**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on records reviewed and interviews for one of three sampled residents (Resident #1) who during the overnight shift (11:00 P.M. to 7:00 A.M.) on 1/30/25 into 1/31/25, had an unwitnessed fall and was found on the floor by staff, the facility failed to ensure he/she was free from neglect, when although Resident #1 told staff he/she was hurt and was screaming I'm in pain, without assessing him/her for the potential for injuries, Nurse #1 picked Resident #1 up off the floor put him/her in a wheelchair, picked him/her up again, transferred him/her back into bed and left the room. Despite Certified Nurse Aide (CNA) #1 reporting to Nurse #1 that Resident #1 was still complaining of and was in obvious pain, Nurse #1 did not go check on Resident #1 and still did not assess him/her for injuries. Nurse #1 finished his shift, left the facility and never reported the incident to anyone. Day shift nursing staff, who were totally unaware that Resident #1 had an unwitnessed fall on the previous shift, were unable to provide care, as Resident #1 screamed whenever staff tried to touch him/her. Resident #1 was emergently transferred to the Hospital Emergency Department, where he/she was diagnosed with a left hip fracture. Findings include: The Facility's Policy titled, Abuse, dated as reviewed 06/17/24, indicated neglect is defined as the failure of the Facility its employees or services providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. The Policy indicated the Facility is to prevent and prohibit all types of abuse and neglect. The Policy indicated the Facility assures that residents are free from neglect by having the structures and process to provide needed care and services to all residents, which includes but is not limited to the provision of a facility assessment to determine what resources are necessary to care for its residents competently. The Facility's Policy titled, Resident Rights, dated as reviewed 09/10/24, indicated the following: a resident has the right to be treated with respect and dignity; a resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. Review of the Facility's Incident Report, dated 02/06/25, indicated on 01/31/25 sometime around 8:30 A.M. Resident #1 was observed by Certified Nurse Aide (CNA) #2 screaming as if in pain and would not allow CNA #2 to provide care to him/her. The Report indicated Resident #1 reported 10/10 pain (a pain scale where 0 is no pain and 10 is the worst pain imaginable, severe or unbearable pain) his/her leg. The Report indicated Resident #1 informed Nurse #2 and the Staff Development Coordinator (SDC) that he/she had fallen out of bed in the early morning and two men assisted him/her back to bed. The Report indicated Resident #1's left leg was rotated outward and noted to be larger than the right leg. The Report indicated Emergency Medical Services (911) had been called and in the Emergency Department Resident #1 was found to have a Displaced Proximal Left Femoral Subtrochanteric Fracture (break in thigh bone just below the bony prominence in the lower part of the hip). Resident #1 was admitted to the Facility in December 2024, diagnoses included Rhabdomyolysis (breakdown of muscle tissue), Hypertension (high blood pressure), Orthostatic Hypotension (low blood pressure that happens when standing up from sitting or lying down), Bradycardia (slower than expected heart rate, generally beating fewer than 60 minute), Wedge Compression fracture of T11-T12 vertebra subsequent encounter for fracture with routine healing (occurs when the front (anterior) portion of the vertebra collapses, resulting in a wedge-shaped deformity), difficulty with walking, muscle weakness and history of falling. Review of Resident #1's admission Minimum Data Set (MDS) Assessment, dated 12/19/24, indicated Resident #1's Brief Interview for Mental Status (BIMS), score was 14/15 (score of 13-15 indicates intact cognition, 12-8 indicates moderate cognitive impairment, 0-7 indicates severe cognitive impairment). Review of the Certified Nurse Aide (CNA) #1's Written Witness Statement, dated 02/03/25, indicated on 01/31/25 at 2:30 A.M., she was helping Resident #3, heard a fall [loud bang] and left Resident #3's room to see what was going on. The Statement indicated Resident #1 was on the floor screaming, help me. The Statement indicated CNA #1 told Nurse #1, to call the ambulance because Resident #1 was screaming, but Nurse #1 said they should put Resident #1 back into bed. The Statement indicated Nurse #1 picked Resident #1 up off the floor put him/her into his/her wheelchair, then picked Resident #1 up from his/her wheelchair and put him/her into the bed. The Statement indicated CNA #1 did not move or touch Resident #1, but did hold the wheelchair. The Statement indicated she (CNA #1) was uncomfortable, that Resident #1 was screaming, I'm in pain, and that Nurse #1 told her not to say anything about this. During an interview on 03/18/25 at 2:00 P.M., (and during a follow-up interview on 03/19/25 at 1:07 P.M.) CNA #1 said on 01/31/25, sometime around 2:30 A.M., she heard a loud bang while providing care to Resident #3 and went to find out what the noise was. CNA #1 said the noise came from the room diagonally across from the room she was providing care in. CNA #1 said she found Resident #1 in his/her room lying face up on the floor and called Nurse #1 for help. CNA #1 said when Nurse #1 came to the room, Resident #1 was screaming, I'm in pain, I'm in pain. CNA #1 said that Nurse #1 said to get Resident #1 up off the floor. CNA #1 said she told Nurse #1 No, that in school she learned that when a patient falls and screams, they may have something broken and that they should call an ambulance. CNA #1 said Nurse #1 said No, we do not need to call the ambulance, and told her to bring Resident #1's wheelchair over to him. CNA #1 said she brought the wheelchair over to Nurse #1 and Nurse #1 picked up Resident #1 up off the floor, by himself, that Resident #1 was screaming, I'm in pain, I'm in pain. and placed him/her in the wheelchair. CNA #1 said then Nurse #1 transferred Resident #1 out of the wheelchair by himself to the bed. CNA #1 said Resident #1 was still screaming, I'm in pain. CNA #1 said Nurse #1 did not perform an assessment on Resident #1 prior to moving Resident #1 up off the floor and did not even check his/her vital signs. CNA #1 said shortly thereafter, she and Nurse #1 left the room at the same time and Resident #1 was still saying he/she was in pain. CNA #1 said she asked Nurse #1 if he was going to call 911 and complete the paperwork and Nurse #1 said, to her Forget about it, Forget about it. CNA #1 said around 4:00 A.M., she assisted Resident #1's roommate with care and Resident #1 was moaning like he/she was in pain. CNA #1 said she told Nurse #1 again about Resident #1's pain and asked him to take Resident #1's vital signs and to see if he/she was ok. CNA #1 said Nurse #1 waved his hand in a backward motion at her, as if he was dismissing her concerns and telling her to go away. CNA #1 said she never saw Nurse #1 go check on or assess Resident #1, after she asked him to. During an interview on 03/18/25 at 1:15 P.M., Nurse #2 said on 01/31/25 she started her shift around