Based on observation, interview, and record review, the facility failed to provide timely treatment for 1 of 3 residents (R68) reviewed for change of condition in the sample of 33. This failure resulted in R68 delay in treatment and requiring hospital admission. Findings include: 1. R68's nursing notes, dated 12/01/2024 at 10:17 AM, documents attempted to contact radiology for x-ray results and left message on answering machine. R68's nursing notes, dated 12/1/2024 at 1:23 PM, documents, contacted Nurse Practitioner unable to obtain x-ray results and resident continues with decline in physical mobility, cough with yellow sputum, afebrile, wheezing bilateral upper lobes. and received NO (nurse order) for Ceftriaxome IM QD (daily) x 3 days. CBC (complete blood count) and CMP (comprehensive metabolic profile) on Monday 12-02-24. R68s' nursing notes, dated 12/01/2024 at 11:13 PM, documents, resident experiencing nasal congestion, denies dyspnea or shortness of breath. Resident afebrile at 98.4 F. Diffuse wheezing auscultated to bilateral lungs. Resident denies experiencing a productive cough. Resident has brisk capillary refill with no cyanosis present. HOB elevated pulse oximetry at 98% on room air. R68's final x-ray results, dated 12/2/2024 at 7:41AM, documents minimal bibasilar airspace disease, may represent atelectasis, aspiration or pneumonia. R68's nursing notes, dated 12/02/2024 at 09:02 AM, documents, resident noted to have increase in weakness requiring use of sit-stand. He continues to have cough, congestion, and wheezing heard in upper and bilateral lobes. Vitals were 145/77, 89% on RA (Room air), (initiated PRN oxygen at 2L) , T (Temperature):100, RR (Respiratory Rate) 20 (Pulse), P 77. He states during exertion he is SOB (Short of breath) but not at rest. Resident placed into isolation r/t (related to) s/s (signs and symptoms) and awaiting test at this time. On 12/2/2024 at 10:33AM, R68 stated, I am sick that is why I am in isolation R68's Hospital history and physica,l dated 12/2/2024 at 4:11PM, documents coarse lung sounds throughout with diffuse expiratory wheeze. Complaint community acquired pneumonia. R68's hospital admission history and physical documents R68 complains of body aches, weakness and non -productive cough. R68's history and physical documents assessment and plan ; community acquired pneumonia, supplemental oxygen via nasal cannula, titrate as able, vitals every 4 hours, respiratory failure. On 12/5/2024 at 12:50PM, V1, Administrator, stated she took R68 to the local hospital for an X-ray on Saturday 11/30/2024, as (x-ray company) could not be at facility until Monday. V1 stated when called hospital for x-ray results were told x-ray results not be read until Monday. V2 stated X-ray results came in sometime on Monday. The facility policy Change in a resident's condition, revised 12/02, documents, the facility shall promptly notify the resident, and /or residents's representative, and his or her attending physician of changes in the resident's condition and/or status. The policy documents the nurse will notify the resident's attending physician when there is a significant change in the resident's physical , mental , or psychosocial status; deemed necessary or appropriate in the best interest of the resident. The facility policy diagnostic service dated revised 11/28/17 documents provision has been made for promptly and conveniently obtaining required clinical laboratory , x-ray and other diagnostic services from clinical laboratory or diagnostic service, physicians office or hospital.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to supervise and prevent an altercation for 2 of 2 (R3, R4) residents, reviewed for incidents and accidents in a sample of 5. This failure resulted in R4 being sent to the local emergency department after an altercation with R3 and sustaining facial contusion, contusion of both forearms and contusion to her right shoulder. Finding includes: R3's Minimum Data Set, dated [DATE], documented R3 was unable to complete the questions to gauge his cognition. It continued to document he was severely impaired for decision making, Physical behavioral symptoms directed towards other that had been occurring for 1 to 3 days and that he also had the ability to put others at significant risk for physical injury. R3's Face Sheet, undated, documented diagnoses of Dementia with agitation, Dementia with Anxiety and Blindness Right and Left eye. R3's Care Plan, dated 8/8/2023, documented, When (R3) is displaying s/s of behaviors offer to call his wife (V16, R3's wife). It continues, If (R3) displays behaviors during cares, allow him space and attempt task at a later time. R4's MDS, dated [DATE], documented R4's cognition was severely impaired. R4's Face Sheet, undated, documented a diagnosis of Dementia without behavioral, psychotic mood or anxiety disturbance. R3's Progress notes, dated 04/03/2024 at 1:00 PM, documented, [Recorded as Late Entry on 04/04/2024 11:04 AM] Resident was very confused and agitated with staff, Resident was yelling, help call the police, and was exit seeking. Resident did become combative with staff, and bit this nurse's arm, but did not break the skin. Resident was redirected, and his wife was called for a distraction. R3's Progress notes, dated 04/03/2024 at 2:19 PM, documented, Resident was increasingly agitated, with minimal success in redirecting with multiple different approaches attempted. His wife came to facility and talked with him to calm him. Resident setting in his room with his wife listening to a ballgame. R3's Progress notes, dated 04/04/2024 at 09:23 AM, documented, (Resident) continues to have behaviors. (Resident) was assisted down to ride the exercise bike with therapy ad he refused to stand up and participate. Staff unable to redirect and had to bring (Resident) back to his room and assisted into recliner. Continues on rexulti medication change. R3's Progress notes, dated 04/06/2024 at 3:01 PM, documented, Resident was verbally aggressive this afternoon for a short period and was redirected with some effort. R3's Progress notes, dated 04/12/2024 at 2:22 PM, documented, Resident having verbal and physical behaviors towards staff. Stating he was going to get his hammer and hit this nurse and other staff. Redirected to recliner in room and resident continued to attempt to stand up and yell and hit staff. (as needed) Ativan given and able to redirect resident back into recliner and rest at this time. R3's Progress notes, dated 04/12/2024 at 10:56 PM, documented, (Resident) has extreme outburst with verbal and physical behaviors. Attempted to give prn Ativan, and (resident) spit it at nurse. (Continued) to attempt to de-escalate (resident) with no effect. CNA holding (resident) arms, as he was attempting to hit other (resident). Called (resident) wife/POA (Power of Attorney) and she came to facility with her daughter and finally got (resident). to lay down and rest. No further behaviors reported this (hour of sleep). MD (Medical Director) here this pm to give injection in rt knee. Tolerated well (without complaints). R3's Progress notes, dated 04/25/2024 at 10:43 PM, documented, Resident very aggressive with staff, kicking out and grabbing staff. Resident yells shut up and leave