Based on interviews, review of facility policy, and record reviews, it was determined the facility failed to provide services as outlined by the comprehensive care plan and that met professional standards of quality for one of 24 sampled residents (R) (R#26) related to thoroughly assessing the resident after a significant change in condition and ensuring pain management. Harm was identified to have occurred on 4/23/23, when staff were returning R#26 to their room after a shower and the resident's right foot hit a door frame. The resident immediately complained of pain and stated the pain radiated from their foot upward to the hip. The resident continued to complain of pain after the incident and requested an x-ray of the leg. Nursing staff assessed the resident's right foot but did not address the resident's continued complaints of pain to the right leg and thigh area or requests for an x-ray until 4/25/23 On 4/24/23 an x-ray was ordered, and R#26 had a fractured femur (bone in the upper part of the leg). This failure resulted in the delay of obtaining an x-ray which was positive for a fractured femur and ultimately resulted in R#26 having uncontrolled pain for approximately two days. Findings included: A review of the facility policy titled Pain Management, with an implementation date of 3/1/23, revealed The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. A review of the facility policy titled, Change in a Resident's Condition or Status, with a revised date of May 2022, indicated, The nurse will notify the resident's Attending Physician or physician on call when there has been a(an): significant change in the resident's physical/emotional/mental condition; specific instruction to notify the Physician of changes in the resident's condition. The policy further indicated The nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status. A review of the admission Record indicated the facility admitted R#26 on 3/2/18 with diagnoses that included multiple sclerosis, obesity, depression, hypertension, chronic pain, and diabetes. The admission Record also indicated on 5/21/23 a diagnosis of fracture of the right femur had been added. A review of the significant change in status Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 5/6/23, indicated R#26 was cognitively intact, with a Brief Interview for Mental Status (BIMS) score of 15. The MDS revealed R#26 required extensive to total assistance for all activities of daily living (ADLs) and required supervision with eating. Active diagnoses included a fracture. The MDS indicated the resident had not had pain in the last five days but had received non-medication interventions for pain. A review of the Care Plan for R#26, initiated on 3/3/18, with a revision date of 5/24/23, indicated R#26 was at risk for pain related to decreased mobility, weakness, and multiple sclerosis. The facility developed interventions that directed staff to administer pain medications per orders, notify the physician if interventions were unsuccessful or if a current complaint was a significant change from the resident's past experience with pain; observe and report changes in usual routine, sleep patterns, decrease in functional abilities, decrease in range of motion, or withdrawal/resistance to care; observe/document side effects of pain medication; report complaints of pain or requests for pain medication to the nurse; provide non-pharmacological interventions. A review of Progress Notes, dated 4/23/23 at 1:05 p.m. and designated as a late entry, indicated the nurse had been notified by the certified nursing assistant (CNA) that R#26 had hit their right foot, and the resident had complained of pain from the right foot radiating upward. The note indicated as needed (PRN) medication was given as ordered. A review of Progress Notes, dated 4/23/23 at 7:21 p.m., indicated R#26 was returning to the resident's room when the resident's foot struck the room door. The note indicated R#26 complained of pain, and a PRN medication was given. The note further indicated the physician was notified and a message was left. The note did not contain documentation that outlined any injury the resident may have sustained and did not include the quality and quantity of pain experienced by R#26. A review of the April 2023 Medication Administration Record (MAR) indicated the nurse gave acetaminophen 500 milligrams (mg), two tablets, on 4/23/23 at 3:00 p.m., or approximately two hours after the incident. There was a U under the time, and the key on the MAR indicated that meant the effectiveness of the medication was unknown. A review of an incident report, initiated on 4/23/23 at 2:16 p.m., indicated R#26 complained of pain to the right leg. The incident report indicated the resident's description of the incident was that the resident's foot dropped and hit the door when returning to their room. Per the resident's description, I felt a lot of pain shooting from the foot up the hip. The nurse documented no injuries were observed at the time of the incident. The incident report indicated the resident's level of pain on a 0-10 scale was a nine at the time of the incident. The incident report further indicated the resident had no observed injuries post incident and the resident's pain was rated as a four on a 0-10 scale. The incident report indicated pain medication was administered. The incident report indicated the physician was notified on 4/23/23 at 4:43 p.m. There was a note on the