at 8:00 A.M. and had not receive an oncoming Nurse Change Shift Report from Nurse #1, because he had left the Facility prior to her arrival. Nurse #2 said the other nurse who was working with her on the day shift did not report to her that there was any change of condition or a fall regarding Resident #1. Review of the Nurse #1 Written Witness Statement, dated 01/31/25, indicated he was called into Resident #1's room by CNA #1, because Resident #1 was seated halfway in his/her wheelchair and CNA #1 could not sit him/her up by herself. The Statement indicated he assisted Resident #1 in the wheelchair and back to bed with CNA #1's help and left for the day. The Statement indicated Nurse #1 did not witness any fall. During an interview on 04/01/25 at 9:40 A.M., Nurse #1 said on the night shift (1/30/25 into 1/31/25), he did not hear Resident #1 fall, and when he transferred Resident #1 into bed, he/she was not in pain. Nurse #1 denied he received any reports from CNA #1 that Resident #1 was in pain and that he had no idea how Resident #1 fractured his/her hip. During an interview on 03/19/25 at 9:40 A.M., the Director of Nurses (DON) said she received a phone call on 01/31/25, at around 9:00 A.M. from the Staff Development Coordinator (SDC) that Resident #1 reported he/she had fallen during the overnight shift, and two men picked him/her up and put him/her back into bed. The DON said the SDC reported that Resident #1's left hip was larger than his/her right and Resident #1 was sent to the Hospital. The DON said she had not received any phone calls from the night shift Nurse (Nurse #1) regarding Resident #1's fall on 01/31/25. The DON said she had asked the SDC to start an investigation. The DON said it was not until she and the Administrator spoke with CNA #1 on 02/03/25 and obtained her statement that they were informed Resident #1 had fallen on 01/31/25, and had been found on the floor. The DON said CNA #1 told them she called Nurse #1 for help, told him that they should call 911 and that Nurse #1 told her (CNA #1), No, we were going to put him/her back to bed. The DON said CNA #1 said Resident #1 told them (CNA #1 and Nurse #1) he/she was in pain and that his/her leg hurt. The DON said she reviewed Resident #1's Medical Record and there was no documentation related to Resident #1's fall on 01/31/25, that there were no Nursing assessment including no pain assessment, no documentation to support the Physician was notified of Resident #1's acute pain to obtain orders, and that Resident #1 was not given any medication to treat or manage his/her pain. The DON said her expectations were that the Nursing staff follow the Facility's Policy and Procedures which included that Resident #1 should not have been moved off the floor after the fall occurred until Nursing completed a Nursing Assessment which includes a physical and pain assessment and taking care of the resident's needs immediately. The DON said Nursing staff should have called Emergency Medical Services if Resident #1 was in pain and/or an injury was suspected. The DON said her expectations were that Nursing notify the Physician, Health Care Proxy, Facility Management, complete the Fall Packet/Risk Management Progress Note, and inform the oncoming shift. Review of Resident #1's Hospital Discharge summary, dated [DATE], indicated Resident #1 had an unwitnessed fall at the Facility, was diagnosed with a Closed Displaced Subtrochanteric Fracture of the Left Femur, with the broken pieces out of alignment, treated surgically using a metal rod (intramedullary nail) inserted into the bone's hollow channel) on 02/01/25. On 03/18/25, the Facility was found to be in Past Non-Compliance and provided the surveyor with a plan of correction which addressed the area of concern as evidenced by: A) 01/31/25, Resident #1 was transferred to the Hospital and was found to have a Displaced Proximal Left Femoral Subtrochanteric Fracture (break in thigh bone just below the bony prominence in the lower part of the hips). B) 02/03/25, Nurse #1 was suspended pending an Investigation, and on 02/06/25, Nurse #1 was terminated from the Facility. C) 02/07/25, Resident #1 returned to the Facility status post Left Femur Open Reduction and Internal Fixation (ORIF) with intramedullary nail on 02/01/25, and his/her Care Plans were reviewed and updated as needed. D) 02/07/25, the Director of Nursing and Cooperate Nurse reviewed and performed an audit of the Facility's previous three months of resident falls, including conducting an audit related to Nurse #1's involvement with any Facility incidents. There were no concerns identified during the audits and it was determined Nurse #1 was not involved in any of the fall incidents. E) 02/10/25 through 02/26/25, the Staff Development Coordinator provided in-person education to all Licensed staff on the following topics: - Fall Management - Review Policy & Procedure - Assessments - Fall Reporting Tools - Falls - Immediate action - Reporting - Resident Rights, Abuse and Neglect F) 02/20/25 an Ad-Hoc Quality Assurance Performance Improvement (QAPI) meeting was held with the Facility leadership team. The Director of Nursing and the Cooperate Nurse developed a plan of correction related to the deficient practice, the plan and corrective measures were reviewed. G) 02/26/25 and ongoing, the Unit Manager and Director of Nursing review each fall (Incident/Accident Reports) to ensure Licensed Staff are following Facility's Policy and Procedure, they will collect the data and present findings to QAPI Committee. H) Effectiveness of corrective action plan will be reviewed during Monthly QAPI meetings until further notice. I) Director of Nursing and Executive Director are responsible for overall compliance.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on records reviewed and interviews, for one of three sampled residents (Resident #1) who during the overnight shift (11:00 P.M. to 7:00 A.M.) on 1/30/25 into 1/31/25, had an unwitnessed fall, was found on the floor by staff complaining of pain, the facility failed to ensure he/she was provided care and services that met professional standards of nursing practice, when although Resident #1 was crying out in pain, without completing any type of assessment, Nurse #1 picked Resident #1 up off the floor, initially put him/her in a wheelchair, then transferred him/her again by picking him/her up out of the wheelchair, put him/her in bed, and left the room. Nurse #1 did not complete any type of assessments, did not document the fall in a progress note that night, did not complete an incident report, and did not inform oncoming nursing staff during change of shift report that Resident #1 had been found on the floor after an unwitnessed fall and had been complaining of pain since the fall. Resident #1 was transferred to the Hospital Emergency Department, at the start of the day shift, where he/she was diagnosed with a left hip fracture. Findings include: Standard Reference: Standard of Practice Reference: Pursuant to Massachusetts General Law (M.G.L), chapter 112, individuals are given the designation of registered nurse and practical nurse which includes the responsibility to provide nursing care. Pursuant to the Code of Massachusetts Regulation (CMR) 244, Rules