**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, hospital record review, review of the facility's fall investigation, resident interview, staff interview, and policy review, the facility failed to ensure Resident #34, who fell during staff care, was provided timely, adequate and necessary assessment/monitoring and care to treat a fracture and prevent discomfort and potentially additional injury. In addition, the facility failed to adequately and timely assess and report to the physician a change in Resident #41's eye condition to ensure timely and proper care was provided. Actual harm occurred on 10/17/24, when Resident #34 sustained a fall with injury during a physical therapy treatment that was not reported or immediately treated. At the time of the fall, Physical Therapy Assistant (PTA) #420 assisted Resident #34 back to a standing position, assured Resident #34 there was no serious injury, then assisted Resident #34 back to his chair. PTA #420 then obtained and placed an ice pack on the resident's injured left leg and encouraged Resident #34, who was in pain at that time, not to tell anyone about the fall or he (PTA #420) would be fired. PTA #420 failed to document or report the fall. An x-ray was ordered on 10/17/24 of the left leg due to swelling and complaints of pain but was not obtained until 10/18/24 at 3:20 P.M., after PTA #420 provided additional therapy services to the resident. The resident was subsequently diagnosed with a fractured leg which was not initially assessed until 10/19/24. This affected two residents (#34 and #41) of four residents reviewed for quality of care and treatment for change of condition. The facility census was 65. Findings include: 1. Record review for Resident #34 revealed an admission date of 08/25/23. Diagnoses included abnormal coagulation profile, muscle weakness, unsteady on feet, fusion of spine, sacral and sacrococcygeal region, and acute embolism, thrombosis of deep veins of left upper extremity pyogenic arthritis and gout. Review of the Fall Risk - Evaluation dated 08/07/24 at 12:27 P.M., revealed Resident #34 was alert and oriented, had no falls in the last three months, had moderate/severe unsteadiness and required physical assistance. Review of the care plan dated 09/13/24 revealed Resident #34 was at risk for falls due to impaired balance/poor coordination and being unsteady on feet. Interventions included to provide assistance with transfer and ambulation as needed. Review of the progress note dated 10/14/24 at 4:09 A.M., completed by Registered Nurse (RN) Nurse Manager #349 revealed Resident #34 was skilled for pyogenic (painful infection caused by when a joint is invaded by an infectious agent) arthritis. Resident #34 received Physical Therapy (PT) due to unsteadiness on his feet. Resident #34 was alert and oriented times-four (person, place, time, and event). Resident #34 was pleasant and cooperative and had no complaints of pain or discomfort. Resident #34 required extensive assistance with activities of daily living (ADLs). Review of the Physical Therapy Treatment Encounter dated 10/17/24 electronically signed at 4:53 P.M. (untimed for the time of the actual treatment), by PTA #420, revealed the resident had precautions for fall risk. Therapy treatment was completed and documented. Response to treatment: Physical Therapy (PT) session completed with no concerns, or complications. Call light in reach upon exiting, and all infection control policies were followed per facility guidelines. Review of a nursing progress note dated 10/17/24 at 6:55 P.M., completed by Registered Nurse (RN) #350, documented Resident #34 complained of pain and swelling to the left (L) knee. The Certified Nurse Practitioner (CNP) was notified. Laboratory testing (Uric acid level) was ordered for A.M. as well as a two view L knee x-ray. Review of the Physical Therapy Treatment Encounter dated 10/18/24 electronically signed at 4:56 P.M. (untimed for the time of the actual treatment) by PTA #420, revealed precautions included fall risk. Therapy session completed and documented. Ice packs applied for 20 minutes duration on anterior aspect of left knee to reduce pain symptoms. Response to treatment: PT session completed with no concerns, or complications on this date. Call light left in reach of resident upon exiting, all infection control policies were followed per facility guidelines. Review of the progress noted for Resident #34 dated 10/18/24 at 7:57 P.M., completed by RN #350 revealed two view x-rays of the left knee completed. Results pending. Review of the progress note for Resident #34 dated 10/19/24 at 12:09 A.M., completed by Licensed Practical Nurse (LPN) #421 documented received call from (X-ray Company #422), fracture noted to the right (clarified left) proximal tibia. A new order was received to send (Resident #34) to the emergency room (ER). Review of the progress note for Resident #34 dated 10/19/24 at 12:17 A.M., completed by LPN #421 included informed (Resident #34) of abnormal x-ray result and that he needed to go to ER. Resident agreed and stated he would inform his wife. Review of the progress note for Resident #34 dated 10/19/24 at 12:56 A.M., completed by LPN #421 included 911 arrived at facility, Resident #34 was transferred to stretcher by 911. Resident stated to 911 I fell a few days ago in the doorway right here, my left leg hurts 9 out of 10. Emergent 911 verified to this nurse the right tibia had a fracture, this nurse reviewed x-ray report, and this x-ray was for right tibia. Review of the progress note for Resident #34 dated 10/19/24 at 12:57 A.M., completed by DON revealed a clarification: left tibia (fracture). Review of the progress note for Resident #34 dated 10/19/24 at 10:57 A.M., completed by LPN #332 documented Resident #34 returned to facility from Hospital #423. Resident #34 had a left tibial fracture. Resident #34 returned with a new script for Oxycodone five milligrams (mg) every six hours as needed for three days for pain. Resident #34 complained of pain to the left leg. Resident #34 was to keep the leg straight and elevated at all times. Review of the progress note for Resident #34 dated 10/19/24 at 1:39 P.M., completed by LPN #332, documented this nurse received in report today that the resident was sent out to hospital for leg pain. Resident #34 had stated that he had fallen while doing therapy. Resident #34 stated he was walking with the therapist when the therapist told him to stop because a piece had fallen off his chair and he had wanted to pick. Resident #34 stated when the therapist was doing this, resident's legs gave out and he fell. Resident #34 stated the therapist had picked him up off the floor and placed him into his wheelchair and gave him an ice pack. Resident #34 returned from Hospital #423 today 10/19/24 with a new diagnosis of left tibial fracture. Resident #34 had an immobilizer in place. Resident #34 was to keep left leg elevated as much as possible and needed to keep left leg as straight as possible. Review of the hospital discharge instructions from Hospital #423 with a visit date of 10/19/24 at 12:56 A.M., completed by Physician #424, documented the diagnosis was a nondisplaced fracture of proximal end of left tibia. (A tibial fracture is a break in the larger bone of your lower leg, this bone is also called the shin bone). Review of the Medication Administration Record (MAR) for Resident #34 revealed Oxycodone HCL five milligrams (mg) was administered on 10/19/24 at 1:00 P.M., for complaints of pain rated an eight on a scale of one to 10. The medication was documented as effective for pain. Further review of the MAR revealed Tylenol 325 mg two tablets were administered on 10/17/24 and 10/18/24 for complaints of pain rated a five, on 10/20/24 for pain rating of eight, and 10/21/24 for pain rating a nine. Review of the typed Facility Investigation form dated 10/21/24, (untimed), completed by Regional Director of Rehab Services #426, documented on Saturday, 10/19/24, the writer was made aware Resident #34 was sent out to the hospital on [DATE] and was found to have a tibia fracture. The DON reported (Resident #34) told her staff on 10/19/24 that he was working with PTA (#420) on Thursday, 10/17/24 and he fell during the therapy session. The patient (Resident #34) also told the nursing PTA #420 told him not to tell anyone about the fall. The Facility Investigation form included a phone interview with PTA #420, review of the progress notes including the x-ray results indicating a left proximal tibia fracture, statement from Certified Occupational Therapy Assistant (COTA) #428, Resident #34, and therapy notes. The last paragraph of the Facility Investigation completed by Regional Director of Rehab Services #426 dated 10/21/24, revealed this writer spoke to PTA #420 and informed him that his employment with the company was terminated effective immediately. Upon receival of this information, PTA #420 confessed that the fall did happen with him and that he was scared to say anything because it was his first week there and he tried to give the resident ice packs. The form was hand signed by completed by Regional Director of Rehab Services #426 and dated 10/22/24. Review of the Modification of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #34 was cognitively intact. Resident #34 had impairment on one side of the upper extremity and impairments on both sides of the lower extremities. Resident #34 used a wheelchair for mobility. Resident #34 required partial/moderate assistance for bed mobility and substantial/maximum assistants for chair/bed-to-chair transfer. The ability to walk 10 feet in a room, corridor, or similar space was not attempted due to medical condition or safety concerns. Resident #34 did not receive scheduled pain medication, received as needed pain medication. Resident #34 had one fall with major injury since admission or prior assessment. Review of the physician orders from Hospital #423 Orthopedics follow up visit, dated 10/25/24, (untimed) revealed an order for knee immobilizer, at all times, non-weight bearing (NWB), follow up in one week for repeat x-rays, must remove the brace daily and cleanse skin to avoid breakdown. Interview and observation on 11/24/24 at 11:40 A.M. and 11/25/24 at 4:56 P.M., with Resident #34, revealed Resident #34 was sitting up in his wheelchair with his left leg elevated on the leg rest with a therapy band securing the leg to the leg rest. Resident #34 was wearing a knee immobilizer. Resident #34 stated his left tibia was fractured. Resident #34 stated he was working with therapy in his room when he fell, it was around 11:00 A.M., several weeks ago. Resident #34 stated, I was walking to the door with the therapist, I had a gait belt on and using the walker. Resident #34 confirmed the therapist was holding onto his gait belt while they were walking and revealed they heard something fall off the chair behind them. The therapist turned to look and saw it was the control knob from the chair. Resident #34 stated, The therapist told me to stop, I stopped, then I went down to my knees. Resident #34 revealed he fell as the therapist went to pick the object up from the floor. Resident #34 stated, Right after I fell, he stood me right up. I told him it hurt, it was a 10 out of 10 (pain scale), I told him that. He said I will put ice on it, you will be alright. He sat me in my chair, I told him I was hurting, he said don't worry, it ain't broken or you couldn't stand, he told me again please don't tell anybody or I will get in trouble. Resident #34 repeated, I did not tell anybody because I didn't want him to get into trouble because he asked me not to or he would get fired. Resident #34 revealed the next day the same therapist came back to work with him. The therapist put ice on his leg and kept moving his leg back and forth. Resident #34 stated, I told him it hurt, he kept moving it and telling me it will be ok. Resident #34 revealed he did tell (RN #350) that day about the fall with therapy and told her he did not want the therapist to get into trouble. Interview on 11/25/24 at 12:04 P.M., with Director of Rehabilitation (DOR) #425 and Regional Director of Therapy (RDOT) #426, revealed they were aware Resident #34 had a fall with a fracture that occurred while Resident #34 was receiving therapy services. RDOT #426 revealed on Saturday (10/19/24) in the morning, DOR #425 called him and told him. RDOT #426 instructed DOT #425 to call PTA #420. DOR #425 revealed she was made aware Resident #34 had a fracture, Saturday (10/19/24) in the morning. DOR #425 was told Resident #34 reported he fell during therapy and the therapist told him not to tell anyone. DOR #425 revealed she would also expect the therapist to report to nursing when a resident had a fall immediately then follow up with reporting to therapy. DOR #425 revealed when she spoke on the phone with PTA #420, he denied Resident #34 falling. RDOT #426 revealed the therapist does not document the time the therapy was received; the expectations are they finish therapy with residents, then document at the end of the day before going home. RDOT #426 revealed PTA #420 was suspended until further investigation. On Monday, 10/21/24, DOR #425 spoke with Resident #34, who confirmed what happened. RDOT #426 revealed he then called PTA #420 on 10/21/24 to terminate his employment. After termination, PTA #420 confirmed Resident #34 did have a fall during therapy on 10/17/24 and he did not say anything because he was scared for his job. PTA #420 stated Resident #34 was standing while PTA #420 was providing contact guard. Something fell off the wheelchair, when he took his hand off the gait belt to pick it up, Resident #34's legs gave out and he fell. RDOT #426 revealed PTA #420 admitted to telling Resident #34 not to tell anyone. DOR #425 confirmed if a resident had a suspected injury or change in condition, therapy would be held until the results of the change were determined. Interview on 11/25/24 at 12:47 P.M., with Director of Nursing (DON) and Regional Clinical Service Director (RCSD), revealed the DON was notified on 10/19/24 by the night shift nurse that Resident #34 was sent to the hospital for a fracture. DON revealed the next morning, the day shift nurse reported Resident #34 told the Emergency Medical Squad (EMS) he had a fall with therapy. DON revealed the staff interviewed Resident #34, he was upset, he did not want the therapist to get into trouble. DON confirmed RN #350 was aware of the pain and swelling in the leg on 10/17/24. DON revealed she would have expected when a resident had a change in condition including unusual swelling and pain in an extremity, she would be notified by the staff at that time of the change. DON confirmed if the resident received therapy, the Therapy Director should have also been notified of the change in condition to prevent further potential injury. DON confirmed the x-ray result originally stated it was the right knee. Review of the x-ray result with DON confirmed an addendum was completed and concluded the proximal tibial fracture left. DON confirmed the x-ray was ordered on 10/17/24 documented at 6:55 P.M. and not completed until 10/18/24 at 3:20 P.M. and documented results received until 10/19/24 at 12:09 A.M. DON revealed she was unsure why the x-ray company did not complete the x-ray until the following afternoon but would look into it. Interview on 11/25/24 at 5:06 P.M., with RN #350 revealed she was an Interim Unit Manager. She assessed Resident #34 on 10/17/24 because he was complaining of pain in the left leg. During the assessment she also noted the leg was swollen. RN #350 revealed Resident #34 was lying in bed at the time, she asked if he did something to the leg and Resident #34 responded with, he was just having pain. RN #350 revealed she called the CNP who ordered a uric acid level due to his history of gout and ordered an x-ray. RN #350 revealed it was either on 10/17/24 in the evening or 10/18/24 in the morning, that Resident #34's wife told her about the fall with therapy. RN #350 stated, I do not normally inform therapy of changes in residents, not all residents receive therapy, so nursing does not normally notify therapy. RN #350 revealed she did not know why the x-ray took a whole day to come and revealed she did not call the x-ray company to confirm when they were coming. Review of the policy titled, Fall Management Guidelines, dated 12/13/23, documented a fall was defined as unintentionally coming to rest on the ground, floor or other level with or without injury to the resident. If a resident has just fallen or is observed on the floor without a witness to the event, evaluate for possible injuries to the head, neck, spine, and extremities prior to moving the resident. Obtain vital signs, evaluate for signs and symptoms or complaints of pain, complete range of motion with the resident, complete a head-to-toe skin assessment, if there is evidence of injury, provide appropriate first aid and/or obtain medical treatment immediately. Review of the policy titled, Change in Condition Notification, dated 08/09/23, revealed the policy of the facility was to notify the resident, his or her attending physician/practitioner, and the resident's designated representative of changes in the resident's medical/mental condition and or status. The nurse would notify the resident, his or her attending physician/practitioner, and the resident's designated representative when there was an accident or incident involving the resident which resulted in an injury and has the potential for requiring physician /practitioner intervention. 2. Record review for Resident #41 revealed an admission date of 04/16/20. Diagnoses included dementia and presence of intraocular lens. On 07/08/24, Resident #41 started on hospice services. