**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of the medical record for Resident #55 revealed an admission date of 02/20/19. Diagnoses included major depressive disorder, Multiple Sclerosis (MS) weakness, and a stroke. Review of the quarterly MDS assessment, dated on 02/20/19 revealed the resident had minimal cognitive impairments and required extensive assistance of two with her care. Review of a SRI dated on 03/15/19 revealed Resident #55 reported to the Director of Nursing (DON) STNA #120 pulled her by her arm and leg when turning her. Resident # 55 noted bruises on her arms. Resident #55 also revealed STNA #120 yelled at her. The facility substantiated the SRI. Review of a statement in the facility investigation provided by LPN #121 noted Resident #55 told the LPN she would have bruises in the morning on 03/14/19 due to the way STNA #120 turned her and was rough and called her names. Review of the written statement by Registered Nurse (RN) #115 revealed on the morning of 03/15/19 at 8:00 A.M. Resident #55 reported STNA #120 was yelling at her and was rough leaving bruises on her arms. Resident #55 told RN #115 she was awake and shaking in her bed the rest of the night afraid STNA #120 would return. Observations of Resident #55 on 04/01/19 at 3:00 P.M. revealed the resident was in her room sitting in her wheel chair. The resident was alert and oriented and agreed to the interview. Resident #55 noted she had small yellow bruises on her right arm. Interview with Resident #55 on 04/01/19 at 3:00 P.M. revealed on the night of 03/14/19 STNA #120, pulled her by her arm and leg yanking the resident over to her side. STNA #120 then began to verbally abuse the resident. Resident #55 noted the STNA called her fat and told her she was ugly. The resident stated it made her feel so degraded and worthless. Resident #55 said she was trying very hard to lose some weight and had been feeling good about her progress. Resident #55 was tearful during the interview. The resident said for the rest of the night she lay awake shaking and would not put her call light on until the next morning when she was sure STNA #120 was gone. The resident said she was relieved STNA #120 would not be back. Interview on 04/04/19 at 10:00 A.M. with the Director of Nursing (DON) revealed LPN #121 did not report the allegation of abuse the night of 03/14/19. The DON was not informed of the allegation until the morning of 03/15/19. The DON also confirmed the SRI involving STNA #120 abusing Resident #55 was substantiated. Review of the Abuse Policy dated on 08/16/19 revealed the facility does not condone abuse by any one of any kind. Any individual observing an incident of abuse must immediately report to a member of the management immediately. Abuse is defined as willful infliction of injury, unreasonable confinement , intimidation, punishment, resulting in physical harm, pain, or mental anguish. This deficiency substantiates Master Complaint Number OH00103564 and Complaint Number OH00103353. Based on medical record review, review of hospital records, review of a facility Self-Reported Incident (SRI), review of staff time card punches, observations, review of the facility abuse policy, and interviews with staff, residents, and a police detective, the facility failed to implement their abuse policy when one State Tested Nurse Aide (STNA) neglected to report that he had dropped a resident during an improper transfer, and one additional STNA who was aware the resident had been dropped also neglected to report the incident. This resulted in Immediate Jeopardy and serious life-threatening injuries when Resident #40 experienced increased pain and suffering due to the delayed identification of the extent of the injuries sustained by the resident during the improper transfer. Resident #40 was then transferred to the emergency room of a local hospital where she was found to have acute fractures to both the left and right distal femurs, and remote right pubic rami fractures. This resulted in Immediate Jeopardy for one (#40) of five residents reviewed for abuse and neglect. Additionally, the facility failed to ensure one (#55) out of five residents reviewed were free from verbal abuse by a staff member that was not Immediate Jeopardy. The facility census was 78. On 04/04/19 at 2:37 P.M., the Licensed Nursing Home Administrator (LNHA), Director of Nursing (DON), and Corporate Director of Nursing (CDON) #150 were notified Immediate Jeopardy began on 03/21/19 at approximately 7:15 P.M., when STNA #123 dropped Resident #40 during an improper