and Regulations 3.02 and 3.04 define the responsibilities and functions of a registered nurse and practical nurse bear full responsibility for systematically assessing health status and recording the related health status and recording the related health data. They also stipulate that both the registered and practical nurse incorporated into the plan of care and implement prescribed medical regimens. The rules and regulations 9.03 define standards of Conduct for Nurses where it is stipulated that a nurse licensed by the Board shall engage in the practice of nursing in accordance with accepted standards of practice. The Facility's Policy titled Incident and Reportable Event Management, dated as reviewed 09/25/24, indicated an accident refers to any unexpected or unintentional incident, which results or may result in injury or illness to a resident. The Policy indicated an unwitnessed or witnessed fall is an event management, a fall refers to unintentionally coming to rest on the ground, floor, or other lower level, but not as a result of an overwhelming external force; An episode where a resident lost his/her balance and would have fallen, if not for another person or if he or she had not caught him/herself, is considered a fall; a fall without injury is a fall, unless there is evidence suggesting otherwise and when a Resident is found on the floor, a fall is considered to have occurred. The Policy indicated if an event Incident/Injury occurs the Licensed Nurse should do the following: - Evaluate the residents and render first aid if needed. The Nurse evaluation be completed prior to moving a resident who has fallen, to determine presence of injury. - Create an event note and include the following details: Assessment details of the resident-including location details of the resident; Presence or absence of injury, and any treatments rendered; If resident can report what occurred, this should be included in the notes; Notification of Family or responsible party; and Notification of Physician and any orders received. - Create a risk report in the electronic system and identify the most appropriate type of event from the available options in the system. - Notify the following in accordance with state and federal requirements including the Supervisor on duty and/or Director of Nursing. Review of the Facility's Incident Report, dated 02/06/25, indicated on 01/31/25 sometime around 8:30 A.M. Resident #1 was observed by Certified Nurse Aide (CNA) #2 screaming as if in pain and would not allow CNA #2 to provide care to him/her. The Report indicated Resident #1 reported 10/10 pain (a pain scale where 0 is no pain and 10 is the worst pain imaginable, severe or unbearable pain) in his/her leg. The Report indicated Resident #1 informed Nurse #2 and the Staff Development Coordinator (SDC) that he/she had fallen out his/her bed in the early morning and two men assisted him/her back to bed. The Report indicated Resident #1's left leg was rotated outward and noted to be larger than the right leg. The Report indicated Emergency Medical Services (911) had been called and in the Emergency Department Resident #1 was found to have a Displaced Proximal Left Femoral Subtrochanteric Fracture (break in thigh bone just below the bony prominence in the lower part of the hip). Review of Resident #1's Hospital Discharge summary, dated [DATE], indicated Resident #1 had an unwitnessed fall at the Facility, was diagnosed with a Closed Displaced Subtrochanteric Fracture of the Left Femur, with the broken pieces out of alignment, treated surgically using a metal rod (intramedullary nail) inserted into the bone's hollow channel) on 02/01/25. Resident #1 was admitted to the Facility in December 2024, diagnoses included Rhabdomyolysis (breakdown of muscle tissue), Hypertension (high blood pressure), Orthostatic Hypotension (low blood pressure that happens when standing up from sitting or lying down), Bradycardia (slower than expected heart rate, generally beating fewer than 60 minute), Wedge Compression fracture of T11-T12 vertebra subsequent encounter for fracture with routine healing (occurs when the front (anterior) portion of the vertebra collapses, resulting in a wedge-shaped deformity), difficulty with walking, muscle weakness and history of falling. Review of Resident #1's admission Minimum Data Set (MDS) Assessment, dated 12/19/24, indicated Resident #1's Brief Interview for Mental Status (BIMS), score was 14/15 (score of 13-15 indicates intact cognitive, 12-8 indicates moderate cognitive impairment, 0-7 indicates severe cognition impairment). Review of Resident #1's Care Plan, titled Pain, dated 01/07/25, indicated Resident #1's Pain interventions included to anticipate the resident's need for pain relief and respond immediately to any complaints of pain, pain meds as ordered, observe and report to Nurse any signs or symptoms of non-verbal pain and observe and report to Nurse resident complaints of pain or requests for pain treatment. During an interview on 03/18/25 at 2:00 P.M., (and during a follow-up interview on 03/19/25 at 1:07 P.M.) Certified Nurse Aide (CNA) #1 said on 01/31/25, sometime around 2:30 A.M., she heard a loud bang while providing care to Resident #3 and went to find out what the noise was. CNA #1 said the noise came from the room diagonally across from the room she was providing care in. CNA #1 said she found Resident #1 in his/her room lying face up on the floor and she called Nurse #1 for help. CNA #1 said when she called for help, Nurse #1 was at the Nurses Station sitting in a chair, his feet were up on another chair, he had a blanket covering him and his eyes were closed. CNA #1 said she called Nurse #1's name, he did not answer, then she called his name again and he jumped. CNA #1 said when Nurse #1 came to Resident #1's room, he/she was screaming, I'm in pain, I'm in pain. CNA #1 said Nurse #1 said to get Resident #1 up off the floor. CNA #1 said she told Nurse #1 No, they should not move him/her. CNA #1 said she told Nurse #1 that in school she learned that when a patient falls and screams, they may have something broken and they needed to call for an ambulance. CNA #1 said Nurse #1 said to her, No, we do not need to call the ambulance, and told her to bring Resident #1's wheelchair over to him. CNA #1 said she brought the wheelchair over to Nurse #1 and Nurse #1 picked up Resident #1 up off of the floor, by himself, and put him/her in the wheelchair, and that Resident #1 was screaming, I'm in pain, I'm in pain. CNA #1 said Nurse #1 then transferred Resident #1 out of the wheelchair by himself to the bed. CNA #1 said Resident #1 was still screaming, I'm in pain. CNA #1 said Nurse #1 did not perform an assessment on Resident #1 prior to him moving Resident #1 up off the floor and did not even check his/her vital signs. CNA #1 said shortly thereafter, she and Nurse #1 left the room at the same time and Resident #1 was still crying out in pain. CNA #1 said she had asked Nurse #1 if he was going to call 911 and complete the paperwork and Nurse #1 said to her, Forget about it, Forget about it. CNA #1 said around 4:00 A.M., she assisted Resident #1's roommate with care and Resident #1 was moaning like he/she was in pain. CNA #1 said she had informed Nurse #1 