**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, review of emergency room records, review of the facility incident and accident logs, interview and facility policy review, the facility failed to develop and implement a comprehensive and individualized fall prevention program to prevent falls including a fall with major injury for Resident #60. Actual Harm occurred on 09/04/24 at 7:45 P.M. when Resident #60, who was identified as a high fall risk and experienced recent falls without individualized fall prevention interventions implemented to prevent further falls, climbed out of bed, unassisted and had to be lowered to the floor by State Tested Nursing Assistant (STNA) #222 when she became unsteady and began to fall. The resident denied pain on 09/04/24 and was assisted back to bed; however, on 09/05/24 at 8:29 A.M. an order was received for an immediate (STAT) x-ray of the right hip, pelvis, femur and knee due to complaints of increased pain. On 09/05/24 at 1:00 P.M. the facility was notified the resident had acute fractures of the distal femur and proximal tibia (as a result of the incident on 09/04/24) and was transferred to the emergency room (ER) for further evaluation and treatment. This affected one resident (#60) of three residents reviewed for falls. Findings Include: Review of the medical record for Resident #60 revealed an admission date 12/21/19 with diagnoses including heart failure, muscle weakness, depression, dementia, osteoporosis, osteopenia, and syncope. Resident #60 was receiving hospice services for end stage heart failure. Review of Resident #60's at risk for falls/injury related to cognitive impairment, dizziness, history of falls, impaired balance, pain, osteoporosis, syncope related to aortic stenosis, poor safety awareness with impulsiveness noted at times care plan dated 01/06/20 revealed interventions including to encourage the resident to change positions slowly due to dizziness dated 01/06/20, room moved to a higher traffic area on 02/14/24, staff to anticipate needs dated 01/06/20, visual reminders to utilize call light for assistance dated 02/17/24, proper footwear to be worn at all times while out of bed dated 06/15/24, encourage non-skid/gripper socks when shoes are off dated 01/06/20, a personal alarm bed/chair to alert staff of unassisted transfer check for placement and function every shift was implemented on 07/07/24 and a fall intervention for a medication review completed by hospice was implemented on 07/29/24. Review of the physician orders dated 07/07/24 revealed an order for a personal alarm bed/chair to alert staff of unassisted transfers. Check for placement and function every shift (alarms to sound to walkies and computer only as to be non-disruptive.) Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] Resident #60 had severely impaired cognition and required minimal assistance with transfers, ambulated with the assist of a walker and stand-by assist from staff, and moderate assist with activities of daily living (ADL) tasks. Review of the facility incident logs dated 07/01/24 to 09/30/24 revealed Resident #60 had witnessed falls on 08/26/24 and 09/04/24, and unwitnessed falls on 07/07/24, 07/21/24, 07/28/24, and 07/29/24. Review of Resident #60's fall investigations revealed the following: A fall on 07/07/24 at 9:46 A.M. revealed Resident #60 was observed by a visitor to be sitting on the floor inside the room with her back against the side stand with the walker noted in the doorway to the bathroom. Resident #60 stated she struck her head on the side stand when she fell. There was no redness or swelling observed to the left side of the head. A fall intervention for the use of a bed/chair alert alarm pad was implemented. Review of the Post-Fall Risk assessment dated [DATE] revealed the resident was determined to be a high fall risk. A fall on 07/21/24 at 10:25 P.M. revealed Resident #60 was observed on her knees at her bedside. Resident #60 sated she had been ambulating and fell onto buttocks and bilateral knees. Resident #60 complained of pain to her bilateral knees and buttocks. Resident #60 was able to move all extremities. Resident #60 was placed into the recliner with the alert bed/chair alarm in place. There was no fall interventions implemented following the fall. A fall on 07/28/24 at 11:50 A.M. revealed Resident #60 was observed sitting on the floor beside the recliner with her back against a suitcase and the bookshelf. Resident #60 complained of pain to her back and a bruise was noted to be forming on the lower back from falling on the suitcase. There was no mention of the alert bed/chair alarm to be sounding at the time of the fall. A fall intervention for a medication review to be completed by hospice was requested. A fall on 07/29/24 at 3:44 P.M. revealed Resident #60 was observed sitting on the floor with her legs