**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility failed to have effective systems in place for identifying the development of skin breakdown which delayed treatment and interventions. Resident #39's skin was intact on re-admission on [DATE]. On 1/4/25 excoriation was noted on her buttocks. There were no further documented assessments until a wound assessment dated [DATE] recorded Resident #39 developed an unstageable (full thickness skin and tissue loss where the extent of tissue damage cannot be determined due to presence of slough, a yellow/white layer of dead skin tissue, or eschar, dry dead tissue, obscuring the wound bed) 5 centimeter (cm) by 5cm right buttocks pressure wound. Resident #39's right buttocks pressure wound deteriorated and required hospitalization for an infected right buttocks/sacral pressure wound on 2/17/2025. Resident #39 received intravenous antibiotic therapy and a debridement (a medical procedure to remove dead, damaged or infected tissue from a wound to promote healing and prevent infection) of the right buttocks pressure wound while in the hospital. Resident #39 was discharged back to the facility on 2/24/25 with orders for oral antibiotics for 5 days. The deficient practice occurred for 1 of 2 residents reviewed for pressure ulcer care (Resident #39). Findings included: Resident #39 was admitted to the facility on [DATE] with diagnoses including coronary artery disease and renal insufficiency. Resident #39 was discharged to the hospital and readmitted to the facility on [DATE]. Resident #39's skin assessment dated [DATE] recorded there were no skin issues. There was no documentation observed in Resident #39's electronic medical record or on Resident #39's Medication Administration Record (MAR) to alert the nursing staff to conduct a weekly skin assessment. The care plan dated 11/19/2024 indicated Resident #39 was a potential risk for skin breakdown. Interventions included observing the skin weekly and notifying the nurse of any changes in the development of new skin impairments. Physician orders dated 11/19/2024 included a supplement that provided additional calories and protein 60 milliliters (mL) three times a day for weight management. Resident #39's recorded weight in the medical record on 11/20/2024 was 180.2 pounds (lbs). The admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #39 was cognitively intact with severely impaired hearing. Resident #39 was always incontinent of urine and stool and required total assistance with bed mobility and activities of daily living. There were no dental issues coded on the MDS for Resident #39. The MDS assessment further indicated Resident #39 was at risk for developing a pressure ulcer but was not marked as having a pressure ulcer or skin impairment. On 12/19/24 Resident #39 was ordered a high protein nutritional supplement 30mL daily for weight management. Resident #39's medical record documented skin assessments were conducted on 12/15/2024 with no skin issues recorded and on 1/4/2025 with skin excoriation (the act of abrading or wearing off the skin) recorded to the buttocks. There was no further documentation of the excoriation or assessment of Resident #39's skin until the Treatment Nurse's pressure wound assessment on 1/17/25. A review of nursing documentation from 11/19/2024 to 1/17/2025 in the electronic medical record recorded Resident #39 was turned and repositioned and provided incontinence care. There was no documentation of the development of a pressure wound for Resident #39. On 3/27/2025 at 1:36 pm in an interview with Nurse Aide (NA) #2, she stated Resident #39 required assistance in turning and incontinent care and Resident #39 was checked for incontinence and repositioned every two hours. She recalled Resident #39 not having any skin breakdown when admitted to the facility and stated she couldn't recall Resident #39's skin on her buttocks being red or irritated. She stated when she observed a quarter size red open area to Resident #39's buttocks while providing care, she informed the Treatment Nurse. NA #2 was unable to recall the date she informed the treatment nurse. Documentation of a wound assessment dated [DATE] by the Treatment Nurse recorded Resident #39 had an unstageable 5cm by 5cm right buttocks pressure wound. The right buttocks pressure wound assessment recorded the pressure wound was 90% dark eschar (dry dead tissue) and 10% pink tissue with moderate amount of serous exudate (drainage). There was no odor, tunnelling (narrow opening or passageway extending from a wound underneath the skin), or undermining (erosion that occurs under the edges of a wound) recorded. The Treatment Nurse recorded the physician and