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #41 was severely cognitively impaired. Resident #41 was dependent on staff for personal hygiene. Review of the physician orders for Resident #41 dated 02/11/21 revealed an order to use eye drops solution (Carboxymethylcellulose Sodium) instill one drop in both eyes every 12 hours as needed for dry eye. On 08/15/24, there was an order to wash the left eye with baby shampoo at bedtime for redness, discontinue when resolved. Review of the care plan dated 09/27/24 revealed Resident #41 had an eye infection both eyes. Interventions included to give therapeutic ointments, drops as ordered by physician, monitor/document/report to physician as needed (PRN) the following signs and symptoms: redness of the eye, pain, swelling, tearing of the eye, discharge, change in conjunctiva, and wash eye to remove crust and discharge PRN. Review of the progress notes for Resident #41 from 11/20/24 through 12/02/24 at 10:00 A.M. revealed no documentation regarding Resident #41's left eye. Observations on 11/24/24 at 8:45 A.M. revealed Resident #41 was sitting in the dining room. Resident #41's left eye was red, the lower eye lid was swollen, there was crusty yellow drainage on her upper and lower eye lashes, and yellow mucous drainage was stringing as Resident #41 opened and closed her eye. At 11:08 A.M., Resident #41 was sitting in the lounge. Resident #41's left eye continued to be red, the lower eye lid was swollen, there was crusty yellow drainage on her upper and lower eye lashes, and yellow mucous drainage was stringing as Resident #41 opened and closed her eye. Observation and interview on 12/02/24 at 10:11 A.M. revealed Resident #41 was sitting in a chair in her room. Registered Nurse (RN) Hospice Nurse #430 was present and preparing to leave. Observation of Resident #41's left eye and interview with RN Hospice Nurse #430 confirmed Resident #41's left eye continued to be red with a swollen lower eye lid and crusty yellow drainage on her lashes. RN Hospice Nurse #430 stated she didn't know Resident #41 well, as she was just filling in for the day (12/02/24). Interview on 12/02/24 at 10:12 A.M. with Licensed Practical Nurse (LPN) #328 stated Resident #41's eye was like that all the time. Interview and observation on 12/02/24 at 10:19 A.M. with Certified Nurse Practitioner (CNP) #431 revealed he was not told Resident #41's eye was red. CNP #431 stated Resident #41 had eye infections in the past but he did not visit her unless asked because Resident #41 currently received hospice services. Observation with CNP #431 of Resident #41's left eye revealed Resident #41 stated when asked by CNP #431 her left eye hurt a tiny bit. CNP #431 stated Resident #41's left lower eye lid was swollen, had red conjunctivitis, and she had a bacterial infection. CNP #431 stated he planned to treat the eye with tobramycin eye drops. CNP #431 stated he was not made aware of Resident #41's left eye swelling and drainage and stated the staff should have notified him. Interview on 12/02/24 at 10:44 A.M. with Regional Clinical Service Director #427 stated if a resident had a change in condition, the nurses were to notify the physician, family, and hospice, the primary physician was still to be notified even if a resident received hospice services. Review of the facility policy titled Change in Condition Notification dated 08/09/23 revealed it was the policy of the facility to notify the resident, his or her attending physician/practitioner, and the resident's designated representative of changes in the resident's medical/mental condition and or status.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, hospital record review, review of the facility's fall investigation, review of witness statements, resident interview, staff interview, and policy review, the facility failed to ensure a Resident #34, who was at risk for falls, was provided necessary assistance to prevent an avoidable fall from occurring that resulted in major injury to the resident. Actual harm occurred on 10/17/24, during a physical therapy treatment, when Resident #34, sustained a fall with injury while ambulating with Physical Therapy Assistant (PTA) #420. At the time of the incident, PTA #420 let go of Resident #34's gait belt, (a safety belt used to prevent falls, by providing a handle for caregivers to hold onto to help residents regain balance if they start to fall) during the therapy session and turned away from Resident #34. The resident fell sustaining a fracture to the left leg. This affected one resident (#34) of four residents reviewed for falls/accidents. The facility census was 65. Findings include: Record review for Resident #34 revealed an admission date of 08/25/23. Diagnoses included abnormal coagulation profile, muscle weakness, unsteady on feet, fusion of spine, sacral and sacrococcygeal region, and acute embolism, thrombosis of deep veins of left upper extremity pyogenic arthritis and gout. Review of the Fall Risk - Evaluation dated 08/07/24 at 12:27 P.M., revealed Resident #34 was alert and oriented, had no falls in the last three months, had moderate/severe unsteadiness and required physical assistance. Review of the care plan dated 09/13/24 revealed Resident #34 was at risk for falls due to impaired balance/poor coordination and unsteady on feet. Interventions included to provide assistance with transfer and ambulation as needed. Review of the progress note dated 10/14/24 at 4:09 A.M., completed by Registered Nurse (RN) Nurse Manager #349 included Resident #34 was skilled for pyogenic (painful infection caused by when a joint is invaded by an infectious agent) arthritis. Resident #34 received Physical Therapy (PT) due to unsteadiness on his feet. Resident #34 was alert and oriented times-four (person, place, time, and event). Resident #34 was pleasant and cooperative and had no complaints of pain or discomfort. Resident #34 required extensive assistance with activities of daily living (ADLs). Review of the Physical Therapy Treatment Encounter dated 10/17/24 electronically signed at 4:53 P.M. (untimed for the time of the actual treatment), by PTA #420, revealed precautions included fall risk, left lower extremity (LLE) ankle foot orthosis (AFO), dialysis P.M.- five times a week, and slide board for transfers. PT transfer sit to /from stand times three trials with forward wheeled walker (FWW) via caregiver assist (CGA)/min A (minimum assistants), verbal /visual cues for positioning, technique, and facilitate anterior weight shifting, patient (pt) performed static standing times three trials for 2-3 minutes duration approximately each via CGA. Bilateral upper extremity (BUE) support, verbal cues for postural corrections, and to ensure pt. safety, pt. performed seated exercise to increase strength, endurance, and range of motion (ROM) to improve quality and safety with all functional mobility, verbal/visual cues for technique, and form, marches, long arch quad-extending (LAQs), ankle pumps, and hip abduction (abd)/adduction (add), 10x 2-3 minutes, pt. challenged and fatigued. Response to treatment: Physical Therapy (PT) session completed with no concerns, or complications. Call light in reach upon exiting, and all infection control policies were followed per facility guidelines. Review of the progress note dated 10/17/24 at 6:55 P.M., completed by Registered Nurse (RN) #350, documented Resident #34 complained of pain and swelling to the left (L) knee. The Certified Nurse Practitioner (CNP) was notified. Laboratory testing (uric acid level) was ordered for A.M. as well as a two view left knee x-ray. Review of the Physical Therapy Treatment Encounter dated 10/18/24 electronically signed at 4:56 P.M. (untimed for the time of the actual treatment) by PTA #420, revealed precautions included fall risk, LLE AFO, dialysis P.M. five times a week, slide board for transfers. PT performed seated therapeutic exercises (therex). RLE active range of motion (AROM), LLE active assist range of motion (AAROM) due to pain with movement. 