drawn up between the bookshelf and the recliner with her walker tipped over. Resident #60 was observed with a hematoma forming to the right side of her forehead. Resident #60 did not have appropriate footwear in place. The fall intervention implemented was for a medication review to be completed by hospice. The medication review was completed on 07/30/24 with no new orders or changes to the resident's medications. A fall on 08/26/24 at 11:20 P.M. revealed Resident #60 was ambulating unassisted with her walker, in the hallway. Resident #60 stopped ambulating and fell backwards onto the floor forcefully striking the back of her head on floor. Upon assessment a large lump was palpated to the left back of her head and her blood pressure and pulse were elevated. Resident #60 complained of pain to her head. Resident #60 had appropriate footwear in place. There was no mention of the alert bed/chair alarm sounding. Resident #60 was sent to the hospital for further evaluation and possible treatment. There was no fall interventions implemented following the fall. Review of Resident #60's emergency room paperwork dated 08/26/24 revealed Resident #60 was diagnosed with an acute right posterior head contusion and returned to the facility. A fall on 09/04/24 at 7:45 P.M. revealed Resident #60 was observed by State Tested Nursing Assistant (STNA) #222 standing at her bedside, unassisted, with the alert alarm sounding. Resident #60 became unsteady and started to slide downwards. STNA #222 assisted Resident #60 down to the floor, in a seated position with her legs extended outwards. Resident #60 was assessed for injury by Registered Nurse (RN) #259. There were no indication of injury and Resident #60 denied pain. Resident #60 was assisted off the floor and into a wheelchair, taken to the restroom and then assisted back into bed. There was no fall intervention implemented following the fall. The facility was unable to provide evidence the falls were reviewed to determine a root cause, identify a trend or to ensure appropriate, individualized fall prevention interventions were added to the resident's plan of care for the falls dated 07/29/24 (a duplicate intervention to the fall that occurred on 07/28/24), 08/25/24 and 09/04/24. Review of the nurse progress note dated 09/05/24 at 8:29 A.M. (the first progress note entry after the resident's fall on 09/04/24) revealed an order was received for STAT x-rays to the right hip, pelvis, femur and knee due to complaints of increased pain. On 09/05/24 at 1:00 P.M. the facility was notified (by the x-ray company) the resident sustained acute fractures of the distal femur and proximal tibia and was transferred to the emergency room (ER) for further evaluation and treatment. Review of Resident #60's emergency room documents, dated 09/05/24, revealed Resident #60 was diagnosed with a displaced fracture the distal (lower) right femur, a fracture of the neck of the right fibula, and a possible fracture line of the right tibial plateau per x-ray of right leg and pelvis. Resident #60's Power of Attorney (POA) requested to not pursue any surgical intervention for the fractures given Resident #60's severe medical problems. Review of Resident #60's Treatment Administration Record dated 09/01/24 to 09/05/24 revealed documentation of completion for monitoring the personal alarm to the bed/chair to alert staff of unassisted transfers, check for placement and function every shift. Observation on 09/30/24 at 10:00 A.M. revealed Resident #60 resting in bed with an alert alarm pad in place, a visual reminder to use the call light, and her call light was within reach. Interview on 10/01/24 at 10:07 A.M. with the Director of Nursing (DON) revealed Resident #60 was at high risk for falls due to a history of falls, unsteady gait, dementia, and being restless at times. The DON stated Resident #60 was ambulatory with the use of a walker and would ambulate in the hallways of the facility with staff assistance. At times, Resident #60 would not be content to sit in the recliner or lay in bed and would be known to pack her suitcase with her belongings, verbally stating she wanted to leave the facility. She also shared the resident was known to have increased restlessness in the evening/nighttime and she had observed this when she sometimes worked the evening shift on the floor. The facility had moved Resident #60 from her original room on the back hallway to a room closer to the nurses' desk and on a higher trafficked hallway for better monitoring of Resident #60. The DON shared nurses were to assess the resident, check for injuries, complete paperwork and notifications. If the nurse could not determine an intervention to implement, they would contact the nurse on-call for ideas. The DON then stated the fall would be reviewed in the risk meeting to make sure the paperwork is completed, and