Resident #39's Representative were notified, and treatment was started with the application of silver alginate (highly absorbent, antimicrobial pad) and covered with a foam dressing. Physician orders dated 1/20/2025 included an order to cleanse the unstageable right buttock with normal saline, pat dry with gauze, apply skin prep to the periwound (skin around a wound) and allow to dry. Silver alginate was to be applied to the wound and the wound covered with a foam dressing every Monday, Wednesday and Friday. A review of Resident #39's January 2025 Medication Administration Record recorded Resident #39 received wound care as ordered. Resident #39's weight was recorded in the medical record on 1/24/2025 as 192.3 pounds that was a 12.1 lbs increase in weight. Dietary notes dated 1/30/2025 reported Resident #39 had an unstageable pressure wound to the right buttocks and Resident #39 was receiving a high protein nutritional supplement 30 milliliters daily and a supplement that provides additional calories and protein for persons at high risk for malnutrition 60 milliliters three times a day to aid in wound healing. The dietary note recorded Resident #39 consumed 50-100% of a regular mechanical soft diet and recommended ordering a Multivitamin (MVI) and Ascorbic Acid (Vitamin C) 500milligrams to further aid in wound healing. A review of Resident #39's January 2025 and February 2025 Medication Administration Record recorded Resident #39 was started on a Multivitamin (MVI) and Ascorbic Acid on 1/31/2025 and received the two dietary supplements, MVI and Ascorbic Acid as ordered. Documentation of the wound assessment on 2/4/2025 by the Treatment Nurse recorded Resident #39's unstageable right buttocks pressure wound measured 5 cm by 5 cm with eschar. Moderate serous exudate was recorded with no tunneling, undermining, odor or signs of infection. The wound bed was described as 90% dry, dark eschar and 10% pink tissue. The Treatment Nurse recorded the physician and Resident #39's Representative was notified. The wound was cleansed with normal saline and pat dried with gauze. Skin prep (forms a protective film on the skin) was applied to the periwound and allowed to dry. Silver alginate was applied and covered with a foam dressing. Resident #39's weight was recorded in the medical record on 2/8/2025 as 177.3 lbs that was a 15 lbs weight loss. Physician progress notes dated 2/14/2025 recorded the nursing staff reported Resident #39 was refusing to eat and was unable to chew food due to pain. Resident #39's gum on the left upper canines was observed swollen and Nurse Practitioner #1 ordered Amoxicillin 500 milligrams three times a day for five days. Documentation of the wound assessment on 2/14/2025 recorded a stage IV (most severe form of pressure injury that extends through skin, underlying tissue, muscle and bone) right buttocks pressure wound measured 5cm by 5cm by 0.8 cm and there was 1 cm of undermining in the position of 6-11 o'clock of the wound and 0.7cm from the position of 2-5 o'clock. Heavy serous exudate was documented with no odor or sign of infection. The wound bed was recorded as 50% deep red tissue, 15% fascia (layer of connective tissue below the skin), 15% muscle and necrotic (dead tissue) with 15% stringy gray colored dead tissue and 5% adipose (fat) tissue. The wound assessment recorded the physician and Resident#39's Representative were notified. Treatment of the right buttocks pressure wound included cleaning with normal saline, patting the area dry, applying skin prep to the periwound and allowing it to dry. The wound was packed with saline-moistened polyurethane foam dressing impregnated with methylene blue and covered with a foam dressing. Resident #39's dressing was ordered to be changed every Monday, Wednesday and Friday. On 2/17/2025 a wound assessment note by the Treatment Nurse recorded Resident #39's right buttocks pressure wound was measuring 7cm by 11cm by 2cm and was recorded as a stage IV pressure ulcer with an opened area measuring 7cm by 4cm and a 7cm by 4cm patch of dark dry eschar beside the opened area. Documentation of the wound recorded the opened area was tunneling underneath the eschar area with a heavy serous exudate and 40% of the area was dark, dry eschar, 40% deep pink tissue, and 10 % fascia, 50% adipose tissue and 5% bone. The wound was cleansed with normal saline and packed with saline moistened polyurethane foam dressing impregnated with methylene blue and covered with a foam dressing. The physician and Resident #39's Representative was notified and Resident #39 was scheduled to attend an appointment at the wound clinic on 2/17/2025. On 3/27/2025 at 12:58 pm in an interview with the Treatment