**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, photographic evidence review, and staff, Law Enforcement Officer, Wound Nurse Practitioner, and Medical Doctor interviews, the facility failed to protect a vulnerable resident's right to be free from physical restraints when Resident #1 was found with socks placed on each hand and held in place by rubber bands wrapped around each wrist for 1 of 3 residents reviewed for restraints (Resident #1). On 01/27/25 at approximately 12:00 AM, Resident #1 was observed with socks covering each hand that were secured with rubber bands wrapped around each wrist, effectively forming tourniquets (device often used in emergency situations to apply pressure to a limb or extremity to stop blood flow) on her wrists, but not in a controlled manner. Her hands appeared larger than normal through the socks and the rubber bands had to be cut in order to remove the socks from Resident #1's hands. Resident #1's right hand was edematous (abnormally swollen due to an accumulation of fluid in the bodies tissues) and bright red in appearance. There were several blisters on the top of the hand, a large fluid filled blister in the palm of the hand with some drainage and a red ligature (visible indentation left on the skin) mark around the right wrist. Resident #1 was evaluated by the Wound NP on 01/27/25 who noted the blister on the palm of Resident #1's right hand measured 17 centimeters (cm) by 20 cm by 0 cm and ordered wound treatment to be applied daily. The reasonable person concept was applied to this deficiency as a reasonable person would not expect to have socks placed on their hands preventing them from freely moving their fingers or using their hands and would experience pain from rubber bands wrapped tightly around their wrists to hold the socks in place. Findings included: Resident #1 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease, dementia and multiple sclerosis (a chronic disease that affects the central nervous system). The quarterly Minimum Data Set (MDS) assessment dated [DATE] assessed Resident #1 with severe impairment in cognition. She required total staff assistance for all self-care tasks, mobility and transfers. She had no impairment in her upper or lower extremities and displayed no behaviors or rejection of care. The MDS noted Resident #1 weighed 97 pounds, had no unhealed pressure ulcers or other skin conditions, received hospice care, and used no restraints. A care plan last revised on 11/14/24 revealed Resident #1 had a behavior problem of coprophagy (eating feces). Interventions included for staff to intervene as necessary, divert attention, monitor and provide hygiene care as needed. The care plan did not include any intervention to apply socks and/or rubber bands to her hands. Review of the physician orders for Resident #1 revealed no order for restraints or the application of socks or rubber binding to her hands and/or wrists. A Situation, Background, Assessment and Response (SBAR) summary note written by Nurse #1 on 01/27/25 at 12:30 AM revealed in part, Resident #1 had socks on both hands for protection from scratching and digging. The socks were removed to assess the skin and Resident #1's hands were swollen with serum (clear, watery liquid) blisters to the right hand. The on-call provider and Director of Nursing (DON) were notified. A telephone interview was conducted with Nurse #1 on 01/29/25 at 1:48 PM. Nurse #1 revealed she was employed by the facility and verified she was assigned to provide Resident #1's care on Sunday 01/26/25 to Monday 01/27/25 during the hours of 11:00 PM to 7:00 AM. Nurse #1 recalled around 12:30 AM, Nurse Aide (NA) #1 came to let her know that Resident #1 was found with socks on her hands, rubber bands around her wrists and her hands were swollen. Nurse #1 stated she immediately went to assess Resident #1, NA #1 had already removed the sock and rubber bands off Resident #1's right hand and Nurse #1 stated she cut the sock and rubber bands off Resident #1's left hand. Nurse #1 recalled Resident #1's right hand was swollen, blistered and red and her left hand was swollen but not blistered. Nurse #1 notified the DON, called the on-call provider and while waiting for a return phone call from the on-call provider, she went ahead and provided treatment to Resident #1's right hand. Nurse #1 stated she looked through Resident #1's medical records and did not see any physician orders for socks to be placed on her hands and there was no intervention in her care plan either. Nurse #1 explained Resident #1 would play in her feces on occasion and she could only assume that was why someone had placed the socks and rubber bands on her hands; however, that was not an intervention the facility typically used. She did not know who applied the socks or rubber bands on Resident #1's hands or how long they had been in place. Nurse #1 stated during her assessment, Resident #1 did not display signs or symptoms of pain as she had just received her scheduled morphine (pain medication) earlier that evening. Nurse #1 stated no one had mentioned anything to her about the socks and rubber bands observed on Resident #1's hands until it was brought to her attention by NA #1. A telephone interview was conducted with Nurse Aide (NA) #1 on 01/29/25 at 1:21 PM. NA #1 revealed she was employed by the facility and verified she was assigned to provide Resident #1's care on Sunday 01/26/25 to Monday 01/27/25 during the hours of 11:00 PM to 7:00 AM. NA #1 recalled she was doing her initial incontinence rounds when she first went in to check on Resident #1 around 12:00 AM. When she went into Resident #1's room and pulled back the covers she observed socks on both of Resident #1's hands that were being held in place by rubber bands. NA #1 stated she thought the rubber bands had been wrapped around Resident #1's wrists at least twice. She stated she could tell Resident #1's hands were swollen even with the socks on because her hands were pressed tightly against the socks and looked much bigger than they should have been. She explained Resident #1's hands were so large, she was not able to pull the socks or rubber bands off and had to cut them in order to remove them from Resident #1's hands. NA #1 stated she started with the right hand and once the sock was removed, she immediately noticed Resident #1's right hand was very swollen, the skin of her hand and wrist was bright red in appearance and there were red marks around her wrist where the rubber bands had been that started to bruise. Resident #1 also had several blisters on top of the right hand and a large blister covering the palm of her right hand that were leaking. NA #1 stated she immediately informed Nurse #1 and when Nurse #1 came to the room to assess Resident #1 she instructed NA #1 to cut the rubber bands and sock off the left hand. NA #1 recalled Resident #1's left hand was also swollen but less red in appearance with no blisters that she recalled and there were red marks around Resident #1's left wrist where the rubber bands had been. NA #1 was not sure who put the socks and rubber bands on Resident #1's hands but recalled staff mentioning in the past that Resident #1 messed with her feces; however, NA #1 had never witnessed Resident #1 display that type of behavior. NA #1 stated if Resident #1 had messed in her feces when she provided her care, she would have just cleaned her up and would never have placed socks and/or rubber bands on her hands to deter the behavior because it would be considered a restraint. A Wound Nurse Practitioner (NP) progress note dated 01/27/25 revealed in part, Resident #1 was seen for a new skin and wound consult. The Wound NP noted facility staff reported Resident #1 had a new blister on the right hand that was caused by socks being secured on her hands. The Wound NP's assessment revealed Resident #1 had a new nonthermal (raised, fluid-filled pocket on the skin that is not caused by heat or burns) blister on the right hand with partial thickness (forms on the skin between the top and middle layer of skin) and measured 17 cm by 20 cm by 0 cm. The periwound (area of skin surrounding the blister) was noted as fragile with erythema (redness of the skin) and edema (swelling). The Wound NP provided recommendations for wound treatment, to notify the Wound NP or provider when the blisters ruptured and become an open wound and to not place/secure socks or any dressing/covering tightly on Resident #1's hand or anywhere on the extremities that could restrict blood flow. A telephone interview was conducted with the Wound NP on 01/30/25 at 3:31 PM. The Wound NP stated when he evaluated Resident #1 on 01/27/25, she had multiple fluid-filled blisters on the dorsal (part of the hand where the knuckles are located) side of the hand and a large blister on the palm of her hand. He stated from what the blisters looked like when he evaluated Resident #1, the damage from the blisters seemed superficial and he left the blisters intact to let them heal naturally. The Wound NP stated the binding used on Resident #1's wrists to keep the socks on her hands was what caused the blisters and swelling. A Medical Doctor (MD) progress note dated 01/27/25 read in part, Resident #1 was seen to evaluate blisters on her right hand. The MD noted socks were placed on both hands, secured with rubber bands, to prevent Resident #1 from scratching certain parts of her body which sometimes gathered fecal matter and the right rubber band was much tighter than the left and it was unclear exactly how long the rubber bands had been on Resident #1's wrists. When the socks were removed, there was an extensive amount of blisters noted to the right hand. The MD assessment revealed Resident #1's right hand had large, raised blisters on the [NAME] (palm) surface and dorsal surface that did not look indurated (hardening and thickening of the skin) and there was no black eschar (dead tissue) or skin discoloration. Resident #1 had good distal vascularity (blood flow in the extremities) and was moving all fingers without difficulty. There was some non-pitting edema noted around the wrist area and the rubber band mark just below the wrist was barely noticeable. The MD cleaned the blisters with alcohol, used a sterile needle to puncture the blisters and clear serous (watery) fluid drained from the blisters. A topical antibiotic cream and gauze dressing was applied to Resident #1's right hand. Resident #1's left hand had a small blister measuring one (1) cm along the thenar eminence (area of the palm at the base of the thumb) with no discoloration or induration noted. Resident #1 was able to move all the fingers of the left hand without difficulty and had good distal vascularity. The blister was drained using a sterile needle and dressing applied. During an interview on 01/29/25 at 4:20 PM and follow-up telephone interview on 01/29/25 at 5:33 PM, the MD stated when he assessed Resident #1 on 01/27/25 she had fluid-filled blisters on the top of the right hand and a large blister on the palm of the right hand that appeared superficial with no black eschar or signs of infection. When he cleansed and punctured the blisters there was no tinge of blood in the serous fluid drainage. He stated Resident #1 had good range of motion in her fingers, good capillary refill (clinical test that assesses the speed of blood flow through the capillaries) and no arterial compromise (condition that occurs