an intervention had been implemented. Further interview revealed the resident had fallen on night shift, 09/04/24 and when she (the DON) worked the floor as an aide on 09/05/24, we (she did not indicate who the other staff was) went in to reposition Resident #60 for breakfast and she was complaining of her right leg hurting. The DON stated she had the nurse call (the physician) for X-ray orders. The X-rays were completed and that is how the facility learned the resident had fractures and she was sent to the ER for evaluation. Interview on 10/01/24 at 11:35 A.M. with RN #163 revealed the process for completing a post fall assessment, implementation of fall interventions and updating the fall care plans for residents had been the responsibility of RN #163 to help with the administrative nurse's workload but her administrative job responsibilities had been removed. Interview on 10/01/24 at 11:45 A.M. with the DON confirmed Resident #60 did not have fall interventions implemented for falls which occurred on 07/21/24, 07/28/24, 08/26/24 and 09/04/24. The DON stated there should be interventions implemented for each fall that occurs with a resident. Further interview with the DON revealed several nurses were assisting with the follow-up regarding falls and sometimes they did not have time to review the falls to ensure interventions are added to prevent future falls. During the onsite survey, attempts were made to reach STNA #222 via phone; however, no return call was provided. Review of the facility's policy titled, Accident/Incident Reporting last revised 08/13/14 revealed, Accidents and incidents are to be promptly and thoroughly reviewed and investigated. An incident is defined as an event, occurrence or happening that may result in actual or potential harm of a resident. The purpose of the incident reports are to facilitate the early detection problems or compensable events; to establish a foundation for early investigation of all potentially serious events; to develop a database for long-range problem detection, analysis and correction; to enable cross-reference with other risk detection systems; to investigate and respond to serious adverse events, in accordance with accrediting bodies standards. When an incident occurs, the individual discovering the incident will notify the supervisor immediately with observations or identification of the incident; follow-up with the resident and family/caregiver and resident's physician as indicated; Complete the Incident Report Form within 24 hours of the incident; the Administrator/Designee will review the incident report and request the necessary follow-up from the appropriate personnel. Corrective actions will be implemented and evaluated for effectiveness as indicated; A witness statement will be obtained, if applicable; Investigation will be completed, and findings will be documented.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, policy review and staff interview the facility failed to implement adequate skin risk interventions and treatment for Resident #5, who was cognitively impaired, at risk for pressure ulcer development and dependent on staff for turning and repositioning, to prevent the development of a pressure ulcer to the resident's left heel. Actual harm occurred on 05/21/23 when an order for skin prep was obtained for Resident #5's heels with no corresponding assessment or information related to why. On 05/24/23 the wound Certified Nurse Practitioner (CNP) assessed Resident #5 to have a Stage III (full-thickness loss of skin, in which adipose (fat) is visible in the ulcer. Slough and/or eschar may be visible) pressure ulcer to the left heel. However, treatment orders were not implemented until 05/31/23 (ten days after the ulcer was potentially first identified). This affected one resident (#5) of three residents reviewed for pressure ulcers. Facility census was 67. Finding include: Review of the medical record revealed Resident #5 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included fracture of left femur, pneumonia, type 2 diabetes mellitus, embolism and thrombosis of deep veins of left lower extremity, dementia, anxiety, and chronic kidney disease. Record review revealed a plan of care dated 02/03/21 reflecting Resident #5 was at risk for skin breakdown. Interventions included to encourage resident to turn and reposition, perform skin checks and report any new areas, assist with incontinence care, pressure redistribution mattress to bed, and apply treatment as ordered. The care plan did not include any pressure related interventions for the resident's heels. A Braden Scale for Predicting Pressure Ulcer Risk dated 03/16/23 revealed Resident #5 was at very high risk for the development of pressure ulcer. Clinical suggestions included to elevate heels off the bed, turn and reposition at least every two hours