Nurse, she stated the nursing staff were to conduct and document skin assessments weekly and notify her when skin breakdown was identified. The Treatment Nurse stated she was aware of the excoriated skin to Resident #39's buttocks documented on the skin assessment dated [DATE] and it was treated with barrier cream. She stated NA #2 informed her on 1/17/2025 of an area to Resident #39 buttocks that was observed as black eschar and weekly assessments and treatments were started based on the skin protocol. She explained Resident #39 wound remained a stable eschar wound tissue until 2/14/2025 when an area of the dry dead tissue was observed opened with no odor or drainage. The Treatment Nurse explained she had called the wound clinic for a referral when the right buttocks pressure wound was identified and was scheduled to go to the Wound Clinic on 2/17/2025. She stated on 2/17/2025, Resident #39's wound was observed worsening due to increase in size, drainage and odor. She explained since Resident #39 was scheduled to attend her first initial visit to the wound clinic on 2/17/2025, she called and notified the wound clinic of the change in Resident #39's right buttocks pressure wound. She stated the wound clinic requested Resident #39 to attend the scheduled appointment at the wound clinic on 2/17/2024 and if needed, the wound clinic would send Resident #39 to the hospital for admission. The wound clinic notes dated 2/17/2025 recorded Resident #39 was presenting to the wound clinic for the first time with an existing stage IV pressure injury that had worsen. The wound clinic note recorded the right buttocks pressure wound was very foul smelling with a necrotizing (death of bodily tissue) appearance at the undermined areas that was very concerning for a necrotizing soft tissue infection (NSTI). The pressure wound located on the right buttock/sacral area was recorded measuring 3.5cm by 8cm by 2 cm with black, green, red and tan colored wound bed with moderate amount of green serous exudate. The periwound was recorded as blanchable erythema (redness) with no tunneling and 4.5 cm of undermining. The wound was cleansed and dressed, and the wound clinic consulted the hospitalist (physician that works at the hospital) to direct admit Resident #39 from the wound clinic to the hospital. A review of the hospital Discharge summary dated [DATE] recorded Resident #39 was admitted from the wound clinic due to foul smelling and worsening of right buttock/sacral pressure wound on 2/17/2025. During hospitalization, Resident #39 received debridement on 2/20/2025 of the right buttock/sacral pressure wound and intravenous (medical technique that involves administering fluids, medications and nutrients directly into a vein) antibiotics. Resident #39 was discharged from the hospital and re-admitted to the facility on [DATE]. The discharge summary included physician orders for Amoxicillin-Potassium Clavulanate Tablet 875-125 milligram (mg) twice a day for wound infection for five days. There was no order for wound care on the discharge summary. Physician orders dated 2/24/2025 included the following orders: Amoxicillin-Potassium Clavulanate Tablet 875-125 milligram (mg) twice a day for wound infection for five days and cleansing the right buttock/sacrum with a topical super-oxidated solution formulated to combat bacteria and facilitate wound healing moistened gauze, pat dry with gauze and apply skin prep to periwound and allow to dry thoroughly. The application of an enzymatic debriding ointment was ordered to the areas of yellow/white dead skin tissue and the wound packed with a topical super-oxidated solution formulated to combat bacteria and facilitate wound healing moistened gauze and covered with a bordered foam dressing every day for a stage IV pressure ulcer. A review of Resident #39's February 2025 and March 2025 MAR recorded Resident #39 received the prescribed antibiotic and wound treatments. Physician orders dated 3/25/2025 included cleansing the right buttock/sacral wound with a wound solution that contains pure hypochlorous acid that fights bacteria and infection moistened gauze, patting the area dry with gauze, applying a thin layer of zinc-oxide based ointment and then nystatin (antifungal medication) powder to the periwound, applying an ointment that removes dead tissue to the areas of yellow/white dead tissue and packing the wound with a topical super-oxidated solution formulated to combat bacteria and facilitate wound healing moistened gauze and covering with a bordered foam dressing every day and evening shift. On 3/25/2025 at 3:03pm, the Treatment Nurse was observed changing Resident #39's right buttock/sacral pressure wound. The