managers, and/or Administrator will complete an audit of 5 facility wheelchair medical transports weekly x 4 weeks to ensure resident is secured properly and safely in the van prior to transport. The Administrator and/or DON will address all concerns identified during the audit to include but not limited to immediately stopping all medical transport for any concerns identified. The Social Worker will complete 5 resident questionnaires weekly x 4 weeks utilizing the Resident Questionnaire Van Transport. This questionnaire is to identify any concerns related to van transport. The Administrator and/or DON will address all concerns identified during the questionnaires to include but not limited to immediately stopping all medical transport for any concerns identified. The Administrator will present the findings of the Resident Questionnaires Van Transport and Medical Transport Audits to the Quality Assurance Committee on 3/7/23 and monthly x 1 month. The Quality Assurance Committee will review the Resident Questionnaires Van Transport and Medical Transport Audits monthly x 1 months to determine trends and/or issues that may require further interventions put into place and to determine the need for further and/or frequency of monitoring. The Administrator and DON were responsible for the implementation of corrective actions to include all 100% audits, in-services and monitoring related to the plan of correction. Date of corrective action completion: 3/8/23. The facility's credible allegation of Immediate Jeopardy removal was validated on 7/5/23 and the corrective action plan was verified as completed on 3/8/23. The validation was evidenced by staff interviews, record reviews, and review of competency training logs. The interventions included verified training for the previous transportation driver with a certificate of completion for safe transport, continuous audit of the transportation driver's performance with weekly performance checklists, initial and continuous questionnaires for alert and oriented residents related to their transportation experience, and audits of incident reports within 30 days of the incident on 3/2/23.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interviews and physician interview the facility failed to protect a resident's right to be free from abuse. Staff provided care on a cognitively impaired resident who was resisting and flailing her arms and legs. The resident's arm was held down while care was provided, and staff continued to provide care even when they knew it was a struggle. The resident sustained a femur (upper thigh) fracture and required surgery. This deficient practice was for 1 of 1 resident reviewed for abuse (Resident #222). Immediate Jeopardy began on 3/25/22 when NA #1 (Nursing Assistant) and NA #2 provided care to Resident #222 when the resident was resistant, and the resident sustained a right femur fracture. Immediate Jeopardy was removed on 10/15/22 when the facility provided and implemented an acceptable credible allegation of Immediate Jeopardy removal. The facility will remain out of compliance at a lower scope and severity level of D (no actual harm with a potential for minimal harm that is not immediate jeopardy) to ensure monitoring of systems put in place are effective and to complete employee in-service training. Findings Included: A review of Resident #222's closed record revealed she was admitted to the facility on [DATE]. Her diagnoses included dementia, hypertension, glaucoma, psychotic disturbance, mood disturbance, anxiety, and anemia. The admission Minimum Data Set (MDS) dated [DATE] revealed Resident #222 had severe cognitive impairment. She required extensive assistance with bed mobility and total assistance with toilet use. The MDS indicated Resident #222 did not have behaviors. Resident #222 was care planned on 2/17/22 for problematic manner in which resident acts characterized by inappropriate behavior; resistive to treatment/care related to: argumentative, aggressive, combative to staff during care. The goal included will receive care within resident's choices and preferences through next review. Interventions included the following: o Allow for flexibility in ADL routine to accommodate resident's mood. o Document care being resisted per facility protocol and notify physician of patterns in behavior. o Elicit family input for best approaches to resident o If resident refuses care, re-attempt at another time. o Provide non-care related conversation proactively before attempting ADL Record review revealed the following nurses note by the former Director of Nursing on 3/25/22 at 8:35 PM: Approximately 12:46 PM Nurse #5 came to my office stating that