**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and staff, resident, family, Physician, Medical Director, and Nurse Practitioner interviews, the facility failed to notify the Physician when a resident (Resident #69) reported she had fallen and was experiencing acute pain after the reported fall. Due to ineffective communication between staff a medical provider was not notified of the fall until the following day which delayed x-rays, medical interventions and an evaluation in the emergency department. Resident #69 sustained an acute proximal tibia and fibula fracture (breaks in the upper part of the shinbone (tibia) and the smaller bone of the lower leg (fibula) from the reported fall and required a two day hospitalization. Orthopedics recommended hinged knee brace with non-weight bearing status to the right lower extremity. This deficient practice occurred for 1 of 3 residents reviewed for notification of changes. Findings included: Resident # 69 was admitted to the facility on [DATE]. Her diagnoses included cerebral infarction (stroke) and hemiplegia (paralysis) affecting the dominant right side. An observation and interview were conducted with Resident #69 on 6/9/25 at 10:52 AM. Resident #69 was observed in her room in her bed covered with a sheet. She was noted to be grimacing. When spoken to by the surveyor Resident #69 replied in Spanish. The surveyor asked Resident #69 Habla Ingles (speak English?), Resident #69 replied no. Resident #69 was asked by the surveyor dolor (pain)? Resident #69 replied see (yes) mucho (a lot) and grabbed her right leg at the knee. Resident #69 proceeded to uncover her right leg. When she uncovered her right leg Resident #69 began grimacing, crying, and moaning. A pillow was observed under her lower right leg. There was light blue/ purple colored bruising along her right shin and to the top of her right knee. Her right lower leg and knee had visible swelling present. Resident #69 said pain was mucho, diez (a lot, 10). The bathroom was in front of Resident #69's bed. She pointed at her right leg and the bathroom and said bano (bathroom). Resident #69's roommate was in the room who was also Spanish speaking. The roommate approached Resident #69's bed while the surveyor was in the room. The roommate translated that Resident #69 stated she had fallen on Saturday in bathroom and had a lot of pain in her leg. An additional interview was conducted with Resident #69 on 6/12/25 at 2:13 PM with Physical Therapy Assistant (PTA) #1 providing translation. Resident #69 stated she had gone to the bathroom with two staff members. She reported when she was getting off the toilet, she was holding on to the assist rail, and all a sudden she started falling. Resident #69 said she fell onto her right knee and had pain in her right knee immediately but did not cry or scream out. She said the staff member in the bathroom could not reach her fast enough to keep her from falling. She explained that the staff member who was in the bathroom with her helped her up and sat her in her wheelchair. She reported two female staff members put her back into bed after. Resident #69 stated no one asked her if she was hurt or anything afterwards, that they just put her back into bed. A telephone interview was conducted with NA #6 on 6/10/25 at 3:35 PM. NA #6 reported that she worked the night shift (7:00 pm to 7:00 am) on Saturday 6/7/25. She said at the start of her shift around 7:00 PM she was doing rounds and Resident #69's roommate was in the doorway of their room and asked her to come into the room. The roommate told her Resident #69 was having bad pain in her right knee. NA #6 recalled Resident #69 was in bed. She stated she looked at Resident #69's right knee and the top of her kneecap was bruised. NA #6 explained that the roommate assisted with translating for Resident #69 and she asked what had happened. NA #6 stated Resident #69 said she had fallen earlier that day in the bathroom and that she had fallen on her knee. NA #6 reported she asked Resident #69 if she was by herself when she fell or if staff were helping her. Resident #69 told her two girls had been helping her in the bathroom, but she did know who they were. NA #6 said she went and reported what Resident #69 was saying to the day shift (7:00 am to 7:00 pm) Nursing Supervisor. She recalled the Nursing Supervisor said she did not know anything about Resident #69 falling and the Nursing Supervisor went to check on Resident #69. A telephone interview was conducted with the day shift weekend Nursing Supervisor on 6/10/25 at 11:50 AM. The Nursing Supervisor stated a Nurse Aide (NA) came and got her around shift change on Saturday (6/7/25) around 7:30 PM and asked her to check on Resident #69. She reported the NA told her Resident #69 was saying she had fallen and was having pain in her right knee. She said she could not remember the name of the NA who came and got her. The Nursing Supervisor explained she went to Resident #69's room to assess her. She said Resident #69 was in pain and said her knee was hurting when she saw her. She reported Resident #69's roommate was present in the room and provided translation for what Resident #69 said happened. The Nursing Supervisor said Resident #69 reported she had fallen about an hour prior while she was being assisted in the bathroom by staff. The Nursing Supervisor reported she asked the day shift nurse (Nurse #8) if Resident #69 had fallen during the shift. She said Nurse #8 reported she did not know anything about Resident #69 having a fall. The Nursing Supervisor stated she updated Nurse #8 on what Resident #69 was reporting and told her what she needed to do. The Nursing Supervisor said she explained to Nurse #8 what she needed to do for the fall and told her she needed to call the physician and the Director of Nursing (DON). The Nursing Supervisor stated she had also made the oncoming night shift nurse (Nurse #9) aware of what was going on and what Resident #69 had reported. The Nursing Supervisor said she did not call the physician on Saturday. The Nursing Supervisor stated she did not think Nurse #8 had called anyone or done anything for the fall because when she returned on Sunday there was no documentation to indicate the physician had been notified or about the fall. The Nursing Supervisor said she went to assess Resident #69 on Sunday around 11:00 AM and that she was still hurting. She said she knew she was in pain because she was grimacing and holding her right leg. She stated when she looked at Resident #69's knee on Sunday there was swelling and bruising to the top of her knee. The Nursing Supervisor said she talked to Nurse #10, who was Resident #69's assigned nurse on Sunday day shift to ask him if he got anything in report about Resident #69 falling. She stated she could not remember if Nurse #10 had said yes or no. The Nursing Supervisor said she spoke to Resident #69's Family Member on the phone on Sunday. She stated that the Family Member reported Resident #69 told him she had fallen last night and was having pain. The Nursing Supervisor explained that she contacted the on-call provider on Sunday about Resident #69's pain and the fall she reported. She stated the on-call provider ordered an x-ray of Resident #69's right leg and as needed ibuprofen for pain. The Nursing Supervisor said she called the mobile x-ray company and placed an order for them to come to the facility to complete the x-ray. The Nursing Supervisor stated she called Resident #69's Family Member back and updated him on the new orders for Resident #69. A telephone interview was conducted with Nurse #8 on 6/10/25 at 1:49 PM. Nurse #8 stated she was the assigned nurse for Resident #69 on day shift on Saturday 6/7/25. She reported she had given shift report to the oncoming night shift nurse (Nurse #9) around 7:00 PM. Nurse #8 explained the day shift Nursing Supervisor came to her around 7:35 PM and told her Resident #69 was reporting she had fallen one hour ago. She stated no one had reported to her that Resident #69 had fallen during her shift. Nurse #8 said she went to Resident #69's room to check on her and that Resident #69 indicated she was in pain. She reported when she touched Resident #69's right leg she showed an expression of pain that was indicated by facial grimacing. Nurse #8 said it was not a fall that was reported to her during her shift and that it was not reported until 7:35 PM. She explained she had already given report to the night shift nurse (Nurse #9). She reported after she assessed Resident #69 and noticed she was in pain, she communicated to the night nurse, Nurse # 9, what she had seen. Nurse #8 said she asked Nurse #9 to continue the assessment and to complete the post fall things. She stated she did not specifically tell Nurse #9 what she needed to do but said Nurse #9 should have known what to do. She reported Nurse #9 had said yes. Nurse #8 said she assumed Nurse #9 would contact the physician and complete the rest of the post fall documentation. Nurse #8 stated the day shift the Nursing Supervisor had not told her anything specific she needed to do related to the fall. A telephone interview was conducted with Nurse #9 on 6/10/25 at 2:15 PM. She reported she had been the assigned night shift for Resident #69 on 6/7/25. Nurse #9 recalled she had been in the middle of taking report from the off going day shift nurse (Nurse #8). She stated she was outside of Resident #69's room with Nurse #8 and could hear another nurse in the room talking to Resident #69 and her roommate. Nurse #8 stated she did not know who the nurse in the room was, but that she overheard the nurse asking how and when Resident #69 fell. She explained an NA, whose name she did not know, was also in the room and they were trying to figure out how Resident #69 had fallen. She stated she did not see Nurse #8 again after she received report from her. Nurse #9 said the fall had occurred on day shift and she assumed Nurse #8 notified the physician and completed the fall documentation. She stated the Nursing Supervisor had not told her anything she needed to do for the fall. A nursing note dated 6/8/25 at 1:30 PM by Nursing Supervisor read: [family member] called about getting an x-ray and getting something for pain at the right knee for his [Resident #69]. Resident stated she is having pain in her right knee. Nurse evaluated right knee. There was inflammation at site. This nurse spoke with the on call doctor to get an order for an x-ray, that order has been called in to mobile x-ray. Nurse on cart gave as needed (PRN) for pain. Will continue to follow up. A telephone interview was conducted on 6/9/25 at 3:19 PM with Resident #69's Family Member. The Family Member stated they received a phone call from Resident #69 on Sunday (6/8/25). He said resident #69 was crying and said she was hurting. He reported Resident #69 said she had fallen the night before. The Family Member explained he called and spoke with the Nursing Supervisor on Sunday afternoon to ask about the fall, pain medication, and if an x-ray was going to be done. The Family Member said the Nursing Supervisor indicated she was just aware and that she was going to call the physician. The Family Member said Resident #69 could not speak English but that she was alert and oriented. An x-ray report dated 6/8/25 read: There are nondisplaced fractures of the proximal tibia and fibular neck. There are no bony lesions. Degenerative changes are noted. Diffuse osteopenia is noted. The soft tissues are unremarkable. Impression: Acute proximal lower leg fractures. A telephone interview was conducted with the Nurse Practitioner (NP) #1 on 6/10/25 at 4:16 PM. NP #1 stated she was alerted by Nurse #4 on Monday morning (6/9/25) that she had received in report from night shift that Resident #69 had an acute fracture of her knee. NP #1 explained her company's on-call service had not been notified about Resident #69's fall or her having pain over the weekend. She explained that the Medical Director was part of a different physician service group and that sometimes the staff get confused and call the Medical Directors on call service. She said it was okay for staff to call the other physician service group because he was the Medical Director. NP #1 explained she had reviewed documentation for Resident #69 and could not see where a physician was notified about Resident #69's fall or her pain until around 1:00 PM on Sunday. NP #1 said the nursing staff should have called the on-call service Saturday night when Resident #69 reported she had fallen and was having acute pain. NP #1 explained she had spoken with Resident #69 this morning using an interpreter to provide translation because Resident #69 did not speak English. NP #1 said Resident #69 reported on Saturday night she was assisted by a NA to the bathroom and had fallen onto her right knee and that she was in pain all Saturday night and Sunday morning. NP #1's company was contacted on 06/13/25 at 9:58 AM. They stated all calls were logged and there were no calls from the facility on Saturday or Sunday regarding Resident #69. A hospital Discharge summary dated [DATE] indicated Resident #69 had a mechanical fall and was admitted to the hospital on [DATE] with a right nondisplaced proximal tibia and fibula fractures. The discharge summary stated orthopedics was consulted and felt her fractures were amenable to nonoperative management. Orthopedics recommended hinged knee brace with non-weight bearing status to the right lower extremity and close outpatient follow-up with orthopedic services in two weeks. An interview was conducted with the Medical Director on 6/12/25 at 12:00 PM. He stated he did not remember the facility contacting him over the weekend but that he has had a lot of calls since then. He reviewed his calls and stated he did not have a call from the facility. He stated he had been on vacation on Sunday. He said their service tracked all the calls physicians received and he would check to see if there was a log of the facility calling his services over the weekend and call the Surveyor back. A return call was not received from the Medical Director. An interview was conducted with Physician #1 on 6/12/25 at 1:59 PM. He stated he was the on-call provider for the Medical Director physician service group over the weekend. He explained there was a system that tracked all the calls and that he had not been called on Saturday or Sunday about Resident #69. An interview was conducted with the Director of Nursing (DON), Regional Clinical Director, and Administrator on 6/12/25 at 4:00 PM. The Regional Clinical Director said she would have expected the staff to reach out to the DON and Administrator about what Resident #69 was reporting and the pain she was having because the staff did not know what had happened and should have asked for guidance on what they should have done. The Administrator agreed the staff should call the DON to ask for guidance about what the Resident was reporting. They said if someone had that much pain, they would expect the nurse to call the physician. They stated the Medical Director had called back and said one of the on-call providers, part of his service group, had received a phone call on Sunday from the facility where the nurse called and reported the issues with Resident #69, and that was where the orders for the x-ray and ibuprofen had come from.