Treatment Nurse stated that when Resident #39 attended a wound clinic visit on the morning of 3/25/2025, the right buttock/sacral pressure wound was measured and wound clinic notes recorded the pressure wound as 5.3cm by 10 cm by 1 cm and ordered wound care to be performed twice a day. Resident #39 right buttocks/sacral open wound was observed with black colored tissue to the lower left portion of the wound, the center of the wound with a small white patch tissue and the remaining tissue was red in color. There was no foul odor detected from the right buttocks/sacral wound. The Treatment Nurse cleansed the wound with a wound solution that contains pure hypochlorous acid that fights bacteria and infection moistened gauze, applied a zinc-oxide based ointment to the edges covered with nystatin powder, applied an ointment that removes dead tissue to the dark colored tissue inside the wound and packed the wound with a wound solution that contains pure hypochlorous acid that fights bacteria and infection moistened gauze and covered with a foam dressing as ordered by the physician. On 3/27/2025 at 1:25 pm in an interview with Nurse #4, she stated skin assessments were to be conducted by the nursing staff weekly and documented in Resident #39's medical record. Nurse #4 stated she did not know why Resident #39 skin assessments were not conducted weekly. On 3/27/2025 at 12:50 pm in an interview with the Director of Nursing (DON), she stated skin checks were performed daily on residents during baths, showers, incontinence care and with weekly nursing skin assessments. She stated nursing staff were to observe for any changes in resident's skin and report to the Treatment Nurse as needed. She stated skin assessments should have been conducted and documented by the nursing staff for Resident #39 and she was unable to provide a reason why Resident #39's skin assessment were not performed weekly. She stated Resident #39's right buttocks/sacral pressure wound was discussed in morning and evening meetings and Resident #39's wound worsened because Resident #39 stopped eating due to dental issues that were treated. On 3/27/2025 at 1:45 pm in a phone interview with the Medical Director, he stated the Treatment Nurse started providing wound care to Resident #39 when notified of the skin breakdown on 1/17/2025. He explained he reviewed the Treatment Nurse wound assessments weekly and was scheduled to be evaluated at the wound clinic on 2/17/2025. He stated there were no reports of infection to Resident #39's pressure wound until 2/17/2025 and Resident #39 was seen at the wound clinic as scheduled on 2/17/2025. He stated due to the Resident #39's comorbidities, Resident #39 was at risk for developing the pressure wound and the deterioration of the right buttock pressure wound was unavoidable.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, staff and Physician interviews, the facility failed to protect the resident's right to be free from injury of unknown source that resulted in bruising under the eyes and a fracture of the bridge of the nasal bones. This occurred for 1 of 1 cognitively impaired resident reviewed for an injury of unknown source. (Resident #1) Findings included. Resident #1 was admitted to the facility on [DATE] with diagnoses including in part cerebral vascular accident (CVA), quadriplegia, and dementia. The Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #1 had severely impaired cognition. She exhibited no physical or verbal behaviors directed toward others (e.g. hitting, kicking, grabbing, or yelling). She exhibited no other behaviors such as hitting or scratching herself. She required total dependent care by staff for activities of daily living (ADLs). She had no falls and received anticoagulant (prevents clot formation) medications. She had no rejection of care. An Investigation Report dated 04/08/24 revealed that on 04/06/24 Resident #1 presented with swelling and bruising of her nose and under her eyes. A full investigation was conducted on 04/08/24 and it was not determined how the resident sustained the injury. The investigation revealed at approximately 11:00 PM on 04/06/24 Nurse Aide #1 reported swelling on the bridge of Resident #1's nose. Nurse #2 was notified. Nurse #2 instructed Nurse Aide #1 to apply an ice pack to her face. Nurse #2 indicated she administered Tylenol. Nurse Aide #1 stated Resident #1's nose continued to swell and appeared bruised. An x-ray report dated 04/08/24 for Resident #1 revealed a minimally displaced fracture of the nasal bridge. Review of Resident #1's progress notes from 04/05/24 the day prior to the appearance of bruising and swelling under the eyes and the nasal bridge through 04/0624 