**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure a resident's right to be free from physical abuse and psychosocial harm for 1 (#75) of 2 (#46 and #75) residents reviewed for abuse. The facility failed to ensure Resident #75 was free from physical abuse and psychosocial harm by Resident #46. This deficient practice resulted in a psychosocial harm on 03/03/2025 at 12:12 p.m. when Resident #75 reported to S2DON she did not feel safe in her home after an incident where Resident #46 hit her on the head. Resident #75 did not want to leave her room on 03/04/2025 because she was afraid of Resident #46. Resident #75 reported to Resident #87 that she was being scared when Resident #46 returned from the hospital on [DATE]. As a result of the investigation, despite there not being a significant decline in mental or physical functioning for Resident #75, Resident #75 experienced psychosocial harm when she verbalized she was afraid of Resident #46 and wanted to stay in her room after Resident #46 hit her in the head. It could be determined a reasonable person would have experienced psychosocial harm as a result of Resident #46 hitting Resident #75 in the head, since a reasonable person would not expect to be treated in this manner in their own home or a health care facility. Findings: Review of the facility's policy titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program, dated 2001 revealed, in part, the following: Policy Interpretation and Implementation: 1. Protect residents from abuse by anyone including, but not necessarily limited to: 2. Other Residents. Review of the facility's policy titled Recognizing Signs and Symptoms of Abuse/Neglect, dated 2001 revealed, in part, the following: All types of abuse .are strictly prohibited. Policy and Interpretation and Implementation 1. Abuse is defined as willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish. 4. The following are signs and symptoms of abuse/neglect . a. Signs of physical abuse 1. Injuries that are non-accidental or unexplained d. Psychological or behavioral signs of abuse or neglect: 1. Expression of fear of a person or place . Resident #46 Review of Resident #46's clinical record revealed she was admitted to the facility on [DATE] with diagnoses, which included, Paranoid Schizophrenia, Cognitive Communication Deficit, Bipolar Disorder and Unspecified Dementia. Review of Resident #46's quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 02/26/2025 revealed a BIMS (Brief Interview for Mental Status) score of 7, which indicated severe cognitive impairment. Review of the State Agency Report revealed the following: Event Occurred: 03/03/2025 at 9:55 a.m. Victim: Resident # 75 Accused: Resident # 46 Description: Resident #75 was observed standing in the lobby with her hand on the back of her head and stated she hit me and pointed at Resident #46. Resident #75 verbalized she was fearful of Resident #46. Review of Resident #46's nurses' notes revealed, in part, the following: 03/03/2025 at 10:00 a.m. Resident #46 walked up behind Resident #75 sitting on a couch and proceeded to hit Resident #75 on the head. Resident #46 stated, she is trying to kill everyone, and I am going to take care of her myself. Resident #46 was placed on one on one supervision. Resident #75 Review of Resident #75's clinical record revealed she was admitted on [DATE] with medical diagnoses, which included, Unspecified Dementia and Major Depressive Disorder. Review of Resident #75's quarterly MDS with an ARD of 02/26/2025 revealed she had a BIMS of 4, which indicated severe cognitive impairment. Review of Resident #75's nurses' notes revealed, in part, the following: 03/03/2025 at 11:07 a.m. Resident #75 reported to staff she was hit on the back of the head by Resident #46. Review of Resident #75's Nurse Practitioner notes revealed the following: 03/03/2025 Assessment/Plan: Resident #75 was seen today because she was hit in the back of the head by Resident # 46. Resident #75 verbalized she was fearful of Resident #46. On 04/15/2025 at 9:21 a.m., an interview was conducted with Resident #75. She stated she did not remember being hit on the head and could not recall the event. On 04/15/2025 at 9:21 a.m., an interview was conducted with S8LPN. She stated on 03/03/2025, staff reported Resident #46 hit Resident #75 in the head. She stated on 03/04/2025, Resident #75 was scared of Resident #46 and wanted to stay in her room. She stated on 03/10/2025 when Resident #46 returned from the hospital Resident #75 appeared nervous and asked her if Resident #46 was going to hurt her again. On 04/15/2025 at 1:17 p.m., an interview was conducted with Resident #87, a cognitively intact resident. She confirmed she shared a room with