Based on record review, and staff, resident, family, Physician, Medical Director, and Nurse Practitioner (NP) interviews, the facility failed to protect a resident's right to be free from neglect after Resident #69 had a fall during a staff assisted transfer on 6/27/25 (Saturday). The Nursing Supervisor went to assess Resident #69 after a nurse aide told her the resident reported she had fallen and was having pain in her right knee. Resident #69 told the Nursing Supervisor she was in pain and said her knee was hurting. The Nursing Supervisor did not report the fall or pain to a medical provider. Resident #69 spoke Spanish and there was no evidence that staff utilized an interpreter to determine what had occurred or her level of pain. Due to ineffective communication between staff a medical provider was not notified of fall or pain until 6/8/25 at which time orders were received for an x-ray and ibuprofen (a nonsteroidal anti-inflammatory drug) for pain. The x-ray results received on 6/8/25 noted an acute proximal tibia and fibula fracture (breaks in the upper part of the shinbone (tibia) and the smaller bone of the lower leg (fibula) and were not communicated to a medical provider until 6/9/25 when NP #1 assessed the Resident, which further delayed medical interventions and treatment for the fracture. Through an interpreter Resident #69 told NP #1 she had fallen on Saturday and had been in pain all Saturday night and Sunday morning. NP #1 noted Resident #69 was in a lot of pain and crying and ordered an opioid pain medication to treat the pain for the acute fracture of her tibia and fibula. Resident #69 was sent to the hospital emergency room on 6/9/25 and required a two day hospitalization. Orthopedics recommended hinged knee brace with non-weight bearing status to the right lower extremity. Resident #69 stated through an interpreter several days after the fall that no one asked her if she was hurt or anything afterwards, that they just put her back into bed. This deficient practice occurred for 1 of 1 resident reviewed for neglect. Findings included: This tag is cross referred to: F 580- Based on record review, and staff, resident, family, Physician, Medical Director, and Nurse Practitioner interviews, the facility failed to notify the Physician when a resident (Resident #69) reported she had fallen and was experiencing acute pain after the reported fall. Due to ineffective communication between staff a medical provider was not notified of the fall until the following day which delayed x-rays, medical interventions and an evaluation in the emergency room. Resident #69 sustained an acute proximal tibia and fibula fracture (breaks in the upper part of the shinbone (tibia) and the smaller bone of the lower leg (fibula) from the reported fall and required a two day hospitalization. Orthopedics recommended hinged knee brace with non-weight bearing status to the right lower extremity. This deficient practice occurred for 1 of 3 residents reviewed for notification of changes. F684- Based on record review, and staff, resident, family, and Nurse Practitioner interviews, the facility failed to recognize a resident experienced a fall during a staff transfer that resulted in acute pain to her right knee/ leg on 6/7/25. The nurse aides did not report Resident #69 falling to a nurse and Resident #69 was not assessed by a nurse or medical provider before she was moved and transferred back to her bed. In addition, nursing staff did not complete or document comprehensive assessments of the resident and did not recognize Resident #69 needed medical evaluation and treatment. Due to ineffective communication between staff a medical provider was not notified of fall until the following day and x-ray results reported on 6/8/25 were not communicated to a medical provider until 6/9/25, which delayed medical interventions and an evaluation in the emergency department. Resident #69 sustained an acute proximal tibia and fibula fracture (breaks in the upper part of the shinbone (tibia) and the smaller bone of the lower leg (fibula) from the reported fall and required a two day hospitalization. Orthopedics recommended hinged knee brace with non-weight bearing status to the right lower extremity. This deficient practice occurred for 1 of 1 resident reviewed for quality of care (Resident #69). F689- Based on record review, and staff, resident, family, and Nurse Practitioner interviews, the facility failed to provide a safe transfer for a resident who reported she fell during a transfer with staff. Resident #69 stated she was assisted off the toilet by two staff members, had difficulty holding on to the assist rail because her right hand did not work, fell on her right knee and had pain her in right knee immediately. Resident #69 sustained an acute proximal tibia and fibula fracture (breaks in the upper part of the shinbone (tibia) and the smaller bone of the lower leg (fibula) from the reported fall and required a two day hospitalization. Orthopedics recommended hinged knee brace with non-weight bearing status to the right lower extremity. This deficient practice occurred for 1 of 5 residents reviewed for falls (Resident #69). F 697- Based on record review, and staff, resident, family, and Nurse Practitioner (NP) interviews, the facility failed to provide effective pain management for a resident who had acute pain after a reported fall on 6/27/25 (Saturday). Resident #69 spoke Spanish and reported through an interpreter two days after the fall she fell on her right knee during an assisted transfer and had pain immediately which she rated at a pain scale of 9 (Pain scale of 0 is no pain and pain scale of 10 is the worst pain). Due to ineffective communication between staff a medical provider was not notified of fall or pain until 6/8/25 at which time ibuprofen (a nonsteroidal anti-inflammatory drug) was ordered for pain. There was no evidence staff utilized an interpreter to determine an accurate level of pain or the effectiveness of pain medication. The first documented administration of pain medication was on 6/8/25 at 3:52 PM when Resident #69 received ibuprofen for a pain level of 10 which was ineffective. There was no evidence a medical provider was contacted for additional pain medication. NP #1 was notified of the x-ray results on 6/9/25 and assessed Resident #69 and documented the Resident was in a lot of pain and crying. Through an interpreter Resident #69 told NP #1 she had fallen on Saturday and had been in pain all Saturday night and Sunday morning. NP #1 ordered an opioid pain medication to treat the pain for the acute fracture of her tibia and fibula. Resident #69 received the first dose of opioid pain medication on 6/9/25 at 9:34 AM for a pain level of 7 which was documented as effective. This deficient practice occurred for 1 of 1 resident reviewed for pain (Resident #69). F 777- Based on record review, and staff, resident, family, Physician, Medical Director, and Nurse Practitioner interviews, the facility failed to notify the Physician of radiology results for a resident who was experiencing acute pain after a reported fall on 6/7/25. Due to ineffective communication between staff x-ray results reported on 6/8/25 were not communicated to a medical provider until 6/9/25 which delayed medical interventions and an evaluation in the emergency room. Resident #69 sustained an acute proximal tibia and fibula fracture (breaks in the upper part of the shinbone (tibia) and the smaller bone of the lower leg (fibula) from the reported fall and required a two day hospitalization. Orthopedics recommended hinged knee brace with non-weight bearing status to the right lower extremity. This deficient practice occurred for 1 of 3 residents reviewed for notification of radiology results (Resident #69). An interview was conducted with the Director of Nursing (DON), Regional Clinical Director, and Administrator on 6/12/25 at 4:00 PM. They declined to comment on whether they felt like what happened with Resident #69 was neglect.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and staff, resident, family, and Nurse Practitioner interviews, the facility failed to recognize a resident experienced a fall during a staff transfer that resulted in acute pain to her right knee/ leg on 6/7/25. The nurse aides did not report Resident #69 falling to a nurse and Resident #69 was not assessed by a nurse or medical provider before she was moved and transferred back to her bed. In addition, nursing staff did not complete or document comprehensive assessments of the resident and did not recognize Resident #69 needed medical evaluation and treatment. Due to ineffective communication between staff a medical provider was not notified of fall until the following day and x-ray results reported on 6/8/25 were not communicated to a medical provider until 6/9/25, which delayed medical interventions and an evaluation in the emergency department. Resident #69 sustained an acute proximal tibia and fibula fracture (breaks in the upper part of the shinbone (tibia) and the smaller bone of the lower leg (fibula) from the reported fall and required a two day hospitalization. Orthopedics recommended hinged knee brace with non-weight bearing status to the right lower extremity. This deficient practice occurred for 1 of 1 resident reviewed for quality of care (Resident #69). Findings included: Resident # 69 was admitted to the facility on [DATE]. Her diagnoses included cerebral infarction (stroke) and hemiplegia (paralysis) affecting the dominant right side. The quarterly Minimum Data Set Assessment (MDS) dated [DATE] revealed Resident #69 was cognitively intact. The MDS documented that she was dependent on dressing, personal hygiene, toileting, and toilet transfers. The MDS indicated she required substantial/maximal assistance with sit to stand and chair to bed transfers. It was documented on the MDS Resident #69's preferred language was Spanish, and she needed an interpreter. An interview was conducted with Resident #69 on 6/12/25 at 2:13 PM with Physical Therapy Assistant (PTA) #1 providing translation. Resident #69 stated while staff members were assisting her in the bathroom to get off the toilet, she fell onto her right knee. Resident #69 reported she had pain in her right knee immediately but did not cry or scream out. She explained that the staff member who was in the bathroom with her helped her up and sat her in her wheelchair. Resident #69 said she could not see if it was one or two people who helped her off the toilet and back to her wheelchair because she could not see around the larger staff member to see who was in the bathroom with her. She reported two female staff members put her back into bed after. Resident #69 stated no one asked her if she was hurt or anything afterwards, that they just put her back into bed. An interview was conducted on 6/10/25 at 10:46 AM with Nurse Aide (NA) #7. She recalled assisting Resident #69 with toileting on Saturday afternoon (6/7/25); she could not recall the exact time. She stated NA #9 had assisted her with transferring Resident #69 off the toilet. NA #7 reported Resident #69 did not fall during the transfer. She did not recall Resident #69 twisting her leg or her leg getting caught on anything during the transfer. NA #7 was not aware of Resident #69 having pain after the transfer. NA #7 said after Resident #69 was finished in the bathroom, she assisted her back to her bed. An interview was conducted with NA #9 on 6/10/25 at 12:41 PM. NA #9 reported NA #7 had asked her to assist with transferring Resident #69 off the toilet Saturday (6/7/25). She explained Resident #69 was not really able to sit on the toilet because she would lean and was unstable when she was sitting on the toilet. She stated she did not think it was a good idea for Resident #69 to sit on the toilet because she might fall off the toilet. She explained she had been called to assist with transferring Resident #69 off the toilet so Resident #69 would not fall off of the toilet because she was leaning. NA #9 reported she and NA #7 armed and armed her and put her in the wheelchair. She said they each took a side to help her stand up and put her back in the wheelchair. She said during the transfer Resident #69's leg did not give out, get twisted, or catch on anything. NA #9 reported Resident #69 did not have any signs of pain during or after the transfer. A telephone interview was conducted with NA #6 on 6/10/25 at 3:35 PM. NA #6 reported that she worked the night shift (7:00 pm to 7:00 am) on Saturday 6/7/25. She said at the start of her shift around 7:00 PM Resident #69's roommate was in the doorway of their room and asked her to come into the room. The roommate told her Resident #69 was having bad pain in her right knee. NA #6 recalled Resident #69 was in bed. She stated she looked at Resident #69's right knee and the top of her kneecap was bruised. NA #6 explained that the roommate assisted with translating for Resident #69 and she asked what had happened. NA #6 stated Resident #69 said she had fallen earlier that day in the bathroom and that she had fallen on her knee. NA #6 reported she asked Resident #69 if she was by herself when she fell or if staff were helping her. Resident #69 told her two girls had been helping her in the bathroom, but she did know who they were. NA #6 stated the night shift nurse (Nurse #9) was outside of the door when she was talking to Resident #69 and had heard the conversation. NA #6 stated Nurse #9 told her she did not get anything in report about Resident #69 falling. NA #6 said she went and reported what Resident #69 was saying to the day shift (7:00 am to 7:00 pm) Nursing Supervisor. She recalled the Nursing Supervisor said she did not know anything about Resident #69 falling and the Nursing Supervisor went to check on Resident #69. A telephone interview was conducted with the day shift weekend Nursing Supervisor on 6/10/25 at 11:50 AM. The Nursing Supervisor stated a Nurse Aide (NA) came and got her around shift change on Saturday (6/7/25) around 7:30 PM and asked her to check on Resident #69. She reported the NA told her Resident #69 was saying she had fallen and was having pain in her right knee. She said she could not remember the name of the NA who came and got her. The Nursing Supervisor explained she went to Resident #69's room to assess her. She said she did not see anything abnormal when she looked at Resident #69's knee. She did not recall her having bruising or swelling to her knee. She said Resident #69 was in pain and said her knee was hurting when she saw her. She reported Resident #69's roommate was present in the room and provided translation for what Resident #69 said happened. The Nursing Supervisor said Resident #69 reported she had