when blood flow to an area of body is reduced or blocked) when he checked her wrist pulse. The MD stated when he evaluated Resident #1 again on 01/28/25, she had no blister reformation or skin infection and she still had a very good pulse and was moving her fingers. He stated it was going to take some time but her injuries were improving. He explained the rubber bands placed on Resident #1's wrist did not decrease blood flow as circulation was there but the rubber bands did decrease the venous flow (movement of blood from the hand back to the heart) which backed up into the lymphatic flow (extra fluid that drains from cells and tissues in the body that isn't reabsorbed into the capillaries) causing the blisters. The MD expressed it was difficult to determine how long the socks and rubber bands had been in place on Resident #1's hands and wrists; however, without the binding (referring to the rubber bands) around Resident #1's wrists, there would have been no blisters. During an interview on 01/29/25 at 11:50 AM, the investigating Law Enforcement Officer revealed in addition to law enforcement he also had an extensive medical background that included Medical Examiner and forensic pathology. The Law Enforcement Officer stated he observed Resident #1's hands on 01/27/25 and 01/28/25 and took photos of the injuries. The Law Enforcement Officer stated when he observed Resident #1's hands on 01/27/25, her right hand was wrapped in a gauze dressing. Her right hand was almost degloved (type of traumatic injury that involves the skin and soft tissue being torn away from the muscle and connective tissue underneath) and there were red ligature marks on both the right and left wrists. In addition, Resident #1 had a raised blister on the palm of the right hand that he estimated to contain 50 cc (cubic centimeters) of fluid. On 01/28/25, when he observed Resident #1's right hand again with the gauze dressing removed, the MD had already decompressed the blisters. Her right hand and wrist were red and swollen from the wrist to the fingers which he felt was suggestive of cellulitis (bacterial infection of the skin) and there were long strands of skin hanging off the palm. There were no blisters or significant swelling on her left hand but she did have a red ligature mark around her wrist. The Law Enforcement Officer stated he was informed by the facility that rubber bands had been placed around her wrists to hold the socks in place on her hands. The Law Enforcement Officer stated he was currently conducting an investigation. Photographs taken of Resident #1's hands and wrists received via email correspondence dated 01/28/25 from the investigating Law Enforcement Officer were reviewed. In the first three photographs taken on 01/27/25, Resident #1's hand was covered in a gauze dressing and when the dressing was pulled back, the index finger was outside of the dressing and appeared swollen. The middle and ring fingers were bent inside the gauze dressing and you could partially visualize a raised fluid-filled blister starting at the base of the middle and ring fingers leading down the top of the hand. When the dressing was moved to visualize the wrist, the skin was red with a blister and indentation mark on the inside of the wrist where the rubber bands had been. The remaining pictures taken on 01/28/25, revealed the skin on Resident #1's right hand was red from the wrist to the fingers and there was peeling skin on the top and palm. Her left hand and palm had minimal redness with no blisters and a red mark on the wrist. During a follow-up interview on 01/29/25 at 4:09 PM, the investigating Law Enforcement Officer stated he spoke with NA #1. NA #1 sent him photographs she took on 01/27/25 of the socks and rubber bands on Resident #1's hands and wrists. He stated the pictures clearly showed Resident #1's wrists had two rubber bands bound tightly around her wrists. Photographs of Resident #1's hands and wrists that were taken by NA #1 on 01/27/25 and received via email correspondence on 01/29/25 from the investigating Law Enforcement Officer were reviewed. There were three photographs in total. In the first photograph, both of Resident #1's hands were covered in grayish/tan gripper socks. The left hand was more prominent in the photograph and showed two rubber bands, approximately 1/8 of an inch in width, wrapped around the wrist twice and her hand above the wrist appeared 2 to 3 times its normal size in the sock. Her chin was resting on the right hand and the rubber bands were not visible but you could visualize how large her hand appeared in the sock. In the second photograph, the sock and rubber bands had been removed from the right hand and her palm was facing upward. There were red ligature marks on the lower part of the inside of her wrist. The skin on her wrist, hand and fingers were visibly swollen and bright red in appearance. There was a large, raised fluid-filled blister from the edge of the palm to the bend of her fingers that covered the width of the palm. The sock was still on her left hand and you could visualize a rubber band, approximately 1/8 of an inch in width, bound twice around her wrist. In the third photograph, was a left sided view of Resident #1's right hand that was facing upward and tilted slightly. There was a purple colored, bruised area on the outer wrist along the red ligature mark. The skin from the wrist to the fingers were bright red and swollen 2 to 3 times its normal size, resembling a lobster claw. Just underneath the outer edge of the top of the hand were two raised fluid-filled blisters at the base of the hand and a fluid-filled blister at the bend of the ringer finger to the knuckle. A telephone interview was conducted with Nurse #2 on 01/29/25 at 4:59 PM. Nurse #2 revealed she was employed by a staffing agency and verified she was assigned to provide Resident #1's care on Friday 01/24/25 during the hours of 7:00 AM to 3:00 PM. Nurse #2 did not recall noticing socks or rubber bands on Resident #1's hands or wrists. A telephone interview was conducted with NA #2 on 01/29/25 at 12:10 PM. NA #2 revealed she was employed by a staffing agency and verified she was assigned to provide Resident #1's care on Friday 01/24/25, Saturday 01/25/25 and Sunday 01/26/25 during the hours of 7:00 AM to 3:00 PM. NA #2 stated she could not honestly recall noticing if Resident #1 had socks or rubber bands on her hands or wrists on 01/24/25 but she did notice the socks on Resident #1's hands when she started her shifts on 01/25/25 and 01/26/25. She explained the socks were placed neatly around Resident #1's hands and she left them on her hands thinking they had been put there by the previous shift as an intervention to keep her from messing in her feces. When asked what she meant by the socks being neatly placed on Resident #1's hands, she stated the socks were pulled down to the tips of the fingers and covered her hand but did not recall them appearing to be tight. NA #2 stated she did not recall noticing any rubber bands around Resident #1's wrists holding the socks in place and felt she would have seen them if they had been there. NA #1 expressed that it was possible the rubber bands could have been folded up in the socks and she just didn't notice. A telephone interview was conducted with NA #3 on 01/30/25 at 2:42 PM. NA #3 revealed she was employed by a staffing agency and verified she was assigned to provide Resident #1's care on Friday 01/24/25 to Saturday 01/25/25 during the hours of 4:30 PM (she arrived late to work) to 7:00 AM and again on Sunday 01/26/25 during the hours of 3:00 PM to 11:00 PM. NA #3 recalled on 1/24/25 she was assigned to the left side of 500 Hall (side where Resident #1 resided) and NA #4 was assigned to right side of 500 Hall. NA #3 recalled on 01/24/25 Resident #1 was observed eating her feces after an incontinence episode. She could not remember the exact time but stated at one point during the shift, NA #4 had assisted her with cleaning up Resident #1. NA #3 recalled Resident #1 had socks on her hands that were removed and after care was provided, NA #4 placed new socks back on Resident #1's hands. At that point, NA #3 stated she went to assist Resident #1's roommate while NA #4 left the room. When NA #4 returned, she noticed he had rubber bands in his hands and he went around the privacy curtain to Resident #1. NA #3 stated she did not see NA #4 place the rubber bands around Resident #1's wrists but knew that he had because the rubber bands were on Resident #1's wrists when she checked on her again later in the shift. NA #3 explained she thought that was strange when NA #4 put the socks on Resident #1's hands but he told her that's just what they do and she just assumed that was facility protocol to try and keep Resident #1 from messing in her feces. NA #3 stated she knew that the use of the socks and/or rubber bands on Resident #1's hands were considered a restraint and she didn't question NA #4 further because he was sort of training her and seemed to know the residents well. NA #3 stated she honestly did not think the socks or rubber bands would harm Resident #1 and didn't think much about it the remainder of the shift because it was a busy night. NA #3 recalled when she started her shift on 01/26/25, Resident #1 still had the same socks on both her hands along with the rubber bands around her wrists that were put on 01/24/25 by NA #4. NA #3 could not recall how the socks looked when she started her shift on 01/26/25 or how Resident #1's hands and wrists appeared with the socks in place. NA #3 explained she really wasn't paying attention to how Resident #1's hands presented on 01/26/25 because most of the shift Resident #1 was sleeping on her hands or her hands were under the cover and she couldn't say for sure whether Resident #1's hands appeared larger than normal or swollen. NA #3 restated she knew for a fact that the socks and rubber bands were placed on Resident #1's hands by NA #4 01/24/25 and indicated everyone who worked with Resident #1 since that date would have seen the socks and rubber bands but they all dropped the ball, herself included. A telephone interview was conducted with NA #4 on 01/31/25 at 1:59 PM. NA #4 revealed he was employed by a staffing agency and verified he worked on Friday 01/24/25 during the hours of 3:00 PM to 11:00 PM on Resident #1's hall with NA #3. He explained NA #3 was assigned to provide care to the residents on the left side of 500 Hall where Resident #1 resided and he was assigned to provide care to the residents on the right side of the hall. NA #4 stated it was sometime after supper between 7:00 PM and 8:00 PM when he went to assist NA #3 with cleaning up Resident #1 after she had an incontinence episode. NA #4 recalled when he and NA #3 went into Resident #1's room he noticed that she was eating her feces and she had feces all over her body, mouth and inside of her mouth. NA #4 stated he did not notice Resident #1 with any socks or rubber bands on her hands or wrists when he used facility wipes to clean her hands, fingers and nails and he did not put any socks or rubber bands on her hands when he was done. NA #4 stated after cleaning Resident #1's hands, he assisted NA #3 with giving Resident #1 a bed bath, changed the bed linens and then he left the room. He stated he did not go back in Resident #1's room the remainder of the shift. NA #4 stated he knew people were aware that Resident #1 would