while in bed. Review of the treatment administration record (TAR) revealed on 05/21/23 the record was updated to include skin prep to be applied to Resident #5's heels and the resident's heels were to be floated. However, review of skin assessments and progress notes revealed no documentation/assessment(s) pertaining to Resident #5's heels at this time or any additional information related to why this order was initiated. A wound care note by the wound CNP dated 05/24/23 revealed Resident #5 had a new Stage III pressure ulcer to the left heel that measured 3.5 centimeter (cm) long and three cm wide. The note revealed the wound was to be cleansed and patted dry, and alginate (highly absorbent, antimicrobial dressing) was to cover the wound bed and then cover with adhesive foam dressing three times a week. Review of the TAR revealed no evidence of this treatment being initiated at that time. Review of a facility wound evaluation flow sheet completed by the Assistant Director of Nursing (ADON), dated 05/30/23 revealed Resident #5 had an in-house pressure ulcer to left heel that measured 3.2 cm long and 3 cm wide. The current treatment initiated on 05/30/23 revealed for silver alginate to be applied and the wound covered with an abdominal (ABD) dressing. The evaluation revealed Resident #5's heels were to be floated. Review of the TAR revealed the first treatment with alginate and was documented as being completed on 05/31/23. Review of the significant change Minimum Data Set (MDS) 3.0 assessment, dated 08/01/23 revealed Resident #5 had severe cognitive impairment and required extensive assistance from two staff for bed mobility and transfers. A plan of care, dated 08/09/23 revealed Resident #5 had open areas. Interventions included to apply treatment to area as ordered, encourage to elevate heels while in bed and encourage to turn and reposition. The most current wound care note, dated 08/15/23 revealed Resident #5 had an unstageable pressure ulcer to left heel that measured 1.2 cm long by one cm wide. An order for wound care revealed the area was cleansed and patted dry; apply alginate cut to cover the wound bed and then cover with an adhesive foam dressing three times a week on Tuesday, Thursday, and Saturday. On 08/24/23 at 8:21 A.M. Resident #5 was not observed in her room. An air mattress was observed and was in place and functioning to the resident's bed and pressure relieving boots were observed placed in a chair in the room. On 08/24/23 at 1:28 P.M. Resident #5 was observed laying in bed. One pressure relieving boot was noted to be in a chair in Resident #5's room. On 08/28/23 at 8:04 A.M. Resident #5 was observed in the dining room sitting in a wheelchair with pressure relieving boots in place to both feet. There was no physician order for the use of the pressure relieving boots and staff did not document the application of the boots on the administration record for the resident. Interview on 08/28/23 at 4:49 P.M. with the facility Corporate Nurse (CN) verified there was no documentation of Resident #5's heels being floated prior to 05/21/23. The CN verified there was no documentation of an assessment or what Resident #5's heels looked like on 05/21/23 when the order was received to apply skin prep and float heels. The CN also verified the order from the wound CNP on 05/24/23 was not implemented until 05/31/23. Review of the Wound and Skin Care Policy and Procedure dated 06/07/16 revealed treatment would be initiated as ordered by the physician. A Stage III pressure ulcer was defined as a full thickness of skin loss with exposed subcutaneous tissue with may include or be covered by necrotic tissue. The wound presents as a deep crater with or without undermining. This deficiency represents non-compliance investigated under Complaint Number OH00145762.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of hospital records, review of a fall investigation, facility policy review and resident and staff interview the facility failed to provide timely and effective pain management for Resident #35 following a fall with injury. Actual harm occurred on 09/15/20 at 2:15 P.M. when Resident #35, who exhibited moderate cognitive impairment and required extensive staff assistance for activities of daily living, sustained a fall with verbalization of pain, guarding to the right hip and an inability to bear weight following the incident. The facility failed to provide effective pain management/pain medication to the resident following the incident or notify the physician of the pain level. The resident was assessed to have pain rated a seven out of 10 on a scale from one to ten with ten being the worst pain and did not consume dinner on 09/15/20. The resident was subsequently diagnosed with a displaced fracture to the right hip which required surgical intervention. The resident was transported