Resident #75. She stated on 03/03/2025, Resident #75 was sitting on the couch in the activity room and Resident #46 walked behind the couch and hit Resident #75 three times on the head with a closed fist. She stated Resident #75 told her she was scared Resident #46 would hurt her again when Resident #46 returned from the hospital on [DATE]. On 04/16/2025 at 11:25 a.m., an interview was conducted with S14DOO. He stated on 03/03/2025 he walked out of the conference room and into the activity room and saw Resident #75 holding her head. He stated Resident #75 pointed to Resident #46 and stated she hit me. On 04/16/2025 at 12:38 p.m., an interview was conducted with S7NP. She stated she was informed on 03/03/2025 that Resident #46 hit Resident #75 on the head. She stated she assessed Resident #46 and Resident #75 on 03/03/2025. She stated Resident #75 did not have any injuries but verbalized she was afraid of Resident #46 on 03/03/2025. On 04/16/2025 at 12:57 p.m., an interview was conducted with S2DON. She stated on 03/03/2025 it was reported Resident #46 hit Resident #75 on the head. She stated Resident # 75 had short term memory loss and was cognitively impaired. She stated initially Resident # 75 verbalized she was scared of Resident #46 but as time progressed, Resident #75 remembered less and less and was no longer fearful of Resident #46. She confirmed being hit on the head would be considered physical abuse and residents should feel safe in their home. On 04/16/2025 at 1:35 p.m., an interview was conducted with S1ADM. He stated he reviewed the video footage from 03/03/2025 and Resident #75 was sitting on the couch and Resident #46 walked behind her. He stated Resident #46's hand was open and he could not tell if she hit Resident #75. He stated Resident #75 then was seen holding her head with her hand and reported Resident #46 hit her on the head. He stated Resident #46 had an acute psychotic episode on 03/03/2025 and therefore he did not think it was physical abuse.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to ensure each resident had the right to be free from physical abuse by another resident for 2 (#1 and #3) of 3 (#1, #2, and #3) sampled residents reviewed for abuse. The facility failed to ensure Resident #1 and Resident #3 were free from physical abuse by Resident #2. This deficient practice resulted in an actual harm on 11/22/2024, at 3:56 p.m., when Resident #2, a resident know with physically abusive behaviors towards other residents, physically punched Resident #1 in the face and neck multiple times resulting in Resident #1 being evaluated and treated at a local hospital with diagnostic testing. Resident #1 experienced physical pain, facial swelling, and bloody drainage from the nose as a result of this incident. The facility implemented corrective actions which were completed prior to the State Agency's investigation, thus it was determined to be a Past Noncompliance Harm. Findings: Cross Reference F656 Review of the facility's policy titled, Abuse, Neglect, Exploitation and Misappropriation Prevention Program, revised April 2021, revealed the following, in part: Policy Interpretation and Implementation 1. Protect residents from abuse by anyone including but not limited to .other residents. Resident #1 Review of Resident #1's Clinical Record revealed he was admitted to the facility on [DATE], with diagnoses which included Hypertensive Heart Disease and Stroke with Left Sided Weakness. Review of Resident #1's Quarterly Minimum Date Set (MDS) with an Assessment Reference Date (ARD) of 10/08/2024 revealed in part, a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. Resident #2 Review of Resident #2's Clinical Record revealed he was admitted to the facility on [DATE], with diagnoses which included Dementia with Behavioral Disturbances and Psychotic Disorders. Review of Resident #2's admission MDS with an ARD of 10/08/2024 revealed, in part, a BIMS of 5, which indicated the resident had severe cognitive impairment. Review of Resident #2's Plan of Care, dated 09/30/2024, and updated 11/22/2024, revealed in part: Focus: Behavior Management History of sun downing, confusion, wandering, delusional, hallucinations, cursing, yelling/screaming, takes items from others, refusal of meds at times. 11/04/2024 verbal altercation with peer. 11/06/2024 pushed a peer causing her to fall. Interventions: emergency room Evaluation, Psych NP evaluation, Medications adjusted. 