at 11:00 PM when the injury was identified revealed no documentation of an injury that occurred. There were no reported falls. Review of the Medication Administration Record (MAR) dated April 2024 revealed Resident #1 received scheduled Plavix (prevents blood clot formation) 75 milligrams (mg) every morning for anticoagulation therapy. A known side effect of this medication included bruising. During an observation on 04/26/24 at 11:30 AM of Resident #1 was observed lying in bed. She was oriented to person only. She could not verbalize the cause of her injury. She was noted to have a small yellow discolored area under her left eye suggestive of an old bruise. A full skin assessment was observed with the assigned nurse. There were no further injuries noted. During an interview on 04/26/24 at 11:45 AM Resident #1's roommate who was alert and oriented reported the bruising suddenly appeared under her eyes, but she didn't know what happened. She indicted she had never witnessed any staff member mistreating Resident #1. She stated Resident #1 had dementia and was resistive to care at times, but she had not witnessed her falling from bed or having any accidents related to her injury. During a phone interview on 04/26/24 at 5:20 PM Nurse #2 stated she came on shift at 11:00 PM on 04/06/24 and was the assigned nurse for Resident #1. She stated Nurse Aide #1 asked her to go down and look at Resident #1. She went down at that time and observed bruising and swelling underneath her left eye. Resident #1 was not able to verbalize what caused the injury. She stated she did not receive any report from the day shift nurse (Nurse #1) who reported to her when she came on duty regarding an injury. She reported that Resident #1 received anticoagulant medication, so she wasn't alarmed because the bruising and swelling was a small area. She asked Resident #1 if her face bothered her and she said yes. She reported she administered Tylenol 650 milligrams once at that time and applied an ice pack. Nurse #2 stated although her eye was bruised and swollen it did not look like a serious injury. She asked Nurse Aide #1 what happened, and she could not provide an answer. She stated when Nurse #1 came in the next day, she mentioned it to her, but Nurse #1 didn't know what could have happened to cause the injury. She stated she gave Nurse #1 report and went home. She stated it was a small bruise with no open areas, and no bleeding or other signs of trauma. She stated she decided she would let the day shift nurse notify the doctor. She stated since the incident she had received in service training on reporting injuries of unknown source, abuse training, and monitoring for an acute change in condition. During an interview on 04/26/24 at 12:45 PM Nurse #1 stated she was Resident #1's assigned nurse on Saturday 04/06/24 from 7:00 AM through 11:00 PM. She stated when she left her shift on 04/06/24 at 11:00 PM there was no bruising, swelling, or injury. She stated Nurse Aide #1 reported to her earlier that day around 4:00 PM on 04/06/24 that Resident #1 had blood on her gown. She assessed Resident #1 and observed blood coming from her mouth and determined she had bitten her tongue. They cleaned her mouth and held pressure and the bleeding stopped. Nurse #1 reported she left the room and finished her medication pass. Before leaving her shift at 11:00 PM she reported Resident #1 did not have anything wrong with her face and her mouth was not bleeding, and there was no bruising or swelling. She stated she returned to work the next morning and Medication Aide #1 reported to her that Nurse Aide #1 reported that Resident #1 had a black and bruised eye. Nurse #1 stated Nurse #2 who was on duty during the night shift, did not report anything to her regarding the injury. Nurse #1 stated she assessed Resident #1 just after 7:00 AM and noted that her left eye was bruised and red. She reported she reviewed her electronic medical record and there was no documentation as to what happened. She stated she called and informed the Director of Nursing (DON) about the unexplained injury sometime that day on 04/07/24 but thought it was before 5:00 PM and the DON stated she would take care of it. She reported Resident #1 never complained of pain on 04/07/24. She indicated that although Resident #1 had dementia she was oriented to person and could voice her needs. She stated Resident #1 had been in the facility for years and did not have a history of falls that she was aware of. She stated Resident #1 would tense up when turning her and providing care. She required total care by staff and used the mechanical lift for transfers but stayed in bed most of the time. She stated Resident #1 would