again about Resident #1's pain and asked him to take Resident #1's vital signs and to check to see if he/she was ok. CNA #1 said Nurse #1 waved his hand in a backward motion at her, as if he was dismissing her concerns and telling for her to go away. CNA #1 said she did not see Nurse #1 go check on or assess Resident #1 when she asked him to. Review of the Facility's Witness Statement, dated 01/31/25, written by Nurse #1, indicated he was called into Resident #1's room by CNA #1, because Resident #1 was halfway seated in his/her wheelchair and CNA #1 could not sit him/her up by herself. The Statement indicated he assisted Resident #1 in the wheelchair and back to bed with CNA #1's help and left for the day. The Statement indicated Nurse #1 did not witness any fall. During an interview on 04/01/25 at 9:40 A.M., Nurse #1 said on 01/30/25 he started his shift around at 3:00 P.M. and ended his shift on 01/31/25 around 7:00 A.M. Nurse #1 said Resident #1 was alert to self but confused. Nurse #1 said Resident #1 was able to express if he/she was in pain or in discomfort. Nurse #1 said at the start of the 11:00 P.M. to 7:00 A.M. shift, Resident #1 was in bed sleeping and he did not see Resident #1 again until around 4:30 A.M. or 5:00 A.M. Nurse #1 said he was at the Nursing station, preparing to start his morning medication pass when CNA #1 called him to help her, because Resident #1 was position half way out (sliding) of his/her wheelchair and CNA #1 was unable to sit up Resident #1 in his/her wheelchair. Nurse #1 said he had asked Resident #1 what he could do to help him/her and if he/she needed to go to the bathroom. Nurse #1 said Resident #1 said, No. Nurse #1 said he pulled on Resident #1's pants to get him/her back in a sitting position in his/her wheelchair and then transferred him/her back into bed. Nurse #1 said that although Resident #1 was in bed at the start of the shift, that he did not know how Resident #1 had gotten into the wheelchair that night. Nurse #1 said he did not see Resident #1 fall and said he does not know how Resident #1 fractured his/her hip. Nurse #1 said he did not need to assess Resident #1 since he had no concerns and Resident #1 did not say anything to him about being in pain. Nurse #1 said he did not hear any banging noises during the 11:00 P.M. to 7:00 A.M. shift. Nurse #1 said he did not observe Resident #1 to be in pain and was not informed by anyone that Resident #1 was in pain. Nurse #1 said around 5:30 A.M. or 6:00 A.M., was the last time he saw Resident #1, because he had gone to the room to help his/her roommate. Nurse #1 said Resident #1 was not in pain then. Nurse #1 said he did not speak to any oncoming shift staff regarding Resident #1. Nurse #1 said he had no clue what happened to Resident #1. Review of Resident #1's Medical Record indicated there was no documentation of Resident #1's fall, no incident report, no type of assessment including Pain and Neurological as having been completed on 01/31/25, by Nurse #1. During an interview on 03/18/25 at 1:15 P.M., Nurse #2 said on 01/31/25 she started her shift around at 8:00 A.M. and did not receive an oncoming Nurse Change of Shift Report from Nurse #1 because he had left the Facility prior to her arrival. Nurse #2 said there was no progress note or incident report in Resident #1's Medical Record about him/her being found on the floor during the overnight shift or that he/she had complained of being in pain all night. During an interview on 03/18/25 at 4:31 P.M., the Unit Manager said her expectations was that Nurses would immediately assess a resident after a fall for the potential for injury and pain prior to moving them and notify the oncoming shift Nursing Staff of any incidents, accidents or changes in a resident. The Unit Manager said she reviewed Resident #1's Medical Record and there was no documentation of Resident #1's fall, no notification to Physician or Facility Administrative Staff, no incident report, and no assessments, having been completed on 01/31/25, by Nurse #1. During an interview on 03/19/25 at 9:40 A.M., the Director of Nurses (DON) said she and the Administrator interviewed Nurse #1 and he said around 4:30 A.M., CNA #1 called him to help her since Resident #1 was hanging out off his/her wheelchair and he assisted Resident #1 back to bed. The DON said she had asked Nurse #1 if he completed an assessment since Resident #1 was positioned that way in his/her wheelchair and that Nurse #1 said, No. that there was no need to assess Resident #1 and there was nothing wrong with him/her. The DON said she asked Nurse #1 if Resident #1 fell and he said, No. The DON said Nurse #1 did not respond when she asked how he thought Resident #1 obtained a hip fracture. The DON said she reviewed Resident #1's Medical Record and there was no documentation related to Resident #1's fall on 01/31/25, that there were no nursing assessments including a pain assessment, and no documentation to support the Physician was notified of Resident #1's new onset of acute pain. The DON said her expectations were that the Nursing staff to follow the Facility's Policy and Procedures which include residents should not have been moved off the floor after a fall occurred until first completing a thorough Nursing Assessment. The DON said Nursing staff should call Emergency Medical Services if Resident #1 was in pain and or an injury was suspected. On 03/18/25, the Facility was found to be in Past Non-Compliance and provided the surveyor with a plan of correction which addressed the area of concern as evidenced by: A) 01/31/25, Resident #1 was transferred to the Hospital and was found to have a Displaced Proximal Left Femoral Subtrochanteric Fracture (break in thigh bone just below the bony prominence in the lower part of the hips). B) 02/03/25, Nurse #1 was suspended pending an Investigation, and on 02/06/25, Nurse #1 was terminated from the Facility. C) 02/07/25, Resident #1 returned to the Facility status post Left Femur Open Reduction and Internal Fixation (ORIF) with intramedullary nail on 02/01/25, and his/her Care Plans were reviewed and updated as needed. D) 02/07/25, the Director of Nursing and Cooperate Nurse reviewed and performed an audit of the Facility's previous three months of resident falls, including conducting an audit related to Nurse #1's involvement with any Facility incidents. There were no concerns identified during the audits and it was determined Nurse #1 was not involved in any of the fall incidents. E) 02/10/25 through 02/26/25, the Staff Development Coordinator provided in-person education to all Licensed staff on the following topics: - Fall Management - Review Policy & Procedure - Assessments - Fall Reporting Tools - Falls - Immediate action - Reporting - Resident Rights, Abuse and Neglect F) 02/20/25 an Ad-Hoc Quality Assurance Performance Improvement (QAPI) meeting was held with the Facility leadership team. The Director of Nursing and the Cooperate Nurse developed a plan of correction related to the deficient practice, the plan and corrective measures were reviewed. G) 02/26/25 and ongoing, the Unit Manager and Director of Nursing review each fall (Incident/Accident Reports) to ensure Licensed Staff are following Facility's Policy and Procedure, they will collect the data and present findings to QAPI Committee. H) Effectiveness of corrective action plan will be reviewed during Monthly QAPI meetings until further notice. I) Director of Nursing and Executive Director are responsible for overall compliance.