the resident leg is swollen, and it was not like that this morning on her assessment. I went to the resident's room and the resident bed was noted to be pulled out of the wall at the foot of the bed. The therapy director was standing on the right side of the bed against the wall. Occupational Therapy and the charge nurse were standing on the left side of the bed. The resident was laying on her back with her right foot partially off the bed. The resident left leg was on the bed. The resident left thigh appeared swollen and warm to touch. No discoloration, bruising or redness noted. Her skin color to her right thigh was in normal limits with the rest of her body. The resident was attempting to move her leg. I informed the patient several times while in the room not to move her leg, we needed to send her to the emergency room for evaluation. While in the room the resident did not appear to be in pain, she was answering questions but was becoming agitated when asked about her leg. She stated, you see my leg don't you. I asked her what happened to her leg, and she stated she did not know what happened to her leg, but something was wrong with it. I asked her did anyone hurt her, and she stated, no. Resident was left with nurse so I could notify the MD and receive an order for transport to emergency department. Physician notified and stated ok to send to emergency department. A second note by the former DON dated 3/28/22 at 3:25 PM read as follows: Correction the resident's right thigh appeared swollen. Her left leg was within normal limits. A telephone interview was conducted with NA#1 on 10/14/22 at 9:12 AM. She stated she went to provide incontinence care to Resident #222 on 3/25/22. She stated Resident #222 was resistant and was flailing both her arms and legs. She stated she stopped and went into the hall and asked someone to come help her. NA #1 stated the whole thing was a struggle. She stated NA#2 came in the room to assist and her and NA#2 tried to be careful and keep Resident #222 safe. She stated NA#2 adjusted the bed away from the wall and positioned herself at the head of the bed. NA#1 stated NA#2 held one of Resident #222's arm to keep her from moving and hurting herself while she continued to give care. NA#1 stated even though Resident #222 was combative, they still tried to give care. She reported there was a lot of fighting and resisting and Resident #222 was moving both her arms and her legs. NA#1 stated when they rolled Resident #222 over on her back was when she noticed a deformity in her leg, and she went to get a nurse. NA#1 stated NA#2 and well as herself were from an agency and did not work for the facility. Attempts made to contact NA#2 were unsuccessful. Nurse #5 was interviewed on 10/14/22 at 11:00 AM. She stated she was the nurse caring for Resident #222 on 3/25/22. Nurse #5 reported she left for lunch and when she came back, she could hear Resident #222 saying go get the nurse so she went to her room. Nurse #5 stated she entered Resident #222's room and noticed her right leg laterally rotated towards the right. She stated she evaluated patient leg/femur and it was swollen and hot to the touch. Resident #222 yelled out in pain and stated, this bitch broke my leg and she was yanking on it. Nurse #5 stated NA#1 was in Resident #222's room and that's who she was talking about. Nurse #5 stated she left the room to go get the former DON to come to the room. She reported she went to the nurses' station to get the paperwork ready for Resident #222 to be sent to the hospital. On 10/14/22 at 10:15 AM a telephone interview was conducted with Therapist #1. She stated she was in a nearby room and could hear Resident #222 loudly calling for help. She stated she went into the room and saw NA#1 and NA#2 and noticed Resident #222's leg was displaced. She stated she heard the NA's say they were providing care and the resident was agitated. Therapist #1 stated she was holding Resident 222's hand trying to comfort her. She stated she didn't hear Resident #222 say what happened to her leg. An interview was conducted with the Rehab Director on 10/14/22 at 10:05 AM and she stated Therapist #1 texted her and said she needed her in Resident #222's room. The Rehab Director stated Therapist #1 heard Resident #222 screaming and went into her room. The Rehab Director stated she saw the right upper leg was deformed and she got Nurse #1 and the former DON. She stated Resident #222 allowed her to hold her hand to try and comfort her before she left the room. The Rehab Director stated Resident #222 did not say what had happened to her leg. Nurse #1 was interviewed on 10/14/22 at 10:00 AM and he reported he went into Resident #222's room and looked at her leg and went to get the former DON. He stated she came to the room and took over and he left. On 10/13/22 at 5:05 PM a telephone interview was conducted with the former Director of Nursing (DON). She stated what she remembered about the incident involving Resident #222 was NA #1 went in to give Resident #222 a bath and she was combative. She stated she was told by NA#1 Resident #222 was flailing her arms and legs. She stated NA#1 stopped care and went into the hall and got help. NA#2 went into the room to assist with the bath. The former DON reported she was told when Resident #222 was rolled on her back they noticed her leg had a deformity and they went to get Nurse #1 and after he looked at Resident #222's leg he went and got and her. She stated when she entered Resident #222's room she observed Resident #222's right leg externally rotated and swollen. She stated she assessed Resident #222 with no bruising or abrasions. The former DON stated she didn't know if Resident #222 was still combative when NA#2 went into the room. The discharge summary from a local hospital for Resident #222 was reviewed. Resident #222 was admitted to the hospital on [DATE]. A computerized tomography (CT) scan was completed on 3/25/22 and revealed Resident #222 had a stable displaced acute distal femoral (upper leg) fracture. On 3/26/22 she had open treatment of the right femoral shaft with insertion of nail and screws. The discharge summary indicated Resident #222 received physical and occupational therapy and was weight bearing as tolerated. On 10/14/22 at 11:18 AM and interview was conducted with Resident 222's Physician. She stated Resident #222 had advanced dementia and she could be pleasant but on exam, proving care, and providing incontinent care Resident #222 could get combative waving arms about and legs. The Physician stated she went to Resident #222's room and saw the deformity. She reported Resident #222 was hollering in pain. On 10/14/22 at 2:54 PM an Interview was conducted with the Administrator, and she stated when she found out what had occurred the ambulance was still outside with Resident #222 in the back. She stated she ran outside and spoke with Resident #222. The Administrator reported she asked Resident #222 if anyone hurt her, touched her, or harmed her and she responded no. The administrator stated she never had any concerns for abuse based on what Resident #222 reported. The facility was notified of the Immediate Jeopardy on 10/14/22 at 2:24 PM. The facility provided the following credible allegation for abuse. Credible Allegation-F 600 Abuse Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance; and Resident is alert to self with confusion. Brief Interview for Mental Status (BIMS) is 4. Diagnoses include Dementia without behavioral, Cellulitis of left lower limb, Hypertension, Anemia, disturbance, Glaucoma, Pressure ulcer of left heel Unstageable, Chronic kidney disease, Urinary tract infection, Uterovaginal prolapse, Bacteremia and osteoarthritis. The resident was able to make her needs known. On 03/25/22 at, 12:15 pm nursing assistant (NA) #1 entered resident room to provide incontinent care. Resident # 222 was agitated and declined care. On 03/25/22 at 12:20pm, NA #2 heard resident yell ouch. NA #1 came out and asked NA #2 for assistance with incontinent care. NA#1 and NA #2 returned to the resident room to provide care. The bed was positioned slightly away from the wall. Resident was lying on right side with brief off and legs positioned slightly off the bed on the right side. NA #2 adjusted the bed slightly further away from the wall and positioned self at head of resident bed to assist with care. At no time during the conversation with the nurse did the resident identify a specific individual or specific event. On 3/25/22 at approximately 12:46 pm, the Director of Nursing (DON) notified of potential injury to Resident # 222. DON entered resident room and observed resident right leg externally rotated and swollen. DON assessed resident with no bruising or abrasions noted. Resident stated, nothing happened, and no one has hurt me, I don't know what is wrong with it and attempted to move right leg from side to side. On 3/25/22 at 12:46 pm, the DON notified the physician of potential injury to Resident # 222 with new order to transfer to the emergency room for evaluation and treatment. On 3/25/22 at approximately 12:46 pm, Emergency Medical Services (EMS) notified to transport Resident # 222 to the emergency room for evaluation and treatment. On 3/25/22, the assigned nurse informed the resident representative (RR) of pain and swelling of Resident # 222's right thigh and that resident