me alone when asked if we can help. Resident rolling in (wheelchair) at this time, one on one with staff. R3's Progress notes, dated 04/26/2024 at 11:38 AM, documented, (Resident) continues to have agitation and behaviors towards staff. He yells out at staff and does not want anyone touching him he states. He is having hallucinations that he is on the battlefield and people are trying to kill him. Staff able to redirect and resident currently resting in bed at this time. R3's Progress notes, dated 04/28/2024 06:53 AM, documented, Resident observed throwing drawers in resident room, physical and verbal behaviors towards staff as staff were attempting to redirect resident. CNA's notified nurses. Nurses attempted to redirect resident as well. Resident continued with physical behaviors which made resident very unsteady causing nurses to lower resident to floor for safety precautions. Resident continued to scream and yell out and continued with physical behaviors. Nursing staff notified MD on the phone and gave orders to administer 1 time dose of IM (Intramuscular) 2MG (miligram) dose of Ativan. POA contacted and made aware of behaviors and orders from MD for one time order of im Ativan. Verbal consent given from POA at this time. MD states he is sending script to pull from stat safe. R3's Progress notes, dated 04/29/2024 at 10:15 PM, CNA reported that she heard a noise. Upon arriving at a female Resident's room she turned on the light and observed from the doorway this Resident was standing beside female Resident's bed and CNA observed a lamp in his right hand. Before she could get to Resident he hit the female Resident in the right side of the head with the lamp. Resident had noted to have ahold of the lamp shade that was still attached to the lamp and started tearing up the lamp shade. CNA reported that Resident called the lamp a horse. While attempting to redirect Resident from the area he reached for a plastic cup and hit female Resident in the head then attempted to hit CNA with lamp. Resident then was able to remove light bulb and threw it on the other side of the bed causing it break on the floor. Second CNA made the nurse aware. Resident redirected out of the room to his room. This nurse observed Resident attempting to ambulate unassisted and he lost his balance, when this writer attempted to assist Resident he became combative. With assist of CNA, Resident redirected to his recliner. Resident continued to talk about a horse to staff.in his room with no noted behaviors. He continued to talk about the horse as he was leaving with EMTs (Emergency Medical Technicians) Policeman present. The facility's Abuse Final for R3, dated 5/3/24, documented, .Interventions in place to ensure increased supervision of hall. Incident was behaviorally related due to the medication change and resident mental status. Will continue to monitor resident and redirect from behaviors. Staff in serviced on making sure that they are stationing themselves centrally on the hall to ensure resident safety. R4's Progress note, dated 04/28/2024 at 11:21 PM, documented, It was reported to this nurse that res was lying in bed sleeping CNAs heard a loud noise and CNAs ran to check on resident, a male resident was in her room and had hit res in the head with a lamp and then a cup, Res very upset very agitated, c/o rt eye pain, when this nurse assessed res Pupil active, no discoloration to eye res said she had vision but blurry, res had no bumps or lacerations to head, res was sent out to (local Hospital) for evaluation per (Emergency Medical Services). R4's Progress note, dated 04/29/2024 at 01:31 AM, (Resident) returned from (Local Hospital) with contusion to left forearm/right forearm/right shoulder strain and slightly red facial contusion near (right) eye, Right shoulder and forearm negative negative of fracture and CT (CAT scan) of face with contrast results negative of fractures. R4's Local Hospital Record, dated 4/28/24, documented, History of chief complaint: Patient struck about the head with a lamp and fist by male resident of the Nursing home. Patient complains of bilateral forearm pain and right shoulder pain. She suffers from dementia. It continues, Impression: #1 facial contusion, contusion of both forearms, contusion right shoulder. On 5/10/2024 at 5:19 PM, R3 was sitting at the table calmly waiting for dinner. R4 was standing at the big picture window watching a squirrel eat birdseed. On 5/20/2024 at 11:15 AM, R3 was sitting in his bedside chair and his call light was within reach. R3 was taking his shoes and socks off. There were no activities being performed, during this investigation, in the memory unit. There was 1 Certified Nurse Assistant (CNA) in the dining area with a few residents present. On 5/20/24 at 1:15 PM, V13, Certified Nurse Assistant, (CNA), stated on/around 4/28/24 around 11:00 PM, everything was going fine. He continued to state he and the other CNA had just walked up and down the hallway and R3 was in his bed. He continued to state he went to the nurse's station to get report, was there about 5 minutes and they heard a loud noise. V13 and V15, CNA, ran to R4's room and when they entered, V13 saw R3 with a lamp in his hand. The other CNA, (V15), told him to go get the nurse and he did. He also stated he did not see R3 hit R4. When asked if he was made aware R3 had behaviors earlier that day, he said he was made aware. When V13 was asked about if R3 had any special interventions for behaviors, he stated there are interventions on the care plan. On 5/20/24 at 2:35 PM, V15, CNA, stated she just got to the Memory Care Unit and was getting report when her and V13, CNA, heard a loud noise. They ran to R4's room, turned on the light, and saw R3 swinging the lamp. She was able to get the lamp from the resident, and at the same time, R3 grabbed R4's cup and hit her in the head with it. V15 continued to state R3 thought it was a horse. V15 also stated that doesn't usually work in the Memory care unit and was unaware of R3's increased behavior issues. On 5/20/24 at 2:20 PM, V14, Licensed Practical Nurse (LPN), stated when she came to the nursing home, the incident with R3 and R4 just happened. V14 assessed both and sent both residents to the hospital. She did not witness the incident. V14 also stated R3 has had increased behaviors for the past month, and they were changing his medication. She continued to state they redirect him, talk to him, but since he is blind, he really doesn't watch tv. She also stated she does not recall if she was told he was having behaviors earlier that day, and he was really a sweet person. V14 continued to state his dementia was advancing, and with his blindness it has gotten worse, and he was very sensitive to loud noises. On 5/10/24 at 4:03 PM, V4, CNA, stated, I was working on the day shift, and he (R3) was fine. Nothing about him was out of the ordinary. He does have bad vision. He can only see shadows. On 5/10/24 at 3:30 PM, V2, Director of Nurses (DON), stated, (R3) has a BIMS (Brief Interview of Mental Status) of 1. He lives on the Memory Unit. He got a hold of a lamp in another resident's room (R4) and hit her over the head with it. She was not hurt, but both parties went to the ER (Emergency Room) to be checked out. A police