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on records reviewed and interviews, for one of three sampled residents (Resident #1) who during the overnight shift (11:00 P.M. to 7:00 A.M.) on 1/30/25 into 1/31/25, had an unwitnessed fall, was found on the floor by staff and was crying out in pain, the facility failed to ensure he/she was provided with care and treatment consistent with professional standards of practice related to pain management. Certified Nurse Aide (CNA) #1 said she found Resident #1 on the floor in his/her room, he/she was crying out in pain and immediately called Nurse #1 for help. CNA #1 said she asked Nurse #1 more than once to check on Resident #1 that night, because he/she kept crying out in pain. Nurse #1 did not complete a pain assessment on Resident #1, there was no documentation to support Nurse #1 medicated or did anything to treat or manage Resident #1's pain including not notifying the Physician. Day Shift nursing staff were unable to provide care, as Resident #1 screamed whenever staff tried to touch him/her, he/she was transferred to the Hospital Emergency Department, and was diagnosed with a left hip fracture. Findings include: The Facility's Policy titled Pain Assessment and Management, dated reviewed 09/05/24, indicated that the Facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. The Policy indicated based on the comprehensive assessment of a resident, the Facility must ensure that residents receive the treatment and care in accordance with professional standards of practice, the comprehensive care plan, and the resident's choices related to pain management. The Policy indicated all residents will be assessed for pain indicators upon admission/readmission, quarterly and with any change in condition. The Facility's Policy titled Changes in Resident's Condition or Status, dated reviewed 09/05/24, indicated the Facility will notify the resident, his/her primary care provider, and resident/resident representative of changes in the resident's condition or status. Review of the Facility's Incident Report, dated 02/06/25 at 1:48 P.M., indicated on 01/31/25 sometime around 8:30 A.M. Resident #1 was observed by Certified Nurse Aide (CNA) #2 screaming as if in pain and would not allow CNA #2 provide care to him/her. The Report indicated Resident #1 reported 10/10 pain (a pain scale where 0 is no pain and 10 is the worst pain imaginable, severe or unbearable pain) in his/her leg. The Report indicated Resident #1 informed Nurse #2 and the Staff Development Coordinator (SDC) that he/she had fallen out his/her bed in the early morning and two men assisted him/her back to bed. The Report indicated Resident #1's left leg was rotated outward and noted to be larger than the right leg. The Report indicated Emergency Medical Services (911) had been called and in the Emergency Department Resident #1 was found to have a Displaced Proximal Left Femoral Subtrochanteric Fracture (break in thigh bone just below the bony prominence in the lower part of the hip). Review of Resident #1's Hospital Discharge summary, dated [DATE], indicated Resident #1 had an unwitnessed fall at the Facility, was diagnosed with a Closed Displaced Subtrochanteric Fracture of the Left Femur with the broken pieces out of alignment, treated surgically using a metal rod (intramedullary nail) inserted into the bone's hollow channel) on 02/01/25. Resident #1 was admitted to the Facility in December 2024, diagnoses included Rhabdomyolysis (breakdown of muscle tissue), Hypertension (high blood pressure), Orthostatic Hypotension (low blood pressure that happens when standing up from sitting or lying down), Bradycardia (slower than expected heart rate, generally beating fewer than 60 minute), Wedge Compression fracture of T11-T12 vertebra subsequent encounter for fracture with routine healing (occurs when the front (anterior) portion of the vertebra collapses, resulting in a wedge-shaped deformity), difficulty with walking, muscle weakness and history of falling. Review of Resident #1's admission Minimum Data Set (MDS) Assessment, dated 12/19/24, indicated Resident #1's Brief Interview for Mental Status (BIMS), score was 14/15 (score of 13-15 indicates intact cognition, 12-8 indicates moderate cognitive impairment, 0-7 indicates severe cognitive impairment). Review of Resident #1's Care Plan, titled Pain, dated 01/07/25, indicated Resident #1's Pain interventions included to anticipate the resident's need for pain relief and respond immediately to any complaints of pain, pain meds as ordered, observe and report to Nurse any signs or symptoms of non-verbal pain and observe and report to Nurse resident complaints of pain or requests for pain treatment. Review of Resident #1's Medication Administration Record, for January 2025, indicated Resident #1 had the Physician's Orders for medications for pain management as follows: - Lidocaine External Patch 4% apply at 9:00 A.M. to Left & Right lower back for Pain and Remove patch at 9::00 P.M. - Tylenol (Acetaminophen) Oral Tablet 325 mg (milligram), give two tablets every 6 hours as needed for pain. Further Review of the MAR indicated up until 01/31/25 Resident #1 had only requested Tylenol once. Documentation on the MAR for 01/31/25, indicated that, despite CNA #1 reporting to and making Nurse #1 aware, more than once that Resident #1 was moaning and saying he/she was in pain, he/she was not administered anything to treat or manage his/her pain. There was no documentation to support the Physician was notified or that new orders were obtained to treat his/her acute pain. During an interview on 03/18/25 at 2:00 P.M., (and during a follow-up interview on 03/19/25 at 1:07 P.M.) CNA #1 said on 01/31/25, sometime around 2:30 A.M., she heard a loud bang while providing care to Resident #3 and went to find out what the noise was. CNA #1 said she found Resident #1 in his/her room lying face up on the floor and she called Nurse #1 for help. CNA #1 said Nurse #1 came to Resident #1's room, that Resident #1 was screaming, I'm in pain, I'm in pain, but that Nurse #1 told her to get Resident #1 up off the floor. CNA #1 said she told Nurse #1 No, they should not move him/her. CNA #1 said she told Nurse #1 that in school she learned that when a patient falls and screams, they may have something broken and they needed to call for an ambulance. CNA #1 said Nurse #1 said No, we do not need to call for an ambulance, and said to bring Resident #1's wheelchair over to him. CNA #1 said Nurse #1 picked up Resident #1 off the floor, by himself and that Resident #1 was screaming, I'm in pain, I'm in pain and placed him/her in the wheelchair. CNA #1 said then Nurse #1 transferred Resident #1 out of the wheelchair by himself to the bed, and that Resident #1 was still crying out, I'm in pain. CNA #1 said when she and Nurse #1 left the room, she asked Nurse #1 if he was going to call 911 and complete the paperwork and that Nurse #1 said, Forget about it, Forget about it! CNA #1 said around 4:00 A.M., she