transfer and then neglected to report he had dropped the resident. The resident complained of increased pain to both knees on 03/21/19, 03/22/19, and 03/23/19 without notification of the resident's physician until 03/24/19. Resident #40 was then transferred to the emergency room on [DATE] where she was found to have acute fractures to both the left and right distal femurs, and remote right pubic rami fractures and subsequently required hospitalization. The Immediate Jeopardy was removed on 03/26/19 when the facility suspended STNA #123 and #127 and interviewed and/or assessed all residents on STNA #123's assignment (300 Hall) to ascertain if any improper transfer occurred or injury had been sustained as a result of care delivered by the nurse aide, or any other staff person, and the facility implemented the following corrective actions: • On 03/24/19, the DON notified the Medical Director to discuss the resident's current medical condition. • On 03/24/19, the facility initiated an investigation into the root cause of Resident #40's injuries by interviewing nursing staff and obtaining written statements. The facility continued interviewing all nursing staff who had contact with Resident #40 prior to 03/24/19 to ascertain the source of the injuries. • On 03/25/19, the DON and Doctor of Physical Therapy (DPT) #203 began in-servicing STNA's on abuse, transfers, incident reporting, and cooperating with an investigation. The in-services were completed on 03/25/19. • On 03/25/19, the DON and DPT #203 began audits of transfers that included return demonstration from nursing staff. The audits have been completed daily Monday through Friday and will be continued daily Monday through Friday for three weeks, then weekly for three weeks, and then monthly for three months. • On 03/25/19, the Clinical Reimbursement Specialist, Registered Nurse (RN) #247 audited all resident's comprehensive care plans for transfer status. • On 03/26/19, the DON and CDON #150 audited all resident care cards ([NAME]) and care plans to ensure the proper transfer status was reflected on the care plan. • On 03/26/19, licensed nurses were in-serviced by the DON regarding notification of the physician with all resident accidents, incidents, and changes in condition. The in-services were completed on 03/26/19. • On 03/26/19, the CDON #150 met with the Medical Director and reviewed the status of the facility's investigation into Resident #40's injuries and the plan of action. A facility SRI was submitted to the state survey agency on 03/26/19 identifying Resident #40's femur fractures as injuries of unknown origin. • On 03/26/18 a detective from the County Sherriff's office (Detective #163) arrived at the facility and initiated an investigation into the source or Resident #40's injuries. The Sherriff's office was contacted by the resident's family. • On 03/28/19, the LNHA and the DON initiated audits related to abuse/neglect. The audits have been completed daily Monday through Friday and will continue daily Monday through Friday for three weeks, then weekly for three weeks, then monthly for three months. • On 04/02/19, STNA #123 and STNA#127 were terminated from the facility at the conclusion of Detective #163's investigation. • On 04/03/19 and 04/04/19, STNAs #08, #73, #83, #84, #51, #69, #74, and #58 were interviewed to ascertain if they had received in-service education regarding the facility's abuse policy, abuse/neglect reporting procedures and incident reporting, safe transferring of residents, reviewing care cards ([NAME]) and if they had been observed performing transfers. All staff interviewed reported they had been educated regarding the aforementioned topics and had been observed by either the DON or DPT #203 while they were transferring residents. • On 04/04/19, STNAs #73, #84, #83, #69, and #51 were observed transferring residents from one surface to another and competently performed the transfers consistent with the respective resident's written plan of care. • On 04/04/19, Licensed Practical Nurses (LPN) #99, #109, #94, #93, #96, and #97 were interviewed to ascertain if they had received in-service education and training on notification of change in resident's condition, incident reporting, abuse/neglect reporting procedures and incident reporting. All nurses interviewed communicated they had received in-service education regarding the aforementioned topics and were able to verbalize what was learned. • During the survey, three (#07, #70 and #10) additional residents were reviewed for abuse and neglect. No concerns