was being sent to the emergency room (ER) for evaluation. On 03/25/22 at 12:48 pm, the Administrator notified of potential injury to Resident # 222. On 3/25/22 at approximately 1:00 pm, EMS transported Resident # 222 to the emergency room for evaluation and treatment. On 3/25/22 the Administrator completed and faxed the Initial Report to the Health Care Personnel Investigation Unit related injury of unknown origin. On 3/31/22, the Administrator completed and faxed the Investigation Report to the Health Care Personnel Investigation Unit related injury of unknown origin. On 03/25/22, the DON initiated an audit of all residents not able to report for signs and symptoms of a fracture including bruising, pain, swelling, skin tears. Audit was completed on 03/25/22 with no additional concerns identified. On 03/25/22 the Register Nurse (RN) Supervisor interviewed all alert and oriented residents regarding: Have you sustained any injury that has not been reported to staff? The assigned nurse will address all concerns identified during the questionnaires. Questionnaires were completed on 03/28/22 with no additional concerns identified. Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete. On 03/28/22, the DON initiated Staff Quiz with all therapy staff, nurses and nursing assistants to include agency regarding Combative /Aggressive Residents. This quiz is to validate staff knowledge on combative/aggressive residents to include reporting combative/ aggressive behaviors and leaving resident in a safe manner when combative/ aggressive and attempting care when calm. Quizzes will be completed by 3/28/22. After 3/28/22, After 3/28/22, the Receptionist will mail quiz to any therapy staff, nurse or nursing assistant who has not worked or who has not received the quiz with instructions to complete, sign and return to the DON prior to next scheduled shift. On 4/22/22, a mandatory in-service was completed with the attendance of the Administrator, and Director of Nursing regarding reportable allegations including to always ensure the involved resident and all other residents are safe and protected first, removing the alleged perpetrator, placing the perpetrator in a non-resident care area, if the perpetrator is another resident supervise the resident until details of the incident can be determined and appropriate interventions initiated, assessment of the resident and reporting within a 2 hour time frame. On 6/16/22, a town hall meeting was held by the Administrator with nurses, nursing assistants, therapy staff, housekeeping, dietary staff, social worker, accounts receivable/payable, receptionist, maintenance and admission staff regarding Abuse to include removing identified staff immediately to protect the resident and reporting abuse. On 03/28/22 the DON initiated in-service with all therapy staff, nurses and nursing assistants to include agency in regards to (1) Combative Residents with emphasis on making sure resident is safe and leave resident to calm down then re-approach for care, (2) Turning and Positioning with care with emphasis on technique for turning and positioning, (3) Signs and Symptoms of a fracture with emphasis on identifying signs/symptoms of a fracture and immediately reporting symptoms to nursing (4) Safe Handling with emphasis on checking care guide prior to providing care to ensure safety of the resident and (5) Pain with emphasis on immediately reporting pain with care to the nurse for pain management. In-services will be completed by 3/28/22. After 3/28/22, the Receptionist will mail in-services to any therapy staff, nurse or nursing assistant who has not worked or who has not received the in-service with instructions to read, sign and return to the DON prior to next scheduled shift. All newly hired therapy staff, nurse or nursing assistant to include agency will be in-serviced during orientation regarding Combative Residents, Turning and Positioning, Signs and Symptoms of a Fracture, Safe Handling and Pain. On 10/14/22, an in-service was initiated by the Administrator with 100% of all staff to include nurses, nursing assistants, medication aides, dietary staff, housekeeping staff, therapy staff, Administrator, Admissions Coordinator, Accounts Receivable, Account Payable, Activities Director, Medical Records, Central Supply Clerk, Maintenance Director, Social Worker (SW), and receptionist regarding burn out, abuse. The in-service included the definition of physical abuse and the consequences if found guilty of abuse. In-services to be completed by 10/14/22. After 10/14/22, any employee who has not completed the training will not be allowed to work until completion. Date of credible allegation of immediate