eat her feces on occasion because when he started at the facility approximately a year ago, he had noticed her with socks on her hands and when he asked staff about it they told him the socks were placed on her hands to keep her from messing in her feces and/or eating her feces. When NA #4 was asked who had told him that information, he could not recall the names and stated they were agency staff. NA #4 explained anytime he had an assigned residents that would dig in their briefs, he just cleaned them up, usually gave them a shower or bed bath, and never put socks or rubber bands on their hands. NA #4 restated he did not observe or place any socks and rubber bands on Resident #1's hands and wrists when he assisted NA #3 on 01/24/25 and was not sure who did. During a follow-up telephone interview on 02/05/25 at 3:01 PM, the investigating Law Enforcement Officer stated he had received a text message from NA #3 that she had sent to NA #4 prior to the Law Enforcement Officer's interview with NA #3 on 01/30/25. A summarization of the text message revealed NA #3 informed NA #4 that everyone thought she had placed the rubber bands and socks on Resident #1's hands and she would not take the fall for him over something he did. A telephone interview was conducted with Nurse #3 on 01/30/25 at 3:04 PM. Nurse #3 revealed she was employed by the facility and verified she was assigned to provide care to Resident #1 on Saturday 01/25/25 and Sunday 01/26/25 during the hours of 7:00 AM to 7:00 PM. Nurse #3 stated on 01/25/25, Resident #1 was in bed most of the day covered with a blanket and she didn't recall noticing Resident #1's hands. On 01/26/25, Nurse #3 stated she saw the socks on both of Resident #1's hands but did not see any rubber bands. She stated she did not remove the socks from Resident #1's hands to observe the skin and explained the socks did not seem tight or swollen and there was no redness to her arms that she recalled. Nurse #3 stated she didn't question why the socks were placed on Resident #1's hands because she knew that Resident #1 would play in and eat her feces and no one had brought any concerns regarding the socks to her attention. A telephone interview was conducted with NA #5 on 01/30/25 at 10:08 AM. NA #5 revealed she was employed by the facility and verified she worked on Saturday 01/25/25 during the hours of 7:00 AM to 3:00 PM on Resident #1's hall with NA #2. She explained NA #2 was assigned to provide care to the residents on the left side of 500 Hall where Resident #1 resided and she was assigned to provide care to the residents on the right side of the hall. NA #5 recalled sometime right after lunch, NA #2 asked her to pull Resident #1 up in bed and when she did, she noticed Resident #1 had socks on each hand with one rubber band around each wrist that was holding the socks in place. NA #5 stated she did not notice anything unusual about how her hands looked with the socks on nor did she recall noticing any signs of swelling or redness on the visible skin. NA #5 expressed she did not question why Resident #1 had socks and rubber bands on her hands, did not remove them and just assumed the socks were put on for a reason. A telephone interview was conducted with NA #6 on 01/30/25 at 11:32 AM. NA #6 revealed she was employed by a staffing agency and verified she was assigned to provide care to Resident #1 on Saturday 01/25/25 to Sunday 01/26/25 during the hours of 3:00 PM to 7:00 AM. NA #6 recalled when she started her shift on 01/25/25, Resident #1 had had socks on her hands with one (1) rubber band wrapped around each wrist holding the socks in place. She explained the rubber bands were slid over the wrist, not wrapped twice or tight, and described it like someone who would put a hair tie on their wrist loosely in case they wanted to pull their hair up. NA #6 stated usually the nurses were the only ones that had rubber bands and she just assumed the nurses had put the socks and rubber bands on Resident #1's hands and wrists for a particular reason and didn't ask anyone about it. NA #6 stated she assumed it was standard protocol because she was told that Resident #1 liked to dig in her bottom and play with/eat her fecal matter. NA #6 revealed she also worked on Sunday 01/26/25 to Monday 01/27/25 during the hours of 11:00 PM to 7:00 AM and had gone into the room with NA #1 to check on Resident #1. NA #6 recalled there were rubber bands wrapped around Resident #1's wrist multiple times to hold the socks in place and even with the socks on her hands, you could see that Resident #1's hands were huge. NA #6 stated NA #1 had to cut the rubber bands off of Resident #1's wrist and she had blisters on her hands that had leaked through the socks onto the bed linens. NA #6 stated NA #1 immediately informed Nurse #1 who came and assessed Resident #1. NA #6 restated she did not question or ask why Resident #1 had socks and rubber bands on her hands and wrists on 01/25/25 and was not sure who put them on Resident #1's hands. Unsuccessful telephone attempts were made on 01/29/25 at 1:12 PM and 01/31/25 at 10:18 PM for an interview with Nurse #4 who was employed by a staffing agency and was assigned to provide Resident #1's care on Saturday 01/25/25 during the hours of 7:00 PM to 7:00 AM. During interviews on 01/29/25 at 3:42 PM and 01/30/25 at 9:40 AM, the Director of Nursing (DON) revealed she received a call from Nurse #1 on 01/27/25 around 1:15 AM informing her that she (Nurse #1) had observed socks on both of Resident #1's hands with rubber bands placed tightly around her wrists, both hands were swollen and the right hand had blisters. The DON recalled when she arrived at the facility around 1:35 AM, Nurse #1 had already provided wound care and bandaged Resident #1's hand. When the DON removed the bandages from Resident #1's hand, both hands were pink and swollen and the right hand had several blisters on the top part of the hand and one large blister covering the palm of the right hand. The DON stated during the assessment, she did not notice any indentation from the rubber bands on Resident #1's wrists due to all the swelling and Resident #1 did not display any signs or symptoms of discomfort or pain. The DON stated she called the Administrator to inform him of the incident and then started an investigation. She stated Resident #1 was evaluated by the MD 01/27/25, he started Resident #1 on an antibiotic prophylactically (treatment taken to prevent or protect against infection) and provided orders for wound treatment twice a day. The DON recalled the MD stating based on the extent of Resident #1's injuries, the rubber bands had been on her wrists for less than 7 hours and if they had been in place any longer, there would have been more cell death. She stated when she spoke with Resident #1's Responsible Party (RP) on 01/27/25 to inform the RP of what had occurred, the RP reported being aware that socks were being put on Resident #1's hands because she played with her feces and was ok with them being used. She explained to Resident #1's RP that type of intervention was not something the facility would use as it was considered a restraint. The DON verified socks placed on the hands and secured with rubber bands was never an appropriate intervention to use on any resident and facility hired and agency staff were informed during orientation that restraints were not something the facility used. During an interview on 01/30/25 at 4:44 PM, the Administrator recalled he woke up around 5:30 AM on 01/27/25 and noticed he had missed a call from the DON. He called the DON and she informed him of the incident involving Resident #1. When asked what he was told by the DON, he stated at that point she was describing the aftermath, basically the extent of Resident #1's injuries. The Administrator stated when he arrived at the facility and observed Resident #1's hands, she still had a good deal of swelling in the right hand and the right hand was red and blistered. Resident #1's left hand was a little less red and swollen with no blisters. The Administrator stated when they started their investigation, they initially thought the rubber bands were placed on Resident #1's wrists on Sunday 01/26/25 during second shift (3:00 PM to 11:00 PM); however, they were learning new details about when the rubber bands were actually placed on her wrists. He stated staff had been trained there was a zero tolerance for abuse and neglect that included the use of restraints. He indicated they were still in the process of conducting an investigation and had not yet been able to narrow it down to a specific individual or how long the socks and rubber bands had been in place on Resident #1's hands. The Administrator, DON and Regional Director of Operations were notified of Immediate Jeopardy on 01/29/25 at 6:00 PM. The facility provided the following Credible Allegation of Immediate Jeopardy removal: Address how corrective actions will be accomplished for those residents who have been affected by the deficient practice: On 1/27/2025, Resident #1 was observed with a sock on each hand. A binding had been placed around each wrist to hold the socks in place. The facility failed to comply with its abuse and restraint policies and did not protect a resident with severe cognitive impairment from abuse through the use of restraints. On 01/27/2025, a nurse aide removed the band and sock from one hand, and the licensed nurse removed the sock and band from resident #1's oth[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, photographic evidence review and staff interviews, the facility failed to implement their abuse policy and procedure when nursing staff failed to identify and immediately report the use of a physical restraint for a resident with no medical symptoms along with no assessment for the need for a physical restraint. Staff reported observing socks placed on Resident #1's hands held in place by rubber bands wrapped around each wrist on 01/24/25 without immediately reporting to the Administrator. On 01/27/25 at approximately 12:00 AM, Resident #1 was observed with socks covering each hand that were secured with rubber bands wrapped around each wrist, effectively forming tourniquets (device often used in emergency situations to apply pressure to a limb or extremity to stop blood flow) on her wrists, but not in a controlled manner. Her hands appeared larger than normal through the socks and the rubber bands had to be cut in order to remove the socks from Resident #1's hands. Resident #1's right hand was edematous (abnormally swollen due to an accumulation of fluid in the bodies tissues) and bright red in appearance. There were several blisters on the top of the hand, a large fluid filled blister in the palm of the hand with some drainage and a red ligature (visible indentation left on the skin) mark around the right wrist. Resident #1 was evaluated by the Wound NP on 01/27/25 who noted the blister on the palm of Resident #1's right hand measured 17 centimeters (cm) by 20 cm by 0 cm and ordered wound treatment to be applied daily. This was for 1 of 3 residents reviewed for abuse and restraints (Resident #1). Findings included: The facility's policy titled, Abuse and Neglect Protocol dated 06/13/21, revealed a policy statement that read in part, Our residents have the right to be free from abuse, neglect, misappropriation, exploitation, corporal punishment, physical or chemical restraints imposed for