incident report dated 4/26/23 (no time documented), that indicated the CNA informed the nurse that while taking the resident in the shower chair back to the resident's room after a shower, the resident hit their right foot. The note indicated the nurse assessed the resident, the resident complained of pain to the right foot radiating upward, PRN pain medication was administered as ordered, and the physician was notified. The note further indicated on 4/25/23 the resident voiced that PRN acetaminophen was not relieving the pain and the physician was notified. The physician ordered an x-ray of the right lower extremity. The note indicated the x-ray was positive for a right femur (bone in the upper part of the leg) fracture. The note indicated the resident was transferred to the hospital in stable condition. A review of Progress Notes revealed no assessments were completed to determine any injuries or determine R#26's pain level on Monday, 4/24/23 or Tuesday, 4/25/23. A review of the April 2023 MAR revealed R#26 received no pain medication on 4/24/23, 4/25/23, or 4/26/23. A review of Progress Notes revealed on 4/25/23 at 3:19 p.m., LPN #22 completed a SBAR (an acronym for Situation, Background, Assessment, and Recommendations. The SBAR is a form used to gather data prior to calling a physician for a change in a resident's condition). The SBAR indicated R#26 had uncontrolled pain. On 4/25/22 at 3:50 p.m., the nurse documented R#26 had pain in the right leg from the hip going to the knee and informed the nurse the Tylenol was not relieving the pain. The physician ordered an X-ray of the right leg. A review of a Progress Note, dated 4/25/23 at 7:44 p.m., indicated R#26's physician went to the facility, evaluated R#26, and ordered transfer to the hospital. A review of a radiology report, dated 4/25/23, indicated R#26 had sustained an overlapping, separated fracture through the proximal third of the femur. An interview was held with R#26 on 6/1/23 at 8:30 a.m. R#26 stated that on Sunday, 4/23/23, before lunch, CNA #9 had given the resident a shower. On the way back into the resident's room, R#26's foot struck the door frame. R#26 stated that when the foot struck the door frame, the resident yelled and had immediate pain, described as horrendous, extending from the foot to the thigh. R#26 stated the nurse looked at the foot, and although the resident stated they kept telling the nurse the pain went to the thigh, the nurse only looked at the foot. R#26 stated they asked for an x-ray, and the nurse stated she would recommend an x-ray. R#26 stated that every time the resident was moved, they experienced horrible pain in the thigh. The resident added they did not receive an x-ray on Sunday or Monday and finally, because they continued to ask about an x-ray, the resident stated that on Tuesday, an x-ray was done. R#26 stated that later on Tuesday, 4/25/23, the Director of Nursing (DON) reported the resident had sustained a femur fracture. R#26 stated they had a hard time sleeping after the incident and had to lie very still to avoid pain. R#26 stated they had to keep requesting the x-ray, and they felt that was why it took two days to have the x-ray completed and added they were not sure they would have ever gotten an x-ray if they had not continued to ask staff for an x-ray on a daily basis. R#26 stated that on Monday, 4/24/23, and on Tuesday, 4/25/23, there was no nurse that looked at the resident's leg. R#26 stated the CNA was the only one that seemed to care the resident was in pain. The resident stated the pain was so bad they almost cried and used deep breathing to help control the pain. Resident #26 described the pain as dull pain to sharp, intense pain and added they rated the least amount of pain felt from 4/23/223 to the time of transfer to the hospital on 4/26/23 was an eight on a 0-10 scale. R#26 stated CNA #9 continued to ask about pain and report to the nurses, and the resident felt it was the nurses and the facility that had not followed up as they should have. During an interview with CNA #9 on 6/1/23 at 9:00 a.m., she stated R#26 immediately yelled out when their foot struck the doorway. CNA #9 stated R#26 asked her to report to the nurse that their side was hurting due to the foot striking the doorway, and the CNA confirmed she had reported to LPN #10. The CNA stated LPN #10 went to speak with R#26. CNA #9 stated that by the end of the shift, R#26 stated they felt a little better. The CNA stated she told the nurses the Tylenol was not working for R#26. During an interview with LPN #10 was interviewed on 6/1/23 at 12:19 p.m. she stated CNA #9 reported R#26's incident to her. The LPN stated she had only examined the resident's foot and found no redness or open areas. LPN #10 stated R#26 had complained only of mild pain. LPN #10 stated she reported the incident to the physician, who ordered Tylenol for pain and to continue to monitor the resident. LPN #10 stated the results of the monitoring and assessment should be documented in the progress notes and on the 24-hour report to let the on-coming nurse know. The nurse stated she was unsure if the resident required pain medication on the day of the incident, but if she had given pain medication, it would have been documented. LPN #10 stated she had reported the incident to the nurse supervisor who completed the incident report and stated she had expected the supervisor to write a note in the progress notes. The nurse stated she did not remember