report was filed. He has very poor vision. His family says that he is totally blind, but he can see shadows. When this happened, they were immediately separated. (V1) and I were notified. (R3) was in the middle of a med (medication) change. He was being taken off of Seroquel and had started Rexulti. When (R1) came back, he was placed on 1 to 1 supervision until the next morning. He really didn't understand, but he did know that he hurt someone. (R4) she didn't remember anything about it. The next morning, she thought she was in a golfing accident. Staff told me he thought he was trying to saddle his horse. The next morning, neither of them remembered. Doctors have been keeping a close eye on him and have changed his meds. He does have behaviors but nothing violent. He is doing much better now. This happened in the middle of shift change between evening and night shift. On 5/10/24 at 4:10 PM, V3, Memory Unit Director, stated, (R3) would have his moments when he would get agitated, but nothing threw up flags to us that he needed constant supervision. When he does get agitated, he is very easy to redirect. This happened during shift change, so both evening shift and night shift were present. On 5/20/2024 at 2:45 PM, V1, Administrator stated she has increased staff on the memory hall for extra supervision. On 5/21/2024 at 10:21 AM, V1, Administrator, stated they do not have a specific policy related to Dementia Care or Supervision of Residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, and record review, the facility failed to assess residents for fall precautions, failed to implement appropriate fall interventions, and failed to ensure resident safety during transfers, for 5 of 7 residents (R6, R8, R10, R20, R27) reviewed for falls and transfers in the sample of 44. This failure resulted in R6 having a fractured left hip and having a closed vs open reduction of her left hip with nailing surgery. The findings include: 1. R6's Face Sheet, undated, documents R6 was admitted to the facility on [DATE], with the diagnoses of Dementia, Atrial Fibrillation, Major depressive disorder, Type 2 Diabetes Mellitus (DM), and Left femur fracture. R6's Care Plan, dated 3/02/23, documents R6 is at risk for falls related to diagnosis of dementia, unsteadiness on feet, muscle wasting and atrophy, depression, incontinence and use of psychotropic medication. Interventions: 12/18/23: Staff to keep resident within view while in common area, 12/12/23: Occupy resident with meaningful distractions, 12/5/23: Observe frequently and place in supervised area when out of bed, 11/20/23: Encourage shoes while ambulating, 10/2/23: Encourage resident to stay in common areas when it is not bedtime. Redirect with activity, 9/6/23: Dycem replaced on wheelchair and cushion, 8/27/23: encourage resident with an activity while other residents are being put to bed, 8/14/23: PT (physical therapist)/OT (occupational therapist) to evaluate chair positioning, 8/14/23: Call don't fall signs placed in resident room, 6/26/23: Dycem applied to wheelchair and on top of wheelchair cushion, 4/20/23: Make sure resident is wearing grip socks while ambulating, 4/20/23: Grip tape applied to the floor in front of the toilet, 4/10/23: Make sure tennis balls are on the wheeled walker 3/2/23: Provide with wheelchair and walker, Encourage to use side rails/enablers as needed. R6's Minimum Data Set (MDS), dated [DATE], documents R6 has a severe cognitive impairment and requires extensive assistance from one to two staff members for all Activities of Daily Living (ADLs). R6 is occasionally incontinent of urine and always continence of bowel. The Facility's Fall Log, dated 6/1/23 through 12/18/23, documents R6 has had a falls on 6/21/23, 6/25/23, 7/7/23, 7/13/23, 7/20/23, 8/10/23, 8/26/23, 9/4/23, 9/25/23, 11/6/23, 12/4/23, 12/5/23, and 12/10/23. R6's admission Fall Risk Assessment, dated 3/1/23, documents R6 is a High Fall Risk. R6's Fall Risk Assessment, dated 4/24/23, documents R6 is a High Fall Risk. R6's Fall Risk Assessment, dated 7/29/23, documents R6 is a High Fall Risk. R6's Fall Risk Assessment, dated 12/4/23, documents R6 is a High Fall Risk. R6's Nursing Note, dated 4/1/23 at 6:00 PM, documents, CNA reported to nurse that resident had fallen after standing from dining room and tripped over the foot of her walker and lost her balance. CNA stated she did not hit her head. Neuros (neurological checks) and VS (vital signs) WNL (within normal limit), during assessment of LLE (left lower extremity) resident verbalized 7/10 pain to left hip. MD (Medical Doctor) made aware and gave orders to send resident to ER (emergency room) and stated to update him with results once notified of results. POA (Power of Attorney) notified as well. There is no new fall intervention seen in R6's Care Plan after her fall on 4/1/23. R6's Nursing Note, dated 4/3/23 at 6:51 AM, documents, Resident found sitting on floor next to her walker in her bedroom. Residents bottom was facing the window and her legs/feet were facing the bedroom door. Resident states she was trying to go to the bathroom and her knees started to buckle so she knelt down and sit on her butt. VSS (vital signs stable) (see vitals), Head to toe assessment complete with no s/s (signs/symptoms) of rotation, deformity, shortening of limbs noted. No s/s of bruising or open wounds. Residents states, I am ok I just wanted to get to the bathroom then go eat breakfast. Educated resident on using call light for help and she verbalized understanding. Fall was witnessed by CNA (see Event) Dr. notified, and POA Notified. R6's Social Service Note, dated 4/10/23 at 10:25 AM, documents, Root Cause Analysis: Investigation into falls on 4/3 and 4/1 were completed by the IDT (Interdisciplinary team). It was determined that on 4/1 resident was standing from breakfast with w/w (wheeled walker). Resident tripped over the flip flop décor on bottom of wheelchair. Décor was removed and replaced with tennis balls. On 4/3 resident was attempting to transfer herself to the bathroom with w/w when her legs buckled and she lowered herself to the floor. Assist resident in mornings, and make sure that she has assistance when needed due to weakness in morning. R6's Care Plan Intervention, dated 4/10/23, documents Make sure tennis balls are on the wheeled walker. R6's Nursing Note, dated 4/19/23 at 6:15 AM, documents, [Recorded as Late Entry on 04/21/2023 11:33 AM] Called to (unit) by staff to find resident laying on the floor on her back with her head down by the sink. She denies pain moves all extremities without difficulty. She does have a 0.5 cm (centimeter) skin tear noted on her Rt (right) elbow that was cleansed and Steri-strips applied. Staff reports that there were no lights on in the room when they entered the room the floor was dry and resident had regular socks on her feet with no shoes on. Resident assisted off the floor by 2 staff at this time. R6's Social Service Note, dated 4/20/23 at 11:11 AM, documents, Root Cause Analysis: Investigation into fall on 4/19/2023 was completed by the IDT. It was determined that resident fell while ambulating in her room. Make sure the resident is wearing grip socks while up ambulating. There is no new fall intervention added to R6's Care Plan after her fall