purposes of discipline or convenience and not required to treat the resident's medical symptoms, and involuntary seclusion. All reports of resident abuse, neglect and injuries of unknown source shall be promptly and thoroughly investigated by facility management. The policy interpretation and implementation section revealed in part, that any staff member or person affiliated with this facility who witnessed or believed a resident had been a victim of mistreatment, abuse, neglect, or any other criminal offense shall immediately report the mistreatment or offense to the Administrator or Director of Nursing Services. Resident #1 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease, dementia and multiple sclerosis (a chronic disease that affects the nervous system). A telephone interview was conducted with Nurse Aide (NA) #2 on 01/29/25 at 12:10 PM. NA #2 revealed she was employed by a staffing agency and verified she was assigned to provide Resident #1's care on 01/24/25, 01/25/25 and 01/26/25 during the hours of 7:00 AM to 3:00 PM. NA #2 stated she could not honestly recall noticing if Resident #1 had socks or rubber bands on her hands or wrists on 01/24/25; however, she did notice the socks but no rubber bands on Resident #1's hands when she started her shifts on 01/25/25 and 01/26/25. She explained she left the socks on Resident #1's hands thinking they had been put there by the previous shift as an intervention to keep her from messing in her feces. NA #2 verified she did not ask anyone why Resident #1 had socks on her hands nor did she report it to anyone. She stated if she had known the socks should not have been on Resident #1's hands she would have told someone. NA #2 confirmed she had received inservice education on the facility's abuse and neglect policy and restraints and was instructed to immediately report any concerns to the Nurse Supervisor, DON or Administrator. A telephone interview was conducted with NA #3 on 01/30/25 at 2:42 PM. NA #3 revealed she was employed by a staffing agency and verified she was assigned to provide Resident #1's care on 01/24/25 to 01/25/25 during the hours of 4:30 PM (she arrived late to work) to 7:00 AM and again on 01/26/25 during the hours of 3:00 PM to 11:00 PM. NA #3 recalled on 1/24/25 Resident #1 had an incontinence episode and NA #4 had assisted her with cleaning up Resident #1. NA #3 stated Resident #1 had socks on her hands that were removed and after care was provided, NA #4 placed new socks back on Resident #1's hands. At that point, NA #3 stated she went to assist Resident #1's roommate while NA #4 left the room. When NA #4 returned, she noticed he had rubber bands in his hands and he went around the privacy curtain to Resident #1. NA #3 stated she did not see NA #4 place the rubber bands around Resident #1's wrists but knew that he had because the rubber bands were on Resident #1's wrists when she checked on her again later in the shift. NA #3 explained that when NA #4 put the socks on Resident #1's hands, she thought that was strange but NA #4 told her that's just what they do and she just assumed that was facility protocol to try and keep Resident #1 from messing in her feces. NA #3 confirmed she had received inservice training on abuse and restraints and was instructed to immediately report any concerns to administration. She stated she knew that the use of the socks and rubber bands on Resident #1's hands were considered a restraint and she didn't report it to anyone or question NA #4 further because he was sort of training her and seemed to know the residents well. NA #3 recalled when she started her shift on 01/26/25, Resident #1 still had the same socks on both her hands along with the rubber bands around her wrists that were put on 01/24/25 by NA #4. NA #3 could not recall how the socks looked when she started her shift on 01/26/25 or how Resident #1's hands and wrists appeared with the socks in place. NA #3 restated she knew for a fact that the socks and rubber bands were placed on Resident #1's hands by NA #4 on 01/24/25 and everyone who worked with Resident #1 since that date would have seen the socks and rubber bands but they all dropped the ball, herself included. A telephone interview was conducted with NA #5 on 01/30/25 at 10:08 AM. NA #5 revealed she was employed by the facility and verified she worked on 01/25/25 during the hours of 7:00 AM to 3:00 PM on Resident #1's hall with NA #2. NA #5 recalled on 01/25/25 sometime right after lunch, NA #2 asked her to pull Resident #1 up in bed and when she did, she noticed Resident #1 had socks on each hand with one rubber band around each wrist that was holding the socks in place. NA #5 stated she did not notice anything unusual about how her hands looked with the socks on nor did she recall noticing any signs of swelling or redness on the visible skin. NA #5 expressed she did not question why Resident #1 had socks and rubber bands on her hands or report it to anyone. She stated she did not remove them and just assumed the socks were put on for a reason. NA #2 confirmed she had received inservice education on the facility's abuse and neglect policy and restraints and was instructed to immediately report any concerns to the Administrator. A telephone interview was conducted with NA #6 on 01/30/25 at 11:32 AM. NA #6 revealed she was employed by a staffing agency and verified she was assigned to provide care to Resident #1 on 01/25/25 to 01/26/25 during the hours of 3:00 PM to 7:00 AM. NA #6 recalled when she started her shift on 01/25/25, Resident #1 had had socks on her hands with one (1) rubber band wrapped around each wrist holding the socks in place. She explained the rubber bands were slid over the wrist, not wrapped twice or tight, and described it like someone who would put a hair tie on their wrist loosely in case they wanted to pull their hair up. NA #6 stated usually the nurses were the only ones that had rubber bands and she just assumed the nurses had put the socks and rubber bands on Resident #1's hands and wrists for a particular reason and didn't ask anyone about it. NA #6 stated she assumed it was standard protocol because she was told that Resident #1 liked to dig in her bottom and play with/eat her fecal matter but realizes she should have told someone. She confirmed she had received inservice education on the facility's abuse and neglect policy and restraints and was instructed to immediately report any concerns to the Administrator. NA #6 restated she did not ask anyone why Resident #1 had socks and rubber bands on her hands and wrists on 01/25/25 nor did she report it to anyone. A telephone interview was conducted with Nurse #3 on 01/30/25 at 3:04 PM. Nurse #3 revealed she was employed by the facility and verified she was assigned to provide care to Resident #1 on 01/25/25 and 01/26/25 during the hours of 7:00 AM to 7:00 PM. Nurse #3 stated on 01/26/25 she saw socks on both of Resident #1's hands but did not see any rubber bands. She stated she did not remove the socks from Resident #1's hands to observe the skin and explained the socks did not seem tight or swollen and there was no redness to her arms that she recalled. Nurse #3 stated she didn't question why the socks were placed on Resident #1's hands or report it to anyone because she knew that Resident #1 would play in and eat her feces and no one had brought any concerns regarding the socks to her attention. Nurse #3 confirmed she had received inservice education on the facility's abuse and neglect policy and restraints and was instructed to immediately report any concerns to the Administrator. A telephone interview was conducted with Nurse Aide (NA) #1 on 01/29/25 at 1:21 PM. NA #1 revealed she was employed by the facility and verified she was assigned to provide Resident #1's care on Sunday 01/26/25 to Monday 01/27/25 during the hours of 11:00 PM to 7:00 AM. NA #1 recalled she was doing her initial incontinence rounds when she first went in to check on Resident #1 around 12:00 AM. When she went into Resident #1's room and pulled back the covers she observed socks on both of Resident #1's hands that were being held in place by rubber bands. NA #1 stated she thought the rubber bands had been wrapped around Resident #1's wrists at least twice. She stated she could tell Resident #1's hands were swollen even with the socks on because her hands were pressed tightly against the socks and looked much bigger than they should have been. She explained Resident #1's hands were so large, she was not able to pull the socks or rubber bands off and had to cut them in order to remove them from Resident #1's hands. NA #1 stated she started with the right hand and once the sock was removed, she immediately noticed Resident #1's right hand was very swollen, the skin of her hand and wrist was bright red in appearance and there were red marks around her wrist where the rubber bands had been that started to bruise. Resident #1 also had several blisters on top of the right hand and a large blister covering the palm of her right hand that were leaking. NA #1 stated she immediately informed Nurse #1 and when Nurse #1 came to the room to assess Resident #1 she instructed NA #1 to cut the rubber bands and sock off the left hand. NA #1 recalled Resident #1's left hand was also swollen but less red in appearance with no blisters that she recalled and there were red marks around Resident #1's left wrist where the rubber bands had been. NA #1 was not sure who put the socks and rubber bands on Resident #1's hands but recalled staff mentioning in the past that Resident #1 messed with her feces; however, NA #1 had never witnessed Resident #1 display that type of behavior. NA #1 stated if Resident #1 had messed in her feces when she provided her care, she would have just cleaned her up and would never have placed socks and/or rubber bands on her hands to deter the behavior because it would be considered a restraint. A telephone interview was conducted with Nurse #1 on 01/29/25 at 1:48 PM. Nurse #1 revealed she was employed by the facility and verified she was assigned to provide Resident #1's care on Sunday 01/26/25 to Monday 01/27/25 during the hours of 11:00 PM to 7:00 AM. Nurse #1 recalled around 12:30 AM, Nurse Aide (NA) #1 came to let her know that Resident #1 was found with socks on her hands, rubber bands around her wrists and her hands were swollen. Nurse #1 stated she immediately went to assess Resident #1, NA #1 had already removed the sock and rubber bands off Resident #1's right hand and Nurse #1 stated she cut the sock and rubber bands off Resident #1's left hand. Nurse #1 recalled Resident #1's right hand was swollen, blistered and red and her left hand was swollen but not blistered. Nurse #1 notified the DON, called the on-call provider and while waiting for a return phone call from the on-call provider, she went ahead and provided treatment to Resident #1's right hand. Nurse #1 stated she looked through Resident #1's medical records and did not see any physician orders for socks to be placed on her hands and there was no intervention in her care plan either. Nurse #1 explained Resident #1 would play in her feces on occasion and she could only assume that was why someone had placed the socks and rubber bands on her hands; however, that was not an intervention the facility typically used. Nurse #1 stated no one had mentioned anything to her about the socks and rubber bands observed on Resident #1's