to the hospital on [DATE] at 9:15 P.M. (seven hours after the fall occurred). Hospital records revealed the resident's pulse was elevated at 101 beats per minute on 09/15/20 at 11:09 P.M. and upon physical examination, the resident was noted to be uncomfortable with a complaint of right hip pain with any attempted motion. The resident was medicated with narcotic pain medication in the hospital. This affected one resident (#35) of one resident reviewed for pain management. Findings include: Review of Resident #35's medical record revealed an original admission date on 04/13/20 and readmission on [DATE] with diagnoses including acute cystitis (urinary tract infection) without hematuria (blood in urine), cognitive communication deficit, lack of coordination, chronic kidney disease, spondylosis (a general term for age-related wear and tear of the spinal disks) in the lumbar region, prostate cancer, chronic atrial fibrillation, low back pain, bilateral osteoarthritis of hip, weakness, abnormalities of gait and mobility, presence of neurostimulator, essential tremor, ataxia (a lack of muscle control or coordination of voluntary movements such as walking), and a history of falling. Review of Resident #35's care plan, dated 07/24/20 and revised on 08/02/20 revealed the resident was at risk for pain. The plan revealed staff should administer medication as ordered and per the resident's preference and request. The resident should be assisted with repositioning as needed. Alternative pain relief measures should be attempted to include a back rub, relaxation, repositioning, exercise, or music prior to administering any PRN (as needed) medications. The physician should be consulted as needed related to the resident's pain. The resident should be observed for any signs or symptoms of pain, including any nonverbal signs of pain such as facial grimacing, restlessness, or grabbing an effected area. Therapy services as ordered by the physician. Review of the admission Minimum Data Set (MDS) 3.0 assessment, dated 07/24/20 revealed Resident #35 had a Brief Interview for Mental Status (BIMS) score of 11 which reflected mild cognitive impairment. The assessment revealed the resident required extensive assistance from two staff to complete tasks including bed mobility and toileting and was totally dependent on two staff to complete transfers. The resident was not assessed for walking in his room due to the activity not occurring however, the resident was assessed to be unsteady and required staff assistance to stabilize when he moved on and off the toilet or completed a surface-to-surface transfer, for example transferred from his bed to a chair or wheelchair. Review of physician's orders for Resident #35, for September 2020 revealed an order, initiated on 09/15/20 at 8:00 A.M. for Norco (a narcotic pain medication) 5-325 milligrams (mg) with instructions to administer the medication orally once daily for three days and then discontinue. The resident also had an order for Acetaminophen 650 mg with instructions to administer the medication orally three times daily for pain. Lastly, the resident had an order for Acetaminophen 650 mg with instructions to administer the medication orally every eight hours as needed for pain. The resident had an additional order to be monitored for any signs or symptoms of verbal or nonverbal pain every shift. Review of Resident #35's Medication Administration Record (MAR) from 09/01/20 to 09/30/20 revealed the resident received a dose of Norco 5-325 mg on 09/15/20 upon rising in the morning. The resident also received three doses of Acetaminophen 650 mg as routinely ordered on 09/15/20. There was no additional pain medication administered to the resident on 09/15/20. There was no documentation confirming whether the medication was effective in controlling the resident's pain. The resident was monitored for signs and symptoms of verbal and nonverbal pain in the morning on 09/15/20 and reported a pain level of five out of ten with ten being the worst pain. The resident was noted to be hospitalized during the night shift observation. Review of Resident #35's nursing progress notes revealed on 09/15/20 at 2:15 P.M. the resident had a fall while attempting to ambulate to the restroom without assistance. The resident was assessed by Licensed Practical Nurse (LPN) #22. The resident was noted to be guarding the area and stated he was having pain in his right hip area. The resident was not able to bear a lot of weight to his right leg. Neurological checks were initiated. Additionally, red areas were noted to the resident's left temple and right side of his head at his hairline. The resident's sister, the Director of Nursing (DON), and physician were notified of the fall and a new order was received for a STAT (immediate) x-ray of the resident's right hip/femur (thigh bone) area. There