receiving a report from the CNA that it was not the resident's foot hurting but the thigh. LPN #10 stated the facility policy for documentation after an incident or change in resident's condition was for nurses to document every shift for 72 hours. During a telephone interview held with LPN #22 on 6/1/23 at 1:12 p.m. she stated that when she came to work for the 7:00 a.m. to 7:00 p.m. shift on Monday, 4/24/23, she had not been informed about R#26's incident by staff and added it was R#26 that told her they had incurred an accident after their shower. LPN #22 stated that on Monday (4/24/23) R#26 described the pain as shooting from knee to hip. The nurse stated she did not ask the resident to rate the pain and just checked the spot to confirm a pain assessment had been completed. The nurse stated she gave the resident Tylenol but returned to R#26 and asked if the pain had been relieved and had no explanation why the Tylenol was not documented as given. LPN #22 confirmed that she was supposed to ask the residents if the Tylenol had been effective. The nurse stated that after an incident or a change in condition, the policy was to assess and document every four hours. She stated she had not assessed the resident on Monday, 4/24/23, and was unable to tell if the resident's leg was swollen or bruised and had no reason for the lack of assessment or documentation. She stated on Tuesday (4/25/23) she had not assessed R#26's leg and hip but knew the resident's pain was uncontrolled. The nurse was unable to give a reason why there was no documentation that the resident was provided acetaminophen as ordered for pain on 4/25/23. During an interview with LPN #17, who was the Unit Manager, on 6/1/23 at 2:57 p.m. they stated that when a resident experienced a change in condition, the expectation was for nurses to document every shift for 72 hours or until resolution of the problem. LPN #17 stated that for the incident involving R#26, the nurses were expected to assess the injured area and assess the resident's pain level every shift. LPN #17 stated it was not the responsibility of the resident to remind staff about the incident and continue to request an x-ray. LPN #17 stated the expectation was for each nurse to document their assessment findings in the progress notes. During an interview with LPN #21, who functioned as the Staff Development Coordinator, on 6/1/23 at 3:24 p.m. she stated that for an incident or a change in condition, nurses were expected to assess the resident and document every shift for 72 hours and added the documentation should be found in the progress notes. LPN #21 stated that for R#26, documentation was expected to include the resident's pain level, signs of redness or bruising to the area that struck the door, or any new complaints the resident had. During an interview with the DON on 6/1/23 at 4:30 p.m., she stated nurses were taught to assess and document every shift for 72 hours for any incident that occurred. The DON stated she had reviewed R#26's medical record and found assessments and documentation were limited after the incident involving R#26 on 4/23/23. She stated she found that nurses had not assessed the resident daily and had not asked the resident about their pain level daily. The DON stated that when the incident occurred, the nurse was expected to complete a head-to-toe assessment for R#26, look for signs and symptoms of pain, ask other staff what had happened, and notify the physician of the incident and assessment findings. The DON stated she expected the nurse to have checked on the resident again before the end of the shift. The DON stated the nurse that had requested the one-time dose of Tylenol on 4/23/23 should have asked for an x-ray at that time, since the Tylenol ordered for the resident had not relieved the pain. The DON stated that from what staff told her, R#26's pain was controlled but added R#26 had told her the pain had not been controlled. The DON stated the nurse that worked Monday from 7:00 a.m. to 7:00 p.m. should have assessed R#26 and should have given the resident acetaminophen, called the physician, reminded the physician about the incident, told the physician about the shooting pain, informed the physician the acetaminophen was not relieving the pain, and requested an x-ray. During an interview with R#26 again on 6/223 at 12:04 p.m., they indicated the pain had decreased their appetite and added that after the incident, they ate almost nothing for lunch and only small amounts for dinner on 4/23/23. R#26 stated they tried to place the bed in a higher position to eat and immediately felt pain and added the focus was on trying to avoid the pain. R#26 added that when staff provided baths or incontinence care, no matter how careful staff tried to be, the pain was a 10 on a 0-10 scale. During an interview with the Administrator on 6/2/23 at 1:47 p.m., she stated that when a resident had an incident, she expected the nurses to assess the resident's condition, including pain, and provide documentation on the resident's condition. During an interview with the physician (MD) for R#26 by telephone on 6/2/23 at 2:35 p.m., she stated staff had called her on Sunday, 4/23/23, and told her R#26 had an incident that involved hitting the resident's foot against the door frame. The MD stated she was not informed R#26's pain extended from the knee to the hip and had not been told the pain was severe. The MD stated she had ordered acetaminophen 1000 mg to be given every eight hours and had ordered that staff monitor the resident. The MD stated had she been made aware of R#26's pain level and the location of the pain, from the knee to the hip, she would have ordered the x-ray before 4/25/23.