on 4/19/23. R6's Nursing Note, dated 4/20/23 at 3:20 AM, documents, Resident was found sitting on the floor in the her bathroom yelling out for staff. She stated she went to get off of the stool and slipped down to the floor. Denies hitting head. Stated she landed on her buttocks and sat against the bathroom door. She complained of left hip pain immediately and leg is bent up. She will not let us straighten leg out stating the pain is absolutely horrible. Large skin tear noted to left elbow with scant amount of bleeding noted. R6's Nursing Note, dated 4/20/23 at 3:51 AM, documents, Resident did have rubber sole shoes on, floor level dry and free of clutter. She was ambulating with use of walker. Denied any dizziness or other complications. Room was well lit. R6's Social Service Note, dated 4/20/23 at 11:13 AM, documents, Root Cause Analysis: Investigation into fall on 4/20/2023 was completed by the IDT. It was determined that resident fell off the toilet while taking herself to the bathroom. Resident was sent to ER and determined that her left hip was broke. (sic) Grip tape was placed in front of toilet. R6's Care Plan Intervention, dated 4/20/23, documents, Grip tape applied to the floor in front of the toilet. On 12/20/23 at 9:35 AM, there was no grip tape seen in front of R6's toilet as specified in the Care Plan. R6's Nursing Note, dated 4/21/23 at 9:50 AM, documents, Called (Regional Hospital) and rec'd (received) update on resident, surgery scheduled for today at 2:30 PM, having a closed vs open reduction of left hip with nailing, not looking at discharge until next week possibly. R6's Nursing Note, dated 6/21/23 at 9:55 PM, documents, Resident was observed on the floor on her knees leaning against the bed in an unoccupied room. There was another female Resident sitting on the side of the bed. This Resident stated she was trying to get on the bed. Two staff transferred Resident to w/c (wheelchair). ROM (range of motion) WNL x 4 extremities. No injuries noted to head or body. Noted both knees to have small pinkish area on each. Resident stated her knees hurt. Resident was moving both feet to move w/c without c/o (complaint of) or noted difficulty then ambulated to toilet from w/c with use of w/w and assist of two staff with no c/o or noted difficulty. Dr. at facility to see Resident and assessed her with NNO (no new orders). Tylenol given with no further c/o knee pain. Made RN (Registered Nurse) DON (Director of Nursing) and POA/daughter aware of this event. Will fax Dr. with an update. VS 134/64 78 20 98.0 SpO2 96% RA (room air). Not compliant with Neuros. R6's Care Plan does not have any new interventions added to the Care Plan after this fall on 6/21/23. R6's Nursing Note, dated 6/25/23 at 3:32 PM, documents, CNA's reported that resident had slid out of wheelchair in sitting area. Resident observed sitting in upright position in front of wheelchair. Resident completed ROM to all extremities without limitations or pain voiced. Resident denies pain/discomfort at this time. Resident vs WNL, resident neuros WNL to resident baseline. MD notified and POA made aware. R6's Care Plan Intervention, dated 6/26/23, documents Dycem applied to wheelchair and on top of w/c cushion. R6's Nursing Note, dated 7/7/23 at 6:53 PM, documents, Resident found on floor next to toilet. She was between the wall and toilet sitting on her buttocks holding onto the assist bar. Resident was attempting to transfer self off of the toilet. No injuries noted at this time. Denies any pain at this time. Had rubber sole shoes in place, pants were mostly pulled up chair was locked and in doorway. Daughter (Name) notified of incident. Doctor notified. Neuros started and WNL, ROM WNL. Staff educated not to leave room while she is on toilet. R6's Care Plan does not have any new interventions added to the Care Plan after this fall on 7/7/23. R6's Nursing Note, dated 7/13/23 at 9:01 PM, documents, Res (resident) noted to tip recliner over in the common room and rolled out of it onto the floor. When this nurse arrived, res was lying on her stomach with her Right arm pinned below her. 3 staff members rolled res over onto her back to assess further. ROM WNL. No rotation or shortening of extremities. VS WNL neuro checks WNL. skin tear noted to right lower arm with bruising surrounding area. Bruise noted to right elbow and to left knee. Skin tear cleansed and steri-strips applied. No other injuries noted. Res denied pain elsewhere. Assisted back to recliner. Began conversing with staff again. Continue to monitor vs with neuros per protocol. MD made aware via fax. To notify family in the morning at a more decent hour. R6's Care Plan does not have any new interventions added to the Care Plan after this fall on 7/13/23. R6's Nursing Note, dated 7/20/23 at 10:59 PM, documents, 8:10 PM Resident was observed laying on her left side on the floor beside her bed. Her w/c (wheelchair) was near her. Resident stated she was trying to get into bed. No injuries noted to head or other areas. ROM not done d/t (due to) Resident c/o pain to both hips and lower back. BS (blood sugar) 205. Resident alert and verbal. Made Dr. aware. New order given to send to ER to eval (evaluate) and tx (treat). Made POA/daughter aware. Ambulance called. Resident sent to (local hospital) ER via ambulance. Sent Face Sheet, orders and DNR (Do Not Resuscitate). Made RN (Registered Nurse) at (local hospital) ER aware and gave report. Administrator and RN, DON aware. R6's Care Plan does not have any new interventions added to the Care Plan after this fall on 7/20/23. R6's Nursing Note, dated 8/10/23 at 6:50 PM, documents, Resident slid out of wheelchair trying to reach for items. Fall witnessed did not hit head and just slid to floor. She did land on her buttocks with no injuries noted and no complaints of pain. ROM WNL. Daughter notified of her sliding out of her wheelchair with no injuries. Doctor notified. Will consider adding [NAME] to top of cushion to help prevent sliding. R6's Care Plan Intervention, dated 8/14/23, documents, Call Don't Fall signs placed in resident room. R6's Nursing Note, dated 8/26/23 at 8:30 PM, documents, Resident observed on floor in kitchen laying on her right side, w/c was near her feet. Resident did hit her head. ROM WNL x 4 extremities. Resident rubbed her head stating that is where she hit her head, mid left back of head. No area noted. No other injuries noted. VS 134/70 74 20 97.6 SpO2 96% RA. Made Dr. aware of this event, Resident hitting head mid left side, Coumadin use, recent INR (International Normalized Ratio). Stated to monitor and report significant changes. Aware of HS (hours sleep) meds and stated to continue with meds as ordered. Made POA/daughter aware and she agrees with Dr. Made Administrator aware. At this time a slightly elevated area is noted to mid left back of head. Area is pinkish. Resident given PRN Tylenol d/t to stating, Oh, it hurts a little, when asked if her head hurt. Denies pain anywhere else. Resident is alert and verbal. Moves all extremities with no noted difficulty or c/o. R6's Care Plan Intervention, dated 8/27/23: encourage resident with an activity while other residents are being put to bed. R6's Social Service Note, dated 8/27/23 at 2:18 PM, documents, Root Cause