hands until it was brought to her attention by NA #1. During interviews on 01/29/25 at 3:42 PM and 01/30/25 at 9:40 AM, the Director of Nursing (DON) revealed she received a call from Nurse #1 on 01/27/25 around 1:15 AM informing her that she (Nurse #1) had observed socks on both of Resident #1's hands with rubber bands placed tightly around her wrists, both hands were swollen and the right hand had blisters. The DON stated she went to the facility, called the Administrator to inform him of the incident and then started an investigation. The DON stated socks placed on the hands and secured with rubber bands was considered a restraint and never an appropriate intervention to use on any resident. She explained facility hired and agency staff were informed during orientation that restraints were not something the facility used and they should immediately report to her or another member of Administration anytime restraints were observed in use. During an interview on 01/30/25 at 4:44 PM, the Administrator recalled he woke up around 5:30 AM on 01/27/25 and noticed he had missed a call from the DON. He called the DON and she informed him of the incident involving Resident #1. When asked what he was told by the DON, he stated at that point she was describing the aftermath, basically the extent of Resident #1's injuries. The Administrator stated when they started their investigation, they initially thought the rubber bands were placed on Resident #1's wrists on 01/26/25 during second shift (3:00 PM to 11:00 PM); however, they were learning new details about when the rubber bands were actually placed on her wrists. He stated all staff had been trained that there was a zero tolerance for abuse and neglect that included the use of restraints. He further stated it was his expectation for staff was to immediately report any suspicion of abuse which would include the use of restraints and explained if staff had questions or concerns about something unusual they had observed, then they were to report their concerns to him or the DON. Review of the initial allegation report submitted by the facility to the Division of Health Service Regulation (DHSR) revealed an allegation type of resident abuse and noted Resident #1 was found with socks on her hands and a soft binding to hold the socks in place. The socks were immediately removed, all other facility residents were checked for similar interventions with no other concerns identified, staff education was initiated, and an investigation was underway. It was noted the facility was made aware of the incident on 01/27/25 at 1:15 AM, the initial report was submitted to DHSR via fax transmission on 01/27/25 at 2:43 AM and law enforcement was notified. The initial report was completed and signed by the Director of Nursing (DON). Photographs taken of Resident #1's hands and wrists received via email correspondence dated 01/28/25 from the investigating Law Enforcement Officer were reviewed. In the first three photographs taken on 01/27/25, Resident #1's hand was covered in a gauze dressing and when the dressing was pulled back, the index finger was outside of the dressing and appeared swollen. The middle and ring fingers were bent inside the gauze dressing and you could partially visualize a raised fluid-filled blister starting at the base of the middle and ring fingers leading down the top of the hand. When the dressing was moved to visualize the wrist, the skin was red with a blister and indentation mark on the inside of the wrist where the rubber bands had been. The remaining pictures taken on 01/28/25, revealed the skin on Resident #1's right hand was red from the wrist to the fingers and there was peeling skin on the top and palm. Her left hand and palm had minimal redness with no blisters and a red mark on the wrist. Photographs of Resident #1's hands and wrists that were taken by NA #1 on 01/27/25 and received via email correspondence on 01/29/25 from the investigating Law Enforcement Officer were reviewed. There were three photographs in total. In the first photograph, both of Resident #1's hands were covered in grayish/tan gripper socks. The left hand was more prominent in the photograph and showed two rubber bands, approximately 1/8 of an inch in width, wrapped around the wrist twice and her hand above the wrist appeared 2 to 3 times its normal size in the sock. Her chin was resting on the right hand and the rubber bands were not visible but you could visualize how large her hand appeared in the sock. In the second photograph, the sock and rubber bands had been removed from the right hand and her palm was facing upward. There were red ligature marks on the lower part of the inside of her wrist. The skin on her wrist, hand and fingers were visibly swollen and bright red in appearance. There was a large, raised fluid-filled blister from the edge of the palm to the bend of her fingers that covered the width of the palm. The sock was still on her left hand and you could visualize a rubber band, approximately 1/8 of an inch in width, bound twice around her wrist. In the third photograph, was a left sided view of Resident #1's right hand that was facing upward and tilted slightly. There was a purple colored, bruised area on the outer wrist along the red ligature mark. The skin from the wrist to the fingers were bright red and swollen 2 to 3 times its normal size, resembling a lobster claw. Just underneath the outer edge of the top of the hand were two raised fluid-filled blisters at the base of the hand and a fluid-filled blister at the bend of the ringer finger to the knuckle. The Administrator was notified of Immediate Jeopardy on 01/29/25 at 6:00 PM. The facility provided the following corrective action plan: Address how corrective actions will be accomplished for those residents who have been affected by the deficient practice: On 1/27/2025, resident #1 was observed with a sock on both hands and rubber bindings had been placed around each wrist to hold the socks in place. This intervention caused swelling, redness, and a 17 x 20-centimeter blister on resident #1's right hand and redness and swelling on the left hand. The facility failed to comply with the abuse policy when 7 staff members were aware of the socks and/or rubber bindings and failed to report this form of restraint to facility administration. Because of the failure to report, the facility did not protect a resident with severe cognitive impairment from abuse through unnecessary restraints. On 01/27/2025, seven staff members who admitted to knowledge of the socks and/or rubber bindings being on resident #1's hands and failing to report, were suspended pending investigation by the Director of Nursing (DON). Staff interviews attest that staff members began seeing the socks and/or rubber binding beginning on 1/19/25. On 01/27/2025, 1:1 education was provided verbally by DON to staff who reported knowledge of socks and/or rubber binding on resident #1's hands regarding abuse policy, restraint policy and the requirement to report suspected or actual abuse to the administrator or DON. On 01/27/2025, immediately following identification of concerns, DON initiated investigation. Investigation is ongoing by Administrator, DON, and Assistant Director of Nursing (ADON) and Unit Managers. All perpetrators who were aware of the use of socks and/or bindings on resident #1's hands, failed to report, and failed to remove the coverings and/or bindings are being terminated. How will the facility identify other residents having the potential to be affected by the same deficient practice: In an ad hoc Quality Assurance Process Improvement (QAPI) meeting on 1/27/25, the abuse and reporting policy was reviewed by the administrator to ensure no changes were needed. In attendance at this meeting were the DON, ADON, and Unit Managers. It was determined that no changes were needed. On 1/27/2025, the DON completed interviews with all residents having a Brief Interview for Mental Status (BIMS) of 10 or greater to ensure that they had not experienced any abuse that had not been reported. There were no new findings. Hard copies of these interviews reside in the facility. On 1/27/2025, the DON completed skin assessment with all residents having a BIMS of 9 or less to ensure there was no visual indication of abuse that had not been reported. There were no new findings. Hard copies of these interviews reside in the facility. On 1/27/2025, DON and Administrator completed interviews with all staff working over the last 5 days. These staff members were interviewed to determine if they were aware of any other incidents of using interventions that restrict movement or abuse that had not been reported. There were no new findings. Hard copies of these interviews reside in the facility. On 1/27/2025, the Administrator reviewed all grievances and facility reported incidents for the last 30 days to ensure that there were no examples of a failure to report incidents as required by facility abuse and reporting policy. There were no new findings. What measures will be put into place or systemic changes made to ensure that the deficient practice will not occur: On 1/27/2025, the DON/Designee conducted all staff education in person and/or by telephone on the facility abuse and restraint-free policy to include a zero-tolerance for any type of resident abuse or failure to report an incident or suspected incident of abuse. Education also included that all residents have the right to be free from harm, including unnecessary or excessive physical restraint, including applying socks and bindings to hands to hinder manifestations of behaviors or for resident safety. Education focused not only on the requirement to report any unusual devices that could restrict movement, but to have open communication with the Administrator, DON, ADON, and Unit Managers about the resident population, asking questions or inquiring about any treatment or intervention that is new, uncommon, or suspected as possible abuse or a restraint. Newly hired or contracted staff will be educated prior to accepting an assignment and caring for residents. No staff will provide resident care without completing education. DON and ADON will be responsible for tracking education for all staff including new hires and contract staff. The administrator notified DON and ADON of these responsibilities on 1/27/2025. On 01/27/2025, DON or designee educated all staff in person and/or by telephone to proper notification and appropriate intervention for unsafe or other unusual behaviors. Newly hired or contracted staff will be educated prior to accepting an assignment and caring for residents. No staff will provide resident care without completing education. DON and ADON will be responsible for tracking education for all staff including new hires and contract staff. The administrator notified DON and ADON of these responsibilities on 1/27/2025. How will the facility monitor its corrective actions to ensure that the deficient practice will not recur: On 1/27/2025, during an ad hoc QAPI meeting, a root cause analysis was completed, and the root cause was identified as the need for additional staff education on the requirement to report unusual behavior or concerns about any intervention that restricts movement when visualized, as well as the requirement to report any incident or suspected incident of abuse immediately to the Administrator or DON. The decision was made to complete the