jeopardy removal was competed on 10/15/22. On 10/15/22 the credible allegation of immediate jeopardy removal was validated by onsite verification. Record review indicated an in-service was completed on 10/14/22 with 100% staff to include nurses, nursing assistants, medication aides, dietary staff, housekeeping staff, therapy staff, Administrator, Admissions Coordinator, Accounts Receivable, Account Payable, Activities Director, Medical Records, Central Supply Clerk, Maintenance Director, Social Worker (SW), and receptionist regarding burn out, abuse, definition of abuse, and consequences of abuse of found guilty. A review of the in-service sign-in sheets as well as staff interviews conducted on 10/15/22 verified education was provided on abuse. After 10/14/22, any employee who has not completed the training will not be allowed to work until completion. The facility's immediate jeopardy removal date of 10/15/22 was verified.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and record review the facility failed to protect residents when NA #1 and NA #2 were not removed from resident care assignments after an allegation of abuse with Resident #222. NA #1 and NA #2 continued to provide resident care. This had the high likelihood to put other residents at high risk for abuse and harm. The facility also failed to conduct a thorough investigation. Immediate jeopardy began on 3/25/22 when the facility allowed NA #1 and NA #2 to continue working after Resident #222 stated, That bitch broke my leg and She was yanking on it. The immediate jeopardy was removed on 10/15/22 when the facility implemented a credible allegation of jeopardy removal. The facility will remain out of compliance at a lower scope and severity D to ensure monitoring systems are put into place and are effective to complete employee in-service training. Findings Included: Resident #222 was admitted to the facility on [DATE]. Her diagnoses included dementia. The admission Minimum Data Set (MDS) dated [DATE] revealed Resident #222 had severe cognitive impairment. She required extensive assistance with bed mobility and transfers occurred once or twice. Total assistance was needed for toilet use and supervision for eating. The MDS indicated Resident #222 had no rejection of care. Record review revealed the following nurses note by the Director of Nursing (DON) #2 on 3/25/22 at 8:35 PM: Approximately 12:46 PM Nurse #5 came to my office stating that the resident leg is swollen, and it was not like that this morning on her assessment. I went to the resident's room and the resident bed was noted to be pulled out of the wall at the foot of the bed. The therapy director was standing on the right side of the bed against the wall. Occupational Therapy and the charge nurse were standing on the left side of the bed. The resident was laying on her back with her right foot partially off the bed. The resident left leg was on the bed. The resident left thigh appeared swollen and warm to touch. No discoloration, bruising or redness noted. Her skin color to her right thigh was in normal limits with the rest of her body. The resident was attempting to move her leg. I informed the resident several times while in the room not to move her leg, we needed to send her to the emergency room for evaluation. While in the room the resident did not appear to be in pain, she was answering questions but was becoming agitated when asked about her leg. She stated, You see my leg don't you. I asked her what happened to her leg, and she stated she did not know what happened to her leg, but something was wrong with it. I asked her did anyone hurt her, and she stated, no. Resident was left with nurse so I could notify the MD and receive an order for transport to emergency department. Physician notified and stated ok to send to emergency department. A second note by the DON #1 dated 3/28/22 at 3:25 PM read as follows: Correction the resident's right thigh appeared swollen. Her left leg was within normal limits. Record review revealed on 3/31/22 the facility sent their investigation report on Resident #222 for an injury of unknown cause to the state survey agency. The report indicated Adult Protective Services and law enforcement were notified of the incident. The facility reported incident was unsubstantiated for injury of unknown cause. The summary of the facility investigation read as follows: Resident #222 was unable to tell what occurred when asked. Resident #222 reported that she was up walking around cleaning. Resident #222 was unable to walk around without assistance and had not been cleaning. Resident #222 did not report any abuse per Administrator interview in the presence of 2 Emergency