push staff away at times when they attempted to administer medications or provide care. She stated Resident #1 was not able to turn or reposition herself without assistance. She stated since the incident Resident #1 had no changes in her behavior and remained at baseline. Nurse #1 stated since the incident she had received training on monitoring for an acute change in condition, abuse training, and reporting a change in condition, reporting skin issues, and signs and symptoms of fractures. During an interview on 04/26/24 at 1:20 PM Nurse Aide #1 stated she worked a double shift on 04/06/24 from 3:00 PM through 7:00 AM on 04/07/24 and was assigned to Resident #1. She stated when she arrived for work around 3:30 PM she provided incontinence care and saw a speck of blood on her gown near her neckline. She called for Nurse #1 to look at her. There were no skin tears and at that moment she started spitting out a small amount of blood. She thought she may be losing a tooth. The nurse assessed her and thought she bit her tongue and instructed her to get her cleaned up. She stated Resident #1 had no complaints of pain and they checked her teeth to make sure none were loose. Resident #1 seemed okay, and she continued on with her shift. Later that evening around 11:30 PM she noticed Resident #1's face turning red, and she had bruising under her eyes. She reported this to Nurse #2, the oncoming 11:00 PM to 7:00 AM nurse. Nurse #2 went in around 11:15 PM and told her to get an ice pack and put the ice pack on her face for 1 hour. Nurse Aide #1 went back to remove the ice pack an hour later and noticed her eye was getting darker on both sides under her eyes. She reported this to Nurse #2 right away and the nurse told her she was going to leave it for the morning nurse at 7:00 AM since it was late. She indicated she was not given any further instruction that night from Nurse #2. She stated Resident #1 required total care and used the mechanical lift for transfers. She indicated she could not turn or reposition herself without staff assistance. She was disoriented most of the time. She stated she was called in to work the next week during the investigation and was told that Resident #1 had a broken nose. She stated she had no idea of how the injury occurred. She stated she received in-service training regarding abuse and reporting injuries. During an interview on 4/26/24 at 1:50 PM Nurse Aide #2 stated she worked Saturday 04/06/24 from 7:00 AM to 10:00 PM and was assigned to Resident #1 from 7:00 AM until 3:00 PM. She stated after she arrived for her shift, she checked on her residents and reported nothing unusual regarding Resident #1. She reported there was no redness, or bruising. She gave her a bath around 10:30 AM Saturday morning. She moved her bed away from the wall due to her pushing against the wall and resisting when trying to change or reposition her. She stated she acts as though she doesn't like to be repositioned, so she uses her arms to block. She indicated Resident #1 could not turn and reposition without staff assistance. She reported she did not have bed rails on the bed. She gave the bath, repositioned her, and sat her up in the bed to get ready for lunch at that time and there was nothing unusual noticed. She checked on her again at lunch and nothing was unusual. She went in her room again around 2:30 - 2:45 PM to change her and there were no signs of bruising or swelling. She stated around 3:15 PM the nurse aide for 2nd shift reported her mouth was bleeding. Nurse #1 told her she had just checked her, and nothing was wrong with her mouth. She stated she was surprised to hear of her mouth bleeding because she had just left her at 2:45 PM and she was fine. She stated at 3:00 PM she changed assignments and only saw her at a glance later that day. When she returned to work Sunday morning, she was assigned to Resident #1 again. When she went in to see her at the beginning of her shift she had two black eyes. She stated she immediately reported it to Nurse #1. Nurse #1 went in to assess her and didn't know what had happened. She stated she thought the injury happened overnight. She stated she received in service training since this incident on abuse turning and repositioning, falls, skin tears, reporting changes in behaviors, and reporting signs of bruising. During an interview on 4/26/24 at 1:00 PM Nurse Aide #3 stated she worked on Friday 04/05/24 from 7:00 AM until 3:00 PM the day prior to the reported injury and was assigned to Resident #1. She reported there was no bruising or swelling observed during that time. She didn't know how the injury occurred but was later told she had a broken nose. She stated Resident #1 was