Analysis: Investigation into fall on 8/26/2023 was completed by the IDT team. It was determined that resident fell while attempting to ambulate. When staff is working with other residents for bed and behaviors, encourage resident with a independent activity to keep her busy. R6's Nursing Note, dated 9/4/23 at 3:33 PM, documents, Resident was found in dining room. Resident was in front of wheelchair on her left side. Resident stated she was a little sore. No shortening, ROM x 4, Neuros and vitals WNL. POA aware. Admin aware. MD faxed. Will continue to monitor. R6's Care Plan Intervention, dated 9/6/23, documents, Dycem replaced on WC and cushion. R6's Social Service Note, dated 9/6/23 at 7:48 PM, documents, Root Cause analysis: IDT completed investigation into fall on 9/4/2023. It was determined resident fell sliding out of the wheelchair, Dycem added to wheelchair. R6's Nursing Note, dated 9/25/23 at 2:02 PM, documents, Resident stated went into her room, shut the door and got up to go the bathroom. Resident was found sitting in her room on her bottom, with feet straight out. ROM unchanged. Denies any c/o pain or discomfort. Vitals within normal limits. Dr. notified of incident. POA notified. R6's Care Plan does not have any new interventions added to the Care Plan after this fall on 9/25/23. R6's Social Service Note, dated 10/2/23 at 12:05 PM, documents, Root Cause Analysis: Investigation into fall on 9/25/2023 was completed by the IDT team. It was determined that resident fell while in room attempting to transfer her self. Staff encouraged to redirect resident to common areas when not in bed, and engage her with activities. R6's Care Plan Intervention, dated 10/2/23, documents, Encourage resident to stay in common areas when it is not bedtime. Redirect with activity. R6's Nursing Note, dated 11/6/23 at 7:45 PM, documents, Resident was sitting in wheelchair in her room at foot of bed near bathroom door. She stood up and starting walking across the room. Her legs gave out and she sat down on the floor. Her feet were bare, lights on, floor level, clean, dry and free of clutter. Could not get to resident fast enough before she fell, she did not hit her head. ROM done with no complaints of pain. No external fixation or shortening of legs noted. She did complain of general pain after a while, PRN Tylenol given with relief. MD notified and daughter to be notified. Will continue to monitor. R6's Care Plan does not have any new interventions added to the Care Plan after this fall on 11/6/23. R6's Social Service Note, dated 11/9/23 at 10:04 AM, documents, [Recorded as Late Entry on 11/20/2023 10:05 AM] Root Cause Analysis: Investigation into fall completed by the IDT. It was determined that resident fell while attempting to ambulate to the bathroom. Resident to have shoes and grip socks on while ambulating. R6's Nursing Note, dated 12/4/23 at 1:30 PM, documents, [Recorded as Late Entry on 12/04/2023 07:37 PM] Resident was in common area and was trying to transfer self into recliner and slid onto bottom. Head was not hit and no injury noted. Will pass along to nurse to make Dr. and POA aware of event. R6's Nursing Note, dated 12/5/23 at 1:50 PM, documents, Resident attempted to transfer to recliner in common area and fell to floor. Resident did not hit her head. CNA was unable to get to her in time. B/P 159/76 P 76 R 22 T 97.5 SpO2 98% ROM WNL Resident had no c/o pain. Resident was transferred up from floor to recliner. R6's Care Plan Intervention, dated 12/5/23, documents Observe frequently and place in supervised area when out of bed. R6's Nursing Note, dated 12/10/23 at 5:27 PM, documents, CNA states she heard patient yelling out. Went to assess and patient was noted in sitting position in dining room with wheelchair next to her. Writer assess patient and she stated she did not hit her head. Patient was noted in sitting position next to wheelchair. Patient was in a well lit area and appropriate fitting shoes. Patient able to move all extremities with ease. Denies pain or discomfort at this time etc. denies needing to go to the bathroom. Assist for floor to bed via (full body mechanical lift). Neuro checks WNLs. R6's Care Plan Intervention, dated 12/12/23, documents, Occupy resident with meaningful distractions. R6 was left unsupervised and found on the floor. On 12/19/23 at 9:27 AM, R6 was sitting in recliner watching movie with other residents, with no staff seen in the room. On 12/20/23 at 9:35 AM, R6 was seen sitting in her wheelchair in the dining room doing activities with staff. There were no Call Don't Fall signs posted in R6's room, and there was no grip tape in front of her toilet as specified in the Care Plan. On 12/19/23 at 10:04 AM, V5, Certified Nursing Assistant (CNA), stated, We try to keep our residents supervised to help keep them from falling, and there are interventions placed in their care plan for falls. On 12/26/23 at 10:40 AM, V6, CNA, stated, No, (R6) does not have a Dycem on her wheelchair. 2. R8's Face Sheet, undated, documents R8 was admitted to the facility on [DATE], with the diagnoses of Dementia, Overactive bladder, Dysuria, and Anxiety disorder. R8's Care Plan includes Problem, start date of 7/24/23, R8 is at risk for falling related to decreased mobility, generalized weakness, dementia, incontinence, psychotropic medication use. Interventions: 9/25/23: Scoop mattress added to bed, 8/14/23: Dycem added to wheelchair, 7/24/23: Ensure that commonly used or reached for items are within close proximity to R8 while in bed, Ensure familiar items are present in room such as old pictures of resident when young, with parents, etc., familiar decorations from resident's prior home, or familiar afghan/blanket on bed, Use simple sentences with ADL (Activities of Daily Living) cares including nouns and verbs only (example: Use the toilet), Utilize verbal and tactile cues. Organize supplies from left to right to provide visual stimulation with tasks and task segmentation, Use simple, familiar commands and words that are familiar to the resident (i.e. [NAME] = bathroom), Hold chair steady for R8 during transfers, Provide frequent reminders and assistance for toileting and other personal care ADL needs, Alternate Call Light, Encourage R8 to use side rails and hand rails as needed. The Facility's Fall Log, dated 6/1/23 through 12/18/23, documents R8 had falls on 6/1/23, 6/16/23, 8/11/23, and on 9/16/23. R8's Clinical Record documents R8 also had falls 3/14/23, 3/25/23, 4/2/23, 5/3/23, 5/12/23, 5/16/23, 5/17/23. R8's Care Plan did not include R8 as a fall risk with interventions until 7/24/23, after R8 had fallen nine times. R8's MDS, dated [DATE], documents R8 has a severe cognitive impairment and is dependent on staff for ADLs and is frequently incontinent of urine and occasionally incontinent of bowels. On 12/19/23 at 10:04 AM, V5, CNA, stated, We try to keep our residents supervised to help keep them from falling and there are interventions placed in their care plan for falls. R8's Nursing Note, dated 3/14/23, documents, Resident was found on floor in bed room next to his bed on his bottom. Residents back was against the bed, feet pointing to his roommates bed and resident was not in non skid socks at that present time. Resident states he slid