Medical Services personnel. Resident #222 replied, No when asked if anyone hurt or harmed her. Nurse #5 was interviewed on 10/14/22 at 11:00 AM. She stated she was the nurse caring for Resident #222 on 3/25/22. Nurse #5 reported she left for lunch and when she came back, she could hear Resident #222 saying go get the nurse so she went to her room. Nurse #5 stated she entered Resident #222's room and noticed her right leg laterally rotated towards the right. She stated she evaluated patient leg/femur and it was swollen and hot to the touch. Resident #222 yelled out in pain and stated, This bitch broke my leg and she was yanking on it. Nurse #5 stated NA #1 was in Resident #222's room and that's who she was talking about. Nurse #5 stated she left the room to go get the DON #1 to come to the room. She reported she went to the nurses' station to get the paperwork ready for Resident #222 to be sent to the hospital. On 10/14/22 at 2:54 PM an interview was conducted with the Administrator, and she stated when she found out what had occurred the ambulance was still outside with Resident #222 in the back. She stated she ran outside and spoke with Resident #222. The Administrator reported she asked Resident #222 if anyone hurt her, touched her, or harmed her and she responded no. An interview was conducted with NA#1 on 10/14/22 04:21 PM. She stated after the incident with Resident #222 she went back to work and provided care for other residents in the facility. Attempts made to contact NA#2 were unsuccessful. An interview was conducted with the Administrator on 10/14/22 at 4:12 PM, and she stated she interviewed Resident #222 while she was in the ambulance about to leave for the hospital on 3/25/22. She stated Resident #222 reported to her no one hurt her, touched, or harmed her. She had no concerns regarding abuse based on what Resident #222 reported to her. She stated an investigation was not conducted regarding abuse, but an investigation was completed regarding an injury of unknown cause. The Administrator stated she did not believe abuse based on what Resident #222 had stated. The Administrator reported NA#1 and NA#2 were not sent home after the incident and they continued to provide care to other residents in the facility for the remainder of their 8-hour shift. The Administrator stated had abuse been a concern, NA#1 and NA#2 would have been escorted out of the building and an abuse investigation would have been conducted. The facility was notified of the immediate jeopardy on 10/14/22 at 3:57 PM. The facility provided the following credible allegation of immediate jeopardy removal. Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance; and Resident is alert to self with confusion. Brief Interview for Mental Status (BIMS) is 4. Diagnoses include Dementia without behavioral, Cellulitis of left lower limb, Hypertension, Anemia, disturbance, Glaucoma, Pressure ulcer of left heel Unstageable, Chronic kidney disease, Urinary tract infection, Uterovaginal prolapse, Bacteremia and osteoarthritis. The resident was able to make her needs known. On 03/25/22 at, 12:15 pm nursing assistant (NA) #1 entered resident room to provide incontinent care. Resident # 222 was agitated and declined care. On 03/25/22 at 12:20 pm, NA #2 heard resident yell ouch. NA #1 came out and asked NA #2 for assistance with incontinent care. NA#1 and NA #2 returned to the resident room to provide care. The bed was positioned slightly away from the wall. Resident was lying on right side with brief off and legs positioned slightly off the bed on the right side. NA #2 adjusted the bed slightly further away from the wall and positioned self at head of resident bed to assist with care. The resident was agitated, failing arms and yelling. Resident hit NA #2 in the chest when failing arms so NA#2 held the resident 's hands while NA#1 provided incontinent care. After the incontinent care provided, NA #1 and NA #2 rolled resident back to supine (lying face upward) position using draw sheet. Left leg landed onto the bed in an anatomically correct position. The right leg was rotated to the right from the knee downward and positioned slightly off to the right side of the bed. NA #2 noticed swelling and abnormal position of leg. NA #1 and NA #2 stopped care. NA #2 left room to notify the nurse. On 3/25/22 at 12:45pm, Nurse #1 entered resident room and noted right leg laterally rotated towards the right. The nurse evaluated patient leg/femur noted to be swollen and hot to the touch. Patient yelled out in pain. The resident stated, this bitch broke my leg. At no time during the conversation with the nurse did the resident identify a specific individual or specific