assisted Resident #1's roommate with care and Resident #1 was still moaning like he/she was in pain. CNA #1 said Resident #1 had to urinate, but she was unable to assist him/her to use a urinal/bedpan, because when she touched Resident #1 to move him/her, he/she was in pain. CNA #1 said she was unable to pull down Resident #1's pants and that just touching Resident #1, he/she was groaning in pain. CNA #1 said she informed Nurse #1 again about Resident #1's pain, asked him to take Resident #1's vital signs and to check to see if he/she was ok. CNA #1 said Nurse #1 had motioned his hand in a backward motion at her as if he was dismissing her concerns and telling her to go away. During an interview on 03/19/25 at 2:29 P.M., CNA #2 said she worked with Resident #1 in the past, had worked with Resident #1 the day prior and he/she had not been in or complained of pain. CNA #2 said she was usually able to get Resident #1 out of bed without any difficulty or concerns. CNA #2 said on 01/31/25, she worked the 7:00 A.M. to 3:00 P.M. shift, and around at 7:45 A.M., she observed Resident #1 in bed, that he/she was screaming and when she tried to assist him/her with care to get him/her out of bed, Resident #1 said to her, I'm in a lot of pain, do not touch me, I'm in a lot of pain. CNA #2 said she could tell by Resident #1's facial expression that he/she was very uncomfortable. CNA #2 said she informed Nurse #2 right away, and she (Nurse #2) immediately assessed Resident #1. During an interview on 03/18/25 at 1:15 P.M., Nurse #2 said on 01/31/25 she started her shift around at 8:00 A.M. and shortly thereafter CNA #2 came to her reporting that Resident #1 was complaining of left leg pain. Nurse #2 said she went to assess Resident #1 and asked Resident #1 to move his/her left leg, and he/she said, No, it hurts. Nurse #2 said when she touched Resident #1's left hip area, he/she said Ouch, Ouch. Nurse #2 said she asked Resident #1 what happened, and Resident #1 said he/she had fallen this morning, and a man got him/her up. Nurse #2 said she asked the Staff Development Coordinator (SDC) and the Unit Manager to come help with assessing Resident #1 with her. During an interview on 03/18/25 at 3:10 P.M., the Staff Development Coordinator (SDC) said on 01/31/25 he helped Nurse #2 assess Resident #1. The SDC said he observed Resident #1's left upper thigh area was larger than his/her right and with any slight movement, Resident #1 said it was very painful for him/her. The SDC said when he assessed Resident #1's pedal pulses (rhythmic throbbing or pulsations that can be felt when palpating the arteries in the feet) his slight touch, per Resident #1, hurt. The SDC said Resident #1 said he/she had fallen out of bed and a male placed him/her back into bed. The SDC said Resident #1 had sweat pants on and they had to cut them off him/her to provide Resident #1 some comfort and relief from the pain. The SDC said Resident #1's left leg was rotated in an outward position and Resident #1's left thigh was twice as large than his/her right. The SDC said Resident #1 was groaning, had facial grimacing and he/she clearly was in pain. The SDC said staff called Emergency Medical Services to transfer Resident #1 to the Hospital. During an interview on 03/18/25 at 4:31 P.M., the Unit Manager said on 01/31/25 she helped assess Resident #1. The Unit Manger said Resident #1 was verbalizing he/she was in pain, she observed that his/her left leg was swollen and was in an externally (outward) rotated position. The Unit Manager said Resident #1 said he/she fell out of bed and a man picked him up and placed him/her back to bed. The Unit Manager said Resident #1's was wearing sweat pants that were tight, staff were unable to take them off him/her because Resident #1 was in so much pain, so they had to cut them off him/her. The Unit Manager said her expectations was that Nurses would immediately assess a resident after a fall for the potential for injury and pain prior to moving them. The Unit Manager said she reviewed Resident #1's Medical Record and there was no documentation of Resident #1's fall, no notification to Physician or Facility Administrative Staff, no incident report and no Pain Assessment completed on 01/31/25, by Nurse #1. During an interview on 04/01/25 at 9:40 A.M., Nurse #1 said on 01/30/25 he started his shift around at 3:00 P.M. and ended his shift on 01/31/25 around 7:00 A.M. Nurse #1 said Resident #1 was alert to self but confused. Nurse #1 said Resident #1 was able to express if he/she was in pain or in discomfort. Nurse #1 said at the start of the 11:00 P.M. to 7:00 A.M. shift, Resident #1 was in bed sleeping and he did not see Resident #1 again until around 4:30 A.M. or 5:00 A.M. Nurse #1 said he was at the Nursing station, preparing to start his morning medication pass when CNA #1 called him to help her, because Resident #1 was position half way out (sliding) of his/her wheelchair. Nurse #1 said he pulled on Resident #1's pants to get him/her back in a sitting position in his/her wheelchair and then transferred him/her back into bed. Nurse #1 said that although Resident #1 was in bed at the start of the shift, that he did not know how Resident #1 had gotten into the wheelchair that night. Nurse #1 said he did not need to assess Resident #1 since he had no concerns and Resident #1 did not say anything to him about being in pain. Nurse #1 said he did not observe Resident #1 to be in pain and was not informed by anyone that Resident #1 was in pain. Nurse #1 said around 5:30 A.M. or 6:00 A.M., was the last time he saw Resident #1, because he gone to the room to help his/her roommate. Nurse #1 said Resident #1 was not in pain then. During an interview on 03/19/25 at 9:40 A.M., the Director of Nurses (DON) said she reviewed Resident #1's Medical Record and there was no documentation related to Resident #1's fall on 01/31/25, that there were no Nursing assessments including a pain assessment, no documentation to support the Physician was notified of Resident #1's acute pain to obtain new orders, and that Resident #1 was not given any medications to treat or manage his/her pain. On 03/18/25, the Facility was found to be in Past Non-Compliance and provided the surveyor with a plan of correction which addressed the area of concern as evidenced by: A) 01/31/25, Resident #1 was transferred to the Hospital and was found to have a Displaced Proximal Left Femoral Subtrochanteric Fracture (break in thigh bone just below the bony prominence in the lower part of the hips). B) 02/03/25, Nurse #1 was suspended pending an Investigation, and on 02/06/25, Nurse #1 was terminated from the Facility. C) 02/07/25, Resident #1 returned to the Facility status post Left Femur Open Reduction and Internal Fixation (ORIF) with intramedullary nail on 02/01/25, and his/her Care Plans were reviewed and updated as needed. D) 02/07/25, the Director of Nursing and Cooperate Nurse reviewed and performed an audit of the Facility's previous three months of resident falls, including conducting an audit related to Nurse #1's involvement with any Facility incidents. There were no concerns identified during the audits and it was determined Nurse #1 was not involved in any of the fall incidents. E) 02/10/25 through 02/26/25, the Staff Development Coordinator provided in-person education to all Licensed staff on the following topics: - Fall Management - Review Policy & Procedure - Assessments - Fall Reporting Tools - Falls - Immediate action - Reporting - Resident Rights, Abuse and Neglect F) 02/20/25 an Ad-Hoc Quality Assurance Performance Improvement (QAPI) meeting was held with the Facility leadership team. The Director of Nursing and the Cooperate Nurse developed a plan of correction related to the deficient practice, the plan and corrective measures were reviewed. G) 02/26/25 and ongoing, the Unit Manager and Director of Nursing review each fall (Incident/Accident Reports) to ensure Licensed Staff are following Facility's Policy and Procedure, they will collect the data and present findings to QAPI Committee. H) Effectiveness of corrective action plan will be reviewed during Monthly QAPI meetings until further notice. I) Director of Nursing and Executive Director are responsible for overall compliance.