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, review of facility policy, and record reviews, it was determined the facility failed to provide effective pain management for one of 24 sampled residents (R) (R#26). Harm was identified to have occurred on 4/23/23, when staff were returning R#26 to their room after a shower and the resident's right foot hit a door frame. The resident immediately complained of pain and stated the pain radiated from their foot upward to the hip. The resident continued to complain of pain after the incident and requested an x-ray of the leg. Nursing staff assessed the resident's right foot but did not address the resident's continued complaints of pain to the right leg and thigh area or requests for an x-ray until 4/25/23 On 4/24/23 an x-ray was ordered, and R#26 had a fractured femur (bone in the upper part of the leg). This failure resulted in the delay of obtaining an x-ray which was positive for a fractured femur and ultimately resulted in R#26 having uncontrolled pain for approximately two days. Findings included: A review of the facility policy titled Pain Management, with an implementation date of 3/1/23, revealed The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. A review of the admission Record indicated the facility admitted R#26 on 3/2/18 with diagnoses that included multiple sclerosis, obesity, depression, hypertension, chronic pain, and diabetes. The admission Record also indicated on 5/21/23 a diagnosis of fracture of the right femur had been added. A review of the significant change in status Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 5/6/23, indicated R#26 was cognitively intact, with a Brief Interview for Mental Status (BIMS) score of 15. The MDS revealed R#26 required extensive to total assistance for all activities of daily living (ADLs). Active diagnoses included a fracture. A review of the Care Plan for R#26, initiated on 3/3/18, with a revision date of 5/24/23, indicated R#26 was at risk for pain related to decreased mobility, weakness, and multiple sclerosis. The facility developed interventions that directed staff to administer pain medications per orders, notify the physician if interventions were unsuccessful or if a current complaint was a significant change from the resident's past experience with pain; observe and report changes in usual routine, sleep patterns, decrease in functional abilities, decrease in range of motion, or withdrawal/resistance to care; observe/document side effects of pain medication; report complaints of pain or requests for pain medication to the nurse; provide non-pharmacological interventions. A review of Progress Notes, dated 4/23/23 at 1:05 p.m. and designated as a late entry, indicated the nurse had been notified by the certified nursing assistant (CNA) that R#26 had hit their right foot, and the resident had complained of pain from the right foot radiating upward. The note indicated as needed (PRN) medication was given as ordered. A review of Progress Notes, dated 4/23/23 at 7:21 p.m., indicated R#26 was returning to the resident's room when the resident's foot struck the room door. The note indicated R#26 complained of pain, and a PRN medication was given. The note further indicated the physician was notified and a message was left. The note did not contain documentation that outlined any injury the resident may have sustained and did not include the quality and quantity of pain experienced by R#26. A review of the April 2023 Medication Administration Record (MAR) indicated the nurse gave acetaminophen 500 milligrams (mg), two tablets, on 4/23/23 at 3:00 p.m., or approximately two hours after the incident. There was a U under the time, and the key on the MAR indicated that meant the effectiveness of the medication was unknown. A review of an incident report, initiated on 4/23/23 at 2:16 p.m., indicated R#26 complained of pain to the right leg. The incident report indicated the resident's description of the incident was that the resident's foot dropped and hit the door when returning to their room. Per the resident's description, I felt a lot of pain shooting from the foot up the hip. The nurse documented no injuries were observed at the time of the incident. The incident report indicated the resident's level of pain on a 0-10 scale was a nine at the time of the incident. The incident report further indicated the resident had no observed injuries post incident and the resident's pain was rated as a four on a 0-10 scale. The incident report indicated pain medication was administered. The incident report indicated the physician was notified on 4/23/23 at 4:43 p.m. There was a note on the incident report dated 4/26/23 (no time documented), that indicated the CNA informed the nurse that while taking the resident in the shower chair back to the resident's room after a shower, the resident hit their right foot. The note indicated the nurse assessed the resident, the resident complained of pain to the right foot radiating upward, PRN pain medication was administered as ordered, and the physician was notified. The note further indicated on 4/25/23 the resident voiced that PRN acetaminophen was not relieving the pain and the physician was notified. The