were identified. Although the Immediate Jeopardy was removed, the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility is still in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include: 1. Review of Resident #40's medical record revealed the resident was admitted to the facility on [DATE], and recently readmitted from the hospital on [DATE]. Diagnoses include unspecified multiple injuries, unspecified fracture of lower end of right femur, initial encounter for closed fracture, pain in left leg, pain in right leg, unsteadiness on feet, atherosclerotic heart disease, atrial fibrillation, hypertension, osteoarthritis, and vascular dementia without behavioral disturbance. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #40 had good memory and recall as the resident had a 15 out of 15 on the Brief Interview for Mental Status (BIMS). Further review of the MDS revealed the resident required physical assistance of two staff persons for bed mobility, transferring, and toilet use. Resident #40 did not walk and was assessed as having no fall since the prior assessment. The resident received routine opioid medication daily. Review of the Resident #40's current comprehensive plan of care revealed a care plan dated 10/11/16 indicating the resident was at high risk for falls related to balance deficits, cognitive deficits, deconditioning and fall history. The fall care plan documented staff have been educated on appropriate transfer techniques following instructions on [NAME] for transfer status. Further review of a care plan titled Activities of Daily Living (ADL) self-care deficit which fluctuates related to deconditioning/muscle weakness, fatigue dated 10/11/16 revealed Resident #40 requires extensive to dependent assistance of two staff members for toileting and transfers via a mechanical (Hoyer) lift and two staff members as tolerated. Further review of a [NAME] with a print date of 03/27/19 revealed Resident #40 required extensive to dependent assistance of two staff members for transfers. Review of Resident #40's physician's orders, prior to 03/25/19, revealed the resident had orders to receive Tramadol (opioid medication) 50 milligrams (mg) one time a day for generalized pain, and an additional 50 mg of Tramadol every six hours as needed for pain. In addition, the resident had orders to received acetaminophen 500 mg every eight hours as needed for pain. Review of Resident #40's nursing progress notes revealed on 03/22/19 at 4:33 P.M., LPN #93 documented the resident was administered 50 mg of Tramadol for complaints of bilateral lower extremity pain. LPN #93 documented there was no injury noted. The resident denied falling or injury with impact to her bilateral lower extremities; the resident had a shower during the evening on 03/21/19. LPN #93 noted repositioning was ineffective, passive range of motion was refused and fluids increase was ineffective. LPN #93 further documented arthritis was a chronic issue for the resident, that the resident's left knee was enlarged slightly more than the resident's other knee with no bruising noted. The resident had no complaints of pain upon palpation, no redness, or warmth to the extremity. On 03/22/19 at 11:42 P.M., LPN #113 documented she administered 500 mg of acetaminophen to the resident for complaints of pain to her bilateral lower extremities, not relieved by rest or repositioning. On 03/23/19 at 3:53 P.M., LPN #99 documented she administered 50 mg of Tramadol, as needed, to the resident for pain as Resident #40 was crying, stating she was having pain in her knees. On 03/24/19 at 11:13 A.M., LPN #99 documented she auscultated Resident #40's lung sounds due to the resident experiencing shortness of breath and weakness and rhonchi (abnormal lung sound) was noted to the right lower lobe of the lung. Resident #40 also complained of severe knee pain to bilateral knees. Resident #40's knees were swollen. Resident #40's color was slightly yellow. Resident #40 was very weak and can be incoherent at times. Resident #40 was afebrile, and vital signs were within normal limits. LPN #99 further documented she called Resident #40's physician to ask for STAT (immediate) x-rays and laboratory tests. The on-call physician ordered a chest x-ray and x-rays to both the resident's knees. Resident #40's family member was also notified. On 03/24/19 at 11:34 A.M., LPN #99 documented Resident #40 stated she fell to the floor in her room a few days ago and hit her knees. Resident #40 complained of severe knee pain to both knees and her knees are swollen. When this