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and interview, the facility failed to meet professional standards of care for one Resident (#5), out of a total sample of 21 residents. Specifically: 1. For Resident #5 the facility failed to ensure an occupational therapy assistant provided services within her scope of practice resulting in an injury. Findings include: Review of 259 CMR Board of Allied Health Professionals: 3.00 OCCUPATIONAL THERAPISTS, indicated the following: 1. Evaluation is the process of obtaining and interpreting data necessary for an intervention, including planning for and documenting the evaluation process and results. 2. Occupational Therapy Assistants (OTA) may not initiate or alter an intervention plan without prior evaluation by and approval of, the supervising Occupational Therapist (OT). 3. The OT must be directly involved in the delivery of services during evaluation and re-evaluation. Resident #5 was admitted to the facility in September 2020 with diagnoses including diabetes, Charcot's joint of the left ankle and foot (damage to the ankle and foot when nerve damage has caused a lack of sensation), displaced fracture of the left tibia (lower leg) with routine healing, lateral malleolus of left fibula (ankle) fracture with routine healing and left talus (bone that forms the ankle) fracture with routine healing. Review of the Occupational Therapy (OT) evaluation dated 7/11/23, indicated Resident #5 was referred to therapy for self-feeding due to recent weight loss with a new goal: will improve ability to feed self and efficiently perform eating tasks. Further review of the evaluation failed to indicate that Resident #5 was evaluated by the OT for transfers and the evaluation failed to include a goal for transfers or positioning. Further review failed to indicate a referral to Physical Therapy as Resident #5 was at baseline status for transfers. Review of the OT treatment note dated 7/20/23, indicated the OTA suggested (without the OT evaluating Resident #5) for Resident #5 to transfer to a wheelchair. Resident #5 said he/she was afraid to do the transfer and did not want to attempt transfer to the wheelchair. Resident #5 took two shuffles towards the head of the bed, using a rolling walker for support, and sat on the edge of the bed. The note indicated the OT was present during the transfer but did not have her hand on the Resident as the sit to stand transfer took place to evaluate the ability of the Resident to perform the task safely. A transfer to the wheelchair did not take place. Review of the OT note dated 7/25/23, indicated that Resident #5 was treated by the OTA and was transferred with a max assist of one to stand and pivot into a wheelchair. The evaluating therapist was not present during this transfer to assess the Resident's current level or safety with the transfer. The note was signed at 2:18 P.M. The OT notes failed to indicate the plan of care was modified to include a goal for positioning or transfers and that the OT had assessed Resident #5's transfer status prior to the OTA completing the transfer. Review of the care plan indicated a focus area for Activities of Daily Living (ADL) with an initiation date of 11/18/21, and an intervention of TRANSFER: The Resident requires max assistance by two staff members to move between surfaces. Review of the Progress Note dated 7/25/23, entered at 8:52 P.M., indicated that the nurse was notified by the nursing assistant that she had noted swelling with bruising of the Resident #5's left foot. The nurse assessed Resident #5's left foot and noted that the entire foot and lower leg was significantly swollen. Resident #5 denied any pain (as would be normal with Charcot foot). The nurse practitioner ordered an X-ray of the foot. Review of the X-ray dated 7/25/23, at 9:30 P.M. indicated soft tissue swelling without fracture or dislocation. Review of the progress note dated 7/26/23, entered at 8:13 A.M. indicated that the nurse observed the left foot to be worsening, felt hot to the touch and obtained an order from the nurse practitioner to send Resident #5 to the hospital. Review of the document titled [NAME] Hospital History and Physical Examination, dated 7/28/23, indicated Resident #5 was transferred from [NAME] hospital upon orthopedic evaluation because the physician felt it best to have Resident #5's condition evaluated and treated at [NAME] hospital. Further review indicated the left lower leg with significant swelling and ecchymosis (bruising). Ankle resting inverted with skin tear over the anterior distal tibia and a wound over the lateral malleolus with exposed bone. Further review indicated Resident #5 has an open left ankle fracture. Review of the document titled [NAME] hospital Discharge summary dated [DATE], indicated the following: *The patient is a resident at a nursing home who is non weight bearing, non-mobile at baseline with a known left foot deformity who normally transfers with a Hoyer lift. At the nursing home she/he was transferred while weight bearing resulting in worsening deformity, acute swelling, blister formation and skin breakage with bone exposure. She/he has severe neuropathy at baseline and sensation is diminished on exam. Review of the facility document titled Documentation Survey Report v2 (where Certified Nurse's Aides (CNAs) document daily function of a resident and the level of assistance provided) indicated the following: *In May 2023 Resident #5 was totally dependent on 2 staff members to transfer (full staff performance to complete the task). Walk in room; activity did not occur. *In June 2023 Resident #5 was totally dependent on 2 staff members to transfer. Walk in room; activity did not occur. *In July 2023 Resident #5 was totally dependent on 2 staff members to transfer. Walk in room; activity did not occur. Review of the Minimum Data Set (MDS) dated [DATE], indicated that Resident #5 was totally dependent (full staff performance every time during a 7 day look back period) for transfers and required two + staff members to complete the task. Further review indicated that Resident #5 did not walk in her/his room (activity did not occur). During an interview on 9/14/23 at 7:57 A.M., Certified Nurse's Aide (CNA) #2 said a dependent transfer