1:1 Observation, and 11/19/2024 stepped down to line of sight observation. Review of the facilities incident report dated 11/22/2024, revealed the following in part: On 11/22/2024 at 3:56 p.m. Resident #2 entered the room of Resident #1. Resident #1 told Resident #2 to leave his room. Resident #2 pushed the door open and hit Resident #1 in the face and neck. Resident #1 was sent to the local emergency room. Resident #2 sustained no injuries and was transported to emergency room for evaluation. Review of Resident #2's Nurses' Note dated 11/22/2024 at 7:30 p.m., revealed the following, in part: S3LPN: This nurse was in a room with another resident. I was called down to Resident #1's room. I was informed that Resident #2 had tried to go into Resident #1's room. When Resident #1 tried to close the door, Resident #2 hit Resident #1. Residents were separated. Received order to send residents out for evaluation. On 12/16/2024 at 2:23 p.m., an interview was conducted with Resident #1. He stated on 11/22/2024, Resident #2 entered his room and appeared confused. He stated he made an attempt to redirect Resident #2. Resident #1 stated he was closing his bedroom door when Resident #2 pushed the door open and punched him 3 or 4 times in the face and neck. Resident #1 further stated staff came in the room and removed Resident #2 immediately. Resident #1 stated he had a bloody nose and swollen lip after the incident. He further stated he was given an ice pack for his face, pain medication, and was sent to the emergency room where a CT scan was done of his head. On 12/16/2024 at 2:30 p.m., an interview was conducted with S3LPN. S3LPN confirmed she was the nurse on duty when the incident occurred with Resident #1 and Resident #2 on 11/22/2024. She confirmed Resident #2 had behavioral issues which included becoming agitated. She stated on 11/22/2024 Resident #2 punched Resident #1 in the face, causing blood to come from his nose and a cut on his upper lip. S3LPN stated this was abuse. She stated Resident #2 and Resident #1 were separated immediately. She stated Resident #1 was given an ice pack, Tylenol for pain, and sent to the emergency room for further evaluation. She stated Resident #2 was sent to the emergency room to be evaluated for behaviors on 11/22/2024 and did not return to the facility. She further stated she has had in-services on Wandering Residents, Behavior De-escalation techniques, Identifying Behaviors and Abuse upon hire and on 12/01/2024. S3LPN was able to verbalize processes correctly. On 12/17/2024 at 1:50 p.m., an interview was conducted with S7LPN. She confirmed on 11/22/2024 Resident #2 hit Resident #1. She confirmed Resident #1 had a bloody nose and swollen lip and she provided an ice pack and pain medication to Resident #1 following the incident. She confirmed Resident #2 hitting Resident #1 in the face and neck was physical abuse. She further stated she has had in services on Wandering Residents, Behavior De-escalation techniques, Identifying Behaviors and Abuse upon hire and on 12/01/2024. S7LPN was able to verbalize processes correctly. On 12/18/2024 at 9:35 a.m., an interview was conducted with S5CNA. S5CNA stated he was assigned to care for Resident #2 on 11/22/2024. S5CNA stated Resident #2 was to be in line of sight observations at all times, which meant to keep eyes on Resident #2. He stated he was called away assist another resident and when Resident #2 was out of his line of sight, Resident #2 punched Resident #1. S5CNA confirmed Resident #2 punching Resident #1 in the face was physical abuse. He stated following the incident he was immediately asked to provide a written statement of events and was sent home until the facility's investigation was completed. He stated he was later terminated on 11/26/2024. He stated he was in-serviced, in October 2024 upon hire, on Identifying Behaviors and Abuse. On 12/18/2024 at 12:00 p.m., an interview was conducted with S6SW. She confirmed a transfer summary indicated Resident #2 was discharged from the facility as of 11/29/2024. Resident #3 Review of the Clinical Record revealed Resident #3 was admitted to the facility on [DATE], with diagnoses which included Major Depressive Disorder and Heart Failure. Review of the Quarterly MDS with ARD dated 10/09/2024 revealed Resident #3 had a BIMS score of 14, which indicated she was cognitively intact. Review of facilities incident report dated 11/06/2024 at 8:30 p.m. revealed, in part: At 7:25 p.m. Resident #2 entered Resident #3's room and pushed Resident #3's left shoulder causing her to lose her balance and fall. Resident #3 complained of pain to the right hip, x-ray was ordered, and Resident #2 was placed on 1:1 observation. On 12/16/2024 at 2:10 p.m., an interview was conducted with Resident #3. She stated on 11/06/2024 Resident #2 entered her room, she asked Resident #2 to leave, Resident #2 pushed her on the shoulder causing her to fall. She stated Resident #2 was immediately removed from her room. She was given pain medication