10 times three verbal/visual cues for task instructions, technique, and form marches, LAQs, hip add, hip abd, ankle pumps, and ham curls against yellow tband (therapy band) with RLE only, pt. challenged, ice pack applied for 20 minutes duration on anterior aspect of left knee to reduce pain symptoms. Response to treatment: PT session completed with no concerns, or complications on this date. Call light left in reach of resident upon exiting, all infection control policies were followed per facility guidelines. Review of the progress noted for Resident #34 dated 10/18/24 at 7:57 P.M., completed by RN #350 revealed two view x-rays of the left knee completed. Results pending. Review of the progress note for Resident #34 dated 10/19/24 at 12:09 A.M., completed by Licensed Practical Nurse (LPN) #421 documented received call from (X-ray Company #422), fracture noted to the right (clarified left) proximal tibia. A new order was received to send (Resident #34) to the emergency room (ER). Review of the progress note for Resident #34 dated 10/19/24 at 12:17 A.M., completed by LPN #421 included informed (Resident #34) of abnormal x-ray result and that he needs to go to ER. Resident agreed and stated he would inform his wife. Review of the progress note for Resident #34 dated 10/19/24 at 12:56 A.M., completed by LPN #421 included 911 arrived at facility, (Resident #34) was transferred to stretcher by 911. Patient states to 911 I fell a few days ago in the doorway right here, my left leg hurts 9 out of 10. Emergent 911 verified to this nurse the right tibia had a fracture, this nurse reviewed x-ray report, and this x-ray was for right tibia. Review of the progress note for Resident #34 dated 10/19/24 at 12:57 A.M., completed by DON revealed a clarification: left tibia (fracture). Review of the progress note for Resident #34 dated 10/19/24 at 10:57 A.M., completed by LPN #332 documented Resident #34 returned to facility from Hospital #423. Resident #34 had a left tibial fracture. Resident #34 returned with a new script for Oxycodone five milligrams (mg) every six hours as needed for three days for pain. Resident #34 complained of pain to the left leg. Resident #34 was to keep the leg straight and elevated at all times. Review of the progress note for Resident #34 dated 10/19/24 at 1:39 P.M., completed by LPN #332, documented this nurse received in report today that resident was sent out to hospital for leg pain. Resident #34 had stated that he had fallen while doing therapy. Resident #34 stated that he was walking with the therapist when the therapist told him to stop because a piece had fallen off his chair and he had wanted to pick. Resident #34 stated that when the therapist was doing this, resident's legs gave out and he fell. Resident #34 stated the therapist had picked him up off the floor and placed him into his wheelchair and gave him an icepack. Resident #34 returned from (Hospital #423) today 10/19/24 with a new diagnosis of left tibial fracture. Resident #34 had an immobilizer in place. Resident #34 was to keep left leg elevated as much as possible and needed to keep left leg as straight as possible. Review of the hospital discharge instructions from Hospital #423 with a visit date of 10/19/24 at 12:56 A.M., completed by Physician #424, documented the diagnosis was a nondisplaced fracture of proximal end of left tibia. (A tibial fracture is a break in the larger bone of your lower leg, this bone is also called the shin bone). Review of the Modification of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #34 was cognitively intact. Resident #34 had impairment on one side of the upper extremity and impairments on both sides of the lower extremities. Resident #34 used a wheelchair for mobility. Resident #34 required partial/moderate assistance for bed mobility and substantial/maximum assistants for chair/bed-to-chair transfer. The ability to walk 10 feet in a room, corridor, or similar space was not attempted due to medical condition or safety concerns. Resident #34 did not receive scheduled pain medication, received as needed pain medication. Resident #34 had one fall with major injury since admission or prior assessment. Review of the typed Facility Investigation form dated 10/21/24, (untimed), completed by Regional Director of Rehab Services #426, documented on Saturday, 10/19/24, the writer was made aware Resident #34 was sent out to the hospital on [DATE] and was found to have a tibia fracture. The DON reported (Resident #34) told her staff on 10/19/24 that he was working with PTA (#420) on Thursday, 10/17/24 and he fell during the therapy session. The patient (Resident #34) also told the nursing that (PTA #420) told him not to tell anyone about the fall. The Facility Investigation form included a phone interview with PTA #420, review of the progress notes including the x-ray results indicating a left proximal tibia fracture, statement from Certified Occupational Therapy Assistant (COTA) #428, Resident #34, and therapy notes. The last paragraph of the Facility Investigation completed by Regional Director of Rehab Services #426 dated 10/21/24, revealed this writer spoke to (PTA #420) and informed him that his employment with the company was terminated effective immediately. Upon receival of this information, (PTA #420) confessed that the fall did happen with him and that he was scared to say anything because it was his first week there and he tried to give the patient ice packs. The form was hand signed by completed by Regional Director of Rehab Services #426 and dated 10/22/24. Review of the handwritten witness statement dated 10/21/24, untimed completed by COTA #428 revealed Resident #34 stated on Saturday, 10/19/24, that PTA #420 was walking with him in his room without a gait belt on when patient fell on his knees injuring himself. Patient stated the control knob on the power wheelchair fell on the floor and PTA #420 went to find the knob for the wheelchair to follow behind the patient. Patient stated that PTA told him not to tell anyone he fell. Patient (Resident #34) was given an ice pack by PTA (#420) for leg after fall to relieve pain. The statement included, (Resident #34) asked me to keep the incident quiet. Patient is extremely distraught due to the big setback. Review of the typed statement dated 10/21/24, untimed completed by Director of Rehabilitation #425 revealed the writer asked PTA #420 what happened to Resident #34 on 10/17/24 during his treatment. PTA #420 states, He told me he hurt his knee and banged it on something. PTA #420 told the patient, We can hold off on walking and I will bring you a couple ice packs throughout the day to help with the knee pain. Patient (Resident #34) was agreeable and continued with session that day. On 10/18/24, the writer asked PTA #420 what happened following the complaint of pain on Thursday during the Friday treatment. PTA #420 stated that a male State Tested Nursing Assistant (STNA) from dialysis assisted (PTA #420) in transferring patient from dialysis chair to power chair, PTA #420 noticed no instability throughout the transfer. Patient (Resident #34) reported pain following the transfer but was able to continue on, with therapeutic exercises with ice pack provided by PTA #420. The writer asked PTA #420 if he had a gait belt on during the treatment, PTA #420 stated, I always have a gait belt on any patient I see. PTA #420 stated the patient never reported a fall to him on Thursday or Friday. Review of the physician orders from Hospital #423 Orthopedics follow up visit, dated 10/25/24, (untimed) revealed an order for knee immobilizer, at all times, non-weight bearing (NWB), follow up in one week for repeat x-rays, must remove the brace daily and cleanse skin to avoid breakdown. Interview and observation on 11/24/24 at 11:40 A.M. and 11/25/24 at 4:56 P.M., with Resident #34, revealed Resident #34 was sitting up in his wheelchair with his left leg elevated on the leg rest with a therapy band securing the leg to the leg rest. Resident #34 was wearing his knee immobilizer. Resident #34 stated his left tibia was fractured. Resident #34 stated he was working with therapy in his room when he fell, it was around 11:00 A.M., several weeks ago. Resident #34 stated, I was walking to the door with the therapist, I had a gait belt on and using the walker. Resident #34 confirmed the therapist was holding onto his gait belt while they were walking and revealed they heard something fall off the chair behind them. The therapist turned to look and saw it was the control knob from the chair. Resident #34 stated, The therapist told me to stop, I stopped, then I went down to my knees. Resident #34 revealed he fell as the therapist went to pick the object up from the floor. Resident #34 stated, Right after I fell, he stood me right up. I told him it hurt, it was a 10 out of 10 (pain scale), I told him that. He said I will put ice on it, you will be alright. He sat me in my chair, I told him I was hurting, he said don't worry, it ain't broken or you couldn't stand, he told me again please don't tell anybody or I will get in trouble. Resident #34 repeated, I did not tell anybody because I didn't want him to get into trouble because he asked me not to or he would get fired. Resident #34 revealed the next day the same therapist came back to work with him. The therapist put ice on his leg and kept moving his leg back and forth. Resident #34 stated, I told him it hurt, he kept moving it and telling me it will be ok. Resident #34 revealed he did tell (RN #350) that day about the fall with therapy and told her he did not want the therapist to get into trouble. Interview on 11/25/24 at 12:04 P.M., with Director of Rehabilitation (DOR) #425 and Regional Director of Therapy (RDOT) #426, revealed they were aware Resident #34 had a fall with a fracture