physician ordered an x-ray of the right lower extremity. The note indicated the x-ray was positive for a right femur (bone in the upper part of the leg) fracture. The note indicated the resident was transferred to the hospital in stable condition. A review of the April 2023 Medication Administration Record (MAR) revealed that on 4/23/23 at 3:00 p.m., R#26 was given acetaminophen 500 mg, two tablets for pain that was rated as three on a 0-10 scale. The MAR further indicated R#26 was given acetaminophen 500 mg, two tablets again at 9:01 p.m. on 4/23/23. The MAR indicated the dose given at 9:01 p.m. on 4/23/23 was a one time dose. The April 2023 MAR indicated there was no further pain-relieving medications provided to R#26 after 4/23/23 at 9:01 p.m. A review of the Progress Notes revealed an SBAR (an acronym that stands for Situation, Background, Assessment, Recommendation. This is a form used to collect data to call the physician and provide a complete recapitulation of a change in condition) was completed on 4/25/23 at 3:19 p.m. The SBAR indicated R#26 had uncontrolled pain. At 3:50 p.m., the resident complained of pain in the right leg from the hip going to the knee and stated Tylenol was not helping. A review of the April 2023 MAR revealed no evidence R#26 was provided pain medication even though documentation in the progress notes indicated the resident had uncontrolled pain. A review of Progress Notes indicated Resident #26 was transferred to the hospital for further evaluation on 04/26/2023. A review of a Discharge Summary from the hospital dated 5/1/23, indicated R#26 was admitted to the hospital on [DATE] with a diagnosis of fracture of the shaft of the right femur. The documentation indicated orthopedic surgery, pain control, and supportive care were provided. During an interview with R#26 on 6/1/23 at 8:30 a.m. R#26 stated that on Sunday, 4/23/23, before lunch, CNA #9 had given the resident a shower. On the way back into the resident's room, R#26's foot struck the door frame. R#26 stated that when the foot struck the door frame, the resident yelled and had immediate pain, described as horrendous, extending from the foot to the thigh. R#26 stated the nurse looked at the foot, and although the resident stated they kept telling the nurse the pain went to the thigh, the nurse only looked at the foot. R#26 stated they asked for an x-ray, and the nurse stated she would recommend an x-ray. R#26 stated that every time the resident was moved, they experienced horrible pain in the thigh. The resident added they did not receive an x-ray on Sunday or Monday and finally, because they continued to ask about an x-ray, the resident stated that on Tuesday, an x-ray was done. R#26 stated that later on Tuesday, 4/25/23, the Director of Nursing (DON) reported the resident had sustained a femur fracture. R#26 stated they had a hard time sleeping after the incident and had to lie very still to avoid pain. R#26 stated they had to keep requesting the x-ray, and they felt that was why it took two days to have the x-ray completed and added they were not sure they would have ever gotten an x-ray if they had not continued to ask staff for an x-ray on a daily basis. R#26 stated that on Monday, 4/24/23, and on Tuesday, 4/25/23, there was no nurse that looked at the resident's leg. R#26 stated the CNA was the only one that seemed to care the resident was in pain. The resident stated the pain was so bad they almost cried and used deep breathing to help control the pain. R#26 described the pain as dull pain to sharp, intense pain and added they rated the least amount of pain felt from 4/23/23 to the time of transfer to the hospital on 4/26/23 was an eight on a 0-10 scale. R#26 stated CNA #9 continued to ask about pain and report to the nurses, and the resident felt it was the nurses and the facility that had not followed up as they should have. During an interview with CNA #9 on 6/1/23 at 9:00 a.m., she stated R#26 immediately yelled out when their foot struck the doorway. CNA #9 stated R#26 asked her to report to the nurse that their side was hurting due to the foot striking the doorway, and the CNA confirmed she had reported to LPN #10. The CNA stated LPN #10 went to speak with R#26. The CNA stated she told the nurses the Tylenol was not working for R#26. During an interview with LPN #10 was interviewed on 6/1/23 at 12:19 p.m. she stated CNA #9 reported R#26's incident to her. The LPN stated she had only examined the resident's foot and found no redness or open areas. LPN #10 stated R#26 had complained only of mild pain. LPN #10 stated she reported the incident to the physician, who ordered Tylenol for pain and to continue to monitor the resident. LPN #10 stated the results of the monitoring and assessment should be documented in the progress notes and on the 24-hour report to let the on-coming nurse know. The nurse stated she was unsure if the resident required pain medication on the day of the incident, but if she had given pain medication, it would have been documented. LPN #10 stated she had reported the incident to the nurse supervisor who completed the incident report and stated she had expected the supervisor to write a note in the progress notes. The nurse stated she did not remember receiving a report from the CNA that it was not the resident's foot hurting but the thigh. LPN #10 stated the facility policy for documentation after an incident or change in resident's condition was for nurses to document