and had an x-ray done of her right hip and right elbow. On 12/17/2024 at 1:30 p.m., an interview was conducted with S1DON. She stated on 11/06/2024 Resident #2 went into Resident #3's room, and when she asked him to leave he pushed her on the shoulder causing her to fall down. S1DON confirmed this was resident to resident abuse. S1DON stated Resident #3 was evaluated with x-ray of right hip and right elbow, and was given pain medication as needed. S1DON stated Resident #2 was sent to the emergency room for behaviors and was placed on 1:1 observations upon return to the facility on [DATE]. On 12/18/2024 at 1:32 p.m., an interview was conducted with S1DON. S1DON confirmed Resident #2 pushing Resident #3 causing her to fall and Resident #2 punching Resident #1 was physical abuse. S1DON confirmed S5CNA was aware Resident #2 was to be in line of site at all times prior to leaving the resident unsupervised. S1DON confirmed S5CNA was terminated following the incident that occurred on 11/22/2024. She further on 11/22/2024 a poll was conducted with all CNAs to determine understanding of line of sight supervision and Resident #2's plan of care was updated due to additional behaviors. She stated an in-service was conducted on all nursing staff on supervision and posttest competencies was completed on 12/01/2024. On 12/18/2024 at 3:30 p.m., an interview was conducted with S2ADM. S2ADM confirmed Resident #2 pushing Resident #3 causing her to fall, and Resident #2 punching Resident #1 is abuse. S2ADM confirmed S5CNA was terminated following the incident that occurred on 11/22/2024. He confirmed on 11/22/2024 a poll was conducted with all CNAs to determine understanding of line of sight supervision and Resident #2's plan of care was updated due to additional behaviors. S2ADM stated an in-service was conducted on all nursing staff on supervision and posttest competencies was completed on 12/01/2024. He stated a prevention plan was implemented for behaviors on 11/22/2024 with an expected completion date of 02/15/2025. S2ADM provided documentation the facility initiated an effective Plan of Correction on 11/8/2024, which included: 1. Problem identified: Resident #2 was on direct line of sight supervision due to previous altercation with Resident #3 on 11/06/2024, and left unattended by the CNA on 11/22/2024. Resident #2 got into a physical altercation with Resident #1. 2. Plan of action with projected completion date of: 12/01/2024 Immediate Action: Residents were separated, assessed, and first aid provided. Resident #2 resumed 1:1 supervision until being sent out to the emergency room for evaluation. Facility performed audit to identify all residents with behaviors that could or do affect others. Completed 10/15/2024. Assessment and social history by Director of Social Services on Resident #2 to identify potential causes of behaviors, needs, triggers, or Post Traumatic Stress Disorder. Completed 10/14/2024. Corporate review of Care Plans and behavior residents identified by staff. All care plans were updated by team. Completed 11/15/2024. In-service education on: Wandering Residents, Behavior De-escalation techniques, Identifying Behaviors. Completed 11/17/2024. In-service Staff Supervision and when to report, with written posttest. Completed 12/01/2024. CNA Poll and written statements to determine understanding of Supervision. Completed on 11/22/2024. Plan was revised on 11/22/2024 due to additional behaviors that occurred on 11/22/2024. In-service education on supervision, and posttest competencies. Completed 12/01/2024. S3LPN was verbally educated to report non-compliance with supervision to S1DON. S5CNA was terminated on 11/26/2024 due to failure to follow procedures. Resident #2 never returned to facility and was discharged from facility on 11/29/2024. Plan reviewed and it was determined that Plan of Correction was effective, resolved 12/01/2024. QAPI on behavior interventions initiated on 11/22/2024. Expected completion date 02/15/2025. Throughout the survey from 12/16/2024 to 12/18/2024, observations, interviews, and record reviews revealed the above listed actions were implemented. Random staff interviews revealed staff received training on the facility's abuse policy and procedure and were given questionnaires testing their knowledge. Observations were made throughout the survey with no abuse identified. Observations, interviews, and record review, revealed monitoring had begun with no further issues identified.