out of bed on his bottom trying to get somewhere. Head to toe assessment completed. No apparent injuries noted. No bruising noted. No wounds or bleeding noted. No limb deformity noted. Mobility unaffected. Did c/o pain to right hip but per resident and resident POA he has prior hip surgery and has had hip pain to left hip since. Resident able to bend bilateral knees to abdomen without c/o, able to rotate and flex bilateral arms without c/o. NEURO intact (neuros started due to unwitnessed fall) Bed was at lowest position and call light was within reach. R8's Administrator Note, dated 3/19/23 at 2:43 PM, documents, Root Cause Analysis: Investigation into fall on 3/14/2023 completed by IDT (Intradisciplinary team). It was found that resident was trying to transfer himself without assistance, and fell from bed. Call don't fall signs places in residents room to remind him to call for assistance. On 12/20/23 at 9:32 AM, there was no Call don't fall signs seen in R8's room. R8's Administrator Note, dated 3/28/23 at 2:13 PM, documents, Root Cause Analysis: Investigation into fall on 3/25/2023 completed by IDT. It was determined resident was trying to stand without assistance. Make sure resident is in a supervised area, and wearing slip resistant socks. R8's Nursing Note, dated 4/2/23 at 9:29 AM, documents, Resident observed on floor facing in upright position in front of toilet. Resident voiced that he was trying to go to the bathroom and slid off of the toilet. No injuries noted. VS WNL, Neuro assessment completed with no abnormalities noted to resident baseline. ROM completed x 4 extremities without pain/discomfort. Resident denies pain at this time. MD notified, POA notified. R8's Social Service Note, dated 4/10/23 at 12:06 PM, documents, Root Cause Analysis: Investigation into fall on 4/2/2023 was completed by the IDT team. It was determined that the resident was attempting to transfer himself to the bathroom. staff educated to ask resident frequently if he needs to use the bathroom in hopes to avoid resident attempting to transfer himself. R8's Nursing Note, dated 5/3/23 at 2:48 PM, documents, Resident observed sliding from wheelchair while trying to self transfer to bed. Resident non skid socks were on, but one was turned where grippers were not in correct position. No injury noted. VSS. No c/o pain voiced. POA aware. MD notified via faxed. R8's Nursing Note, dated 5/11/23, documents, Root cause analysis: resident was attempting to transfer self and slid out of wheelchair. Resident noted to be wearing gripper socks inappropriately. Resident to wear slippers with rubber soles or shoes when up in chair. Care plan updated. R8's Nursing Note, dated 5/12/23 at 8:50 PM, documents, [Recorded as Late Entry on 5/13/2023 1:32 AM] Resident was assisted to the floor by staff. He has slumped down so far in his wheelchair his back was the only thing still in the chair. Resident was assisted to the floor by CNA before he tumbled out on his own. Staff was called to assist resident back up in wheelchair. Resident had been readjusted several times in wheelchair prior to this because he keep sliding down. No injuries noted. Doctor notified. Family will be notified. Will continue to monitor. R8's Nursing Note, dated 5/16/23 at 6:53 AM, documents, Resident was found on floor in his room. Back against the wall and stated he hit his head. No bumps noted. Resident was trying to transfer self and was reaching for shoes. Area was free of clutter and floor was dry. Resident states he should have known better. Educated resident on using call light and waiting for assistance. Resident did receive skin tear to left tricep 10 cm by 2 cm. Cleansed with wound cleanser and non-adherent pad applied and gauzed wrapped. Did use steri-strips to place some skin back together. Red mark to right shoulder. Vital signs are 97%, 98.3, 162/94, 78, 12. Does complain of head pain. Neuros are WNL. ROM x4. MD faxed. POA aware. DON (Director of Nursing) notified. Will continue to monitor. R8's Nursing Note, dated 5/17/23 at 8:29 AM, documents, Resident observed on common room area floor, reported by CNA. Resident sitting upright facing tv with wheelchair facing residents right side. Blocks noted to left side of resident on floor. BLE noted equal, ROM to X4 extremities without limitations. Resident denies pain/discomfort. Edema continues to BLE. MD made aware. R8's Nursing Note, dated 6/1/23 at 4:05 PM, documents, Resident had witness fall with no injury. ROM (range of motion) WNL (within normal limits). V/S (vital signs) WNL. Did not hit head. Assist x 2 and gait belt back to w/c (wheelchair). Son and MD made aware. R8's Nursing Note, dated 6/16/23 at 11:14 PM, documents, Resident observed on floor in BR (bathroom) at 7:30 pm. Resident stated he had to go and attempted to transfer self from w/c to toilet. Noted moderate amount of urine on floor near toilet that was not from Resident. Resident stated he hit his head possibly on the door or floor, touching the top left side of head. No noticeable injury. Resident was sitting on his buttocks slightly leaned to right side with right arm holding him up. ROM x 4 with no shortening or rotation noted. Resident did initially c/o right leg pain when he extended the right leg but was able to bend leg and pull it toward him several times with no c/o or noted difficulty. (Name) RN DON (Director of Nursing) also assessed. With assist of three Resident was transferred to his w/c with no c/o pain or discomfort. Resident then used by feet to move around in w/c without c/o pain or noted difficulty. Noted a 2 cm s/t to top of right hand. Area cleansed. Two steri-strips applied. VS 122/74 74 18 98.0 SpO2 94% RA. Made on call (Name) AGNP (Adult-gerontolgy nurse practitioner) aware and of Resident's initial c/o right leg pain. NNO. Stated to monitor and report significant changes. Made POA/son (Name) aware. Resident later c/o of low back pain then denied stating, I guess I'll be sore by morning. Neuros continue to be WNL. R8's Nursing Note, dated 8/11/23 at 12:18 PM, documents, Resident slid out of wheelchair onto his buttocks in dining area during lunch. Fall was witnessed by unit coordinator and 2 CNA staff. No injury noted. ROM WNL for resident. No c/o pain voiced. Neuro WNL for resident. Resident assisted to bathroom per request. MD notified via fax. LM for POA. Awaiting return call. R8's Social Service Note, dated 8/14/23 at 3:11 PM, documents, Root Cause Analysis: Investigation into fall on 8/11/2023 was completed by the IDT team. It was determined that resident slid out of chair while repositioning himself. Dycem added to wheelchair. R8's Care Plan and Intervention, dated 8/14/23, documents Dycem added to wheelchair. On 12/20/23 at 9:32 AM, there was no Dycem to R8's wheelchair seen. R8's Nursing Note, dated 9/16/23 at 12:57 AM, documents, Res rolled out of bed ROM WNL, neuro check started, no pain voiced. R8's Social Service Note, dated 9/25/23 at 9:55 AM, documents, Root cause Analysis: Investigation into fall on 9/16/2023 completed by the IDT. It was determined resident rolled out of bed. Scoop mattress was added to bed for residents safety. R8's Care Plan and Intervention, dated 9/25/23, documents Scoop mattress added to bed. 3. R10's Face Sheet, undated, documents R10 