that occurred while Resident #34 was receiving therapy services. RDOT #426 revealed on Saturday (10/19/24) in the morning, DOR #425 called him and told him. RDOT #426 instructed DOT #425 to call PTA #420. DOR #425 revealed she was made aware Resident #34 had a fracture, Saturday (10/19/24) in the morning. DOR #425 was told Resident #34 reported he fell during therapy and the therapist told him not to tell anyone. DOR #425 revealed when she looked into it, she saw the note indicating Resident #34 was having leg pain Thursday and Friday. DOR #425 revealed no one in nursing told therapy, Resident #34 was having leg pain or an x-ray prior to Saturday and she would expect to know anytime anyone receiving therapy services was having swelling, pain or an x-ray. DOR #425 revealed she would also expect the therapist to report to nursing when a resident had a fall immediately then follow up with reporting to therapy. DOR #425 revealed when she spoke on the phone with PTA #420, he denied Resident #34 falling. RDOT #426 revealed the therapist does not document the time the therapy was received; the expectations are they finish therapy with residents, then document at the end of the day before going home. RDOT #426 revealed PTA #420 was suspended until further investigation. On Monday, 10/21/24, DOR #425 spoke with Resident #34, who confirmed what happened. RDOT #426 revealed he then called PTA #420 on 10/21/24 to terminate his employment. After termination, PTA #420 confirmed Resident #34 did have a fall during therapy on 10/17/24 and he did not say anything because he was scared for his job. PTA #420 stated Resident #34 was standing while PTA #420 was providing contact guard. Something fell off the wheelchair, when he took his hand off the gait belt to pick it up, Resident #34's legs gave out and he fell. RDOT #426 revealed PTA #420 admitted to telling Resident #34 not to tell anyone. DOR #425 confirmed if a resident had a suspected injury or change in condition, therapy would be held until the results of the change were determined. Interview on 11/25/24 at 12:47 P.M., with Director of Nursing (DON) and Regional Clinical Service Director (RCSD), revealed the DON was notified on 10/19/24 by the night shift nurse that Resident #34 was sent to the hospital for a fracture. DON revealed the next morning, the day shift nurse reported Resident #34 told the Emergency Medical Squad (EMS) he had a fall with therapy. DON revealed the staff interviewed Resident #34, he was upset, he did not want the therapist to get into trouble. DON confirmed RN #350 was aware of the pain and swelling in the leg on 10/17/24. DON revealed she would have expected when a resident had a change in condition including unusual swelling and pain in an extremity, she would be notified by the staff at that time of the change. DON confirmed if the resident received therapy, the Therapy Director should have also been notified of the change in condition to prevent further potential injury. DON confirmed the x-ray result originally stated it was the right knee. Review of the x-ray result with DON confirmed an addendum was completed and concluded the proximal tibial fracture left. DON confirmed the x-ray was ordered on 10/17/24 documented at 6:55 P.M. and not completed until 10/18/24 at 3:20 P.M. and documented results received until 10/19/24 at 12:09 A.M. DON revealed she was unsure why the x-ray company did not complete the x-ray until the following afternoon but would look into it. Interview on 11/25/24 at 5:06 P.M., with RN #350 revealed she was an Interim Unit Manager. She assessed Resident #34 on 10/17/24 because he was complaining of pain in the left leg. During the assessment she also noted the leg was swollen. RN #350 revealed Resident #34 was lying in bed at the time, she asked if he did something to the leg and Resident #34 responded with, he was just having pain. RN #350 revealed she called the CNP who ordered a uric acid level due to his history of gout and ordered an x-ray. RN #350 revealed it was either on 10/17/24 in the evening or 10/18/24 in the morning, that Resident #34's wife told her about the fall with therapy. RN #350 stated, I do not normally inform therapy of changes in residents, not all residents receive therapy, so nursing does not normally notify therapy. RN #350 revealed she did not know why the x-ray took a whole day to come and revealed she did not call the x-ray company to confirm when they were coming. Review of the policy titled, Fall Management Guidelines, dated 12/13/23, documented a fall was defined as unintentionally coming to rest on the ground, floor or other level with or without injury to the resident. If a resident has just fallen or is observed on the floor without a witness to the event, evaluate for possible injuries to the head, neck, spine, and extremities prior to moving the resident. Obtain vital signs, evaluate for signs and symptoms or complaints of pain, complete range of motion with the resident, complete a head-to-toe skin assessment, if there is evidence of injury, provide appropriate first aid and/or obtain medical treatment immediately.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, facility policy review and interview, the facility failed to develop and implement a comprehensive pressure ulcer program to prevent the development of pressure ulcers and to ensure pressure ulcers were comprehensively assessed, properly treated, and interventions were initiated to promote healing. Actual Harm occurred on 12/19/23 when Resident #6, who had moderate cognitive impairment, was at risk for skin breakdown and required extensive assistive from two staff for bed mobility developed a new in-house acquired unstageable (dry, leathery, brown or black necrotic (dead avascular) tissue - Eschar, full-thickness pressure injuries in which the base is obscured by slough and/or eschar due to damage of underlying soft tissue from pressure and/or shear) pressure ulcer to the left heel without evidence the area was identified prior to being unstageable and without evidence of effective and individualized interventions to prevent the development of the ulcer. This affected one resident (Resident #6) of three residents reviewed for pressure ulcers, injuries. The facility census was 56. Findings include: Review of Resident #6's medical record revealed an admission date of 07/02/23 with diagnoses including cerebral infarction, human immunodeficiency virus (HIV) disease, type 2 diabetes mellitus with diabetic polyneuropathy, acute pulmonary edema, and vascular dementia. Review of the care plan dated 07/02/23 revealed Resident #6 had potential/actual impairment to skin integrity related to fragile skin and abrasion to left gluteal fold. Interventions included weekly treatment documentation, use caution during transfers and bed mobility, complete Braden scale, and follow facility policy for treatment of injury. Review of Resident #6's Braden Scale for Predicting Pressure Sore Risk dated, 10/01/23, on a scale of at risk 15-18, moderate risk 13-14, high risk 10-12, and very high risk 9 or below revealed Resident #6 was at risk for developing a pressure injury. Review of Resident #6's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE], revealed Resident #6 had moderate cognitive impairment. The assessment revealed Resident #6 required extensive assistance of two staff members for bed mobility and toilet use and Resident #6 was totally dependent on two staff members for transfers with mechanical lift. The assessment revealed the resident had no pressure ulcers or injury, no skin issues noted and was always incontinent of bowel. Review of the Weekly Skin -Total Body Evaluation completed on 11/23/23 and on 11/30/23 reflected Resident #6 did not have any wounds; however, this was identified to be inaccurate as Resident #6's medical record revealed she had a left buttock abrasion as of 11/21/23. Review of Resident #6's Braden Scale for Predicting Pressure Sore Risk dated, 12/04/23, revealed the resident was at risk of developing a pressure injury. Review of Resident #6's Braden Scale for Predicting Pressure Sore Risk dated, 12/07/23, revealed Resident #6 was at a moderate risk for developing a pressure injury. However, upon review of the Braden Scale revealed it was not completed accurately. Under the moisture section it was scored as the resident being rarely moist. Resident #6 had been assessed to be always incontinent of bowel. Review of Resident #6's Weekly Skin- Total Body Evaluation dated 12/14/23 revealed the resident had a wound but it did not specify type of wound or location. a.Review of an incident report dated 12/19/23, revealed the nurse was called into resident's room due to noted new opened area to the resident's left heel. The report did not include a stage of the ulcer. The area was cleansed with normal saline solution, measured at 4.0 centimeters (cm) length by 4.0 cm width with a depth