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to implement the comprehensive person centered care plan for 1 (#2) of 3 (#1, #2, and #3) residents reviewed. The facility failed to maintain line of sight supervision per Resident #2's care plan. This deficient practice resulted in an actual harm on 11/22/2024 at 3:56 p.m., when S3LPN noticed S5CNA failed to maintain line of sight supervision per the care plan on Resident #2, a resident with known physical behaviors towards other residents. During this time, Resident #2 physically assaulted Resident #1. Resident #1 was evaluated and treated at a local hospital with diagnostic testing. Resident #1 experienced physical pain, facial swelling, and bloody drainage from the nose as a result of this incident. The facility implemented corrective actions which were completed prior to the State Agency's investigation, thus it was determined to be a Past Noncompliance Harm. Findings: Cross Reference F600 Review of the facility's policy, dated 07/2017, titled, Safety and Supervision of Residents, revealed the following, in part: Individualized, Resident Centered Approach to Safety: 4) Implementing interventions to reduce accident risks shall include: a. Communicating interventions to all relevant staff; b. Assigning responsibility for carrying out interventions; c. Providing training; and d. Ensuring interventions are implemented Review of Resident #2's Clinical Record revealed he was admitted to the facility on [DATE] and had diagnoses, which included Dementia with Behavioral Disturbances and Psychotic Disorders. Review of Resident #2's admission Minimum Date Set (MDS) with an Assessment Reference Date (ARD) of 10/08/2024 revealed in part, a Brief Interview for Mental Status (BIMS) score of 5, which indicated the resident had severe cognitive impairment. Review of Resident #2's Plan of Care, dated 09/30/2024, and updated 11/22/2024, revealed in part: Focus: Behavior Management History of sun downing, confusion, wandering, delusional, hallucinations, cursing, yelling/screaming, takes items from others, refusal of meds at times. 11/04/2024- verbal altercation with peer. 11/06/2024- pushed a peer causing her to fall. Interventions: 11/06/2024- emergency room Evaluation, Psych NP evaluation, Medications adjusted. 1:1 Observation. 11/19/2024 stepped down to line of sight observation. 11/22/2024- Resident #2 entered the room of a peer and hit peer. Resident separated immediately. Received order from NP to send Resident #2 for eval, 1:1 with staff until left building Review of the facilities incident report dated 11/22/2024, revealed the following in part: On 11/22/2024 at 3:56 p.m. Resident #2 entered the room of Resident #1. Resident #1 told Resident #2 to leave his room. Resident #2 pushed the door open, and hit Resident #1 in the face and neck. Resident #1 was sent to the local emergency room. Resident #2 sustained no injuries and was transported to emergency room for evaluation. Review of Resident #2's Nurses' Note dated 11/22/2024 at 7:30 p.m. revealed the following, in part: S3LPN: This nurse was in a room with another resident. I was called down to Resident #1's room. I was informed that Resident #2 tried to go into Resident #1's room. When Resident #1 tried to close the door, Resident #2 hit Resident #1. Residents were separated. Received order to send residents out for evaluation. On 12/17/2024 at 2:35 p.m., an interview was conducted with S3LPN. She stated on 11/22/2024 she was called from another resident's room because Resident #2 was hitting Resident #1. She stated Resident #2 was care planned to be line of sight supervision by staff after the resident pushed another resident down on 11/06/2024. S3LPN stated line of sight supervision meant keeping a resident in eye view and at arm's reach at all times. She stated, on 11/22/2024 prior to Resident #2's incident, she had to redirect S5CNA 4 to 5 times regarding keeping Resident #2 in line of sight supervision. She stated S5CNA was on his phone, standing in the hall not within arm's reach of Resident #2, and sitting outside when she had to redirect him. She stated she never notified S1DON of having to redirect S5CNA prior to Resident #2 assaulting Resident #1. She further stated she was in-serviced again on line of sight supervision and reporting non-compliance of line of sight supervision by S1DON on 11/22/2024. On 12/18/2024 at 9:35 a.m., a telephone interview was conducted with S5CNA. He confirmed, on 11/22/2024, he was assigned to Resident #2 for line of sight supervision. He stated he understood line of sight to mean keep his eyes on the resident at all times. He confirmed he was not assigned to any other residents during his shift on 11/22/2024. He stated, on 11/22/2024, he took his eyes off of Resident #2 to assist another resident with care. He stated at that time, Resident #2 entered another resident's room and punched that resident in the face. He confirmed he should not have let Resident #2 out of his