fallen about an hour prior while she was being assisted in the bathroom by staff. The Nursing Supervisor said she updated the night shift Nurse (Nurse #9) about what was going on and then went to find the day shift nurse (Nurse #8). The Nursing Supervisor reported she asked Nurse #8 if Resident #69 had fallen during the shift and Nurse #8 reported she did not know anything about Resident #69 having a fall. The Nursing Supervisor further reported she asked Resident #69's assigned NA, NA #7 if Resident #69 had fallen. The Nursing Supervisor stated NA #7 told her Resident #69 had not fallen. She stated she went back to Nurse #8 and updated her on what Resident #69 was reporting and told her what she needed to do. The Nursing Supervisor said she explained to Nurse #8 what she needed to do for the fall and told her she needed to call the physician. She told Nurse #8 she needed to go talk to Resident #69 and her roommate because Resident #69 was reporting she had fallen. She said she told Nurse #8 she needed to call the physician because Resident #69 was in pain, and she only had as needed Tylenol ordered. The Nursing Supervisor stated she also told Nurse #8 she needed to call the Director of Nursing (DON) about what Resident #69 was reporting and the fall. The Nursing Supervisor stated Nurse #8 had said okay. The Nursing Supervisor stated she had also made the oncoming night shift nurse (Nurse #9) aware of what was going on and what Resident #69 had reported. The Nursing Supervisor stated she did not think Nurse #8 had called anyone or done anything for the fall because when she returned on Sunday there was no documentation to indicate anything had been done for Resident #69 or her reported fall and Resident #69 was still having pain. The Nursing Supervisor explained she went to assess Resident #69 on Sunday around 11:00 AM and that she was still hurting. The Nursing Supervisor stated she knew Resident #69 was in pain because she was grimacing and holding her right leg. She stated when she looked at Resident #69's knee on Sunday there was swelling and bruising to the top of her knee. The Nursing Supervisor said she talked to Nurse #10, who was Resident #69's assigned nurse on Sunday day shift to ask him if he got anything in report about Resident #69 falling. She stated she could not remember if Nurse #10 had said yes or no. The Nursing Supervisor explained that she contacted the on-call provider on Sunday about Resident #69's pain and the fall she reported had happened on Saturday. The Nursing Supervisor reported an x-ray was ordered for Resident #69 by the on-call physician on Sunday. She recalled the x-ray was completed and the results returned before the end of her shift on Sunday. She said she had spoken to the DON about the results and that she had told Nurse #10 and Nurse #3 about the x-ray results. She reported she wrote the on-call physician's phone number down for Nurse #10 but had not told him or Nurse #3 to call the physician and report the x-ray results. The Nursing Supervisor said she did not call the x-ray results to the physician. She stated she could not remember what she told Nurse #3 and Nurse #10 to do after that. Nurse #10 was unavailable for interview. A telephone interview was conducted with Nurse #8 (agency nurse) on 6/10/25 at 1:49 PM. Nurse #8 stated she was the assigned nurse for Resident #69 on day shift on Saturday 6/7/25. She reported she had given shift report to the oncoming night shift nurse (Nurse #9) around 7:00 PM. Nurse #8 explained the day shift Nursing Supervisor came to her around 7:35 PM and told her Resident #69 was reporting she had fallen one hour ago. She stated no one had reported to her that Resident #69 had fallen during her shift. Nurse #8 said she went to Resident #69's room to check on her and that Resident #69 indicated she was in pain. Nurse #8 said she assessed Resident #69 by touching areas of her body like her arms and legs. She reported when she touched Resident #69's right leg she showed an expression of pain that was indicated by facial grimacing. She said Resident #69 did not cry or yell out and that the resident did not have any bruising or swelling to her right leg that she recalled. Nurse #8 said it was not a fall that was reported to her during her shift and that it was not reported until 7:35 PM. She explained she had already given report to the night shift nurse (Nurse #9). She reported after she assessed Resident #69 and noticed she was in pain, she communicated to Nurse # 9, what she had seen. Nurse #8 said she asked Nurse #9 to continue the assessment and to complete the post fall things. She stated she did not specifically tell Nurse #9 what she needed to do but said Nurse #9 should have known what to do. She reported Nurse #9 had said yes. Nurse #8 said she assumed Nurse #9 would contact the physician and complete the rest of the post fall documentation. Nurse #8 said she had not done any vital signs, documentation, or incident report related to Resident #69's reported fall. Nurse #8 said if she had done all those things she would have been at the facility another hour and that her agency would not pay her if she was there longer than her scheduled shift. She stated the Nursing Supervisor had not told her anything specific she needed to do related to the fall. A telephone interview was conducted with Nurse #9 on 6/10/25 at 2:15 PM. She reported she had been the assigned night shift nurse for Resident #69 on Saturday night 6/27/25. Nurse #9 recalled she had been in the middle of taking report from the off going day shift nurse (Nurse #8). She stated she was outside of Resident #69's room with Nurse #8 and could hear another nurse in the room talking to Resident #69 and her roommate. Nurse #8 stated she did not know who the nurse in the room was, but that she overheard the nurse asking how and when Resident #69 fell. She explained an NA, whose name she did not know, was also in the room and they were trying to figure out how Resident #69 had fallen. Nurse #9 reported she had thought since it had happened on the day shift that the day shift nurse (Nurse #8) was going to do the fall stuff because it was her shift. Nurse #9 said the nurse who had been in the room talking with Resident #69 about the fall had not told her to do anything. She recalled after Nurse #8 gave her report Nurse #8 had said she was going to step away to do charting. She stated Nurse #8 never came back to talk to her after giving report. Nurse #9 indicated Nurse #8 did not come back and to tell her she had assessed Resident #69 or asked her to do anything related to the fall, she said she never saw Nurse #8 again after report. An interview was conducted with Nurse #3 on 6/12/25 at 6:25 AM. She was the assigned night shift nurse on Sunday 6/8/25 for Resident #69. Nurse #3 reported she received in report from Nurse #10 that Resident #69 had a fractured knee. She also spoke with the day shift Nursing Supervisor who told her they had gotten the x-ray back and knew Resident #69 had a fracture. Nurse #3 stated she knew the day shift nurses had spoken with the Physician at some point, but she did not know if it was before or after they had received the x-ray results. She reported she had not seen the x-ray report. Nurse #3 explained she came in after they had done everything and they were just telling her what had happened. Nurse #3 stated they did not ask her to do anything or tell her she needed to do anything else. Nurse #3 recalled Resident #69's roommate came and got her during the night and let her know Resident #69 was having pain. She did not remember the time. Nurse #3 said she checked on Resident #69 and observed her having pain. She said Resident #69 was pointing at her right leg and she could tell she was having pain by her facial expression and that she was grimacing. Nurse #3 said she gave Resident #69 the PRN ibuprofen. Nurse #3 reported she went back and checked on Resident #69 again about an hour later and she was asleep. Review of Resident #69's medical record on 6/9/25 at 11:00 AM revealed there was no documentation or assessment information from Saturday 6/7/25 related to a fall. Resident #69's last progress note was documented on 6/6/25. There was no additional documentation for Resident #69 until 6/8/25 at 1:30 PM. A nursing note dated 6/8/25 at 1:30 PM by the Nursing Supervisor read: [family member] called about getting an x-ray and getting something for pain at the right knee for his [Resident #69]. Resident stated she is having pain in her right knee. Nurse evaluated right knee. There was inflammation at site. This nurse spoke with the on call doctor to get an order for an x-ray, that order has been called in to mobile x-ray. Nurse on cart gave as needed (PRN) for pain. Will continue to follow up. A telephone interview was conducted on 6/9/25 at 3:19 PM with Resident #69's Family Member. The Family Member stated they received a phone call from Resident #69 on Sunday (6/8/25). He said resident #69 was crying and said she was hurting. He reported Resident #69 said she had fallen the night before. Resident #69 had told him the staff members brought her back and put her into bed and that no one followed up to check on her. The Family Member said Resident #69 could not speak English but that she was alert and oriented. He stated he thought there would be a process for when someone fell and was injured, not just staff putting them back in bed, not contacting the doctor, or not doing any radiology screening. He reported it was around noon the next day when he spoke to the facility and nothing had been done. The Family Member indicated he thought someone would have made a report and called the Doctor. An x-ray report dated 6/8/25 read: There are nondisplaced fractures of the proximal tibia and fibular neck. There are no bony lesions. Degenerative changes are noted. Diffuse osteopenia is noted. The soft tissues are unremarkable. Impression: Acute proximal lower leg fractures. A progress note dated 6/9/25 by Nurse Practitioner (NP) #1 reported Resident #69 was being seen for right leg pain. The progress note indicated an interpreter had been used during the exam. The progress note said Resident #69 reported she had fallen onto her right knee while in the restroom with a NA Saturday night. The note further stated Resident #69 said she immediately had pain and the NA at the time got her up and helped her back to bed. NP #1's note indicated there was no documentation of the fall in the electronic computer system on 6/7/25. The progress note stated on 6/8/25 a nurse contacted the on-call physician who ordered an x-ray. The NP note stated the x-ray was reviewed this morning (6/9/25) by herself and showed a right nondisplaced fracture of the proximal tibia and fibular neck. The progress note indicated Resident #69 reported 8/10 pain to her right leg when attempting to move the leg. The NP progress note additionally said an ortho consult was ordered and non-weight bearing to the right leg was ordered. The progress note reported that NP#1 made the DON aware of what Resident #69 reported occurred Saturday and that there was no documentation. A telephone interview was conducted with the Nurse Practitioner (NP) #1 on 6/10/25 at 4:16 PM. NP #1 stated she was alerted by Nurse #4 on Monday morning (6/9/25) that she had received in report from night shift that Resident #69 had an acute fracture of her knee. She explained if Nurse #4 had not mentioned it to her she would never have known about it. NP #1 explained she reviewed the x-ray of Resident #69's right leg and it showed she had an acute fracture of her tibia and fibula. NP #1 explained she had spoken with Resident #69 this morning using an interpreter to provide translation because Resident #69 did not speak English. NP #1 said Resident #69 reported on Saturday night she was assisted by a NA to the bathroom, and she was attempting to hold onto the assist rail to get onto the toilet and felt weak. Resident #69 told her she missed the assist rail and had fallen onto her right knee and that she was in pain all Saturday night and Sunday morning. NP #1 said she had also spoken with Resident #69's Family Member who reported Resident #69 had called him Sunday and said she was in a lot of pain and had fallen. NP #1 said no one from the facility had contacted her or the company's on-call service over the weekend about Resident #69's fall, her pain, or the x-ray results. She said this morning was the first time she had learned about it. NP #1 explained if Resident #69's leg was not splinted or immobilized there was a risk that the fractures could become more displaced. A hospital Discharge summary dated [DATE] indicated Resident #69 had a mechanical fall and was admitted to the hospital on [DATE] with a right nondisplaced proximal tibia and fibula fractures. The discharge summary stated orthopedics was consulted and felt her fractures were amenable to nonoperative management. Orthopedics recommended hinged knee brace with non-weight bearing status to the right lower extremity and close outpatient follow-up with orthopedic services in two weeks. An interview was conducted with the Director of Nursing (DON), Regional Clinical Director, and Administrator on 6/12/25 at 4:00 PM. They reported when a fall was reported staff were supposed to contact the DON, responsible party, provider, and follow the fall protocol. They explained the fall protocol was to assess for injury/ pain, document the assessment, and complete an incident report. The Regional Clinical Director said she would have expected the staff to reach out to the DON and Administrator about what Resident #69 was reporting and the pain she was having because the staff did not know what had happened and should have asked for guidance on what they should have done. The DON stated if the staff had reached out and called her, she would have told them to call the on-call provider to report that Resident #69 said she had a fall and had pain. The Administrator agreed the staff should call the DON to ask for guidance about what the Resident was reporting. The DON explained she was aware of Resident #69's x-ray results Sunday night. She reported the x-ray report pinged on her computer around shift change on Sunday night at 6:56 PM and she reviewed the report. The DON said she called the facility and spoke to the day shift Nursing Supervisor around 7:00 PM. The DON stated she had called the Nursing Supervisor to notify her and make sure she had the results as well. She reported that the Nursing Supervisor confirmed she had the x-ray results. The DON said she did not tell the Nursing Supervisor what she needed to do. The DON explained that the Nursing Supervisor was not a new nurse and had assumed she knew what to do and knew she needed to call the Physician. The DON said she felt it was common sense that the nurse would call the Physician about critical x-ray results. The DON explained she was hyper focused on trying to figure out the cause of the fractures because she did not know anything about the x-ray or why it had been ordered.