that could not be determined. The report revealed the nurse practitioner (NP) was updated and a new order was obtained for Xeroform, ABD and Kerlix, change dressing every two days and as needed. There was no further description of the wound or an identified stage. The incident report was not a part of Resident #6's medical record. Review of a late entry progress note dated 12/19/23 revealed the physician was updated about a new wound to the resident's left heel and treatment orders were obtained. The note indicated staff would provide updates as available. The medical record did not include what order was obtained or a stage of the ulcer. Review of Resident #6's TAR revealed no evidence a physician order for the left heel was transcribed for treatment. Review of Resident #6's care plan revealed on 12/19/23 pressure reduction interventions were added to include bilateral heel protectors and to encourage resident to float heels and/or wear heel boots. Review of the treatment administration records (TAR) for December 2023 revealed on 12/21/23 an order was transcribed for a treatment to cleanse left heel with normal saline (NS), apply xeroform, ABD, kerlix every tree (3) days and PRN, every day shift every Tuesday, Thursday, and Saturday. The treatment was documented as being completed on 12/21/23 and 12/23/23. Review of the facility concern log for December 2023 revealed on 12/25/23 Resident #6's family had care concerns regarding the resident's left heel dressing changes not being completed. Review of the investigation documents completed on 12/26/23 regarding Resident #6's family concerns on 12/25/23 revealed Licensed Practical Nurse (LPN) #140 received a written warning for failure to carry out job responsibilities. The investigation revealed on 12/21/23, LPN #140 signed the TAR indicating she had completed a left heel dressing change, however on 12/25/23 it was observed the left heel dressing on Resident #6 was dated 12/19/23. Further review of the investigation documents completed on 12/26/23 revealed Registered Nurse (LPN) #148 received a written warning for failure to carry out job responsibilities. The investigation revealed on 12/23/23, RN #148 signed the TAR indicating she completed a left heel dressing change. However, on 12/25/23 it was observed the left heel dressing on Resident #6 was dated 12/19/23. Review of the Wound Care assessment dated [DATE] revealed an initial evaluation of Resident #6's left heel. The wound was assessed to be an unstageable pressure injury wound, with circular black eschar with surrounding callus, no drainage, no signs of infection, measuring 4.2 cm by 3.1 cm with an undetermined depth. There was 40% eschar and the wound based was also composed of 60% white callus. Treatment included to apply skin prep, cover with ABD pad and wrap with Kerlix, change and apply treatment daily and as needed. Review of Resident #6's physician orders dated 12/27/23, revealed orders maintain dressing to left heel each shift. Cleanse left heel with normal saline, pat dry apply skin prep to wound bed and cover with ABD and Kerlix. Change every Tuesday, Thursday, Saturday, and as needed (PRN). Review of the Resident #6's TAR for December 2023 revealed on 12/28/23 a treatment was in place to cleanse left heel with normal saline (NS), pat dry, apply skin prep to wound bed and cover with ABD and kerlix, change daily and PRN every day shift for wound healing. Review of the TAR for Resident #6 for January 2024 revealed on January 10, 2024, a treatment was in place to cleanse left heel with normal saline (NS), pat dry, apply skin prep to wound bed and cover with ABD and kerlix, change every Tuesday, Thursday, and Saturday and PRN every day shift for wound healing. Review of the TAR for January 2024 for Resident #6 revealed an order to monitor and maintain dressing to left heel each shift. Record review revealed no evidence this order was completed on 01/07/24 second shift, 01/09/24 first shift, 01/16/24 first shift, or 01/16/24 first shift as the nurse failed to document the completion of the order. Review of Resident #6's Wound Care evaluation dated 01/30/24 revealed the unstageable pressure injury located on the left heel was improved/healing and measured 2.2 cm x 1.3 cm x with and undetermined depth at this time. The wound base was composed of 100% necrotic patch. Observations beginning on 01/30/24 at 10:04 A.M. and continuing at intermittent intervals throughout the onsite survey revealed Resident #6 had only one heel protector in place, to the left heel. A left heel dressing was in place and dated 01/30/24. Interview on 01/30/24 at 2:35 P.M. with LPN #140 revealed on she saw a dressing in place to Resident #6's left foot on 12/21/23. LPN #140 confirmed she received a written warning on 12/26/23 for not completing a dressing change on 12/21/23 as the dressing on left heel on that date was noted to have been from 12/19/23. Interview on 01/30/24 at 2:55 P.M. with the Director of Nursing (DON) revealed nurses could assess and measure wound(s), then the unit manager does the comprehensive initial assessment of wound(s) the next day. The unit manager was expected to take a picture per policy, have a baseline for that area, measure the wound, and if the wound was really bad notify the wound NP to see if they could come in that day, or get a different order. The DON stated she was not sure how/why the left heel pressure ulcer was identified as an unstageable wound the first time assessed. Interview on 01/30/24 at 4:34 P.M. with LPN #113 confirmed she worked on 12/25/23 as a State Tested Nursing Assistant (STNA) and helped with Resident #6. LPN #113 reported Resident #6's had a dressing to left heel she believed was dated 12/19/23. LPN #113 reported she changed it immediately and let LPN #140 know to document it. Interview on 01/31/24 at 10:38 A.M. with the DON confirmed the Braden Scale for Predicting Pressure Sore Risk dated, 12/07/23 was not accurately completed for the resident. The moisture section was scored as rarely moist when Resident #6 was always incontinent of stool. The DON reported she should have scored the moisture section as occasionally moist due to the resident being always incontinent of bowel. Interview on 01/31/24 at 3:05 P.M with Wound Nurse Practitioner (NP) #160 revealed he comes to the facility once a week to round with unit manager on wounds. Wound NP #160 reported he sees Resident #6 for wounds. Wound NP #160 reported he usually orders both heel protectors, not just one. Review of Resident #6's [NAME] dated 01/30/24 revealed Resident #6 was to wear bilateral heel protector. Interview on 02/01/24 at 7:57 A.M. with Resident #6's daughter revealed she did not know about the resident's left heel wound until 12/19/23 and at that time none of the nurses or aides knew anything about it. On 12/25/23 she saw the resident had a heel dressing in place that was dated 12/19/23. Interview on 02/01/24 at 10:04 A.M. via telephone with RN #148 confirmed she received a write up (disciplinary action) for not completing a dressing change on 12/23/23. RN #148 reported she signed the TAR indicating she did the dressing change. The RN confirmed the dressing on the left heel was dated 12/19/23. Interview on 02/01/24 at 1:33 P.M. with the DON confirmed the treatments/orders were not completed on the dates noted above as ordered when nursing staff failed to document the completion. Interview on 02/01/24 at 8:32 A.M. with Regional Quality Assurance Nurse (RQAN) #139 confirmed the [NAME] (nursing worksheet that includes patient information) dated 01/30/24 showed the resident was to use bilateral heel protectors. On 01/31/24, RQAN #139 changed the [NAME] to reflect only the use of a left heel protector. b. In addition, review of an incident report dated 11/21/23 revealed two open areas noted to the left buttock of Resident #6. The medical record contained no evidence of the wound being assessed until 11/28/23. Review of the Weekly Skin -Total Body Evaluation completed on 11/23/23 and on 11/30/23 reflected Resident #6 did not have any wounds. Review of the wound note, completed by Wound Nurse Practitioner (NP) #160, dated 11/28/23 revealed the resident was seen for a left buttock abrasion that measured 6.2 centimeter (cm) long by (x) 11.0 cm wide x 0.1 cm deep. Wound bed composed of 80% granulation tissue and 20% shallow pink tissue. Elipitical shaped area of shearing type injury. Treatment was ordered to apply zinc oxide cream, change, and apply treatment every shift and as needed (PRN). The NP did not stage the ulcer at that time. Review of the physician orders for Resident #6, dated 11/2023 revealed no orders were in place for the treatment of the left buttock. Review of the Treatment Administration Record (TAR) for November 2023 revealed the treatment for left gluteal fold medial (left buttock abrasion) was not completed as ordered by Wound NP #160. Review of Resident #6's TAR for