total care and required the mechanical lift with 2-person assistance for transfers. She was cooperative with care most days, but she did try to pull on your clothes or would push against the wall when you tried to turn and reposition her or provide any care for her. She stated she typically moved her bed slightly from the wall during care, so she didn't push against the wall, but stated she always pushed the bed back against the wall following care. She stated Resident #1 had dementia but could voice her needs. She had no complaints of pain and no history of falls that she was aware of. She reported it was never determined what caused the injury. She stated she received in-service training on abuse, sliding residents in bed, signs, and symptoms of fractures, and reporting injuries. During a phone interview on 04/26/24 at 4:40 PM the Physician stated he was notified of the injury of unknown source on Monday 04/08/24. He stated he ordered an x-ray that showed a minimally displaced fracture to the nose. He reported he evaluated Resident #1 on Tuesday 04/07/24 and interviewed staff and her roommate and asked if she had been dropped or fallen. He stated he could not determine how the injury occurred. He reported Resident #1 had been bedridden for many years. He stated there was no delay in treatment by doing the x-ray on Monday. He stated Resident #1 was evaluated by the Ear, Nose, & Throat (ENT) physician on 04/11/24 and from the outcome of that evaluation along with conversations with her Responsible Party it was decided that no treatment would be indicated for the nasal fracture. During an interview on 04/26/24 at 3:50 PM the Director of Nursing (DON) stated she was not made aware until Monday 04/08/24 of the injury of unknown source. She reported she found out about Resident #1's injury on Monday morning from either a nurse or nurse aide but could not recall exactly. She went to assess Resident #1's nose and she had bilateral bruising under her eyes and across the bridge of her nose. She started an investigation at that time and the Responsible Party was notified. She stated the Physician was notified on 04/08/24 and ordered an x-ray which resulted in a nasal fracture. The Physician evaluated her on 04/09/24. Resident #1 was evaluated by an Ear, Nose, and Throat (ENT) physician on 04/11/24. She stated the Police came on 04/08/24 and talked with Resident #1 and her roommate. The Police determined no foul play and could not determine what caused the injury. During an interview on 04/26/24 at 6:00 PM the Administrator stated she was notified of the injury late in the day on 04/08/24. She stated an investigation was initiated at that time related to the injury. She stated the Physician, and the Responsible Party were made aware immediately. She stated an x-ray was ordered and showed the nasal fracture. She stated staff statements were obtained during their investigation. Resident interviews were conducted regarding abuse, or injuries that had not been reported and no concerns were identified. She stated they could not determine how the fracture occurred and thought she could have turned into the wall. She stated since the incident they have placed a pad between her bed and the wall. She stated education was provided to all nursing staff regarding the provision of care including abuse training, and monitoring for an acute change in condition including injuries of unknown source. She stated an ad hoc Quality Assurance (QA) meeting was held on 04/09/24 and the decision was made by the Quality Assurance (QA) Committee to initiate a Performance Improvement Plan regarding this occurrence. She reported the Plan of Correction was initiated on 04/08/24 which included monitoring for an acute change in condition to include new bruising, pain, or injury of unknown source. Reporting of an acute change in condition to the DON, physician, and the Responsible Party, and follow through of interventions and monitoring for a change in condition. The Plan of Correction included: Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice; On 04/08/24 Resident #1 was assessed by the Director of Nursing. Resident #1 was noted to have bilateral bruising under her eyes and across the bridge of her nose. On 04/08/24 the physician was notified, an x-ray was ordered which resulted in a minimally displaced fracture of the nasal bridge. The Responsible Party was notified. On 04/08/24 Adult Protective Services and law enforcement were notified. On 04/08/24 through 04/09/24 interviews were conducted with all alert and oriented residents regarding resident abuse and how to report abuse and neglect, and injuries of unknown source. There were no concerns identified. On 