event. On 3/25/22 at approximately 12:46 pm, the Director of Nursing (DON) notified of potential injury to Resident # 222. DON entered resident room and observed resident right leg externally rotated and swollen. DON assessed resident with no bruising or abrasions noted. Resident stated, nothing happened, and no one has hurt me, I don't know what is wrong with it and attempted to move right leg from side to side. On 3/25/22 at 12:46 pm, the DON notified the physician of potential injury to Resident # 222 with new order to transfer to the emergency room for evaluation and treatment. On 3/25/22 at approximately 12:46 pm, Emergency Medical Services (EMS) notified to transport Resident # 222 to the emergency room for evaluation and treatment. On 3/25/22, the assigned nurse informed the resident representative (RR) of pain and swelling of Resident # 222's right thigh and that resident was being sent to the emergency room (ER) for evaluation. On 03/25/22 at 12:48 pm, the Administrator notified of potential injury to Resident # 222. On 3/25/22 at approximately 1:00 pm, EMS transported Resident # 222 to the emergency room for evaluation and treatment. On 3/25/22 the Administrator completed and faxed the Initial Report to the Health Care Personnel Investigation Unit related injury of unknown origin. On 3/31/22, the Administrator completed and faxed the Investigation Report to the Health Care Personnel Investigation Unit related injury of unknown origin. The nursing assistant (NA) #1 and nursing assistant #2 were not removed from the floor following the incident. However, NA #1 and NA #2 did not return to work after their shift, pending the investigation There were no other allegations of injury of unknown origin or allegations of abuse in the past 30 days that identified an employee. On 3/28/22, the Interdisciplinary team reviewed concerns and acute changes from 3/25/22 to 3/27/22 including allegations of abuse and injury of unknown origin with no concerns identified. Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete. On 4/22/22, a mandatory in-service was completed with the attendance of the Administrator, and Director of Nursing regarding reportable allegations including possible abuse, and notification to the Regional [NAME] President and Facility Consultant to always ensure the involved resident and all other residents are safe and protected first, removing the alleged perpetrator, placing the perpetrator in a non-resident care area, if the perpetrator is another resident supervise the resident until details of the incident can be determined and appropriate interventions initiated, assessment of the resident and reporting within a 2 hour time frame. On 6/16/22, a town hall meeting was held by the Administrator with nurses, nursing assistants, therapy staff, housekeeping, dietary staff, social worker, accounts receivable/payable, receptionist, maintenance, and admission staff regarding Abuse to include removing identified staff immediately to protect the resident and reporting abuse. On 10/14/22, an in-service was initiated by the Administrator with 100% of all staff to include nurses, nursing assistants, medication aides, dietary staff, housekeeping staff, therapy staff, Administrator, Admissions Coordinator, Accounts Receivable, Account Payable, Activities Director, Medical Records, Central Supply Clerk, Maintenance Director, Social Worker (SW), and receptionist regarding burn out, abuse and what to do when residents display aggressive behaviors. The in-service included the definition of physical abuse and the consequences if found guilty of abuse. In-services to be completed by 10/14/22. After 10/14/22, any employee who has not completed the training will not be allowed to work until completion. Date of Corrective Action Completion 10/15/22 On 10/15/22 the credible allegation of immediate jeopardy removal was validated by onsite verification. Record review indicated an in-service was completed on 10/14/22 with 100% staff to include nurses, nursing assistants, medication aides, dietary staff, housekeeping staff, therapy staff, Administrator, Admissions Coordinator, Accounts Receivable, Account Payable, Activities Director, Medical Records, Central Supply Clerk, Maintenance Director, Social Worker (SW), and receptionist regarding burn out, abuse, definition of abuse, and consequences of abuse of found guilty. A review of the in-service sign-in sheets as well as staff interviews conducted on 10/15/22 verified education was provided on abuse. After 10/14/22, any employee who has not completed the training will not be allowed to work until completion. The facility's immediate jeopardy removal date of 10/15/22 was verified.