was admitted to the facility on [DATE], with diagnoses of Cerebral infarction, Hemiplegia, Dementia, COVID-19, UTI, Osteoporosis, long term use of Anticoagulants, DVT, and Right hip fracture. R10's Care Plan, dated 11/21/23, documents R10 is at risk for falling r/t generalized weakness, high fall risk medications, pain, dx of OA, hemiplegia, muscle wasting and atrophy, abnormal posture, HTN, and anemia. Interventions: Give resident verbal reminders not to ambulate/transfer without assistance, Grip strips to floor in front of recliner, place call don't fall signs in resident room and on walker and wheelchair, re-educate to call for assistance, Encourage R10 to use environmental devices such as hand grips, hand rails, etc., Therapy to educate Staff on proper transfer technique. It continues R10 requires assistance with her everyday ADLs r/t a diagnosis of dementia. Interventions: Remind R10 the importance of eating, Offer food she likes, easy food to chew, Offer to open packages, cut her food for her, Lay her supplies out left to right, Offer toothpaste within 6 inches of eye level. R10's MDS, dated [DATE], documents R10 has a severe cognitive impairment and requires extensive assistance from one or two staff members for bed mobility, transfers, dressing, toilet use, personal hygiene, and bathing, and requires supervision with set up help for eating. R10 is always incontinent of both bowel and bladder. The Facility's Fall Log, dated 6/1/23 through 12/18/23, documents R10 had a fall on 6/9/23, and 10/2/23. R10's Nursing Note, dated 4/30/23 at 8:25 PM, documents, Res slid out of wheel chair d/t leaning forward to pick up a piece of food off floor, no injuries ROM WNL, no pain voiced. R10's Nursing Note, dated 6/9/23 at 4:24 PM, documents, Resident observed on floor in room sitting in upright position, wheelchair facing in front of resident. Resident denies pain/discomfort. ROM x all extremities without limitations. POA made aware, md notified. VS and neuros WNL. R10's Nursing Note, dated 10/2/23 at 5:35 PM, documents, MD aware of fall and states monitor and report significant changes. R10's Nursing Note, dated 10/3/23 at 9:59 AM, documents, No injuries noted from fall. Will continue to monitor. R10's Social Service Note, dated 10/4/23 at 5:51 PM, documents, Root Cause analysis: Investigation into fall on 10/2 completed by the IDT. It was determined that resident slid from bed, while attempting to transfer. Resident encouraged to call for assistance before attempting to self transfer. On 12/18/23 at 10: 20 AM, R10 was seen sitting in a recliner in living area, napping, covered with blanket, with her wheelchair next to recliner, and no staff present in the living area. On 12/19/23 at 9:27 AM, R10 was sitting in a recliner watching movie with other residents with no staff present in the room. On 12/19/23 at 10:04 AM, V5, CNA, stated, We try to keep our residents supervised to help keep them from falling and there are interventions placed in their care plan for falls. On 12/20/23 at 9:38 AM, R10's fall interventions, according to his Care plan, include verbal reminders not to ambulate without assistance, grip strips to floor in front of recliner, call don't fall signs in room, on her walker and wheelchair. R10 resting in recliner in living area, there is no sign on her walker/wheelchair, no signs posted in her room, there are no grip strips in front of her recliner, and no staff members seen. 4. R27's Face Sheet, undated, documents R27 was admitted to the facility on [DATE], with the diagnoses of Dementia, Falls, Anxiety disorder, and Blindness both eyes. R27's Care Plan, dated 4/25/23, documents R27 is at risk for falls related to di[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to provide timely treatment of a fall with suspected fracture for 2 of 12 residents (R32, R151) in a sample of 33. This resulted in R32 going 2 days without treatment of her fractured elbow and R151 not receiving a timely Xray for a right wrist fracture. Findings include: 1. R32's diagnoses include Age-related osteoporosis without current pathological fracture, Pain in right elbow, unspecified fracture of shaft of right ulna, subsequent encounter for closed fracture with routine healing, multiple fractures of pelvis with stable disruption of pelvic ring, subsequent encounter for fracture with routine healing. R32's Minimum Data Set (MDS), dated [DATE], documents a Brief interview of mental status as a 14 which indicates R32 is cognitively intact. R32's MDS also documents R32 as limited assist of one staff member with transfers, bed mobility, walking, dressing, toilet use and hygiene. R32's Progress Note dated 7/22/2022 at 6:03 PM written by V17, Licensed Practical Nurse (LPN) documents This nurse and another staff member heard resident yelling help. Upon entering the room, resident was observed in floor in the bathroom doorway. She way laying on her right side. This nurse asked resident what she was doing at the time of the fall. She stated, She peed on the floor, so I put paper towels over it and was trying to step over them and I lost my balance. Resident c/o (complained of) pain in her right foot and right elbow. She stated, 'I hit my head real hard.' Neuros WNL (within normal limits) ROM (range of motion) X4 with some pain in [NAME] (upper right extremity). 3.75 cm (centimeter) X 2.5cm skin tear to right elbow. Cleansed with soap and water. 6 steri strips applied. Open to air. Resident c/o pain in right elbow. Right elbow has bruising and swelling. Educated resident on asking for help and using her call light when she needs assistance. Resident understood. MD (medical doctor) made aware. POA (Power of Attorney) called but was busy and was not able to leave a message. Will continue to monitor. R32's progress notes dated 7/22/2022 11:21 PM written by V16, Registered Nurse (RN) documents Resident continues to complain of pain to right elbow. Swelling continues with bruising. Skin tear has been bleeding a small amount at times, dressing applied. Response pending from MD. Elbow elevated on pillow and encouraged not to bend or move it to much at the elbow. Continues on routine Tylenol. Reminded to ask for assistance with all transfers. Will continue to monitor. R32's Progress Note, dated 7/23/2022 6:03 AM written by V16 documents Orders received for x-ray of right elbow to be done this morning. Immobilize elbow and monitor. Orders carried out and Bio tech x-ray notified. R32's Progress Note dated 7/23/2022 at 3:35 PM written by V11, LPN, documents Dressing to rt (right) elbow changed due to bleeding. (Xray company) here this afternoon to obtain x-ray of arm. R32's Mobile X-ray company faxed results to the facility, dated 7/23/22 at 6:09 PM, documented Acute avulsed (small chunk of bone attached to a tendon or ligament gets pulled away from the main part of the bone) fracture proximal ulna (olecranon process). Avulsed fragments vs osteophytes radial head and lateral condyle of humerus. Soft tissue swelling seen around elbow joint. R32's Progress Note, dated 7/23/200 9:12 PM documents Tear to right elbow. Right arm is immobilized and elevated on pillows for comfort. Does complain of pain continues on routine Tylenol. X-ray results still pending. Lung sounds remains diminished in