following audits to maintain compliance with the plan of correction: DON/designee will interview 5 staff members weekly (on alternating shifts) for 8 weeks to identify any concerns for use of restraints, improper behavior management techniques, or abuse to ensure that reporting has occurred if present. DON/designee will review the 24-hour report (that includes Sbars) 5 x weekly for 8 weeks to identify any concerns for use of restraints, improper behavior management techniques, or abuse to ensure that reporting has occurred if present. DON/designee will make a walking round 5 x weekly for 8 weeks to identify any concerns for use of restraints, improper behavior management techniques, or abuse to ensure that reporting has occurred if present. The facility administrator will review findings of audits to identify patterns or trends and will present audits to QAPI for 2 months, adjusting the plan as needed to maintain compliance. IJ removal date is 1/28/25. The facility alleges compliance with this corrective action plan as of 1/28/25. A validation of the facility's corrective action plan for Immediate Jeopardy removal was completed on 01/31/25. Staff interviews revealed they had received inservice education on the facility's abuse policy and use of restraints policy which included the definition of physical restraints. Staff verbalized they were instructed that socks and rubber bands placed on a resident's hands should never be used as an intervention, was considered a restraint and to report any concerns to the Administrator immediately. Review of the attendance sign-in sheets revealed staff inservice education was completed on 01/27/25. Skin assessments were conducted on all cognitively impaired residents with no concerns identified. Alert and oriented residents were interviewed who all reported no concerns with restraints. An audit was conducted on 01/27/25 of all residents with no other restraints identified. All facility staff were interviewed on 01/27/25 and the employees who reported observing the socks and/or rubber bands on Resident #1 but did not remove them or inform anyone were suspended. Monitoring tools initiated on 01/27/25 through 01/31/25 were reviewed and completed as outlined in the facility's credible allegation with no concerns noted as identified. The Immediate Jeopardy removal date of 01/28/25 was validated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff, Responsible Party, Nurse Practitioner and facility Medical Director (MD) interviews, the facility failed to protect a resident from injuries of unknown origin for 1 of 3 residents reviewed for abuse (Resident #1). On the evening of 08/09/22, Resident #1 was observed guarding her right hip and displaying pain during care. On the morning of 08/10/22, Resident #1 hollered out in pain when care was attempted, was sent out to the hospital for evaluation due to increase lethargy, and subsequently admitted for further treatment when diagnosed with the following fractures: 1) an acute (symptoms that are severe and sudden in onset) intertrochanteric fracture (type of hip fracture between the bony points of the top of the bone where the muscles of the thigh and hip attach) of the right proximal (top of the bone, closer to the center of the body) femur (thigh bone) with approximately one shaft width lateral (to the side of, or away from, the middle of the body) displacement (bone snapped in two or more parts and moved so that the two ends are not lined up straight), 3 centimeters (cm) displacement and valgus (occurs when the broken bones are turned outward away from the midline of the body to an abnormal degree) impaction (occurs when the broken ends of the bone are jammed together by the force of the injury), 2) an acute comminuted (the bone has broken into three or more pieces and in most cases, the number of bone fragments corresponds with the amount of force needed to break the bone) fracture of the left proximal femur with subtrochanteric and intertrochanteric components, at least 7 cm proximal displacement with varus (occurs when the broken bones are turned toward the center of the body) angulation (when the two ends of the broken bone are at an angle to each other), and 3) acute nondisplaced fractures (when the bone breaks or cracks but retains its proper alignment) of the left inferior and superior pubic rami (group of bones that make up part of the pelvis) extending into the pubic body that required surgical repair. Immediate Jeopardy began on 08/10/22 when Resident #1 was admitted to the hospital and found to have sustained multiple fractures. Immediate Jeopardy was removed on 11/19/22 when the facility implemented an acceptable credible allegation of Immediate Jeopardy removal. The facility remains out of compliance at a lower scope and severity of D (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) to ensure education and monitoring systems put into place are effective. Findings included: Resident #1 admitted to the facility on [DATE] with diagnoses that included unspecified brain disorder, acute embolism and thrombosis of right tibial vein (blood clot in a vein located deep within the body), and diabetes. The admission Minimum Data Set (MDS) dated [DATE] assessed Resident #1 with severe impairment in cognition. Resident #1 required extensive staff assistance with bed mobility, transfers and toileting and limited staff assistance with walking and locomotion off the unit using a wheelchair for mobility. The MDS further noted she had no impairment of the upper or lower extremities and had no falls since admission. Resident #1's Activities of Daily Living (ADL) care plan, initiated on 08/10/22, revealed she had a self-care performance deficit related to disease process and requiring staff assistance to complete daily ADL tasks. Interventions included: extensive assistance of 1-2 staff members with bed mobility, toileting, and transfers. An incident/accident report dated 08/03/22 and completed by the Unit Supervisor noted in part, Resident #1 was observed knocking over a bedside table and sitting down on the floor from her wheelchair. Resident #1 was assessed by the Unit Supervisor with no injuries identified or signs/symptoms of pain. An incident/accident report dated 08/04/22 and completed by the Unit Supervisor noted in part, Resident #1 was seated in her wheelchair out in the hallway, lurched (make an abrupt unsteady, uncontrolled movement) out of the wheelchair and landed on her knees on the floor. Resident #1 was assessed by the Unit Supervisor with no injuries identified or signs/symptoms of pain. An incident/accident report dated 08/05/22 and completed by the Unit Supervisor noted in part, Resident #1 was seated in her wheelchair out in the hallway and launched herself out of the wheelchair landing on her bottom on the floor. Resident #1 was assessed by the Unit Supervisor with no injuries identified or signs/symptoms of pain. During an interview on 11/10/22 at 2:04 PM, the Occupational Therapy (OT) Assistant revealed he often picked up extra shifts working as a hall Nurse Aide (NA) and was assigned to provide Resident #1's care on 08/05/22 and 08/06/22. The OT Assistant explained Resident #1 was unable to ambulate on her own and required extensive staff assistance with ADL tasks. In addition, he stated Resident #1 would try to stand up unassisted by grabbing onto the handrail while out in the hall, unsteady when attempting to stand and wasn't good with verbal commands. He added nursing staff liked for Resident #1 to be up in her wheelchair during the day so that they could keep her out in the hall in visual sight because if left in bed, she had the tendency to flop around which he described as moving her legs around and not lying still. The OT Assistant recalled on 08/05/22 Resident #1 was at her normal baseline and he got her up and ready for the day without incident. He could not recall the exact time but stated while he was in another resident's room providing care, she fell out of her wheelchair out in the hallway and when he came out of the resident's room, staff were already assisting her up off the floor, but he could not recall who the staff members were. On 08/06/22, the OT Assistant stated he had noticed Resident #1 wasn't feeling well, so he left her in the bed and told the hall nurse she wasn't acting her normal self. He stated Resident #1 remained in bed the duration of his shift and when he provided her care, she did not cry out in pain or display any facial grimaces of discomfort when turned and repositioned nor did he notice any bruising, deformity or other injuries when care was provided. The OT Assistant stated he didn't feel Resident #1 was a good candidate for OT services because she couldn't retain cues or follow verbal commands. The OT Assistant stated other than 08/05/22, Resident #1 had not fallen when he was assigned to provide her care. During an interview on 11/14/22 at 5:09 PM, the Rehab Manager revealed Resident #1 was discharged from Physical Therapy (PT) and OT services on 08/08/22. The Rehab Manager stated on 08/08/22 Resident #1 received lower extremity exercises focusing on range of motion, flexibility and strengthening. The Rehab Manager added Resident #1 needed 50% verbal cueing along with manual resistance to get her to move a little more and she displayed no pain that was addressed during the therapy sessions. She added if Resident #1 had any signs of fracture on 08/08/22 the PT and/or OT therapists would have noticed when doing her lower extremity exercises and no one knew of Resident #1 having any abnormal injuries. The Rehab Manager explained Resident #1 had times when she would be very volatile with extreme movements and then other times, she would be completely docile. She added Resident #1 needed substantial to maximum assistance to transfer from the bed to wheelchair, her participation with therapy sessions would be up and down as she could retain information at times but not consistently, and basically stayed at baseline, not really advancing in therapy goals. A MD progress note dated 08/08/22 revealed in part, Resident #1 was seen at the request of family due to concerns of altered mental status, lethargy, confusion, and poor appetite .she was resting in bed in no obvious distress although she would not keep her eyes open for the family, she's more confused and not acting herself. Concerned she may have a Urinary Tract Infection (UTI) or some other acute issue. The physical exam noted Resident #1 had no joint deformity or swelling, generalized weakness and her skin was warm and dry with very poor skin turgor (ability of the skin to change shape and return to normal). There was no bruising of the extremities noted. As part of the plan, the MD ordered a Urine Culture and Sensitivity (test that checks for bacteria in the urine that could cause an infection). A Nurse Practitioner (NP) progress noted dated 08/09/22 revealed in part, Resident #1 was seen to evaluate current diet orders due to nursing concerns she was on a regular texture diet and had no teeth or dentures. The physical exam noted Resident #1 had no lower extremity edema (swelling). As part of the plan, the NP ordered a Speech Therapy consult. During a telephone interview on 11/16/22 at 8:51 AM, Resident #1's Responsible Party (RP) recalled she had been at the facility the evening of 08/09/22 visiting with Resident #1 and was concerned she wasn't acting right and appeared to be