was no additional documentation in the nurse's notes regarding resident's pain level or status. Review of a written statement from LPN #22 dated 09/15/20, no time provided revealed the nurse responded to Resident #35's room at approximately 2:15 P.M. Upon entering, the resident was found sitting on the floor. The resident stated he was going to the bathroom. The note revealed the resident complained of right hip pain but after he was repositioned in his recliner, facial grimacing and guarding subsided and the resident stated the pain lessened. The resident received routine Norco medication (earlier that morning as scheduled) and routine Tylenol on this date. There was no additional documentation showing the resident was repositioned (or any other non-pharmaceutical interventions were utilized) more than one time when the fall occurred. Review of Resident #35's vital signs on 09/15/20 at 3:03 P.M. revealed the resident was assessed by staff using the Wong-Baker faces pain scale (a nonverbal pain scale). The scale ranges from zero to two with two being the highest indication of pain. The resident was assessed at a one for negative vocalization (occasional moan or groan or low level of speech with a negative quality), a two for facial expression (facial grimacing), a two for body language (rigid, fists clenched, knees pulled up, pulling or pushing away, striking out), and a two for consolability (unable to console, distract or reassure). These scores added together determined a pain level of seven out of ten with ten being the worst pain. There was no additional pain level/assessment documented on 09/15/20 after 3:03 P.M. There was no evidence the physician was contacted to discuss the resident's pain level. Review of Resident #35's meal intakes on 09/15/20 revealed the resident ate 75% to 100% at breakfast and lunch (documented at 1:38 P.M. and 1:39 P.M.). The resident's intake decreased to zero to 25% at dinner (documented at 6:37 P.M.). Review of Resident #35's neurological checks on 09/15/20 from 2:20 P.M. to 8:05 P.M. revealed staff completed checks every 15 minutes for one hour, every 30 minutes for two hours, and every hour for three hours. The resident's blood pressure was 136/72 and his pulse was 86 at 2:20 P.M. At 4:05 P.M., the resident's blood pressure had increased to 144/72. At 5:05 P.M., the resident's blood pressure had increased to 146/66 and his pulse was 88. The resident's pain level was not assessed during any of the neurological checks. Review of Resident #35's fall scene investigation report, completed by LPN #8 and reviewed by the Assistant Director of Nursing (ADON), Social Services (SS) #77, Registered Nurse (RN) #6, the Administrator, and the Director of Nursing, dated 09/15/20 at 2:40 P.M., revealed on 09/15/20 at 2:15 P.M., the resident had an unwitnessed fall while ambulating alone to the bathroom in his room. The resident lost his balance, slipped, and appeared to become weak. The resident was alert and oriented. The investigation did not include any information related to addressing the resident's pain. The resident was not immediately taken to the hospital. The resident was educated on using his call light and waiting for staff to assist him. The Falls Team Meeting Notes at the end of the report stated a STAT (immediate) right lower extremity/hip x-ray was obtained and positive for a proximal femoral neck fracture. The resident was sent to the emergency room, admitted to the hospital, and was pending surgery. Record review revealed no Pain Assessment 3.0 was completed in the electronic charting system at the time of the incident. On 09/15/20 at 8:00 P.M. (nearly six hours after the resident's fall), the mobile x-ray provided arrived at the facility to complete the ordered hip and femur x-rays. Review of Resident #35's x-ray report, electronically signed on 09/15/20 at 8:32 P.M., revealed the findings included an oblique displaced fracture through the neck of the proximal right femur. There was limb retraction or cranial migration by approximately one centimeter (cm). On 09/15/20 at 8:50 P.M. (nearly seven hours after the resident's fall), a report was received from the mobile x-ray provider that confirmed the resident had a proximal right femur fracture and an order was received to send the resident to the emergency room. The Director of Nursing (DON), physician, and the resident's Power of Attorney (POA) were notified. On 09/15/20 at 9:15 P.M. Resident #35 was transferred to the hospital and remained hospitalized until 09/19/20. The resident returned to the facility on [DATE] at 1:50 P.M. with a 26 centimeter (cm) incision on his right hip with 17 staples. Review of the hospital information revealed the resident was administered Hydromorphone (used to treat moderate to severe pain) .5 mg per .5 milliliters (mL) intravenously one time. The resident had