nurse started shift yesterday (on 03/23/19), the night shift nurse stated Resident #40 was in bed all day Friday 03/22/19 due to knee pain. The night shift nurse also stated Resident #40 had bilateral knee pain on Friday, 03/22/19 shift. Resident #40 complained of knee pain yesterday (on 03/23/19) as well. It is to be noted the resident has a diagnosis of dementia and being confused at times. Review of Resident #40's March 2019 Medication Administration Record (MAR) revealed the resident began having documented episodes of increased, sustained pain during the evening of 03/21/19 through the time she was discharged to the hospital on [DATE]. The resident's pain was rated by nurses, either by verbalization by the resident or signs/symptoms of pain on a scale of one through 10, with 10 being the worst pain imaginable. On 03/21/19 at 8:00 A.M., the resident's pain was rated at zero, on 03/21/18 at 10:04 P.M. the resident's pain was rated as a four, on 03/22/19 at 4:33 P.M. the resident's pain was rated at eight, on 03/22/19 at 9:42 P.M. the resident's pain was rated at seven, on 03/23/19 at 8:00 A.M. the resident's pain was rated at seven, on 03/23/19 at 3:53 P.M. the resident's pain was rated at six, on 03/23/19 at 7:25 P.M. the resident's pain was rated at six, on 03/24/19 at 8:00 A.M. the resident's pain was rated at six, and on 03/24/19 at 12:43 P.M. the resident's pain was rated at eight. Review of Resident #40's nursing progress notes, and MAR, failed to reveal any documentation Resident #40's physician was notified of the increased complaints of pain, and continued complaints of pain, until 03/24/19 at 11:34 A.M. Further review of the nursing progress notes revealed on 03/24/19 at 7:19 P.M., LPN #99 documented the x-ray results of Resident #40's knees revealed the resident had acute distal femur fractures. The physician was notified, and an order was received to send the resident to the hospital. The resident was picked up on 03/24/19 at approximately 5:00 P.M. and taken to a local hospital for evaluation. The resident was then admitted to the hospital. Review of hospital records dated 03/24/19 revealed Resident #40 had a fall at the skilled nursing facility. Further review revealed the hospital obtained x-rays of both lower extremities and Resident #40 was found to have an acute fracture of the distal femur, right pubic rami fractures, and an acute fracture of the left distal femur with subluxation and angulation. Resident #40 was subsequently hospitalized for pain relief, orthopedic consult, deep vein thrombosis prophylaxis, placement of an indwelling catheter and to check cardiac status. Resident #40 remained hospitalized until 03/29/19. Review of a facility SRI dated 03/26/19 revealed Resident #40 was found to have bilateral femur fractures on 03/24/19. The SRI, completed by the DON and Licensed Nursing Home Administrator (LNHA), indicated Resident #40 had bilateral femur fractures confirmed through an x-ray. Resident #40 stated she had fallen; however, the facility was unable to confirm a fall through the initial investigation and is now considering this an SRI related to an injury of unknown origin. The SRI further documented the police were notified and on 03/28/19 the facility was notified by a police detective that they did an interview with STNA #123 and he admitted to dropping the resident on 03/21/19 during transfer to the shower chair before the shower occurred. STNA #123 acknowledged that the resident had pain during his shift Friday 03/22/19. He also denies telling LPN #107 about the incident as he had previously stated. Resident #40 received continued routine and as needed medications from Thursday, 03/21/19 at 10:00 P.M. through Sunday, 03/24/19. The facility has concluded STNA #123 will be terminated due to failure to report an incident, failure to cooperate with a facility investigation and negligence. Additionally, the facility has concluded that STNA #127 will be terminated due to failure to cooperate with a facility investigation, failure to report an incident and negligence. Both employees (STNAs #123 and #127) remain suspended as of 03/29/19 and will be terminated once the police detective notifies the facility that they have completed their interviews. LPN #107 remains suspended as of 03/29/19 pending her being questioned by the police detective. The SRI was substantiated. An interview was conducted with the LNHA, the DON, and CDON #150 on 04/03/19 at 3:14 P.M. regarding the SRI and their investigation into Resident #40's injuries. The DON reported through the