in pain. The RP asked Resident #1's nurse if her behavior was normal and the nurse stated it was. The RP added the nurse stated she would continue to monitor her throughout the night and notify her of any changes. The RP stated sometime that evening (08/09/22), she received a call from the nurse who stated she had noticed Resident #1 guarding her hip and displaying pain during care. The RP asked the nurse if she needed to be sent out to the hospital for evaluation and the nurse stated she would have the physician evaluate the next morning and obtain an x-ray. The RP stated on the morning of 08/10/22 when she arrived at the facility, Resident #1 still wasn't acting normal and appeared to be in pain so she requested the facility staff to send her to the hospital for evaluation. During telephone interviews on 11/14/22 at 9:20 AM and 3:24 PM, Nurse #4 confirmed she worked 08/06/22 to 08/09/22 during the hours of 7:00 AM to 7:00 PM and was assigned to provide Resident #1's care. Nurse #4 recalled Resident #1 had remained in bed the entire weekend and did not have any falls during her shifts. Nurse #4 explained Resident #1 moaned at baseline but did not voice complaints of pain or display any non-verbal indicators of pain. Nurse #4 did not recall observing or being notified from NA staff of any bruising or deformity noticed on Resident #1's lower extremities. Nurse #4 confirmed NA #1 assisted while she inserted a catheter to obtain a urine sample from Resident #1 on 08/09/22. Nurse #4 explained they assisted Resident #1 onto her back and NA #1 held Resident #1's legs open slightly by the knees while she inserted the catheter. Nurse #4 stated during the process, she was focused on getting the urine sample and did not recall noticing any deformities or bruising to Resident #1's pelvic/hip region. Nurse #4 stated Resident #1 didn't try to resist and only cried out when the catheter was inserted but did not attempt to move in an effort to resist or try to push them away with her hands. After the urine sample was collected, Nurse #4 stated she assisted NA #1 with cleaning Resident #1 and placing her in a clean brief. Nurse #4 stated she was never told during shift report on 08/06/22 that Resident #1 had fallen on 08/03/22, 08/04/22 or 08/05/22 and didn't learn of her falls until a week later when asked to fill out some paperwork for the former DON. During a telephone interview on 11/15/22 at 1:15 PM, NA #1 confirmed she worked on 08/09/22 during the hours of 7:00 AM to 7:00 PM and was assigned to provide Resident #1's care. NA #1 explained it was the first time she had provided care to Resident #1 and recalled she had remained in bed the entire shift and did not fall. NA #1 could not recall the exact time but at one point during the shift she assisted Nurse #4 with obtaining a urine sample from Resident #1. She explained when they went into Resident #1's room, she was in bed lying on her side, they turned her over on her back, and each held her legs open by placing their hands on her inner thighs. NA #1 stated Resident #1 did not complain of any pain or try to push their hands away in an attempt to get them to stop and only hollered out when Nurse #4 inserted the catheter. After the urine sample was collected, NA #1 stated she and Nurse #4 cleaned Resident #1, placed her in a clean brief, and repositioned her back onto her side in bed. NA #1 stated Resident #1 did not display any signs of discomfort or distress the remainder of the shift. NA #1 did not recall noticing if Resident #1 had any deformity, bruising or redness when they were collecting the urine sample and stated she didn't really pay attention as she was focused on assisting Nurse #4. A nurse progress note written by Nurse #3 dated 08/10/22 at 5:41 AM read in part, Resident #1 holding right hip, grimacing while resting in bed. When ADL/incontinent care was provided, Resident #1 guards right hip/leg, holds right hip, yells out in pain. Note in physician book requesting evaluation and x-ray. During a telephone interview on 11/10/22 at 12:42 PM, NA #2 confirmed she worked on 08/09/22 during the hours of 7:00 PM to 7:00 AM and was assigned to Resident #1's hall; however, she did not specifically recall Resident #1 or care that was provided during her shift. NA #2 did state no residents had fallen during her shift on 08/09/22 and if they had, she would have reported it to the hall Nurse. During an initial telephone interview on 11/10/22 at 3:56 PM and follow-up telephone interviews on 11/15/22 at 12:00 PM and 11/16/22 at 3:56 PM, Nurse #3 confirmed she worked on 08/09/22 during the hours of 7:00 PM to 7:00 AM and was assigned to provide Resident #1's care. Nurse #3 recalled Resident #1 had poor safety awareness, at times she would sit up on the side of her bed and staff would have to help her turn around to lie back down. Nurse #3 added once in bed, Resident #1 might move her arms around a little but not in an aggressive kind of way or attempting to get up out of bed. Nurse #3 explained she kept her medication cart out in the hall outside Resident #1's door so that she could keep an eye on her and another resident across the hall and Resident #1 did not fall during the shift on 08/09/22. Nurse #3 explained staff typically went in pairs to provide Resident #1's care not because she was combative or resistive but more for safety due to her flailing her arms a lot during care, which was her baseline behavior. She stated sometime between 8:30 PM and 9:00 PM she assisted the NA (could not recall the name of the staff member) with providing incontinence care to Resident #1 and when she assisted the NA with turning Resident #1 onto her side, she noticed Resident #1 appearing to guard her hip by reaching over and placing her hand to her right hip but she did not wince or display any signs of acute pain. Nurse #3 recalled thinking is that new referring to Resident #1's behavior and stated as they provided her care, she did not notice deformity, bruising or anything else that appeared acute and Resident #1 did not display any non-verbal indicators of pain. After they had finished providing Resident #1's care, Nurse #3 stated she was repositioned back onto her right side, bed was placed in a low position and she slept fairly well the remainder of the shift. Nurse #3 added on that particular night, Resident #1 wouldn't open her eyes when spoken to but she would verbally respond to simple questions. Nurse #3 stated she spoke with Resident #1's RP that evening (08/09/22) about her condition and recalled asking the RP if it was typical behavior for Resident #1 to guard her hip and keep her eyes closed when talking to her. She remembered the RP asking if Resident #1 needed to go out to the hospital and explained she would monitor Resident #1 closely the remainder of the night and notify the physician to examine Resident #1 and order an x-ray as they usually tried to treat in house before sending residents out to the hospital. When asked about the nurse progress note she wrote on 08/10/22, Nurse #3 stated she used the wrong wording to describe Resident #1's pain the evening of 08/09/22 and explained Resident #1 was not really yelling, just moaning. Nurse #3 added at the time, she did not think Resident #1 had any acute issues that needed immediate attention so she did not call the on-call doctor, just put a note in the physician communication book and reported to the Unit Supervisor the next morning during shift report. During a telephone interview on 11/10/22 at 11:03 AM, NA #3 confirmed she worked on 08/10/22 during the hours of 7:00 AM to 3:00 PM and was assigned to provide Resident #1's care. NA #3 stated it was the first time she had provided care to Resident #1 and recalled she had remained in bed that morning until she was sent out to the hospital and did not fall. NA #3 stated she fed Resident #1 her breakfast, changed and repositioned her in bed and she never cried out or displayed any signs of pain or distress. NA #3 added when care was provided, she did not notice Resident #1 having any deformities, bruising, shortening of the legs and if she had noticed anything abnormal, she would have reported it to the hall nurse. During an interview on 11/10/22 at 2:42 PM, the Unit Supervisor recalled Resident #1 was a massive fall risk and impulsive so staff would keep her in visual sight whenever she was up out of bed in her wheelchair. The Unit Supervisor stated she was the hall nurse assigned to Resident #1's hall on 08/03/22, 08/04/22 and 08/05/22 when she had fallen from her wheelchair. On 08/03/22, the Unit Supervisor stated she was in another resident's room when notified by the Treatment Nurse that Resident #1 had lifted herself up out of the wheelchair and sat down on the floor. The Unit Supervisor stated when she immediately assessed Resident #1, she had no injuries nor displayed any signs of pain. On 08/04/22, the Unit Supervisor stated she was standing at her medication cart when she observed Resident #1 literally launch herself up out the wheelchair which she described as Resident #1 putting her hands on the armrests of the wheelchair and pushing herself forward, landing on her knees on the floor. The Unit Supervisor stated Resident #1 had been in close proximity to her medication cart; however, she couldn't reach Resident #1 fast enough to prevent the fall. She stated Resident #1 was immediately assessed with no injury or bruising noted to her knees, her functional range of motion in the lower extremities were within normal limits and she had no signs or symptoms of pain. On 08/05/22, the Unit Supervisor stated she witnessed Resident #1 impulsively go forward out of her wheelchair landing on her bottom on the floor. She stated Resident #1 was immediately assessed with no injuries or signs of pain and both she and the OT Assistant assisted Resident #1 back into her wheelchair. The Unit Supervisor stated she didn't work again until 08/10/22 and was unaware of Resident #1 having any other falls. The Unit Supervisor recalled on the morning of 08/10/22, she was assigned to provide Resident #1's care and during shift report, Nurse #3 did not report Resident #1 having a fall or any other incident but did state Resident #1 was guarding her hip and suggested they get orders for an x-ray. The Unit Supervisor stated when she went into Resident #1's room the morning of 08/10/22, she was lying in bed, with the bed in a low position, and would not open her eyes but would respond when spoken to. The Unit Supervisor stated when she assessed Resident #1 she did not notice any bruising or other abnormalities, however, she did holler out in pain when she assisted NA #3 with turning her over to be changed. She stated Resident #1's legs were drawn up and when they tried to straighten her legs, she cried out in pain, so they stopped and she obtained orders for an x-ray. She stated Resident #1 did not fall during her shift the morning of 08/10/22 and was sent out to the hospital for evaluation due to increased lethargy. The Unit Supervisor stated due to poor safety awareness, Resident #1's bed was kept in a low position and while it was possible Resident #1 could have physically pulled herself up back into the bed, given her mentation she would have more likely just crawled or sat on the floor. The x-ray report of Resident #1's right femur and hip that was completed at the facility on 08/10/22 revealed in part, acute transverse displaced comminuted