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and staff, resident, family, and Nurse Practitioner interviews, the facility failed to provide a safe transfer for a resident who reported she fell during a transfer with staff. Resident #69 stated she was assisted off the toilet by two staff members, had difficulty holding on to the assist rail because her right hand did not work, fell on her right knee and had pain her in right knee immediately. Resident #69 sustained an acute proximal tibia and fibula fracture (breaks in the upper part of the shinbone (tibia) and the smaller bone of the lower leg (fibula) from the reported fall and required a two day hospitalization. Orthopedics recommended hinged knee brace with non-weight bearing status to the right lower extremity. This deficient practice occurred for 1 of 5 residents reviewed for falls (Resident #69). Findings included: Resident # 69 was admitted to the facility on [DATE]. Her diagnoses included cerebral infarction (stroke) and hemiplegia (paralysis) affecting the dominant right side. The quarterly Minimum Data Set Assessment (MDS) dated [DATE] revealed Resident #69 was cognitively intact. The MDS documented that she was dependent on dressing, personal hygiene, toileting, and toilet transfers. The MDS indicated she required substantial/maximal assistance with sit to stand and chair to bed transfers. It was documented on the MDS Resident #69's preferred language was Spanish, and she needed an interpreter. A care plan dated 1/12/25 read Resident #69 requires staff assistance for activity of daily living (ADL) care needs related to generalized weakness and history of stroke with right side weakness. The care plan interventions included to assist with ADL care needs as needed. The ADL care plan did not specify how Resident #69 transferred. A care Kardex (quick reference tool that summarizes important care information) for Resident #69 included she was dependent for transfers and required a total mechanical lift and two persons assist for transfers. The Kardex stated as of 6/9/25. An observation and interview were conducted with Resident #69 on 6/9/25 at 10:52 AM. Resident #69 was observed in her room in her bed covered with a sheet. She was noted to be grimacing. When spoken to by the surveyor Resident #69 replied in Spanish. The surveyor asked Resident #69 Habla Ingles (speak English?), Resident #69 replied no. Resident #69 was asked by the surveyor dolor (pain)? Resident #69 replied see (yes) mucho (a lot) and grabbed her right leg at the knee. Resident #69 proceeded to uncover her right leg. When she uncovered her right leg Resident #69 began grimacing, crying, and moaning. A pillow was observed under her lower right leg. There was light blue/ purple colored bruising along her right shin and to the top of her right knee. Her right lower leg and knee had visible swelling present. Resident #69 said pain was mucho, diez (a lot, 10). The bathroom was in front of Resident #69's bed. She pointed at her right leg and the bathroom and said bano (bathroom). Resident #69's roommate was in the room who was also Spanish speaking. The roommate approached Resident #69's bed while the surveyor was in the room. The roommate translated that Resident #69 stated she had fallen on Saturday in bathroom and had a lot of pain in her leg. An additional interview was conducted with Resident #69 on 6/12/25 at 2:13 PM with Physical Therapy Assistant (PTA) #1 providing translation. Resident #69 stated she had gone to the bathroom with two staff members. She reported when she was getting off the toilet, she was holding on to the assist rail, and all a sudden she started falling. She explained that one of the staff members helping her had left to go get her wheelchair. She said she was standing at the assist rail, and the other staff member was in the bathroom next to her but was not paying attention to her. She said the staff member was not looking at her and that she was looking out the bathroom door. She recalled the staff members had her hold onto the assist rail in the bathroom. She said she could not hold onto the rail with both her hands because her right hand does not work. Resident #69 reported she had said me estoy cayendo (I'm falling) but the staff members did not understand what she was saying. Resident #69 said she fell onto her right knee and had pain in her right knee immediately but did not cry or scream out. She said the staff member in the bathroom could not reach her fast enough to keep her from falling. She explained that the staff member who was in the bathroom with her helped her up and sat her in her wheelchair. Resident #69 said she could not see if it was one or two people who helped her off the toilet and back to her wheelchair because she could not see around the larger staff member to see who was in the bathroom with her. She reported two female staff members put her back into bed after. Resident #69 stated no one asked her if she was hurt or anything afterwards, that they just put her back into bed. An interview was conducted on 6/10/25 at 10:46 AM with NA #7. She reported she had been Resident #69's assigned NA on Saturday 6/7/25. She said she and NA #8 assisted Resident #69 to the toilet on Saturday. She could not recall the time they had taken her to the toilet but said it had been sometime after lunch and thought it was before dinner but could not remember exactly. She reported she held the back of the wheelchair while NA #8 assisted Resident #69 to transfer from the bed to her wheelchair doing a stand and pivot transfer. She recalled they took Resident #69 into the bathroom that was in her room. She said she stood behind the wheelchair while NA #8 had Resident #69 hold the assist rail in the bathroom with her hand and then assisted her to open her right hand and placed her right hand on the railing. She reported NA #8 assisted Resident #69 to pull up to a standing position using the bathroom railing and then assisted her with a pivot transfer to the toilet. NA #7 reported after the transfer was completed NA #8 left the room. NA #7 reported nothing unusual occurred during the transfer and Resident #69 did not have any indicators of pain during or after the transfer onto the toilet. NA #7 recalled she closed the bathroom door slightly but left it ajar to provide privacy to Resident #69 while she was on the toilet. She stated while Resident #69 was using the toilet she remained in the room and straightened her bed and chatted with the roommate. NA #7 reported when Resident #69 indicated she was finished using the toilet, she asked NA #9 from the doorway to help her transfer Resident #69. NA #7 said she and NA #9 transferred Resident #69 back to her wheelchair using a 2-person transfer. NA #7 again, said nothing unusual occurred during the transfer and that Resident #69 did not cry out or have any indicators of pain during or after the transfer. NA #7 said Resident #69's right leg did not give way, twist, get caught, or hit anything during the transfer. NA #8 reported they then transferred Resident #69 back to her bed. NA #7 said she was not aware of Resident #69 having any pain in her right knee/ leg during her shift on Saturday. An interview was conducted with NA #8 on 6/10/25 at 10:21 AM. She reported she had assisted NA #7 with transferring Resident #69 to the toilet on Saturday. NA #8 was not sure what time they assisted her to the toilet but said it was some time after lunch. She thought it had been before dinner but was not exactly sure. NA #8 stated she had only assisted with transferring Resident #69 onto the toilet and had then left the room. She said nothing unusual happened during the transfer onto the toilet and that Resident #69 did not cry out or have any indicator of pain during or after the transfer to the toilet. An interview was conducted with NA #9 on 6/10/25 at 12:41 PM. NA #9 reported NA #7 had asked her to assist with transferring Resident #69 off the toilet. She explained Resident #69 was not really able to sit on the toilet because she would lean and was unstable when she was sitting on the toilet. She stated she did not think it was a good idea for Resident #69 to sit on the toilet because she might fall off the toilet. She explained she had been called to assist with transferring Resident #69 off the toilet so Resident #69 would not fall off of the toilet because she was leaning. NA #9 reported she and NA #7 armed and armed her and put her in the wheelchair. NA #9 stated Resident #4 was not able to hold onto the assist rail to pull herself up off the toilet. She reported Resident #69 was able to stand and pivot enough to get back into the wheelchair. NA #9 recalled the wheelchair was outside of the bathroom door. She said they each took a side to help her stand up and put her back in the wheelchair. NA #9 stated when they had Resident #69 up and turned/ pivoted her they moved the wheelchair under her and sat her down in the wheelchair. She said during the transfer Resident #69's leg did not give out, get twisted, or catch on anything. NA #9 reported Resident #69 did not have any signs of pain during or after the transfer. A telephone interview was conducted with NA #6 on 6/10/25 at 3:35 PM. NA #6 reported that she worked the night shift (7:00 pm to 7:00 am) on Saturday 6/7/25. She said at the start of her shift around 7:00 PM she was doing rounds and Resident #69's roommate was in the doorway of their room and asked her to come into the room. The roommate told her Resident #69 was having bad pain in her right knee. NA #6 recalled Resident #69 was in bed. She stated she looked at Resident #69's right knee and the top of her kneecap was bruised. NA #6 explained that the roommate assisted with translating for Resident #69 and she asked what had happened. NA #6 stated Resident #69 said she had fallen earlier that day in the bathroom and that she had fallen on her knee. NA #6 reported she asked Resident #69 if she was by herself when she fell or if staff were helping her. Resident #69 told her two girls had been helping her in the bathroom, but she did know who they were. NA #6 said she went and reported what Resident #69 was saying to the day shift (7:00 am to 7:00 pm) Nursing Supervisor. She recalled the Nursing Supervisor said she did not know anything about Resident #69 falling and the Nursing Supervisor went to check on Resident #69. A telephone interview was conducted with the day shift weekend Nursing Supervisor on 6/10/25 at 11:50 AM. The Nursing Supervisor stated a Nurse Aide (NA) came and got her around shift change on Saturday (6/7/25) around 7:30 PM and asked her to check on Resident #69. She reported the NA told her Resident #69 was saying she had fallen and was having pain in her right knee. She said she could not remember the name of the NA who came and got her. The Nursing Supervisor explained she went to Resident #69's room to assess her. She said she did not see anything abnormal when she looked at Resident #69's knee. She did not recall her having bruising or swelling to her knee. She said Resident #69 was in pain and said her knee was hurting when she saw her. She reported Resident #69's roommate was present in the room and provided translation for what Resident #69 said happened. The Nursing Supervisor said Resident #69 reported she had fallen about an hour prior while she was being assisted in the bathroom by staff. The Nursing Supervisor said she updated the night shift Nurse (Nurse #9) about what was going on and then went to find the day shift (Nurse #8). The Nursing Supervisor reported she asked Nurse #8 if Resident #69 had fallen during the shift and Nurse #8 reported she did not know anything about Resident #69 having a fall. The Nursing Supervisor further reported she asked Resident #69's assigned NA, NA #7 if Resident #69 had fallen. The Nursing Supervisor stated NA #7 told her Resident #69 had not fallen. She stated she went back to Nurse #8 and updated her on what Resident #69 was reporting and told her what she needed to do. The Nursing Supervisor said she explained to Nurse #8 what she needed to do for the fall and told her she needed to call the physician and the Director of Nursing (DON). The Nursing Supervisor stated she had also made the oncoming night shift nurse (Nurse #9) aware of what was going on and what Resident #69 had reported. The Nursing Supervisor stated she did not think Nurse #8 had called anyone or done anything for the fall because when she returned on Sunday there was no documentation to indicate anything had been done for Resident #69 or her reported fall. The Nursing Supervisor said she went to assess Resident #69 on Sunday (6/8/25) around 11:00 AM and that she was still hurting. She said she knew she was in pain because she was grimacing and holding her right leg. She stated when she looked at Resident #69's knee on Sunday there was swelling and bruising to the top of her knee. The Nursing Supervisor said she talked to Nurse #10, who was Resident #69's assigned nurse on Sunday day shift to ask him if he got anything in report about Resident #69 falling. She stated she could not remember if Nurse #10 had said yes or no. The Nursing Supervisor said she spoke to Resident #69's Family Member on the phone on Sunday. She said the Family Member reported Resident #69 told him she had fallen and was having pain. The Nursing Supervisor explained that she contacted the on-call provider on Sunday about Resident #69's pain and the fall she reported. She stated the on-call provider ordered an x-ray of Resident #69's right leg and as needed ibuprofen for pain. The Nursing Supervisor said she called the mobile x-ray company and placed an order for them to come to the facility to complete the x-ray. The Nursing Supervisor stated she called Resident #69's Family Member back and updated him on the new orders for Resident #69. A telephone interview was conducted with Nurse #8 (agency nurse) on 6/10/25 at 1:49 PM. Nurse #8 stated she was the assigned nurse for Resident #69 on day shift on Saturday 6/7/25. She reported she had given shift report to the oncoming night shift nurse (Nurse #9) around 7:00 PM. Nurse #8 explained the day shift Nursing Supervisor came to her around 7:35 PM and told her Resident #69 was reporting she had fallen one hour ago. She stated no one had reported to her that Resident #69 had fallen during her shift. Nurse #8 said she went to Resident #69's room to check on her and that Resident #69 indicated she was in pain. Nurse #8 said she assessed Resident #69 by touching areas of her body like her arms and legs. She reported when she touched Resident #69's right leg she showed an expression of pain that was indicated by facial grimacing. She said Resident #69 did not cry or yell out and that the resident did not have any bruising or swelling to her right leg that she recalled. Nurse #8 said it was not a fall that was reported to her during her shift and that it was not reported until 7:35 PM. She explained she had already given report to the night shift nurse (Nurse #9). She reported after she assessed Resident #69 and noticed she was in pain, she communicated to Nurse # 9, what she had seen. Nurse #8 said she asked Nurse #9 to continue the assessment and to complete the post fall things. She stated she did not specifically tell Nurse #9 what she needed to do but said Nurse #9 should have known what to do. She reported Nurse #9 had said yes. Nurse #8 said she assumed Nurse #9 would contact the physician and complete the rest of the post fall documentation. Nurse #8 said she had not done any vital signs, documentation, or incident report related to Resident #69's reported fall. Nurse #8 said if she had done all those things she would have been at the facility another hour and that her agency would not pay her if she was there longer than her scheduled shift. She stated the Nursing Supervisor had not told her anything specific she needed to do related to the fall. A telephone interview was conducted with Nurse #9 on 6/10/25 at 2:15 PM. She reported she had been the assigned night shift nurse for Resident #69 on Saturday night 6/27/25. Nurse #9 recalled she had been in the middle of taking report from the off going day shift nurse (Nurse #8). She stated she was outside of Resident #69's room with Nurse #8 and could hear another nurse in the room talking to Resident #69 and her roommate. Nurse #8 stated she did not know who the nurse in the room was, but that she overheard the nurse asking how and when Resident #69 fell. She explained an NA, whose name she did not know, was also in the room and they were trying to figure out how Resident #69 had fallen. Nurse #9 reported she had thought since it had happened on the day shift that the day shift nurse (Nurse #8) was going to do the fall stuff because it was her shift. Nurse #9 said the nurse who had been in the room talking with Resident #69 about the fall had not told her to do anything. She recalled after Nurse #8 gave her report Nurse #8 had said she was going to step away to do charting. She stated Nurse #8 never came back to talk to her after giving report. Nurse #9 indicated Nurse #8 did not come back and to tell her she had assessed Resident #69 or asked her to do anything related to the fall, she said she never saw Nurse #8 again after report. A nursing note dated 6/8/25 at 1:30 PM by the Nursing Supervisor read: [family member] called about getting an x-ray and getting something for pain at the right knee for his mom. Resident stated she is having pain in her right knee. Nurse evaluated right knee. There was inflammation at site. This nurse spoke with the on call doctor to get an order for an x-ray, that order has been called in to mobile x-ray. Nurse on cart gave as needed (PRN) for pain. Will continue to follow up. An x-ray report dated 6/8/25 read: There are nondisplaced fractures of the proximal tibia and fibular neck. There are no bony lesions. Degenerative changes are noted. Diffuse osteopenia is noted. The soft tissues are unremarkable. Impression: Acute proximal lower leg fractures. A telephone interview was conducted on 6/9/25 at 3:19 PM with Resident #69's Family Member. The Family Member stated they received a phone call from Resident #69 on Sunday (6/8/25). He said resident #69 was crying and said she was hurting. He reported Resident #69 said she had fallen the night before. The Family Member explained he called and spoke with the Nursing Supervisor on Sunday afternoon to ask about the fall, pain medication, and if an x-ray was going to be done. The Family Member said the Nursing Supervisor indicated she was just aware and that she was going to call the physician. He reported Resident #69 had told him a staff member had taken her to the bathroom on Saturday evening. She told him when they were transferring her off the toilet back to her wheelchair, the staff members had told her to hold onto the railing, and she lost her balance and fell onto the floor. The Family Member said Resident #69 could not speak English but that she was alert and oriented. The Family Member reported he had spoken with a provider at the facility earlier today (6/9/25) who let him know about the x-ray results. A telephone interview was conducted with the Nurse Practitioner (NP) #1 on 6/10/25 at 4:16 PM. NP #1 stated she was alerted by Nurse #4 on Monday morning (6/9/25) that she had received in report from night shift (7pm-7am) that Resident #69 had an acute fracture of her knee. NP #1 explained she had asked for the radiology report because it was not in Resident #69 chart, and nothing was documented in her chart about a fall or the injury. She said when she reviewed the x-ray of Resident #69's right leg it showed she had an acute fracture of her tibia and fibula. NP #1 explained she had spoken with Resident #69 this morning using an interpreter to provide translation because Resident #69 did not speak English. NP #1 said Resident #69 reported on Saturday night she was assisted by a NA to the bathroom, and she was attempting to hold onto the assist rail to get onto the toilet and felt weak. Resident #69 told her she missed the assist rail and had fallen onto her right knee and that she was in pain all Saturday night and Sunday morning. NP #1 said she had also spoken with Resident #69's Family Member who reported Resident #69 had called him Sunday and said she was in a lot of pain and had fallen. NP #1 explained this morning she had given orders for pain medication, non-weight bearing status and to try to immobilize her right leg. She stated she had also given an order to refer Resident #69 to the orthopedic walk-in clinic. NP #1 reported she had spoken to the orthopedic office this morning, and they had said they could cast Resident #69 in the office, so she did not have to go the emergency room (ER). NP #1 explained she had been notified around 2:30 PM by the facility that they did not feel they could immobilize Resident #69's leg for transport to the orthopedic office. She said the facility had asked for Resident #69 to go to the ER and she had agreed. NP #1 stated the therapy department at the facility had not felt comfortable splinting or touching Resident #69's leg due to the fractures and that was when she had made the decision to send her out. She explained she had spoken to the facility at 2:55 PM to confirm the ER transfer orders. NP #1 explained if Resident #69's leg was not splinted or immobilized there was a risk that the fractures could become more displaced. NP #1 further explained, a displaced fracture created more issues and was harder to treat. She reported that a non-displaced fracture is treated by keeping the leg immobilized to heal and that a displaced fracture would need surgical interventions to fix it. A hospital Discharge summary dated [DATE] indicated Resident #69 had a mechanical fall and was admitted to the hospital on [DATE] with a right nondisplaced proximal tibia and fibula fractures. The discharge summary stated orthopedics was consulted and felt her fractures were amenable to nonoperative management. Orthopedics recommended hinged knee brace with non-weight bearing status to the right lower extremity and close outpatient follow-up with orthopedic services in two weeks. An interview was conducted with the Director of Nursing (DON), Regional Clinical Director, and Administrator on 6/12/25 at 4:00 PM. The Regional Clinical Director said she would have expected the staff to reach out to the DON and Administrator about what Resident #69 was reporting and the pain she was having because the staff did not know what had happened and should have asked for guidance on what they should have done. The Administrator agreed the staff should call the DON to ask for guidance about what the Resident was reporting. The Regional Clinical Director stated Resident #69 was officially interviewed on Monday 6/9/25 by NP #1 using an interpreter for a more formal interview. She stated Resident #69 had also been interviewed by staff on Saturday and Sunday about what had happened, and all her statements, including the reports from the hospital, had been that she had fallen in the bathroom. The Regional Clinical Director said because Resident #69 had been constant in her statements that she had fallen they had determined her injury was from a fall.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and staff, resident, family, and Nurse Practitioner (NP) interviews, the facility failed to provide effective pain management for a resident who had acute pain after a reported fall on 6/27/25 (Saturday). Resident #69 spoke Spanish and reported through an interpreter two days after the fall that she fell on her right knee during an assisted transfer and had pain immediately which she rated at a pain scale of 9 (Pain scale of 0 is no pain and pain scale of 10 is the worst pain). Due to ineffective communication between staff a medical provider was not notified of fall or pain until 6/8/25 at which time ibuprofen (a nonsteroidal anti-inflammatory drug) was ordered for pain. There was no evidence staff utilized an interpreter to determine an accurate level of pain or the effectiveness of pain medication. The first documented administration of pain medication was on 6/8/25 at 3:52 PM when Resident #69 received ibuprofen for a pain level of 10 which was ineffective. There was no evidence a medical provider was contacted for additional pain medication. NP #1 was notified of the x-ray results on 6/9/25 and assessed Resident #69 and documented the Resident was in a lot of pain and crying. Through an interpreter Resident #69 told NP #1 she had fallen on Saturday and had been in pain all Saturday night and Sunday morning. NP #1 ordered an opioid pain medication to treat the pain for the acute fracture of her tibia and fibula. Resident #69 received the first dose of opioid pain medication on 6/9/25 at 9:34 AM for a pain level of 7 which was documented as effective. This deficient practice occurred for 1 of 1 resident reviewed for pain (Resident #69). Findings included: Resident # 69 was admitted to the facility on [DATE]. Her diagnoses included cerebral infarction (stroke) and hemiplegia (paralysis) affecting the dominant right side. The quarterly Minimum Data Set Assessment (MDS) dated [DATE] revealed Resident #69 was cognitively intact. The MDS documented that she was dependent on dressing, personal hygiene, toileting, and toilet transfers. The MDS indicated she required substantial/maximal assistance with sit to stand and chair to bed transfers. It was documented on the MDS Resident #69's preferred language was Spanish, and she needed an interpreter. The MDS documented Resident #69 did not have pain. Resident #69 did not have a care plan in place for pain. An observation and interview were conducted with Resident #69 on 6/9/24 at 10:52 AM. Resident #69 was observed in her room in her bed covered with a sheet. She was noted to be grimacing. Resident #69 was asked by the surveyor dolor (pain)? Resident #69 replied see (yes) mucho (a lot) and grabbed her right leg at the knee. Resident #69 proceeded to uncover her right leg. When she uncovered her right leg Resident #69 began grimacing, crying, and moaning. A pillow was observed under her lower right leg. There was light blue/ purple colored bruising along her right shin and to the top of her right knee. Her right lower leg and knee had visible swelling present. Resident #69 said pain was mucho, diez (a lot, 10). Resident #69's roommate was in the room who was also Spanish speaking. The roommate approached Resident #69's bed while the surveyor was in the room. The roommate translated that Resident #69 stated she had fallen on Saturday in bathroom and had a lot of pain in her leg. An additional interview was conducted with Resident #69 on 6/12/25 at 2:13 PM with Physical Therapy Assistant (PTA) #1 providing translation. Resident #69 reported she fell in the bathroom when staff were assisting her off the toilet. She said she fell onto her right knee and had pain immediately, she rated the pain as 9/10. Resident #69 reported after she fell her knee had hurt with any movement and when it was at rest. She said it had felt like her knee was constantly being torn apart. A telephone interview was conducted with NA #6 on 6/10/25 at 3:35 PM. NA #6 reported that she worked the night shift (7:00 pm to 7:00 am) on Saturday 6/7/25. She said at the start of her shift around 7:00 PM she was doing rounds and Resident #69's roommate was in the doorway of their room and asked her to come into the room. The roommate told her Resident #69 was having bad pain in her right knee. NA #6 recalled Resident #69 was in bed and she looked at Resident #69's right knee and the top of her kneecap was bruised. NA #6 explained that the roommate assisted with translating for Resident #69 and she asked what had happened. NA #6 stated Resident #69 said she had fallen earlier that day in the bathroom on her knee. She stated Resident #69 was asking for something for pain. NA #6 stated the night shift nurse (Nurse #9) was outside of the door when she was talking to Resident #69 and had heard the conversation. NA #6 stated Nurse #9 told her she did not get anything in report about Resident #69 falling. NA #6 said she went and reported what Resident #69 was saying to the day shift Nursing Supervisor. She recalled the Nursing Supervisor said she did not know anything about Resident #69 falling. She said the Nursing Supervisor went to check on Resident #69. She recalled Resident #69 had pain during the night and that she reported it to Nurse #9. NA #6 said she went to Resident #69's room around 6:15 AM Sunday (6/8/25) to provide incontinent care. She reported when she changed the position of the bed and laid it flat to provide care, Resident #69 started shaking and indicated her knee was hurting. NA #6 stated Resident #69 indicated her knee was hurting by grabbing her knee, grimacing, and crying out. NA #6 stated it was shift change and she reported Resident #69 having pain to Nurse #9 and told the nurse she needed something for pain. An interview was conducted on 6/10/25 at 2:15 PM with Nurse #9. Nurse #9 recalled she went to Resident #69's room to give her nighttime medications Saturday night (6/7/25). She did not recall the time. Nurse #9 explained she asked Resident #69 if she was hurting and she did not get a response from her. She explained Resident #69 spoke Spanish and Nurse #9 stated she was not sure if Resident #69 understood or not when she had asked her about pain. Nurse #9 stated Resident #69 was not grimacing or crying and did not have any indicators of pain. Nurse #9 reported she checked on Resident #69 several times during the night and every time she checked on her Resident #69 was asleep. Nurse #9 stated Resident #69 slept the entire shift up until shift change and no one reported her having pain during the shift. A telephone interview was conducted with the day shift (7:00 am to 7:00 pm) weekend Nursing Supervisor on 6/10/25 at 11:50 AM. The Nursing Supervisor stated a Nurse Aide (NA) came and got her around shift change on Saturday (6/7/25) around 7:30 PM and asked her to check on Resident #69. She