investigation it was determined STNA #123 dropped Resident #40 while transferring her from her bed to a shower chair for an evening shower on 03/21/19, sometime between 7:00 P.M. and 7:15 P.M. at the start of his shift. The DON reported STNA #123 transferred Resident #40 by himself; however, the DON stated Resident #40 required two staff for safe transferring. The DON reported STNA #123 did not report to any staff member or nurse that he had dropped the resident, with the exception of STNA #127 who was getting ready to leave her day shift on 03/21/19. Both STNA #123 and STNA #127 failed to report Resident #40 was dropped during the transfer. CDON #150 communicated that both STNA #123 and STNA #127 were interviewed more than once by the facility and denied any knowledge of Resident #40 falling or being dropped. She stated STNA #123 admitted to dropping Resident #40 to a detective from the county Sherriff's office (Detective #163) during an interview on 03/28/19. CDON #150 shared that finally during STNA #127's third interview, the nurse aide admitted that she was told by STNA #123 on 03/21/19 that he dropped the resident during a transfer. Both STNA #123 and #127 were suspended by the facility on 03/26/19, due to inconsistencies during their second interview regarding Resident #40 and how her injuries may have occurred, and with what was observed on facility cameras the night of the incident. CDON #150 stated both STNA #123 and #127 were being terminated as Detective #163 had concluded his investigation. The facility provided all documentation of the investigation into Resident #40's leg fractures including interviews and statements from nursing staff who worked with the resident from 03/21/19 through 03/24/19. Review of time card punches for STNA #123 revealed the nurse aide continued to care for Resident #40 throughout the night shift (7:00 P.M. through 7:00 A.M.) on 03/21/19 into 03/22/19, and during the night shift on 03/22/19 into 03/23/19, without reporting to nurses or administrative staff that he had dropped the resident. Review of time card punches for STNA #127 revealed the nurse aide continued to work with the resident during the day shift (7:00 A.M. through 7:00 P.M.) on 03/22/19 without reporting to nurses or administrative staff of her knowledge that Resident #40 had been dropped by STNA #123. Resident #40 was observed, and interviewed on 04/02/19 at 6:26 P.M. The resident was resting in bed. During the observation, Resident #40 was observed with braces/splints to the lower extremities. Resident #40 was asked if she could tell this surveyor about how her legs were broken. Resident #40 stated first that she was not sure how her legs were broke, then stated she was getting out of bed and was under the impression that someone gave me a push. Resident #40 then stated her injuries occurred because there were supposed to be two people helping her and I had only one helping. Resident #40 stated the incident happened at night; however, could not recall what staff person was assisting her when it happened, or specifically if it was a man or woman. Resident #40 stated she has not been out of bed since her legs were broken, and that the pain medicine was helping and denied being in pain at that time. An interview was conducted with Detective #163 on 04/04/19 at 9:36 A.M. regarding the investigation into the source of Resident #40's injuries. He reported he could not disclose all the details of the investigation/interviews as the case was still ongoing. Detective #163 was able to share he interviewed STNA #123 on 03/28/19 and the nurse aide admitted to dropping the resident, and at first stated he had told a nurse, then admitted to the detective that he did not tell a nurse. Detective #163 reported STNA #123 admitted to him that the resident was experiencing pain when he worked with her that night on 03/21/19, and during the next night shift on 03/22/19. Detective #163 also reported he interviewed STNA #127 who also stated the resident was experiencing significant pain when she provided incontinence care on 03/22/19 and told the nurse the resident was having knee pain, but affirmed she did not communicate to the nurse that she knew why the resident was having increased pain. An interview with LPN #99 was conducted on 04/04/19 at 10:04 A.M. regarding Resident #40's leg fractures and to ascertain why the resident's physician was not notified regarding the residents increased complaints of pain, and reports of falling/being dropped prior to 03/24/19. LPN #99 stated STNA #69 reported to her on Saturday, 