line of sight. He confirmed he was in-serviced on line of sight supervision prior to his shift on 11/22/2024. He stated he was immediately relieved of his assignment, asked to write a statement of what occurred, sent home until further investigation, and was later terminated on 11/26/2024. On 12/18/2024 at 11:38 a.m., an interview was conducted with S8CNA. S8CNA stated line of sight supervision meant keeping a resident in eye view and at arm's reach at all times. She confirmed she was in-serviced and took a test on supervision of residents in November 2024. On 12/18/2024 at 11:57 a.m. an interview was conducted with S9CNA. S9CNA stated line of sight supervision meant keeping a resident in eye view and at arm's reach at all times. She confirmed she was in-serviced and took a test on supervision of residents in November 2024. On 12/18/2024 at 1:32 p.m., an interview was conducted with S1DON. She stated, on 11/22/2024, she conducted an in-service with S5CNA regarding line of sight supervision prior to the start of his shift. She stated, after Resident #2 hit Resident #1 on 11/22/2024, S3LPN reported she previously had to redirect S5CNA regarding line of sight supervision. S1DON stated the physical abuse could have been prevented if she was made aware S5CNA required redirection to provide line of sight supervision. S1DON stated she immediately in-serviced all nursing staff on line of sight supervision and when to report non-compliance with supervision by polling staff and posttest. On 12/18/2024 at 4:02 p.m., an interview was conducted with S2ADM and S1DON. S2ADM and S1DON confirmed, on 11/22/2024, line of sight supervision was not maintained for Resident #2 and should have been. The facility had implemented the following actions to correct the deficient practice on 11/22/2024: 1. Immediate Action: S3LPN was verbally educated to report non-compliance with supervision to S1DON. 2. S5CNA relieved of duties on 11/22/2024 and later terminated post facility investigation. 3. Resident #2's care plan was revised on 11/22/2024 due to additional behaviors that occurred on 11/22/2024. 4. 11/22/2024 new education implemented with posttest competencies. Random poll conducted to evaluate effectiveness of education on types of supervision. 5. 11/22/2024 in-service nursing staff understanding on different types of supervision the facility provides for residents. 6. In-service staff on supervision and when to report, with written posttest. Completed 12/01/2024. 7. Continued daily monitoring of behaviors that could potentially affect others by DON or designee. Education materials added to new hire packets and annual competencies. 8. Initiated a QA for wandering/behavior preventions and intervention with a target completion date of 02/15/2025. Throughout the survey from 12/16/2024 to 12/18/2024, observations, interviews, and record reviews revealed the above listed actions were implemented. Random staff interviews revealed staff received training on the facility's safety and supervision policy and procedure and questionnaires testing their knowledge. Observations were made throughout the survey with no supervision concerns identified. Observations, interviews, and record review, revealed monitoring had begun

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure a cognitively impaired resident received treatment and care in accordance with professional standards of practice for 1 (#2) of 3 (#1, #2, and #3) sampled residents. The facility failed to ensure: 1. S5LPN transcribed new telephone orders for Tylenol and an X-Ray for Resident #2; 2. S5LPN implemented a new telephone order for an X-Ray for Resident #2 after a fall and complaint of pain; and 3. S5LPN communicated Resident #2's change in status, fall, or new orders of Tylenol and an X-Ray to oncoming staff prior to leaving the facility at the end of her shift. This deficient practice resulted in an actual harm for Resident #2, a severely cognitively impaired resident, beginning on 04/01/2024 at 6:30 a.m. when S5LPN left the facility without communicating Resident #2's fall and new X-Ray order to any other staff. On 04/01/2024, between 10:30 a.m. and lunch time, Resident #2's CNA notified S4LPN that Resident #2 had complained of pain and required increased assistance with a transfer. S2NP assessed Resident #2, and she complained of left leg pain and would not allow S2NP to touch her leg. On 04/01/2024 around 1:41 p.m., a local imaging company was notified of S2NP's left leg and hip X-Ray order. On 04/01/2024 at 4:00 p.m., X-Ray revealed Resident #2 had a Displaced Left Femoral Neck Fracture that required surgical intervention. Due to Resident #2's impaired cognition, she did not recall the above events, but it could be determined that a reasonable person would have suffered physical harm as a result of the failed communication and delayed treatment. Findings: Review of the facility's policy with a revision dated of July 2016 and titled, Medication and Treatment Orders revealed the following, in part: Policy Interpretation and Implementation: 3. Drug and biological orders must be recorded on the Physician's Order Sheet in the resident's chart. 