additional orders for Norco 5-325 mg every six hours as needed for pain, Acetaminophen 650 mg every four hours as needed for pain, and Morphine 2 mg intravenously every three hours as needed for pain during his hospital stay. Review of Resident #35's hospital records, dated 09/15/20 at 11:37 P.M., revealed the resident was seen in the emergency room for an evaluation of a right hip fracture. The x-ray showed an acute displaced fracture of the right femoral neck fracture with proximal displacement. The fracture was discussed with an orthopedic surgeon. The resident was admitted to the hospital with a plan for surgical intervention. The resident's pulse was elevated to 101 on 09/15/20 at 11:09 P.M. and upon physical examination, the resident was noted to be uncomfortable with a complaint of right hip pain with any attempted motion. The resident received pain medication including Hydromorphone 0.5 mg per 0.5 mL intravenously one time and had additional orders for Norco 5-325 mg every six hours as needed, Morphine two milligrams intravenously every three hours as needed, and Acetaminophen 650 mg every four hours as needed for pain. The resident underwent right hemiarthroplasty surgery on 09/17/20 and was discharged from the hospital on [DATE] at 10:38 A.M. On 05/17/21 at 5:29 P.M. and 05/20/21 at 1:04 P.M. interviews with Resident #35 revealed the resident had a fall at the facility and he broke his leg. The resident stated he was scheduled to go home the day after the fall occurred had tried to walk to the bathroom by himself and fell. The resident stated following the fall he was in a lot of pain but thought the staff had given him a pain pill. He stated he continued to have a lot of pain until the time he was sent to the hospital. On 05/19/21 at 4:24 P.M. interview with LPN #22 revealed she responded to a call for a nurse to Resident #35's room on 09/15/20. She had not been assigned to the resident that day. The nurse stated she remembered the resident attempted to walk to the bathroom by himself and fell. The fall resulted in a hip fracture. The nurse stated the fall was not witnessed and a state tested nursing assistant (STNA) had found the resident on the floor and called for a nurse to assist. Since the fall was unwitnessed, the facility policy was to start neurological checks. The nurse confirmed the resident did complain of right hip pain and was not able to bear weight on his right leg. The nurse revealed the resident had received a scheduled Norco medication that morning (before the fall) as well as Tylenol in the afternoon and evening time. The nurse confirmed there was no documentation of whether the medication was effective or not with controlling the resident's pain. The nurse confirmed she did reposition the resident at the time of the fall and it did help reduce the resident's pain but she could not recall how often the resident had been repositioned (or if that occurred at all) before he went to the hospital. The nurse confirmed the physician was notified of the fall and the results of the resident's x-ray but had not been contacted to discuss the resident's pain. On 05/20/21 at 10:43 A.M. and 05/20/21 at 12:26 P.M. interview with the Assistant Director of Nursing (ADON) revealed she thought there was a four hour window for STAT orders to be completed and if it was going to take the provider longer than four hours, they should inform the facility. Later, the ADON revealed there was not a set turn around time for completing a STAT (immediate) x-ray in the contract with the mobile x-ray provider. The ADON revealed the resident agreed to have the x-rays completed at the facility instead of going to the hospital. However, the resident was not told that it could take several hours for the mobile x-rays to be completed because the wait time varied depending on how many drivers the provider had. The ADON confirmed the resident's pain level was assessed at a seven out of ten at 3:03 P.M. and there were no additional pain assessments recorded or documentation about the resident's pain level from 3:03 P.M. until the resident went to the hospital at 9:15 P.M. The ADON confirmed there was no documentation showing whether the medication administered to the resident was effective for controlling the resident's pain. The ADON confirmed there was not any documentation to determine the physician or Certified Nurse Practitioner (CNP) had been contacted to discuss the resident's pain level after the initial notification about the fall. The ADON confirmed a pain assessment was not included as part of the neurological checks that were completed on the resident. Review of the facility policy, titled Pain Management Program, revised on 06/12/17 revealed all residents would be reviewed upon admission, quarterly and prn (as needed) for acute (described as passing in nature), chronic, or no pain.