reported the NA told her Resident #69 was saying she had fallen and was having pain in her right knee. She said she could not remember the name of the NA who came and got her. The Nursing Supervisor explained she went to Resident #69's room to assess her. She said Resident #69 was in pain and said her knee was hurting when she saw her. The Nursing Supervisor said she updated the night shift nurse (Nurse #9) what was going on and then went to find the day shift nurse (Nurse #8). The Nursing Supervisor reported she asked Nurse #8 if Resident #69 had fallen during the shift and Nurse #8 reported she did not know anything about Resident #69 having a fall. She stated she updated Nurse #8 on what Resident #69 was reporting and told her what she needed to do. The Nursing Supervisor said she told Nurse #8 she needed to call the physician and the Director of Nursing (DON). The Nursing Supervisor stated she had also made the oncoming night shift nurse (Nurse #9) aware of what was going on and what Resident #69 was reporting. The Nursing Supervisor stated when she returned on Sunday there was no documentation to indicate anything had been done for Resident #69. The Nursing Supervisor said she went to assess Resident #69 on Sunday around 11:00 AM and that she was still hurting. The Nursing Supervisor stated she knew Resident #69 was in pain because she was grimacing and holding her right leg. She stated when she looked at Resident #69's knee on Sunday there was swelling and bruising to the top of her knee. The Nursing Supervisor said she talked to Nurse #10, who was Resident #69's assigned nurse on Sunday day shift and asked him if he got anything in report about Resident #69 falling. She stated she could not remember if Nurse #10 had said yes or no. The Nursing Supervisor indicated she spoke to Resident #69's Family Member on the phone on Sunday. She said the Family Member reported Resident #69 told him she had fallen and was having pain. The Nursing Supervisor explained that she contacted the on-call provider on Sunday about Resident #69's pain and the fall she reported. She stated the on-call provider ordered an x-ray of Resident #69's right leg and as needed ibuprofen for pain. The Nursing Supervisor stated she called Resident #69's Family Member back and updated him on the new orders for Resident #69. Multiple attempts were made to speak with Nurse #10. He was unavailable to be interviewed. An interview was conducted with NA #7 on 6/10/25 at 10:46 AM. She was assigned NA for Resident #69 on day shift Saturday and Sunday. She stated Resident #69 did not complain of any pain or have any indicators of pain during her shift on Saturday (6/7/25). NA #7 reported when she returned on Sunday Resident #69 was having pain. She recalled checking on Resident #69 between 8:30 am and 9:00 am on Sunday and that Resident #69 was complaining of pain in her right knee/ leg. She said Resident #69 was grimacing and grabbing her knee. NA #7 stated she told Nurse #10 Resident #69 was having pain in her right leg/ knee. NA #7 recalled Nurse #10 saying he had already given Resident #69 her morning medications and there had been Tylenol in her morning medication and that he would be there in a second. NA #7 reported Nurse #10 did go and check on Resident #69 about 15-20 minutes later. NA #7 stated she went to provide incontinent care to Resident #69 around 10:00 AM and that she could tell her knee was still hurting because of her facial expressions, she said Resident #69 was grimacing and closing her eyes. NA #7 stated Resident #69 did not cry or yell out but that she could tell she was hurting. NA #7 stated she went and told Nurse #10 that Resident #69 was still hurting and that Nurse #10 said okay. NA #7 stated she provided incontinent care to Resident #69 again after lunch and she was still having pain. NA #7 indicated she did not notice a change in Resident #69's level of pain from earlier in the shift and felt like it was about the same. She recalled Resident #69 was grabbing her right leg and grimacing, she reported she told Nurse #10 again and that Nurse #10 told her he would go check on Resident #69 and was going to talk to the Nursing Supervisor. Resident #69's June 2025 medication administration record (MAR) revealed an every shift pain assessment. On 6/7/25 Resident #69's pain was documented as a 0 by Nurse #9 for the evening shift and night shift. A telephone interview was conducted on 6/9/25 at 3:19 PM with Resident #69's Family Member. The Family Member stated they received a phone call from Resident #69 on Sunday (6/8/25). He said resident #69 was crying and said she was hurting. He reported Resident #69 said she had fallen the night before and could not sleep all night because she was in a lot of pain. The Family Member explained he called and spoke with the Nursing Supervisor on Sunday and asked about the fall, pain medication, and if an x-ray was going to be done. The Family Member said the Nursing Supervisor indicated she would call the physician. A nursing note dated 6/8/25 at 1:30 PM by the Nursing Supervisor read: [family member] called about getting an x-ray and getting something for pain at the right knee for [Resident #69]. Resident stated she is having pain in her right knee. Nurse evaluated right knee. There was inflammation at site. This nurse spoke with the on call doctor to get an order for an x-ray, that order has been called in to mobile x-ray. Nurse on cart gave as needed (PRN) for pain. Will continue to follow up. An every shift pain assessment on Resident #69's June 2025 MAR, completed by Nurse #10 documented a pain level of 10 for 6/8/25 day shift and a pain level of 0 for the evening shift. A pain level of 2 was documented for the night shift on 6/8/25 by Nurse #8. Review of Resident #69's June 2025 Medication Administration Record (MAR) revealed the following orders: - An order dated 6/2/25 that read: Acetaminophen 325 milligram (mg) give two tablets by mouth every eight hours as needed for pain for 14 days. There was no documentation of the medication being administered from 6/7/25 through 6/9/25. -An order dated 6/8/25 that read: Ibuprofen 600 mg give one tablet by mouth every six hours as needed for inflammation for 5 days. The MAR indicated the order had been entered at 2:25 PM. The MAR documented the medication as administered by Nurse #10 on 6/8/25 at 3:52 PM for a pain level of 10. The MAR further documented the medication was ineffective. The MAR documented the medication was administered again on 6/8/25 at 11:34 PM by Nurse #3 for a pain level of 6 and that the medication was effective. An x-ray report dated 6/8/25 read: There are nondisplaced fractures of the proximal tibia and fibular neck. There are no bony lesions. Degenerative changes are noted. Diffuse osteopenia is noted. The soft tissues are unremarkable. Impression: Acute proximal lower leg fractures. A telephone interview was conducted with Nurse #3 on 6/12/25 at 6:25 AM. She stated she was Resident #69's assigned nurse on Sunday (6/8/25) during night shift . Nurse #3 said she received in report from the day shift nurse, Nurse #10 that Resident #69 had a fractured knee, and she had a new order for PRN pain medication had been put in for her. It was reported to her by Nurse #10 that Resident #69 had pain earlier during his shift and he had given her pain medication. Nurse #3 recalled Resident #69's roommate came and got her during the night and let her know Resident #69 was having pain. She did not remember the time. Nurse #3 said she checked on Resident #69 and observed her having pain. Resident #69 was pointing at her right leg and she could tell she was having pain by her facial expression. Nurse #3 said she gave Resident #69 the PRN ibuprofen. Nurse #3 reported she went back and checked on Resident #69 again about an hour later and she was asleep. Nurse #3 reported she went back to Resident #69's room to administer early morning medications to her roommate and Resident #69 was still asleep. Nurse #3 said she reported to the oncoming dayshift nurse (Nurse #4) Monday morning, what was going on with Resident #69, that she had a fracture, and what Resident #69 had listed PRN for pain. An interview was conducted with Nurse #4 on 6/9/25 at 11:01 AM. Nurse #4 stated she spoke with NP #1 this morning about Resident #69's fracture and pain. She stated NP #1 ordered PRN hydrocodone/ acetaminophen (pain medication) 5/325 mg for Resident #69. Nurse #4 reported she administered the pain medication this morning around 9:30 AM to Resident #69. A pain level of 7 was documented by Nurse #4 on Resident #69's June 2025 MAR every shift pain assessment for 6/9/25 day shift. An active order dated 6/9/25 entered at 9:00 AM was present on Resident #69's June 2025 MAR that read: hydrocodone-acetaminophen (pain medication) oral tablet 5-325 mg, every 8 hours as needed for right leg fracture for 7 days. The MAR documented the medication was administered at 9:34 AM by Nurse #4 for a pain level of 7. The MAR documented the medication as being effective. An interview was conducted with NP #1 on 6/10/25 at 4:16 PM. NP #1 reported she had seen Resident #69 on Monday morning (6/9/25) and had used an interpreter during the visit to translate what was being said. She stated Resident #69 reported she had fallen on Saturday. NP #1 explained she had reviewed the x-ray results of Resident #69 right leg this morning and she had an acute fracture of her tibia and fibula. NP #1 said Resident #69 told her she was in pain when she saw her this morning. She further stated Resident #69 told her she had been in pain all Saturday night and Sunday morning. NP #1 reported Resident #69 was in a lot of pain and crying when she saw her this morning. She stated she ordered the hydrocodone PRN every eight hours for Resident #69 this morning and Nurse #4 had given her a dose. NP #1 stated she told the staff to call her if every eight hours was not enough and she would adjust the frequency so Resident #69 could have pain medication every 4 or 6 hours. NP #1 did not think PRN ibuprofen was enough to treat pain from a fracture. She explained Nurse #4 called her around 3:03 PM asking for more pain medication for Resident #69 but NP #1 said she had just spoken to someone at the facility a few minutes before Nurse #4 called confirming orders to send Resident #69 to the emergency room (ER) for evaluation. An interview was conducted with the Director of Nursing (DON), The Regional Clinical Director, and the Administrator on 6/12/25 at 4:00 PM. They said if someone was having that much pain, they would expect the staff to call the provider about her pain. .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and staff, resident, family, Physician, Medical Director, and Nurse Practitioner interviews, the facility failed to notify the Physician of radiology results for a resident who was experiencing acute pain after a reported fall on 6/7/25. Due to ineffective communication between staff x-ray results reported on 6/8/25 were not communicated to a medical provider until 6/9/25 which delayed medical interventions and an evaluation in the emergency department. Resident #69 sustained an acute proximal tibia and fibula fracture (breaks in the upper part of the shinbone (tibia) and the smaller bone of the lower leg (fibula) from the reported fall and required a two day hospitalization. Orthopedics recommended hinged knee brace with non-weight bearing status to the right lower extremity. This deficient practice occurred for 1 of 3 residents reviewed for notification of radiology results (Resident #69). Findings included: An interview was conducted on 6/12/25 at 2:13 PM with Resident #69. PTA #1 provided translation. Resident #69 stated she fell on Saturday (6/7/25) in the bathroom. She explained she fell onto her right knee and felt pain immediately. Resident #69 stated her right knee, and leg has been hurting the entire time since she fell. She said it had felt like her knee was constantly getting torn apart. Resident #69 said her knee had hurt really bad when they moved her and when she was at rest and her leg was not being moved. A telephone interview was conducted with the day shift (7:00 am to 7:00 pm) weekend Nursing Supervisor on 6/10/25 at 11:50 AM. The Nursing Supervisor stated Saturday 6/7/25 around 7:35 PM Resident #69 was in pain and said her knee was hurting. The Nursing Supervisor said Resident #69 reported she had fallen about an hour prior while she was being assisted in the bathroom by staff. The Nursing Supervisor said she went back to assess Resident #69 on Sunday around 11:00 AM and that she was still hurting. The Nursing Supervisor explained that she contacted the on-call provider on Sunday about Resident #69's pain and the fall she reported. She stated the on-call provider ordered an x-ray of Resident #69's right leg. The Nursing Supervisor said she called the mobile x-ray company and placed an order for them to come to the facility to complete the x-ray. The Nursing Supervisor could not remember what time the mobile x-ray came to the facility to complete the x-ray but stated it was sometime in the afternoon after lunch. The Nursing Supervisor reported the x-ray results came back before she left at the end of her shift. She did not remember what time the x-ray results had come back. The Nursing Supervisor stated she did not call the x-ray results to the physician. The Nursing Supervisor explained she told Nurse #10 the x-ray results and wrote the Physician's number down and gave it to him. The Nursing Supervisor stated she had also told the oncoming night shift (7:00 pm to 7:00 am) nurse (Nurse #3) the results. She said she had not told Nurse #10 or Nurse #3 to call the Physician to report the x-ray results. Nurse #10 was unavailable for interview. An x-ray report dated 6/8/25 read: There are nondisplaced fractures of the proximal tibia and fibular neck. There are no bony lesions. Degenerative changes are noted. Diffuse osteopenia is noted. The soft tissues are unremarkable. Impression: Acute proximal lower leg fractures. At the bottom of the x-ray report a statement read: the report has been successfully faxed, emailed, delivered and/or viewed by the client at [facility] at 2025-06-08 20:02:20 (8:20 PM) central time. Receipt of report was confirmed and read back was given. An interview was conducted with Nurse #3 on 6/12/25 at 6:25 AM. She was the assigned night shift nurse on Sunday 6/8/25 for Resident #69. Nurse #3 reported she received in report from Nurse #10 that Resident #69 had a fractured knee. She also spoke with the day shift Nursing Supervisor who told her they had gotten the x-ray back and knew Resident #69 had a fracture. Nurse #3 stated she knew the day shift nurses had spoken with the Physician at some point, but she did not know if it was before or after they had received the x-ray results. She reported she had not seen the x-ray report. Nurse #3 explained she came in after they had done everything and they were just telling her what had happened. Nurse #3 stated they did not ask her to do anything or