04/08/24 through 04/09/24 skin assessments were completed on all non-alert and oriented residents for signs of abuse and neglect. There were no concerns identified. On 04/08/24 through 04/09/24 grievance logs were reviewed for the past 30 days to ensure all allegations were reported timely. There were no concerns identified. On 04/08/24 through 04/09/24progress notes were reviewed for the last 7 days to ensure documented acute change in condition to include new/worsening pain, bruising, or signs of a fracture were assessed and reported timely to the physician, DON, and Responsible Party. There were no concerns identified. On 04/08/24 the Administrator, and the Director of Nursing were educated by the Clinical Director regarding reportable events including injuries of unknown source or events that were suspicious of a crime and it must be reported to the State Agency within 2 hours. On 04/09/24 through 04/10/24 education was conducted with all nursing staff regarding the facility's abuse and neglect policy, reporting changes in condition, interventions for an acute change in condition, signs/symptoms of fractures, performing neurological checks, and turning and repositioning residents. On 04/09/24 Resident #1 was evaluated by the Physician. There was no new treatment implemented. On 04/11/24 Resident #1 was evaluated by the Ear, Nose, & Throat (ENT) physician. There was no new treatment implemented. Address how the facility will identify other residents having the potential to be affected by the same deficient practice; On 04/08/24 the DON and Staff Facilitator performed skin assessments on cognitively impaired residents to ensure that any concerns or change in condition had been assessed, and interventions initiated if indicated, and the physician notified for further recommendations, and the Responsible Party had been notified with documentation in the electronic medical record. There were no negative findings. There were no negative findings. On 04/08/24 the DON and Staff Facilitator initiated questionnaires of all alert and oriented residents regarding new/worsening pain, injuries not reported to the nurse, and signs/symptoms of a fracture. The questionnaire was to ensure that any concerns or change in condition had been assessed, and interventions initiated if indicated, and the physician notified for further recommendations, and the Responsible Party had been notified with documentation in the electronic medical record. There were no negative findings. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur; On 04/09/24 the DON and Staff Facilitator initiated education with all nursing staff regarding abuse, notification of an acute change with emphasis on assessing a change to include new/worsening pain, signs of a fracture, obtaining vital signs, initiating interventions for an acute change, notification of the physician for further recommendations, and notifying the responsible party to include documentation in the medical record. Education was provided on signs/symptoms of a fracture to include bruising and swelling. Completing neurological checks per the standing order for all known or suspected head injuries or unwitnessed fall. Education was completed by 04/10/24 . After 04/10/24 any staff who had not completed their education would be required to do so prior to the next shift. Newly hired staff would be educated during orientation. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained. The decision to monitor and take to QA was made on 04/09/24. The unit managers will review progress notes 5 times per week for 4 weeks utilizing the acute change auditing tool. The unit manager will address any concerns identified. The Social Worker will complete 5 resident questionaries weekly for 4 weeks to identify any concerns. The unit managers will address any concerns identified. The Administrator and DON will review the audits weekly for 4 weeks to ensure all areas of concern were addressed appropriately. The Administrator or DON will present the findings of the audit tools/questionaries to the QAPI committee for 1 month to review and to determine trends or issues, or the need for continued monitoring. A QAPI (Quality Assurance Performance Improvement ) meeting was held again on 04/16/24 with the Interdisciplinary team where the plan of correction was discussed. The facility alleged compliance with the corrective action plan on 04/12/24. Validation of the corrective action was completed on 04/26/24. This included staff interviews regarding the incident, and in-service training that was received to ensure understanding and knowledge of the training provided. The initial audits were verified. There were no concerns identified.