December 2023 revealed a treatment to Resident #6's left buttock was not completed until 12/27/23. Review of the physician orders dated 12/27/23 revealed orders for left gluteal fold medial to cleanse with normal saline, pat dry, apply zinc oxide to wound bed every shift and PRN for abrasion healing. Review of the December TAR 2023 revealed on 12/27/23 a treatment was in place for left gluteal fold medial to cleanse with normal saline, pat dry, apply zinc oxide to wound bed every shift and PRN for abrasion healing. Review of Resident #6's Wound Care evaluation dated 01/30/24 revealed the left superior buttock abrasion was improving/healing and measured 0.5 cm x 0.7 cm x 0.1 cm with shallow pink tissue seen at the wound base as of this date. Interview on 01/31/24 at 10:38 A.M. with the DON confirmed the Weekly Skin -Total Body Evaluation completed on 11/23/23 and on 11/30/23 reflected Resident #6 did not have any wounds which she stated was not accurately completed. The DON confirmed Resident #6 had a left buttock wound on 11/21/23. Interview on 01/31/24 at 2:35 P.M. with DON and Regional Quality Assurance Nurse (RQAN) #139 confirmed there were no orders in place for the left buttock treatment from the development of the wound on 11/21/23 through 12/27/23. RQAN #139 reported the orders were never completed and therefore did not come across to the TARS. Interview on 01/31/24 at 3:05 P.M. with Wound Nurse Practitioner (NP) #160 via phone revealed he comes to the facility once a week to round with unit manager on wounds. Wound NP #160 reported he sees Resident #6 for wounds. Wound NP #160 reported he was not aware the treatment to Resident #6's buttocks was not completed as ordered. Wound NP #160 confirmed he saw Resident #6 on 11/28/23 for the wound to left buttock and treatment provided at that time. Review of the facility policy, Skin Care Program, revised 01/24/23, revealed it is the responsibility of the Center's Nursing staff to follow the plan of care (POC) and prevent and or promote healing of skin issues unless they are clinically unavoidable. When a new skin issue is noted, the nurse will measure the area initially and then every 7 days until healed. This deficiency represents non-compliance investigated under Complaint Number OH00149710.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, review of an incident report, review of witness statements, review of the mechanical lift user manual, facility policy review, review of the nursing staff schedule, review of a disciplinary form and interview, the facility failed to properly operate a mechanical lift during a transfer of Resident #48. Actual harm occurred on 09/22/23 at approximately 4:00 P.M. when a mechanical lift was used by one-staff member instead of two-staff members, as care planned and per the facility policy, resulting in Resident #48 sustaining a left tibia and left fibula fracture and visit to the emergency room. Subsequently, Resident #48 suffered from severe pain to the left leg resulting in an interference of physical activity. This affected one (Resident #48) of three residents reviewed for mechanical lift transfers. The census was 57. Findings include: Review of the medical record for Resident #48 revealed an admission date of 12/29/22 with diagnoses of need for assistance with personal care, diabetes, end stage renal disease, bipolar disorder, post-traumatic stress disorder and dependence on renal dialysis. Review of the activities of daily living (ADL) care plan dated 03/01/23 revealed Resident #48 had an ADL self-care performance deficit related to activity intolerance, impaired balance and limited mobility. An intervention included to transfer with a Hoyer (mechanical) lift with two-staff. Review of the Minimum Data Set (MDS) 3.0 quarterly assessment dated [DATE] revealed Resident #48 was cognitively intact, was totally dependent on two-persons physical assist with transfers and utilized a wheelchair for mobility. Review of the physician orders from September 2023 revealed Resident #48 was ordered to transfer by a Hoyer lift. The order began on 12/31/22. Review of the nursing progress note dated 09/22/23 timed 7:13 P.M. authored by Registered Nurse (RN) #2 revealed Resident #48 complained of pain to the left knee after transferring back to bed. The Nurse practitioner (NP) was notified and ordered an x-ray. Review of the knee radiology report dated 09/23/23 revealed Resident #48 had marked osteoarthritis of the left knee. Review of the nursing orders administration note dated 09/23/23 timed 11:30 P.M. revealed Resident #48 was administered one tablet of Hydrocodone-Acetaminophen (Norco) orally 5-325 milligrams (mg) (an opioid pain medication) per complaints of left knee pain. Review of the nursing orders administration note dated 09/24/23 timed 6:05 A.M. revealed Resident #48 was administered one tablet of Norco orally 5-325 mg per complaints of left knee pain. Review of the nursing progress note dated 09/26/23 revealed Resident #48 refused a shower stating, I didn't want one because my leg is in too much pain. Review of the physician orders from September 2023 revealed Resident #48 was ordered Diclofenac Sodium Gel 1% (Voltaren gel) apply to left knee topically every day and every shift for pain for seven days. The order began 09/26/23. Review of the nursing progress note dated 09/28/23 revealed a new order was given for Tylenol 650 mg orally every four hours as needed for pain. Resident #24 stated that she felt more pain relief when taking the Tylenol than when she took the as needed Norco. Review of the NP progress note dated 09/29/23 authored by NP #5 revealed Resident #48 was visited and physical exam for left leg pain was completed. Resident #24 complained of acute pain from knee to ankle which started when being transferred over the weekend. Resident #24 was given Voltaren gel without relief. Resident #24 was unable to specify if calf pain, stated it all hurts. The plan indicated stat (immediate) x-ray of left knee and ankle, venous duplex (type of ultrasound used to measure blood flow) left leg and ibuprofen 600 mg twice a day for three days. Review of the radiology results report of the knee dated 09/29/23 revealed Resident #48 had an acute impacted fracture present at the proximal tibia without significant displacement and a nondisplaced proximal fibular fracture was present. The conclusion indicated an acute proximal tibia and fibular fracture. Review of the nursing progress note dated 09/29/23 timed 7:32 P.M. revealed Resident #48 had an x-ray of left knee due to chronic pain. The results showed an acute proximal tibia and fibular fracture. The NP was called and gave orders to send Resident #48 to the emergency room. The writer called an ambulance company, and they did not have anything available on this date and said to try back tomorrow. Another ambulance company was called, and they said to call back in three hours. The writer called the NP who indicated it would be okay to send Resident #48 to emergency room tomorrow. Review of the nursing progress note dated 09/29/23 timed 9:25 P.M. revealed Resident #48 stated the Norco was not effective for the pain. The nurse spoke to the on-call NP who gave orders to send Resident #48 to the emergency room via emergency medical services (911) for uncontrolled pain. Review of the nursing progress notes dated 09/29/23 timed 9:30 P.M. revealed the squad arrived to transport Resident #48 to emergency room. At 9:45 P.M. the squad left with Resident #48 and the nurse called report to hospital emergency room. Review of the transfer form assessment dated [DATE] timed 9:30 P.M. revealed Resident #48's pain level was an eight out of 10 to the left lower leg. Review of the injury incident report for Resident #48 dated 09/29/23 timed 7:00 P.M. authored by the Director of Nursing (DON) revealed Resident #48 reported increased pain to the left lower extremity. No noted bruising or swelling. An x-ray showed tibia and fibula fracture. Resident description: it started when [STNA #1] was putting me back to bed. My knee bent too much. Resident #48 reported a pain level of seven out of 10. Review of the nursing progress note dated 09/30/23 timed 4:07 A.M. revealed the hospital emergency room called and Resident #48 would be returning. Resident #48 had a left proximal tibia and fibula fracture and would come back with an immobilizer on. Review of the nursing progress note dated 09/30/23 timed 11:17 A.M. revealed Resident #48 returned from the emergency room at 11:00 A.M. with a prescription for pain medication faxed to pharmacy and knee immobilizer on left knee. Review of the hospital emergency department discharge instructions dated 09/30/23 timed 12:44 A.M. revealed Resident #48 was diagnosed with a closed fracture of the left tibia and fibula. Resident #48 was ordered Percocet 5 mg-325 mg oral tablet by mouth every six hours for three days. Review of the Medication