every shift for 72 hours. During a telephone interview held with LPN #22 on 6/1/23 at 1:12 p.m. she stated that when she came to work for the 7:00 a.m. to 7:00 p.m. shift on Monday, 4/24/23, she had not been informed about R#26's incident by staff and added it was R#26 that told her they had incurred an accident after their shower. LPN #22 stated that on Monday (4/24/23) R#26 described the pain as shooting from knee to hip. The nurse stated she did not ask the resident to rate the pain and just checked the spot to confirm a pain assessment had been completed. The nurse stated she gave the resident Tylenol but returned to R#26 and asked if the pain had been relieved and had no explanation why the Tylenol was not documented as given. LPN #22 confirmed that she was supposed to ask the residents if the Tylenol had been effective. The nurse stated that after an incident or a change in condition, the policy was to assess and document every four hours. She stated she had not assessed the resident on Monday, 4/24/23, and was unable to tell if the resident's leg was swollen or bruised and had no reason for the lack of assessment or documentation. She stated on Tuesday (4/25/23) she had not assessed R#26's leg and hip but knew the resident's pain was uncontrolled. The nurse was unable to give a reason why there was no documentation that the resident was provided acetaminophen as ordered for pain on 4/25/23. During an interview with LPN #17, who was the Unit Manager, on 6/1/23 at 2:57 p.m. they stated that for the incident involving R#26, the nurses were expected to assess the injured area and assess the resident's pain level every shift. LPN #17 stated it was not the responsibility of the resident to remind staff about the incident and continue to request an x-ray. LPN #17 stated the expectation was for each nurse to document their assessment findings in the progress notes. During an interview with LPN #21, who functioned as the Staff Development Coordinator, on 6/1/23 at 3:24 p.m. she stated that for R#26, documentation was expected to include the resident's pain level, signs of redness or bruising to the area that struck the door, or any new complaints the resident had. During an interview with the DON on 6/1/23 at 4:30 p.m., she stated nurses were taught to assess and document every shift for 72 hours for any incident that occurred. The DON stated she had reviewed R#26's medical record and found assessments and documentation were limited after the incident involving R#26 on 4/23/23. She stated she found that nurses had not assessed the resident daily and had not asked the resident about their pain level daily. The DON stated that when the incident occurred, the nurse was expected to complete a head-to-toe assessment for R#26, look for signs and symptoms of pain, ask other staff what had happened, and notify the physician of the incident and assessment findings. The DON stated she expected the nurse to have checked on the resident again before the end of the shift. The DON stated the nurse that had requested the one-time dose of Tylenol on 4/23/23 should have asked for an x-ray at that time, since the Tylenol ordered for the resident had not relieved the pain. The DON stated that from what staff told her, R#26's pain was controlled but added R#26 had told her the pain had not been controlled. The DON stated the nurse that worked Monday from 7:00 a.m. to 7:00 p.m. should have assessed R#26 and should have given the resident acetaminophen, called the physician, reminded the physician about the incident, told the physician about the shooting pain, informed the physician the acetaminophen was not relieving the pain, and requested an x-ray. During an interview with R#26 again on 6/2/23 at 12:04 p.m., they indicated the pain had decreased their appetite and added that after the incident, they ate almost nothing for lunch and only small amounts for dinner on 4/23/23. R#26 stated they tried to place the bed in a higher position to eat and immediately felt pain and added the focus was on trying to avoid the pain. R#26 added that when staff provided baths or incontinence care, no matter how careful staff tried to be, the pain was a 10 on a 0-10 scale. During an interview with the physician (MD) for R#26 by telephone on 6/2/23 at 2:35 p.m., she stated staff had called her on Sunday, 4/23/23, and told her R#26 had an incident that involved hitting the resident's foot against the door frame. The MD stated she was not informed R#26's pain extended from the knee to the hip and had not been told the pain was severe. The MD stated she had ordered acetaminophen 1000 mg to be given every eight hours and had ordered that staff monitor the resident. The MD stated had she been made aware of R#26's pain level and the location of the pain, from the knee to the hip, she would have ordered the x-ray before 4/25/23.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, staff interviews, and policy review, the facility failed to follow the care plan for one of 39 residents (R#76), who suffered harm during a fall from the bed when staff failed to provide two-person assistance for care. The facility failed to follow the care plan for one of 39 residents (R#71) by failing to apply a right hand splint. In addition, the facility also failed to develop a care plan for R#76 for the use of a low air loss mattress. Findings include: Review of the policy titled, Comprehensive Care Plan, revised May 2021, revealed the center will develop a comprehensive person-centered care plan that identifies each resident's medical, nursing, mental, and psychosocial needs. The comprehensive care plan must ensure that the resident maintains the highest practical physical, mental, and psychosocial well-being. 