requires the use of a mechanical lift and a transfer with maximal assistance with 2 staff members requires the 2 staff members to lift the resident under the arms without the resident's feet touching the floor. CNA said that with either type of transfer, the resident in non-weight bearing and does not participate in the activity. CNA #2 said prior to Resident #5's injury, he/she would transfer with a mechanical lift or maximal assistance from 2 staff members. During an interview on 9/13/23, at 12:02 P.M., the Occupational Therapist said that she completes the majority of the OT evaluations in the facility. The OT said the Occupational Therapist Assistant then completes the treatments but that she treats all residents on caseload every 10th visit to ensure the plan of care is still appropriate. The OT said that it is not within the scope of practice for an occupational therapy assistant to assess a resident or to make changes to the plan of care. The OT said she completed the evaluation for Resident #5 and said she had not assessed the Resident's ability to transfer during the initial evaluation and had not made a goal for transferring. The OT said she had not modified Resident #5's treatment plan prior to the OT assistant completing the transfer and she, herself had not physically assessed the Resident's ability to transfer. The OT said that she was present during the 7/20/23 treatment session, however, did not assess Resident #5's transfer status and that she watched the assistant perform the treatment, (including the resident weight bearing). The OT said she is a newer therapist and since the OTA had more years of experience, she deferred to the assistant. The OT again said it was her responsibility to assess the Resident and develop the plan of care and it is not within the scope of practice for the assistant to do so. During an interview on 9/13/23 at 12:18 P.M., the Director of Rehabilitation (DOR) said the OT is responsible for evaluating the residents of the facility and developing the plan of care. The DOR said the evaluating therapist must continually assess the resident based on the feedback provided by the assistant and change the plan of care if appropriate. The DOR said the Occupational Therapy Assistant should not have transferred Resident #5 without the OT assessing his/her transfer status and a goal being in place. The DOR said if positioning was an issue during feeding, the nursing staff could have transferred the Resident out of bed and the OTA could have begun treatment after the transfer was complete. During a follow up interview on 9/14/23, at 7:42 A.M., the Director of Rehabilitation (DOR) said that therapists use the term dependent and maximum assist of 2 people interchanging. The DOR said that both are considered non-weight bearing but dependent implies the use of a mechanical lift. The DOR then said that when nursing documents a resident is a max assist of 2 people, the staff is lifting the resident and the resident's feet do not touch the floor. The DOR confirmed this is how Resident #5 had been transferring with the staff up until his/her injury on 7/25/23.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to ensure nursing staff implemented orders for one Resident (#5) out of a total sample of 21 residents. Staff failed to remove a leg brace as recommended by the orthopedic surgeon resulting in the worsening of a surgical wound. Subsequently, Resident #5 was hospitalized requiring debridement (a surgical procedure to remove dead tissue) of the wound and sepsis (an infection of the blood stream) with associated Methicillin-resistant Staphylococcus aureus (MRSA) bacteremia requiring a PICC line (a long, thin tube that's inserted through a vein in the arm and passed through to the larger veins near the heart) for IV antibiotics. Findings include: Review of the Treatment of Wounds policy, dated 3/31/23, indicated: It is the intent of this center that a resident having a wound receives necessary medical treatment to prevent infection, deterioration or development of wounds in keeping with the resident's medical condition. Resident #5 was re-admitted to the facility in August 2023 with diagnoses including displaced fractures of the left tibia, lateral malleolus of the left fibula, and left talus. Review of the Minimum Data Set assessment dated [DATE] indicated Resident #5 scored 15 out of a possible 15 on the Brief Interview for Mental Status Exam indicating he/she is cognitively intact. On 9/12/23 at 7:55 A.M., the surveyor observed Resident #5 in bed with his/her left foot in a cast. Review of the hospital discharge paperwork dated 8/4/23 indicated: Patient has cast with window available to do regular wound checks if concerns prior to follow-up visit may come in sooner. Plan to d/c cast when incisions are healed. Review of the orthopedic clinic follow up note dated 8/15/23 indicated Resident #5's left leg was irritated by cast and was replaced with a brace. Instructions indicated: remove brace 2-3 times daily. The instructions were signed and dated by Nurse Practitioner on 8/15/23. Review of the Physicians orders for August 2023, Treatment Administration Record for August 2023, and care plans failed to indicate staff were removing the brace as ordered. Review of the nurse progress notes indicated: 8/16/23: LLE (left lower extremity) Dressing/wrap clean, dry and intact. Pending instructions from orthopedic MD. (The orthopedic MD recommendations to remove the brace 2-3 times a day had been signed and dated by the Nurse Practitioner the day before; 8/15/23) A nursing note written on 8/21/23 indicated the following: This writer, Nurse Practitioner and Director of Rehab assessed wound to left lateral ankle. Moderate amount of serous drainage noted to gauze. Wound bed 50%/50% slough and granulation. Undermining noted to be 2-6 o'clock when cleaning. Surrounding skin red and blanchable, tender to touch and warm on palpitation. Area edematous/swollen. Pt visited surgeon for follow up . Hard cast was removed and replaced with kerlix, ACE wrap and brace that was to be removed TID (three times a day) per day to observe for wound deterioration. [Nurse Practitioner] evaluated and is sending out [to hospital] for further eval. Review of the hospital paperwork dated 9/5/23 indicated Resident #5 was admitted to the hospital with diagnoses of sepsis due to left ankle infection with associated MRSA bacteremia. Resident #5's wound was debrided and a PICC line was placed during the hospitalization to treat the infection with IV antibiotics. During an interview on 9/13/23 9:12 A.M., Unit Manager #1 said that the Nurse Practitioner had signed off on the orthopedics instructions to remove Resident #5's brace 2-3 times daily and it was not carried over to the physician's orders. During an interview on 9/13/23 at 2:45 P.M., the Director of Nursing said that when the Nurse Practitioner had signed off on the orthopedic instructions to remove Resident #5's leg brace, it should have been put in as an order for nursing to follow. During an interview on 9/14/23 at 8:07 A.M Nurse #1 said that Resident #5's cast was completely managed by the orthopedics and at some point was changed. Nurse #1 said that nursing staff did not remove any device off Resident #5's leg.