03/22/19, the resident was having knee pain. LPN #99 shared she physically assessed Resident #40's knees/legs. LPN #99 reported Resident #40's entire legs were not swollen or out of alignment. She reported the resident was alert with confusion at times and didn't really rate her pain using a numerical scale, but she assessed the resident's pain based on observations of the resident, and her verbal expressions of pain. LPN #99 stated on Saturday, 03/22/19, the resident asked to call her daughter, so she dialed the number for her and she spoke with her daughter. She communicated Resident #40's daughter then called her and stated to LPN #99 the resident was reporting that she had been dropped on her knees, and then said that she knew her mother could be confused, and LPN #99 told the daughter she did not have any reports of the resident having fallen, been dropped, or having any injuries. When asked why she did not report to Administrative staff that Resident #40 was saying she had been dropped, LPN #99 stated she did not think it was necessary to report as the claim came from the daughter who did not believe that it had occurred. LPN #99 was then queried as to when the determination was made to contact Resident #40's physician and notify administrative staff regarding the resident's report of being dropped. She stated on Sunday, 03/24/19, STNA #69 called her to come talk with Resident #40 during breakfast so the resident could tell her what she had told STNA#69. LPN #99 stated the resident told STNA #69 and herself that she had been dropped but was confused about when it happened stating something like the day before, the day before yesterday. She communicated the resident reported she thought it was a man who dropped her but was not certain. LPN #99 stated the resident did appear to have swelling in both knees at that time. She reported she called the DON after the resident told her she had been dropped and also called the resident's physician. LPN #99 reported the physician ordered x-rays of both legs on 03/24/19, both legs were positive for fracture, and the resident was then sent out to the hospital for evaluation. An interview was conducted with Receptionist #21 on 04/04/19 at 10:48 A.M. regarding Resident #40's injuries. Receptionist #21 reported she was familiar with the resident and spoke with her daily when she was up. Receptionist #21 stated Resident #40 was not out to the dining area, or reception area, all day on Friday, 03/22/19 or Saturday morning, 03/23/19. She presumed she was in bed. Receptionist #21 reported Resident #40's daughter was in and wanted the resident to get up, and she did come out in the afternoon before the scheduled entertainment arrived. Receptionist #21 communicated that was when Resident #40 told her that her legs were absolutely killing her. Receptionist #21 stated she gently rolled up her pants, as they were loose fitting, and observed the resident's knees were huge and swollen. Receptionist #21 stated she asked the resident how her knees got like that and the resident was not able to exactly state how it happened, but her exact words were that she was dropped. Receptionist #21 stated the resident did state to her it was a male aide, that he did not mean to hurt her, and was confused as to when it exactly happened. Receptionist #21 stated she thought for sure Resident #40's daughter would have known about it, and would have been notified. Receptionist #21 communicated she reported what Resident #40 said to her to the nurse who was caring for her that day, and described LPN #99. She stated she also told the Administrator on the following Monday. The facility policy and procedure titled Reporting Abuse to Facility Management and revised on 08/16/16 was reviewed. The review revealed the policy statement specified it was the responsibility of our employees, facility consultants, attending physicians, family members, visitors, etcetera to immediately report any incident or suspected incident of neglect or resident abuse including injuries of unknown source and theft and/or misappropriation of resident property to facility management. Additionally, the facility policy and procedure titled Reporting/Investigation Resident Accidents/Incidents and revised 08/16/16 revealed the policy statement specified that all accidents/incidents involving residents must be immediately reported to the Administrator and the DON. In addition, all person's witnessing an accident or incident involving a resident must immediately report such information to their department supervisor.