1. Review of the clinical record for R#76 revealed she was admitted to the facility on [DATE] with diagnoses including but not limited to osteoarthritis, hypertension (HTN), anxiety, agitation, pseudobulbar affect, and dementia. The resident's Annual Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) was coded as zero, which indicated severe cognitive impairment. Section G revealed R#76 required extensive assistance of two people with bed mobility and transfers. Review of care plan initiated on 4/10/2019 and revised on 10/6/2021 revealed resident was at risk for falls. Interventions for care include provide assistance as required for completion of activities of daily living (ADL) tasks via two-person assistance. Further review of the residents care plans revealed there was no evidence that a care plan was developed for the use of an air mattress. Review of R#76's Physician Orders revealed an order for an air mattress dated 1/20/2020. Interview on 1/13/2022 at 10:07 a.m. with Minimum Data Set (MDS) Coordinator SS stated the RCS's utilize the task section on the computer to know what care each resident required. MDS Coordinator SS stated the Unit Managers (UM's) were responsible for ensuring the care plan was followed. Interview on 1/13/2022 at 10:18 a.m. with RCS TT stated the task section on the computer would direct the care the resident required. Interview on 1/13/2022 at 10:31 a.m. with UM FF revealed the charge nurse was responsible for ensuring that care was provided per the care plan. During further interview, she stated the UM had the overall responsibility to ensure the care was provided as care planned. Interview on 1/13/2022 at 1:31 p.m. with the Director of Nursing (DON) confirmed the air mattress was not on R#76 care plan at the time of the October 13, 2021 fall. She further stated the intervention for two staff members to perform ADLs as indicated on the care plan, does not always happen. Interview on 1/14/2022 at 9:56 a.m. with RCS PP stated on the day of the fall she was giving R#76 a bed bath around 4:00 a.m. She stated she put the side rail down and turned the resident towards her. She stated when she went to put the sheet on the bottom of the bed, the resident began to slide down and fell to the floor. During further interview, RCS PP stated prior to this incident, she had not received any training regarding putting the air mattress on hold when providing care. Cross Refer F689 2. Review of the clinical record for R#71 revealed resident was admitted to the facility on [DATE] with diagnoses of but not limited to diabetes, hypertension, depression, and hemiplegia affecting the right side. The resident's most recent Quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) was coded as eight, which indicated moderate cognitive impairment. Section G revealed the resident had limitation in range of motion (ROM) on one side of the upper extremities and limitation in ROM on both sides of the lower extremity. The resident was not currently receiving therapy services or restorative services. Review of the resident's care plan initiated on 4/23/2020 and revised on 2/11/2021 documented the resident requires assistance with ADL's related to spastic hemiplegia. Interventions to care include carrot to right hand at all times to prevent further contractures and remove for hygiene, practice passive range of motion (PROM) to right hand and hygiene to both hands during morning care. Apply carrots to right hand. Observation on 1/11/2022 at 9:21 a.m. revealed R#71 was lying in bed and without a splint device in the right hand. Observation on 1/12/2022 at 11:58 a.m. revealed R#71 sitting in her wheelchair and without a splint device in the right hand and the right hand was closed tightly. Observation on 1/13/2022 at 9:17 a.m. revealed R#71 lying in her bed. The resident's right hand was clenched shut and there was no splint device in the right hand. Interview on 1/13/2022 at 9:39 a.m. with the Rehab Director revealed the Resident Care Specialists (RCS's) should put a splint in R#71's hand daily. Cross Refer F688

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, staff interviews and policy review, the facility failed to provide supervision and care to prevent a fall from the bed for one of one residents (R) R#76 reviewed for falls that had a low air loss mattress in use. Actual harm occurred on October 13, 2021, when R#76 had a fall from the bed during the provision of care that resulted in a laceration to the forehead requiring 11 sutures. Findings include: Review of the facility policy titled, Sava Senior Care Low-Air-Loss Therapy Bed Use date 5/21/2021, documented the low-air-loss therapy bed consists of segmented air-filled cushions that provide surface area for pressure relief. To turn and reposition the resident, use the turn-assist feature or maximum-inflate feature to fully inflate the bed. Review of the facility policy titled, Fall Management dated 7/2017, documented the facility would assist each resident in attaining/maintaining his or her highest practicable level of function by providing the resident adequate supervision, assistive devices and/or functional programs, as appropriate, to minimize the risk