bilateral lower bases. Continues to have a non productive dry cough. Sitting up in recliner for pain relief. She is using the stand aid to help with transfers. Will continue to monitor. This Note did not document R32's physician was notified of the x-ray results. R32's Event Report, dated 7/23/2022, includes documentation of pain assessment of right elbow and foot at an 8 on a scale of 1-10. this also documents location of injury to right elbow including bruising, bump, swelling and Range of motion painful/limited to upper extremity. R32's Progress Note, dated 7/24/22 at 10:10 AM documents (X-ray company) x-ray results received impression: acute avulsed fracture proximal ulna (olecranon process), avulsed fragments vs osteophytes radial head and lateral condyle of humerus and soft tissue swelling seen around elbow joint. On call (Nurse Practitioner) made aware and stated to immobilize arm, and to follow with ortho tomorrow 7/25/22. On 11/16/2022 at 2:30 PM V1, Administrator, states she expects her staff to provide prompt care when residents area experiencing a pain and swelling with limited ROM. V1 stated she expected staff to call the doctor after hours instead of faxing. V1 stated that V17 is no longer employed due to issues such as this occurrence. On 11/17/2022 at 8:40 AM V16 stated that V17 had faxed the doctor instead of calling the doctor about R32's fall. V16 stated she called the on called doctor and he returned the call around 4am and gave orders to have an Xray of R32's elbow to be completed in the morning. V16 stated that she called the portable Xray company to see if they could do the Xray because it was the weekend. R32's Progress Note, dated 7/25/2022 signed by Orthopedic doctor documenting: non-weight bearing (NWB) right upper extremity (RUE), encourage Range of motion (ROM) elbow flexion, and sling for comfort. R32's Physician services Note, dated 7/25/2033 documents that contains chief complaint right elbow fracture date of injury 7/23/2022. This document also includes documentation stating On July 23, 2022, patient was in the bathroom when she fell backwards and sustaining a direct impact injury onto her right elbow. She immediate pain in her elbow as well as 2 large skin tears. The Note documents Present clinical examination and imaging are consistent with a left olecranon fracture with displacement and intra articular extension. The family understands that the patient would need surgery to reestablish the extensor mechanism of her elbow, without surgery she will not be able to push up from a chair or pressed down on a walker. R32 stated on 11/15/2022 at 11:00 AM that she had fallen in the bathroom and broke her elbow a few months ago on a weekend and went to the orthopedic doctor on Monday. Policy titled Emergency Care policy Procedure documents immediate care of the resident for falls, check for any apparent dislocation or possible fracture. if signs of this are noted, stabilize resident until ambulance arrives. his document also states care of possible Fractures-transport to hospital. 2. R151's Nurse's Note, dated 10/28/2022 on 3:55 PM, documents, Resident has been attempting to exit memory lane doors this shift. She has been taken for walks and has participated with activities with staff this afternoon. At this time resident was being redirected away from doors by CNA (Certified Nurse Assistant) when laundry staff came through the doors resident turned around and lost her balance falling to the floor hitting her Rt (right) eyebrow on the handrail. Resident has a small laceration with a hematoma noted on Rt elbow bleeding stopped area cleansed and dry drsg (dressing) applied. Resident continues to c/o (complaint) of Rt (right) wrist pain MD (medical doctor) informed with orders rec'd (received) for portable 3 view Rt wrist X-ray. Test ordered from biotech at this time. R151's Nurse's Note, dated 10/29/2022 at 12:00 AM, documents, Resident had been sitting in chair in room, stating she can't walk because her right wrist hurt. Resident was able to walk without difficulty to bathroom with stand by assist. Resident continues with hematoma and bruising to right eyebrow line and eye. Small amount of blood noted at times after resident rubs area. PRN (as needed) Tylenol given for pain. Resident does move right wrist noted it hurts when she tries to grip items or lift items with hand. Currently resting quietly in bed. R151's Nurse's Note, dated 10/29/2022 at 10:00 AM, documents, This nurse confirmed x-ray order with (X-ray Company) and representative stated they did not have a tech (technician) for our area today and they would not be able to come to facility. Notified Nurse Practitioner and order was given to send by ambulance to ED (Emergency Department)/resident refusing to ambulate & c/o (complaint of) pain when attempting to use or grasp anything with right hand. R151's Nurse's Note, dated 10/29/2022 at 12:17 PM, documents, Nurse ED notified facility that resident would be returning with ortho (orthopedic) cast/fracture/right wrist. DON notified & stated she would notify administrator. R151's Hospital Disposition, dated 10/29/22, documents, Discharge DX (diagnosis). Closed fracture of distal end of right radius. On 11/16/22 at 12:08 PM, V19, Licensed Practical Nurse (LPN), stated, She (151) had been at the doors banging on them to get out. The CNA got her redirected and walking away from the doors. Then staff tell me that she has fallen. When I got there, she was on her bottom, sitting up against the wall. She did not complain of pain at all. I assessed her and got her back to her room. Once back in the room she complained of pain of the wrist. There was no swelling or bruising. She continued to complain of wrist pain but no hip pain. Her leg did not have any rotation or shortening. I ordered a STAT (immediately) wrist X-ray. I did not realize that the X-ray had not been done because I was off for a bit after the shift on 10/28/22. If (the mobile X-ray company) had not come for me in a timely manner, I would have called the company and found out what is going on and if they couldn't come, I would have called the doctor and gotten an order to send her to the Emergency Room. On 11/16/22 at 3:45 PM, V14, LPN, stated, I took care of her (R151) after her first fall (10/29/22). I realized that (X-ray company) did not come for her wrist, I called them, and they said that they did not have a technician available. I called the doctor and got an order to send her to the ER (Emergency Room). When I called report to the ER, I told them she was having pain in her wrist and pain with standing. I was not sure if the difficulty with standing was from her wrist because she would use it to pull up or if it was her hip. The hospital just did a wrist X-ray not a hip X-ray. She just held her wrist and complained of pain. She didn't complain of hip pain for me. R151's Face Sheet, undated, documents that R151 was admitted on [DATE] and has diagnoses of Alzheimer's Disease and Fracture Carpal Bone of right wrist. R151's MDS, dated [DATE] documents R151 is severely cognitively impaired. On 11/21/22 at 11:30 AM, V1, Administrator, stated that she expects X-rays to be done timely and if not to call the doctor and get and order to send the resident out to the hospital.