7. Verbal Orders must be recorded immediately in the resident's chart by the person receiving the order . Review of Resident #2's Clinical Record revealed an admission date of 01/31/2021 and diagnoses, which included Unspecified Signs and Symptoms Involving Cognitive Functions and Awareness, Cognitive Communication Deficit, History of Falling, Major Depressive Disorder, and Dementia. Further review revealed a new diagnosis of a Displaced Intertrochanteric Fracture of Left Femur on 04/01/2024. Review of Resident #2's MDS with an ARD of 04/12/2024 revealed she had a BIMS summary score of 99, which indicated Resident #2 had severely impaired cognition. Review of Resident #2's Nurses' Notes dated 04/01/2024 revealed the following, in part: 04/01/2024 at 2:29 a.m. Called to Resident #2's room by her roommate. Resident #2 found on the floor in bathroom. Resident #2 complained of pain to Left Knee. Spoke with S3OCNP at about 1:50 a.m. S3OCNP advised giving Tylenol for Knee Pain and X-Ray on 04/01/2024. Signed S5LPN. Review of Resident #2's Telephone Orders dated 03/31/2024 through 04/01/2024 revealed no evidence S5LPN transcribed the orders for Tylenol or X-Ray received from S3OCNP on 04/01/2024. Review of Resident #2's Hallway 24-Hour Report Log dated 03/31/2024 revealed the following, in part: Change of Condition: Resident #2 - unwitnessed fall New orders 6:00 p.m. to 6:00 a.m.: Resident #2 - X-Ray 04/01/2024 Review of Resident #2's Electronic Physician Orders dated April 2024 revealed no evidence Tylenol or an X-Ray was ordered on 04/01/2024. Review of Resident #2's Nurses' Notes dated 04/01/2024 revealed the following, in part: 4/01/2024 at 6:00 p.m. Late entry 04/01/2024 at 2:00 p.m. Resident #2 sitting in lobby in wheelchair. Resident #2 has complaints of pain to leg to staff. S2NP making rounds and assessed resident. S2NP with orders for X-Ray of Left Hip and Left Leg. Resident propelling self in wheelchair. Resident given Tylenol 650 mg for pain. Signed S4LPN. Review of Resident #2's Telephone Orders dated 04/01/2024 revealed the following: (04/01/2024) X-Ray of Left Leg and Left Hip Signed by S4LPN and S2NP. Review of Resident #2's Physician Progress Note dated 04/01/2024 revealed the following, in part: Assessment/Plan: 1. Left Hip Pain (Primary) Overview: will obtain X-Ray at this time Review of Resident #2's Nurses' Notes dated 04/01/2024 revealed the following, in part: 04/01/2024 at 6:08 p.m. At 4:00 p.m., a local imaging company arrived for X-Rays. Signed S4LPN. Review of Resident #2's Left Hip and Femur X-Ray results dated 04/01/2024 revealed the following, in part: Significant Findings: Displaced Left Femoral Neck Fracture Review of Resident #2's Nurses' Notes dated 04/01/2024 revealed the following, in part: 04/01/2024 at 11:30 p.m. Resident sent to a local emergency room. X-ray results showed Left Femoral Neck Displaced Fracture. An interview was conducted with Resident #2 on 05/06/2024 at 9:10 a.m. Due to Resident #2's impaired cognition, she was unable to recall having a fall, fracture, and/or surgery. A telephone interview was conducted with S5LPN on 05/06/2024 at 11:25 a.m. She confirmed she was assigned to Resident #2 on the early morning of 04/01/2024 when Resident #2 had a fall. S5LPN stated Resident #2's roommate notified her around 1:50 a.m. that Resident #2 was on the floor in the bathroom. She stated Resident #2 complained of left knee pain prior to her getting off the floor. S5LPN stated she notified the on-call nurse practitioner who gave her orders to administer Tylenol and obtain X-Rays in the morning. She stated she did not notify the X-Ray Company of Resident #2's order for an X-Ray. S5LPN stated she documented Resident #2's fall and X-Ray order in the 24-hour report book. She stated she left the facility around 6:30 a.m. that morning, and her relief was not present in the facility to verbally communicate report. S5LPN stated she did not notify any facility oncoming staff of Resident #2's fall, new order for Tylenol, and/or the order for an X-Ray. She stated she administered Tylenol, but did not transcribe the verbal order. She stated she did not transcribe or implement the new order for the X-Ray. An interview was conducted with S6CNA on 05/06/2024 at 1:15 p.m. She confirmed she was assigned to Resident #2 on 04/01/2024 from 6:00 a.m. to 6:00 p.m. She stated she was not aware Resident #2 had a fall on the night shift. She stated she was unable to recall the exact timeline of events, but Resident #2 complained of pain intermittently on 04/01/2024. She stated Resident #2 needed more assistance than normal during a transfer and complained of pain to her leg. She stated she notified S4LPN of Resident #2's change in condition and complaint of pain. An interview was conducted with S4LPN on 05/06/2024 at 11:49 a.m. She confirmed she was assigned to Resident #2 on 04/01/2024 from 6:00 a.m. to 6:00 p.m. S4LPN stated she arrived late to the facility on [DATE] around 7:00 a.m., and S5LPN had already left. S4LPN stated, between BINGO and lunch time, Resident #2's CNA notified her Resident #2 complained of pain and required increased assistance with a transfer. She stated at that point, she read Resident #2's Nurses' Notes and determined Resident #2 had a fall. S4LPN stated she then notified S2NP of Resident #2's change in condition and complaints of pain. S4LPN reviewed Resident #2's Hallway 24-hour report log dated 03/31/2024 and confirmed under new orders for 6:00 p.m. to 6:00 a.m. shift, Resident #2 had a new order for an X-Ray on 04/01/2024. She confirmed the 24-hour report log revealed Resident #2 had an unwitnessed fall. S4LPN confirmed she should have been aware of Resident #2's fall, complaint of pain, and X-Ray order at the beginning of her shift. She stated if she had been aware of Resident #2's change in condition and X-Ray order at the beginning of her shift, she would have immediately assessed Resident #2 and ordered the X-Ray. She stated S5LPN should have notified the X-Ray company when she received Resident #2's X-Ray order. S4LPN explained the nurse who received the X-Ray order was responsible to notify the X-Ray company of the order. She stated she notified a local imaging company of Resident #2's Left Hip and Leg X-Ray order around 2:00 p.m. on 04/01/2024. S4LPN stated the x-ray was performed around 4:00 p.m. A telephone interview was conducted with S3OCNP on 05/06/2024 at 2:26 p.m. She stated she was unable to recall the specified date, time, and scenario regarding Resident #2. She stated if after Resident #2's fall, she complained of pain to her left knee, she would have told the nurse to administer Tylenol and obtain an X-Ray. She stated the expectation would be for the nursing home to notify the X-Ray company first thing the next morning, which was 7:00 a.m. She stated a 2:00 p.m. notification the next day would not have been incredibly sufficient. An interview was conducted with S2NP on 05/06/2024 at 12:22 p.m. She stated, on 04/01/2024 around lunch time, S4LPN reported to her Resident #2 had a fall and was complaining of pain to her left leg. She stated she assessed Resident #2 at that time. She stated Resident #2 was seated in the dining room in her wheelchair. She stated when she attempted to perform range of motion to Resident #2's left leg, Resident #2 would not allow her to touch the leg, and Resident #2 complained of pain. She stated, at that time, she ordered an x-ray of the left hip and leg. She stated she was unaware the on-call Nurse Practitioner ordered x-rays. She stated if the x-rays were ordered overnight, the x-ray company should have been notified at that time. An interview was conducted with a representative from a local imaging company used by the facility on 05/06/2024 at 3:08 p.m. She stated the facility contacted the imaging company on 04/01/2024 at 1:17 p.m. for an x-ray for Resident #2. She stated the imaging company received X-Ray orders 24/7. An interview was conducted with S1DON on 05/07/2024 at 9:33 a.m. She stated residents' change in condition and any new orders should be communicated from shift to shift. S1DON stated there was a 24-hour communication tool at each nurses' station, and there should be a shift to shift verbal report given at the beginning and end of each shift. She stated, ideally, if the day nurse was running late, she would expect the night nurse to give the keys to another day shift nurse and give report so it could be communicated to the oncoming nurse once they arrived. S1DON stated she expected each nurse to review the 24-hour report communication tool at the beginning of their shift. She confirmed Resident #2's fall and X-Ray order was placed on the 24-hour report communication tool. She stated S5LPN should have notified the X-Ray company of Resident #2's X-Ray order when the order was received. S1DON reviewed Resident #2's Physician Orders and Telephone Orders and confirmed the orders S5LPN received for Tylenol and an X-Ray for Resident #2 from S3OCNP were not transcribed and should have been.