for falls. Review of the User-Service Manual Joerns Support Surface DermaFloat LAL (low air loss) Model (mattress in use at time of fall) dated 2015 documented, The Therapy Control Unit Features an autofirm mode which provides maximum air inflation designed to assist both residents and caregivers during resident transfer and treatment. Review of the clinical record for R#76 revealed she was admitted to the facility on [DATE] with diagnoses including but not limited to osteoarthritis, hypertension (HTN), anxiety, agitation, pseudobulbar affect, and dementia. The resident's Annual Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) was coded as zero, which indicated severe cognitive impairment. Section G revealed R#76 required extensive assistance of two people with bed mobility and transfers and had decreased range of motion on one side of her upper extremities. Review of care plan initiated on 4/10/2019 and revised on 10/6/2021 revealed resident is at risk for falls. Interventions to care include provide assistance as required for completion of activities of daily living (ADL) tasks via two-person assistance. There was no evidence on the care plan to indicate the use of an air mattress. Review of R#76's Physician Orders revealed an order for an air mattress dated 1/20/2020. Review of the facility's October 2021 Task List Report which directs the Resident Care Specialist (RCS's) care for each resident, did not indicate that R#76 required two staff assistance with ADLs or identify the use of an air mattress. Review of the Fall Risk Assessment dated 9/2/2021 revealed the resident to be a high risk for falls. Review of the emergency room (ER) documentation dated 10/13/2021 at 7:25 a.m. revealed patient presents with a fall from the bed this morning while getting a bed bath, hit head and has a 10 centimeter (cm) linear laceration to the right forehead and scalp with placement of 11 sutures. Review of the facility's investigation dated 10/13/2021 at 6:40 a.m. revealed the nurse was called to R#76's room by the Resident Care Specialist (RCS) during morning care to observe the resident on the floor. RCS PP stated the resident flip [sic] out of bed when she turned her over. Resident noted to be lying on her right side on the floor with a head injury with excessive bleeding. The air mattress was not put on hold during care. Review of the Director of Nursing's (DON) summary dated 10/13/2021 documented, per Night Supervisor CC, RCS PP was giving morning care and did not place the air mattress on hold. Upon interviewing RCS PP, she stated the resident was on her side and the weight of the resident along with the movement of the air mattress was forceful enough to cause the resident to roll out of the bed onto the floor causing her to hit her head. Observation on 1/11/2022 at 9:09 a.m. revealed R#76 lying in a low bed and floor mats on both sides of the bed. Further observation revealed air mattress had been removed from the bed. Observation on 1/13/2022 at 9:20 a.m. revealed R#76 lying in a low bed with floor mats on both sides of the bed. One-quarter siderails raised on the top portion of the bed. Interview on 1/12/2022 at 1:35 p.m. with the DON revealed RCS PP was providing morning care to R#76 on the day of the fall. She stated RCS PP turned the resident to her side and the air mattress rolled the resident out of the bed and onto the floor. During further interview, DON stated that the resident was sent to the hospital to get stitches in her head. Interview on 1/13/2022 at 1:31 p.m. with the DON confirmed the air mattress was not on the care plan at the time of the fall. She stated, if staff could have two people to do the turn it would be great but in reality, it does not always happen. During further interview, the DON stated the quarter rails were in the raised position when the resident fell. Interview on 1/13/2022 at 4:10 p.m. with the DON stated there was no policy on how to provide care for a resident lying on an air mattress. Interview on 1/14/2022 at 8:59 a.m. with the DON, stated each unit had the [NAME] Book that the Nurses and RCS's could reference for guidelines to care, including the use of an air mattress. Interview on 1/14/2022 at 9:08 a.m. with Night Supervisor CC, revealed on 10/13/2021 the nurse reported to her that R#76 was on the floor. Night Supervisor CC stated that RCS PP was providing care and the air mattress was not on hold per RCS PP. When RCS PP began to turn R#76, the resident fell to the floor on the window side of the room and received a head laceration. She further stated the siderails were raised but did not remember the height of the bed. During further interview, Night Supervisor CC stated if staff think they need help, they need to get another staff member and always turn the resident towards themselves. Interview with RCS PP on 1/14/2022 at 9:56 a.m. stated on the day of the fall she was giving R#76 a bed bath around 4:00 a.m. RCS PP stated she put the side rail down and turned the resident towards her. When I went to put the sheet on the bottom of the bed the resident began to slide down and fell to the floor. During further interview, she stated after the fall we had an in-service and were told that anybody with an air mattress needs to have two people present for any care and staff should place the air mattress on standby. She further stated prior to this incident she had not received any training about putting the air mattress on hold when providing care.