tell her she needed to do anything else. An interview was conducted with Nurse #4 on 6/9/25 at 11:01 AM. She was Resident #69's assigned day shift nurse on 6/9/25. She stated she received in report from Nurse #3 that Resident #69 had a fractured knee. Nurse #4 said she notified NP #1 this morning (6/9/25). A telephone interview was conducted with the Nurse Practitioner (NP) #1 on 6/10/25 at 4:16 PM. NP #1 stated she was alerted by Nurse #4 on Monday morning (6/9/25) that she had received in report from night shift that Resident #69 had a fractured knee. She said when she reviewed the x-ray report, the report said Resident #69 had acute fractures of the tibia and fibula. NP #1 explained her company's on-call service had not been notified about Resident #69's x-ray results over the weekend. She explained that the Medical Director was part of a different physician service group and that sometimes the staff got confused and called the Medical Director's on call service. She said it was okay for staff to call the other physician service group because he was the Medical Director. NP #1 explained she had reviewed documentation for Resident #69 and could not see where a physician was notified of Resident #69's x-ray results. NP #1 said the nursing staff should have called the on-call service on Sunday when Resident #69's x-ray results returned. NP #1 reported if they had called the on-call service, with it being the weekend, they would most likely have given orders to send Resident #69 to the Emergency Department to be evaluated. NP #1 said if she had been the one who received the call over the weekend, she would have been okay waiting to see if she could get her into see an orthopedic first thing Monday morning to save her from an ER visit. She said knowing she had acute fractures she would have ordered something stronger than Ibuprofen to manage her pain. NP #1 explained this morning she had given orders for pain medication, non-weight bearing status and to try to immobilize her right leg. NP #1's company was contacted on 06/13/25 at 9:58 AM. They stated all calls were logged and there were no calls from the facility on Saturday or Sunday regarding Resident #69. A hospital Discharge summary dated [DATE] indicated Resident #69 had a mechanical fall and was admitted to the hospital on [DATE] with a right nondisplaced proximal tibia and fibula fractures. The discharge summary stated orthopedics was consulted and felt her fractures were amenable to nonoperative management. Orthopedics recommended hinged knee brace with non-weight bearing status to the right lower extremity and close outpatient follow-up with orthopedic services in two weeks. An interview was conducted with the Medical Director on 6/12/25 at 12:00 PM. He stated he did not remember the facility contacting him over the weekend but that he has had a lot of calls since then. He reviewed his calls and stated he did not have a call from the facility. The Medical Director stated he was on vacation on Sunday. He said their service tracked all the calls received. He reported he would check to see if there was a log of the facility calling over the weekend and call the Surveyor back. A return call was not received from the Medical Director. An interview was conducted with Physician #1 on 6/12/25 at 1:59 PM. He stated he was the on-call provider for the Medical Director physician service group over the weekend. He explained there was a system that tracked all the calls and that he had not been contacted about Resident #69. Physician #1 stated if he had been called about the x-ray results on Sunday, he would have sent Resident #69 to the ER. Physician #1 said he was not sure if Resident #69's fractures were displaced or non-displaced but that it did not matter, he would have sent her to the hospital for evaluation for orthopedics to see her. He explained at the ER orthopedist would be consulted and decide if Resident #60 needed surgical intervention or if the fractures could be treated with casting or immobilization. Physician #1 indicated unless the family refused there was no reason not to send Resident #69 to the hospital. An interview was conducted with the Director of Nursing (DON), Regional Clinical Director, and Administrator on 6/12/25 at 4:00 PM. The DON explained she was aware of Resident #69's x-ray results Sunday night (6/8/25). She reported the x-ray report pinged on her computer around shift change on Sunday night at 6:56 PM and she reviewed the report. The DON said she immediately forwarded the results to the Administrator and then called the facility and spoke to the day shift Nursing Supervisor at around 7:00 PM. The DON stated she had called the Nursing Supervisor to notify her and make sure she had the results as well. She reported that the Nursing Supervisor confirmed she had the x-ray results. The DON said she did not tell the Nursing Supervisor what she needed to do. The DON explained that the Nursing Supervisor was not a new nurse and she had assumed the Nursing Supervisor knew what to do and knew she needed to call the Physician. The DON said she felt it was common sense that the nurse would call the Physician about critical x-ray results. The DON explained later that night around 8:30 PM herself, the Administrator, and the Regional Clinical Director got together on a three-way call to discuss the situation. They said their conversation was more around trying to figure out what had happened. The DON explained she was hyper focused on trying to figure out the cause of the fractures because she did not know anything about the x-ray or why it had been ordered. They all agreed that the physician should have been notified of the x-ray results.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of video footage, resident and staff interviews, the facility failed to protect a resident's right to be free from physical abuse when a moderately cognitively impaired resident (Resident #3) used a closed fist and punched a severely cognitively impaired resident (Resident #4) in the face. Resident #4 fell backwards, hit her head on the floor and was sent to the emergency room for further evaluation. A computed tomography (CT) scan of the head identified a small intraventricular hemorrhage (a small amount of bleeding inside the ventricles that produce fluid to protect and cushion the brain in the skull) and a scalp hematoma (a collection of blood between the skull the scalp). Neurosurgery was consulted and considered the intraventricular hemorrhage stable, and no further treatment was required, and Resident #4 returned to the facility. Additionally, the facility failed to protect a residents' right to be free from physical abuse when Resident #3 shoved a severely cognitive impaired resident (Resident #12) causing her to fall to the floor. Resident #12 was not injured as a result of the fall. A reasonable person would experience feelings of fear, pain, and anxiety as a result of being physically abused in their home. The deficient practice occurred for 2 of 4 residents (Resident #4 and Resident #12) reviewed for abuse. Findings included: a) Resident #3 was admitted to the facility on [DATE] with diagnoses including dementia, traumatic brain injury (a disruption of normal brain activity), manic depression/bipolar disorder (a mental health condition causing extreme mood changes), unspecified impulse disorder, and seizures related to diffuse traumatic brain injury. The annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #3's speech was clear, hearing and vision were adequate, he had the ability to be understood and understand others, and his cognition was moderately impaired. No physical or other behaviors had occurred during the MDS lookback period. Resident #3 was independent with transfers and walking. Manic depression/(bipolar disease) was an active diagnosis and Resident #3 was currently taking antipsychotic and antidepressant medication. A review of Resident #3's current medication orders included valproic acid 250 milligrams (mg) give one capsule three times a day for bipolar disorder, olanzapine (antipsychotic) 5 mg give one tablet twice a day related to bipolar disorder and unspecified impulse disorder, phenytoin sodium (anticonvulsant) 100 mg extended release give 3 capsules at bedtime for seizures related to diffuse traumatic brain injury. A review of a monitoring tool document dated 3/16/25 revealed Resident #3 was being monitored every 15 minutes after he shoved Resident #12 causing her to fall. The tool was initialed by staff to indicate monitoring of Resident #3 had continued from 3/16/25 and was currently ongoing. The care plan last revised on 3/21/25 revealed Resident #3 had the potential to be verbally aggressive related to a diagnoses of traumatic brain injury, depression, neurocognitive disorder with impulse control disorder. The care plan revealed Resident #3's behaviors were triggered related to his personal belongings and personal space. Interventions included frequent observation, administer medications as ordered and monitor/document for side effects and effectiveness, analyze key times, places, circumstances, triggers, and what de-escalates behavior and document. Resident #4 was admitted to the facility on [DATE] with diagnoses including dementia, metabolic encephalopathy (impaired brain dysfunction causing increased confusion) pneumonia, and respiratory failure. A review of Resident #4's current physician orders revealed no order in place for administration of anticoagulant (increase the time it takes blood to clot) or antiplatelet (reduces the ability of the blood to form a clot) medications. The admission MDS assessment dated [DATE] revealed Resident #4's hearing was highly impaired, speech was unclear, her cognition was severely impaired and sometimes she understood. During the MDS lookback period Resident #4 had demonstrated physical behaviors directed towards others and other behaviors not directed towards others for 1 to 3 days and had rejected care 1 to 3 days. Resident #4 was independent with walking and received no anticoagulant or antiplatelet medications. Resident #4's care plan last revised on 4/14/25 identified she was at risk of falls due to poor safety awareness. Interventions included physical therapy to evaluate and treat as ordered and as needed. The care plan identified Resident #4's behaviors of yelling out, resisting care, refusing medications, impaired cognitive function and communication problems related to dementia and metabolic encephalopathy. Interventions included anticipate and meet the resident's needs, cue, reorient and supervise as needed. Be conscious when Resident #4 was in groups, activities, or the dining room to promote proper communication with others. A review of the video camera footage on 4/24/25 at 12:46 PM revealed on 4/6/25 at 6:30 PM Resident #3 was sitting in a wheelchair in the hallway approximately six feet away from the nurse station on the upper unit. Several nurse and Nurse Aide (NA) staff were around the area and Resident #3 was calm and did not attempt to hit or grab others when they passed. At 6:54 PM Resident #4 came from a room and pointed her finger at Resident #3 and continued to walk pass the nurse station towards Resident #3. As Resident #4 got closer Resident #3 used both arms to create a circular space in front of his chest. Resident #4 continued towards Resident #3 until she stood approximately two feet away facing the left side of Resident #3's wheelchair. Resident #3 extended his left arm and pointed his finger at Resident #4's face. NA #1 stood in front of the nurse station approximately five or six feet away from Resident #3 and #4 and looked up and started to walk towards them. Resident #4 leaned forward to get closer to Resident #3 and without hesitation Resident #3 extended his left arm, used his fist, and hit Resident #4 in the mouth. Resident #4's body fell backwards causing her head to hit the floor. A progress note dated on 4/6/25 at 7:41 PM written by Nurse #1 read in part, Resident #4 was standing next to Resident #3 and as staff tried to redirect Resident #3 punched Resident #4 in the mouth. Resident #4 fell backwards and hit her head on the floor. The note revealed Resident #4 had swelling and bleeding to mid lip, a bump (hematoma) on the back of the head, and a quarter size skin tear on the left elbow. A review of the emergency room report revealed on 4/7/25 a diagnostic CT scan of Resident #4's head identified a small volume, right lateral intraventricular hemorrhage, and scalp hematoma. After neurosurgery consult it was noted the brain bleed was stable and Resident #4 was safe to return to the facility. Discharge instructions recommended Resident #4 to return to the neurosurgery clinic and have a repeat CT scan in 3 to 4 weeks. A review the current physician orders revealed Resident #4's repeat CT scan was scheduled on 5/1/25 at 10:00 AM. A review of the emergency room discharge report revealed Resident #3 was evaluated on 4/6/25 for aggressive behaviors noted as punching another resident. The note revealed Resident #3 denied any physical altercation occurred. A urinalysis identified a moderate amount of leukocyte esterase (white blood cells associated with a urinary tract infection). A physician's order was included for cefuroxime (antibiotic) 500 mg give one tablet twice a day for 7 days (14 doses) to treat or prevent infection and recommended Resident #3 follow up with his primary physician. Resident #3 was discharged back to the facility on 4/7/25. A review of Resident #3's electronic Medication Administration Record (MAR) revealed the physician's order for cefuroxime 500 mg give one tablet twice a day for 7 days was scheduled to be administered at 9:00 AM and 9:00 PM. Nurses initialed the first dose was administered on 4/8/25 at 9:00 PM and continued to be administered as ordered with the last dose given on 4/15/25 at 9:00 AM (14 doses). A phone interview was conducted on 4/25/25 at 1:46 PM with NA #1. NA #1 confirmed she had worked on the upper unit from 7:00 AM through 7:00 PM on 4/6/25. NA #1 revealed she was at the nurse station giving report when she heard someone call out, grab her. NA #1 revealed when she turned around she saw Resident #3 use his fist to punch Resident #4 in the face causing Resident #4 to fall backwards onto the floor. During a phone interview on 4/24/25 at 9:27 AM Nurse #1 revealed the altercation between Resident #3 and Resident #4 occurred on the upstairs unit during shift changed around 7:00 PM on 4/6/25 when she was giving report and counting medications with the oncoming nurse. Nurse #1 described Resident #4 had walked around most of the day and was known to exhibit wandering behaviors including getting into others personal space but, meant no harm. Nurse #1 revealed Resident #3 was sitting in his wheelchair in the hallway near the nurse station and Resident #4 had walked towards him. Nurse #1 stated she heard someone yell out, get her and before anyone did Resident #3 reached up and punched Resident #4 in the mouth causing Resident #4 to fall straight