intertrochanteric fracture femur is noted. No other acute fracture or dislocation. Chronic fracture deformity at right inferior pubic ramus is noted .mineralization is decreased. A telephone interview was conducted on 11/18/22 at 10:16 AM with the X-Ray Representative of the company who performed Resident #1's x-ray at the facility on 08/10/22. The X-ray Representative explained the Radiologist who read Resident #1's x-ray was not able to give a medical opinion on how a fracture could have occurred. She stated the facility had reached out to request a second opinion and when the x-ray was read by second Radiologist, they had agreed with the original findings noted on the x-ray results. The Hospital Transfer Form dated 08/10/22 and completed by the Unit Supervisor revealed Resident #1 was sent to the hospital on [DATE] at 11:30 AM for evaluation of lethargy (condition marked by drowsiness and an unusual lack of energy and mental alertness). The Emergency Medical Services (EMS) report dated 08/10/22 noted upon arrival at the skilled nursing facility, Resident #1 was lying in bed with family and facility staff at bedside. The EMS report read in part, patient had her eyes closed, mumbling incoherently and was positioned oddly in bed with legs turned to the right side. Patient grimaces in pain at any attempt to straighten her extremities and is extremely tender to right hip palpation. Patient left in position of comfort, lifted via sheet and transferred to EMS stretcher. Patient remained stable, appeared comfortable and did not require any further intervention. Patient arrived at the Emergency Department (ED) where care was transferred to ED staff with report given. During a telephone interview on 11/10/22 at 12:25 PM, the EMS Responder recalled when they arrived at the facility on 08/10/22, Resident #1 was lying on the bed in an awkward position with her knees bent and turned to the right side. The EMS Responder could not recall if facility staff reported Resident #1 had fallen that day or within the past few days but stated typically when a hip injury was suspected, they would splint with a pillow placed between the legs; however, Resident #1 would not allow them to do so due to pain so they kept her in position of comfort. The EMS Responder stated with the way Resident #1 was laying, he could not tell if her leg was rotated, deformed or shorter than the other and based on the information provided by facility staff, he just assumed she had a hip fracture and focused on keeping her comfortable during transport to the hospital. The ED physician progress note dated 08/10/22 at 12:33 PM for Resident #1 read in part, patient with increasing lethargy and altered mental status currently being treated for UTI. Patient slipped off the front of her chair today and is thought to have right-sided hip fracture per outside facility. Unclear from physical exam. Patient unable to contribute to history. Further review revealed an addendum that read in part, patient was admitted for severe hypernatremia (high concentration of sodium in the blood) and altered mental status, x-rays of her hips and pelvis were pending. The x-rays show bilateral hip fractures and pubic rami fractures. Orthopedic Surgeon will consult on patient in the hospital. Their severity is concerning and this has been noted by the Orthopedic Surgeon as well. There was no notation of any bruising. The hospital radiology report dated 08/10/22 at 3:26 PM revealed Resident #1 had the following fractures: 1) acute intertrochanteric fracture of the right proximal femur with approximately one shaft width lateral displacement, 3 cm proximal displacement and valgus impaction, 2) acute comminuted fracture of the left proximal femur with likely subtrochanteric and introchanteric components, at least 7 cm proximal displacement with varus angulation, and 3) acute nondisplaced fractures of the left inferior and superior pubic rami extending into the pubic body. Telephone attempt on 11/16/22 at 12:56 PM for interview with the Hospital Radiologist was unsuccessful. The hospital history and physical dated 08/10/22 at 4:59 PM read in part, Resident #1 was admitted to the hospital for evaluation of increased lethargy, UTI and right hip fracture that was identified via x-ray at the skilled nursing facility .she was found on the ground and sent to the emergency room for further evaluation. She was found to have bilateral hip fractures, pelvic fracture and UTI. The physical exam noted Resident #1's hips are deformed and shortened. There was no notation of any bruising. The Orthopedic Surgeon consultation progress note dated 08/10/22 for Resident #1 read in part, admitted for management of altered mental status, recent UTI, and new onset of hip discomfort. The records are not completely available and the history was pieced together through combination discussion with the Hospitalist and family .she has been noted by the family to have a deformity of both lower extremities for at least a few days. Today apparently, she was felt to have had a ground level fall. This was not witnessed. She was transferred to the ED where she was diagnosed with bilateral hip fractures and UTI. Physical Examination: she is lying in the bed with the left lower extremity markedly internally rotated at the hip with the foot lying laterally. She has prominence (projection or protrusion) laterally of her femur, almost tenting (skin maintains a triangular or tentlike appearance when gently pinched) the gluteus maximus. Her right leg has slightly less prominent deformity but there is definite shortening of each extremity .she is grossly neurovascular intact (relating to or involving both nerves and blood vessels) with a bout of skin changes, but again, her exam was limited by her ability to cooperate. Recommendations: when medically cleared, we will proceed with open reduction and internal fixation of each hip .she has these significantly shortened and comminuted fractures that appear much older and much more complex than a simple ground level fall would indicate. During a telephone interview on 11/16/22 at 11:19 PM, the Orthopedic Surgeon declined to have his medical opinion included as part of the investigation regarding Resident #1's fractures. During a telephone interview on 11/14/22 at 11:05 AM, the former Director of Nursing (DON) recalled on the morning of 08/10/22, Nurse #3 reported Resident #1 was complaining of hip pain with movement during care the evening of 08/09/22 and an x-ray was obtained on 08/10/22 of her right hip. The former DON stated when she assessed Resident #1 the morning of 08/10/22, Resident #1 was lying on the right side with her knees bent and was not moaning or showing any signs of discomfort. She recalled Resident #1 would not let staff stretch her legs out and she did not try to roll Resident #1 onto her back but did look at her right hip and groin area and did not notice any redness, swelling or deformity. The former DON stated she spoke with Resident #1's RP who insisted they send Resident #1 out to the hospital and orders were obtained. She added prior to Resident #1's transport to the hospital, the x-ray had been completed and the results were forwarded to the hospital when received. The former DON stated she was not notified of Resident #1 falling on 08/09/22 or 08/10/22 prior to her transport to the hospital. The former DON stated the facility's Medical Director (MD) reviewed Resident #1's medical record but could not remember exactly what was determined to be the root cause related to Resident #1's fractures. During an interview on 11/15/22 at 11:44 AM, the Administrator revealed they had found out about the extent of Resident #1's fractures indirectly when the Admissions Director contacted the hospital for an update on her status. He stated they reached out to the hospital for more information and even requested Resident #1's hospital medical records but never received a response. The Administrator explained since the hospital would not provide any additional information related to Resident #1, their investigation of her injury was based on the x-ray obtained at the facility that showed a right hip fracture and interviews with staff who provided her care and no one reported any knowledge of Resident #1 having fallen after 08/05/22. In addition, the Administrator stated the MD reviewed Resident #1's medical record and based on her diagnoses and degeneration of the bones, he determined the right hip fracture identified via the x-ray completed at the facility was likely pathological in nature. He stated he wasn't clinical and the MD reviewed Resident #1's medical record in attempt to try and figure out how she sustained the fracture. During a telephone interview on 11/14/22 at 12:10 PM, the Nurse Practitioner (NP) confirmed Resident #1 was seen by her on 08/09/22 due to poor appetite and concerns from nursing staff that she wasn't eating because she didn't have any dentures or teeth. The NP stated during her exam, Resident #1 was not complaining of or displaying non-verbal indicators of pain, such a guarding a particular area, nor did she observe any deformity or bruising that would have caused her to look into the acute issues further. The NP stated as part of her exams, she always observed a resident's lower legs to see if there was any edema which would indicate possible heart failure and Resident #1 had none. The NP stated she did not examine Resident #1's hip area and did not recall Resident #1's legs appearing shorter than the other during the examination. The NP stated Resident #1 was very tiny and frail and given her condition, she was prone to fractures. The NP was not aware Resident #1's hospital x-ray identified bilateral hip and pelvic fractures and explained they could have been caused due to her bone density being so poor but it was difficult to say for sure what could have caused her to sustain those types of fractures. During an interview on 11/14/22 at 2:05 PM, the facility MD stated he reviewed Resident #1's medical record as part of the facility's investigation but did not have access to her hospital medical records at the time. The MD stated during her stay at the facility, Resident #1 was able to participate with therapy, had no acute pain and would not have sustained the type of fractures indicated on the hospital x-ray due to a fall from the bed or wheelchair. Instead, he stated those types of injuries as indicated on the hospital radiology report would likely be sustained from a trauma related injury such as a motor vehicle accident, blunt force hitting the bone or a fall from a significant height and even then, the chances of bilateral hip fractures would be unlikely and would not have occurred from a single fall. He stated when he examined Resident #1 on 08/08/22, she did not display any significant pain or indicators of a fracture. He added with her fractures identified at the hospital, she would not have been without severe pain or been able to continue participating with therapy. He further stated he did not think it was possible the fractures could have occurred when she fell out of the wheelchair on 08/04/22 or 08/05/22 and not display any pain until 08/10/22. The MD added if she had an unwitnessed fall on 08/09/22 or 08/10/22, Resident #1 would not have been able to pull herself back up off the floor and into bed. The MD stated with her injuries, he would have expected her to have significant pain, b[TRUNCATED]