Administration Record (MAR) from September 2023 revealed Resident #48 received Norco 5-325 mg one tablet as needed for pain on 09/22/23 at 4:41 P.M., on 09/22/23 at 10:53 P.M. for a pain level of 10, on 09/23/23 at 10:11 A.M., 4:11 P.M. and 10:30 P.M., on 09/24/23 at 6:05 A.M., on 09/25/23 at 11:56 A.M., on 09/25/23 at 8:04 A.M. for a pain level of 10, on 09/26/23 at 10:19 A.M., on 09/27/23 at 4:00 P.M. and on 09/30/23 at 7:41 P.M. Resident #48 did not have Norco administered from 09/12/23 through 09/21/23. Review of the Treatment Administration Record (TAR) from September 2023 revealed Resident #48 had Voltaren gel applied twice a day to her left knee on 09/26/23, 09/27/23, 09/28/23 and 09/29/23. Review of the nursing progress note dated 10/02/23 timed 9:52 A.M. revealed Resident #48 was status post left tibia and fibula fracture. Resident had not complained of any pain. Resident remained on Percocet 5-325 mg every six hours for three days. Resident remained in an immobilizer. Review of the nurse practitioner progress note dated 10/02/23 authored by NP #5 revealed Resident #48 was seen for post emergency room visit and physical exam for tibia/fibula fracture. Repeat x-rays were ordered on 09/29/23 for continued pain to left lower leg. X-ray reports on 09/29/23 noted proximal tibia and fibula fracture to the left leg. Resident #48 was sent to the emergency room for evaluation and returned with immobilizer, Percocet and follow up with orthopedic physician. Resident #48 stated leg was feeling much better with immobilizer and Percocet. Rated pain a two out of 10 to left lower leg. Resident #48 was asked again to explain what happened during transfer on 09/22/23. Resident #48 stated she was transferring via Hoyer lift with aide and stated she bent left leg too far. Denied leg being twisted or hit on anything. The noted indicated NP #5 spoke with STNA #1 who said she pushed Resident #48's shin back slightly toward the resident so that she could move foot around Hoyer lift pole. STNA #1 heard a crack sound. Review of the pain assessment dated [DATE] revealed Resident #48 had a fracture to the tibia and fibula, was able to communicate and could articulate pain and had left lower extremity pain with movement. The pain was described as intermittent and sharp moderate pain. The pain interfered with the resident's physical activity. Percocet was changed from routine to as needed every eight hours for seven days. Review of the orthopedic physician note dated 10/05/23 revealed Resident #48 had a left tibia and fibula fracture. Resident #48 was ordered for left lower extremity to be non-weight bearing, brace could be removed for bathing, monitor daily for skin integrity due to medical history and to follow up in three weeks. Review of the MAR from October 2023 revealed Resident #48 was administered one tablet of Percocet 5-325 mg as needed on 10/02/23 at 9:33 P.M. for a pain scale of seven, on 10/03/23 at 7:03 A.M. for a pain scale of seven, on 10/04/23 at 12:19 A.M. for a pain scale of seven, on 10/04/23 at 7:49 P.M., on 10/05/23 at 9:05 A.M., on 10/06/23 at 8:05 A.M., on 10/08/23 at 12:52 A.M., on 10/09/23 at 5:50 A.M. and 2:13 P.M., on 10/23/23 at 2:59 P.M., on 10/24/23 at 12:34 P.M., on 10/25/23 at 7:46 P.M., on 10/29/23 at 1:00 P.M. and on 10/30/23 at 3:40 P.M. for a pain scale of seven. Review of nurse and STNA schedule from 09/22/23 revealed STNA #1 was assigned to care for Resident #48 from 7:00 A.M. to 7:00 P.M. Review of the witness statement dated 10/02/23 authored by STNA #1 revealed, while hoyering (mechanical lift) a resident alone, her legs ended up on opposite sides of hoyer lift. I then pulled hoyer pad back to get her positioned correctly to place in bed and got her into bed. Review of the witness statement dated 09/30/23 authored by the DON revealed the DON was in facility to interview Resident #48 after receiving notification of fracture to Resident #48's left tibia and fibula. Upon entering room, Resident #48 was in bed, watching television, talking on the phone. No signs or symptoms of acute distress, no objective signs, or symptoms of pain. Resident #48 stated that last week during a Hoyer transfer when STNA #1 was pulling her back, she hit her knee on the middle pole of the Hoyer. The DON inquired if a second STNA was present, and the resident said no. The DON also inquired if resident was in pain, resident stated that she was in pain and rated pain at a seven out of 10. Resident #48 denied swelling or bruising to her left lower extremity over the past week. Treatment options were discussed and Resident #48 was agreeable to waiting for transfer as non-emergent transport was not available at this moment. Resident #48 stated that she wouldn't mind waiting if she could be given something stronger than Norco for pain as he did not feel that Norco was effective. The NP was called and indicated if Resident #48 was in that much pain, call 911 to transfer. Emergency Medical Services was notified and resident was sent to hospital emergency room. Interview on 10/24/23 at 12:40 P.M. with STNA #1 revealed around 4:00 P.M., STNA #1 used the mechanical lift without another staff member to transfer Resident #48 from her motorized wheelchair to bed after the resident returned from dialysis. Resident #48's left foot got caught on the mechanical lift middle bar, so STNA #1 had a hold of the resident/mechanical lift pad with one hand and used her other hand to move the resident's legs around the pole. STNA #1 stated she did not bend the resident's legs back. After the transfer to the bed, Resident #48 complained of being sore however that wasn't unusual for the resident to complain of pain as the resident tended to have leg pain. STNA #1 verified she operated the mechanical lift without another staff member present and verified a mechanical lift was supposed to be operated with two staff members when transferring a resident. Observation on 10/24/23 at 12:50 P.M. revealed Resident #48 was lying in a bariatric bed, feeding herself lunch and watching television. Interview, during the observation, with Resident #48 revealed STNA #1 used the mechanical lift to transfer her from her motorized wheelchair to bed. STNA #1 had Resident #48 in a funky position during the transfer and the resident's left leg get bent all the way back by the rectangle metal bar. Resident #48 explained that she had to be rolled during incontinence care and every day after the incident the pain worsened during rolling to complete incontinence care. Resident #48 rated her pain level ranging from five to nine out of 10 after the incident and stated her pain was pretty severe. Resident #48 stated one day she had to end dialysis early because of being in too much pain after the incident. Resident #48 verified STNA #1 transferred her using the mechanical lift without another staff member present when the injury occurred. Interview on 10/24/23 at 1:35 P.M. with RN #2 revealed the day Resident #48 was transferred back to bed via the mechanical lift with only STNA #1 present, Resident #48 stated, when I was getting into bed, I pulled a muscle in my knee. At the time, RN #2 wasn't aware that STNA #1 used the mechanical lift alone and that the transfer was incorrectly completed. Interview on 10/24/23 at 2:50 P.M. with the DON verified on 09/22/23 STNA #1 completed Resident #48's mechanical lift transfer without another staff member resulting in Resident #48 sustaining a left leg tibia and fibula fracture. The DON also revealed it was her expectation and the facility policy for two staff members to complete a resident mechanical lift transfer. Observation on 10/31/23 at 8:25 A.M. with the DON revealed Resident #48 was wearing a soft leg immobilizer on her left leg extending from above her left knee to above left ankle. Review of the facility's Hoyer lift/mechanical lift policy revised 04/16/23 revealed it was the facility's policy to provide appropriate use of mechanical lifts and to utilize two staff members. Review of the facility's Transferring Using a Mechanical Lift Machine policy dated 09/28/23 revealed at least two nursing assistants (or other licensed and trained staff) were needed to safely move a resident with a mechanical lift. Review of the 2018 mechanical lift user manual for Reliant 600 revealed it was recommended that two assistants be used for all lifting preparations and transferring to/from procedures. Review of the disciplinary written warning form dated 10/02/23 revealed STNA #1 was issued a written warning due to substandard job performance. On 09/22/23, STNA #1 transferred resident from power chair to bed. She did not follow facility policy and procedure of using two staff for all mechanical lift transfers. Resident subsequently sustained an injury to her left knee and reported increase in pain to the area. This deficiency represents non-compliance investigated during the investigation of Complaint number OH00147265.