back hitting her head hard on the floor. Nurse #1 revealed after the altercation she checked Resident #4 for injury and her mouth was bleeding and swollen, there was a pump knot on the back of her head, and a skin tear on the left elbow. Nurse #1 revealed Resident #4 was sent to the emergency room after the fall and Resident #3 was sent within approximately an hour afterwards for evaluation of aggressive behaviors. Nurse #1 revealed Resident #3 had a history of aggressive behaviors, but she had not witnessed him hit another resident before the altercation on 4/6/25. Nurse #1 revealed Resident #4's room was relocated to the downstairs unit and Resident #3's room remained upstairs. Nurse #1 revealed she was educated to monitor Resident #3's whereabouts and redirect other residents and keep them away. Nurse #1 described Resident #3's behaviors as impulsive and not being able to understand how to interact with other residents with dementia. During a phone interview on 4/25/25 at 11:50 AM Nurse #2 revealed the altercation between Resident #3 and Resident #4 occurred on the upstairs unit on 4/6/25 at shift change when she was getting report and counting medications with the previous shift nurse. Nurse #2 stated she heard someone tell a NA, pull Resident #4 away from Resident #3 and when she looked up saw Resident #3 punch Resident #4 in the face causing her to fall backwards onto the floor. Nurse #2 described Resident #3 usually stayed to himself, did not like anyone touching him, and mostly stayed in either his room or the main dining room. Nurse #2 revealed she had not witnessed Resident #3 do anything like that before. Nurse #2 stated she had previously received education to separate residents in attempt to prevent resident-to-resident abuse and she tried to keep other residents away from Resident #3 to ensure they were not standing over him or got close and she did not leave other residents alone with Resident #3. Nurse #2 described Resident #4 like to roam and after the altercation a sitter was placed with her to observe for behaviors or a change of condition. A review of the facility's initial 24 hour report revealed it was completed by the previous Director of Nursing (DON) and dated 4/6/25 at 7:00 PM to indicate the time the facility became aware. The details revealed a resident was wandering and got in the face of another resident and was pushed hard causing a fall. The report indicated both residents were sent to the hospital. A review of the 5-day investigation completed by the previous DON indicated Resident #4's diagnosis of dementia and Resident #3's diagnosis of traumatic brain injury and newly identified acute urinary tract infection were contributing factors that lead to their altercation and unsubstantiated the allegation. During a phone interview on 4/23/25 at 4:46 PM the previous Director of Nursing (DON) confirmed she completed the initial 24 hour report and investigation that involved Resident #3 and Resident #4. She described Resident #3 had a history of traumatic brain injury and did not like others in his space and Resident #4 had wandering behaviors and on 4/6/25 got in Resident #3's face. She had watched the video camera and saw Resident #3 use hand gestures to redirect Resident #4 to move away and when Resident #4 did not she was pushed hard and fell on her back and hit head on the ground. The DON revealed both Resident #3 and #4 were sent to the hospital after the altercation and the hospital was asked to complete a psychiatric evaluation of Resident #3 for aggressive behaviors. She revealed Resident #3 returned with antibiotic treatment for a urinary tract infection. She revealed Resident #4 had small brain bleed the hospital said would resolve without treatment and to follow up with neurosurgery. The DON revealed Resident #4 had no changes in her level of consciousness or mobility after the altercation and room changes were made to prevent future interactions with Resident #3. She revealed facility staff were already educated on what triggered Resident #3's behaviors and to watch his hand gestures, and when another resident was around to move them away. During an interview on 4/24/25 at 3:32 PM the current DON revealed she started her position on 4/12/25 and on 4/6/25 she was the Assistant DON. She revealed Resident #3's location was being monitored prior to 4/6/25 and it was expected he was within eyesight of staff when up and out of his room. She described Resident #4 ambulated without assistance, had dementia, and might not understand hand gestures made by Resident #3 and after the altercation Resident #4 was relocated to a room on the downstairs unit. During an interview on 4/24/25 at 2:32 PM and 3:57 PM the Administrator revealed Resident #3's location on the unit was being monitored every hour prior to the altercation on 4/6/25. The Administrator revealed she did not think Resident #3's reaction was willful or that he intended to hurt Resident #4 because of his diagnosis of traumatic brain injury. The Administrator revealed Resident #3's hourly monitoring of location on the unit was ongoing and he was already on psychiatric caseload and the next scheduled visit was a tele-health visit on 4/28/25. Observations and interviews of Resident #3 were conducted on 4/23/25 at 5:00 PM and 4/24/25 at 7:45 AM. Resident #3's room was located on the upper unit. He was observed in the main dining room/common area sitting in his wheelchair alone at a table or with the wheelchair placed directly in front of the television. He was calm with no signs of increased agitation. When asked if he recalled hitting someone in the face with his fist Resident #3 denied he had hit anyone. Attempts to interview Resident #4 were unsuccessful. Observations of Resident #4 were conducted on 4/23/25 at 5:21PM and 4/24/25 at 8:08 AM. Resident #4's room was located on the lower unit. She was observed to ambulate without assistance. Nurse and NA Staff were observed to provide reassurance and cues for redirection. Resident #4 was not observed to wander. b) Resident #3 was admitted to the facility on [DATE] with diagnoses including dementia, traumatic brain injury (a disruption of normal brain activity), manic depression/bipolar disorder (a mental health condition causing extreme mood changes), unspecified impulse disorder, and seizures related to diffuse traumatic brain injury. The annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #3's speech was clear, hearing and vision were adequate, he had the ability to be understood and understand others, and his cognition was moderately impaired. No physical or other behaviors had occurred during the MDS lookback period. Resident #3 was independent with transfers and walking. Manic depression/(bipolar disease) was an active diagnosis and Resident #3 was currently taking antipsychotic and antidepressant medication. The care plan last revised on 3/21/25 identified Resident #3 had the potential to be verbally aggressive related to a diagnoses of traumatic brain injury, depression, and neurocognitive disorder with impulse control disorder. The care plan revealed Resident #3's behaviors were triggered related to his personal belongings and personal space. Interventions included frequent observation, administer medications as ordered and monitor/document for side effects and effectiveness, analyze key times, places, circumstances, triggers, and what de-escalates behavior and document. A review of Resident #3's current medication orders included valproic acid 250 mg give one capsule three times a day for bipolar disorder, olanzapine 5 mg give one tablet twice a day related to bipolar disorder and unspecified impulse disorder, phenytoin sodium 100 mg extended release give 3 capsules at bedtime for seizures related to traumatic brain injury. Resident #12 was admitted to the facility on [DATE] with diagnoses including dementia and cognitive communication deficit. The quarterly MDS assessment dated [DATE] revealed Resident #12's cognition was severely impaired and had demonstrated wandering behaviors that occurred 1 to 3 days during the lookback period. The MDS revealed Resident #12 was able to walk independently without assistance and did not take anticoagulant or antiplatelet medications. Resident #12's care plan last revised on 3/16/25 identified she was an elopement risk/wanderer related to poor safety awareness. Interventions included distract from wandering by offering activities, food, identify wandering patterns and intervene as appropriate and provide structured activities. The care plan identified Resident #12's cognitive/thought process was impaired related to dementia and included interventions to anticipate needs and allow adequate time to respond. A review of the nurse progress note dated 3/16/25 at 9:15 AM revealed Resident #12 was demonstrating behaviors that included going in resident rooms and taking tables, wheelchairs, and walkers and putting them in the hallway, pacing back and forth and was unable to redirect. A review of the incident report for Resident #12 revealed on 3/16/25 in the common area located on the upper unit Resident #12 started moving Resident #3's belongings and got in his personal space and was pushed that resulted in Resident #12 falling to the ground. No injuries were observed and 1:1 monitoring was initiated to ensure Resident #12's safety and implement redirection. The previous DON completed the report. A review of Resident #12's weekly skin assessment dated [DATE] noted normal skin color that was intact with no redness or bruising. A review of the facility's initial 24 hour report revealed the facility was made aware of an allegation of resident abuse on 3/16/25 at 12:50 PM. The details of incident revealed Resident #12 touched Resident #3's face and when Resident #3 asked Resident #12 to stop Resident #12 did not and was pushed causing her to fall. The previous DON completed the report. A review of a monitoring tool dated 3/16/25 at 2:00 PM revealed staff initialed Resident #3 was being monitored every 15 minutes after shoving Resident #12 causing her to fall. The monitoring times increased to every 30 to 45 minutes to every hour and was currently ongoing. A review of the facility's 5-day investigation revealed the altercation did not result in physical injury, harm or mental anguish and the allegation was unsubstantiated. The facility indicated the root cause of the abuse was Resident #12's insomnia and being newly diagnosed with a urinary tract infection contributed to increased wandering and an invasion of others personal space. The report was completed by the previous DON and included witness statements from NA #2 and a Speech Therapist. A review of Resident #12's MAR revealed cephalexin (antibiotic) 500 mg give one tablet every 12 hours was scheduled to be administered at 9:00 AM and 9:00 PM. Nurses initialed the first dose was given on 3/18/25 at 9:00 PM and continued every 12 hours until the last dose given on 3/25/25 at 9:00 AM to equal 14 doses. Melatonin 5 mg give one tablet at bedtime for insomnia was started on 3/24/25. During a phone interview on 4/25/25 at 12:57 PM, NA #2 confirmed she wrote the witness statement involving a physical altercation between Resident #3 and Resident #12 that happened on 3/16/25. NA #2 stated she saw was Resident #12 falling to the floor but did not see Resident #3 shove or push Resident #12. NA #2 revealed she was talking with the Speech Therapist who was standing in front of her and had a better view of what happened. NA #2 revealed she moved Resident #3 away from the area and obtained Resident #12's vital signs. NA #2 revealed she had not observed Resident #3 hit or push another resident prior to the incident on 3/16/25 and stated, he usually did not bother others. NA #2 described Resident #12 walked independently and wandered and stated, we try to redirect wanderers from getting into other residents' personal space and rooms. She described Resident #12 as unable to cognitively understand to stay away from Resident #3 including if he gestured for her to go away. During a phone interview on 4/25/25 at 2:40 PM, the Speech Therapist confirmed she wrote the witness statement involving a physical altercation between Resident #3 and Resident #12. The Speech Therapist stated she would refer to what was written on her statement was correct and Resident #3 shoved Resident #12 causing her to fall. The Speech Therapist revealed after the incident nursing took over. The Speech Therapist stated she had not observed Resident #3 be aggressive towards another resident and did not recall observing a prior physical altercation between residents. During a phone interview on 4/24/25 at 5:06 PM the previous DON stated after the altercation on 3/16/25 Resident #3's location was being monitored and was ongoing every hour to protect other residents. The DON stated Resident #3 did not typically bother others unless they got in his personal space or face. The DON revealed Resident #12 was not injured and she educated staff about what triggered Resident #3's behaviors and to redirect residents when they got close and in his personal space. A Nurse Practitioner (NP) progress note dated 3/18/25 revealed the NP saw Resident #3 for an angry outburst. The NP noted Resident #3's diagnoses of bipolar, impulse disorder, and traumatic brain disorder and was taking phenytoin. The NP considered the use of phenytoin was for bipolar disorder and made no changes to Resident #3's medications. A NP progress note dated 3/24/25 revealed Resident #3 medications were reviewed. Resident #3 continued to receive divalproex sodium 250 mg three times a day for seizures and behaviors related to bipolar and was followed by psychiatry. The NP noted a neurology consult was scheduled in June and during the exam Resident #3 was calm and cooperative with no behaviors and made no changes to his medications. During an interview on 4/24/25 at 3:32 PM the current DON revealed she started her position on 4/12/25 and previously was the Assistant DON. She revealed Resident #3 typically stayed to himself or near staff. She revealed Resident #3's location was being monitored, and it was expected he was within eyesight of staff when up and out of his room. She revealed Resident #3's room was relocated after the altercation with Resident #12 to prevent further interactions between the two. During an interview on 4/24/25 at 2:32 PM and 3:57 PM the Administrator revealed staff continued to monitor Resident #3's location on the unit every hour. The Administrator revealed she did not think Resident #3's actions were willful because of his diagnosis of traumatic brain injury and his room was relocated downstairs to separate him from Resident #12. The Administrator revealed Resident #3 was already on psychiatric caseload and the next scheduled visit was a tele-health visit on 4/28/25. Attempts to interview Resident #12 were unsuccessful. An observations of Resident #12 on 4/24/25 at 8:16 AM revealed her room was located on the lower unit. Resident #12 was asleep in bed and not observed to wander on the unit.