**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interview, review of facility policies, and review of facility documentation, it was determined that the facility failed to ensure that Resident R29 was free from neglect related to a Registered Nurse failing to immediately assess the resident after being notified of a fall sustained by the resident. Facility staff transferred the resident off the ground to the bed without an assessment from a Registered Nurse for possible injuries, causing the resident to scream with pain. The facility's failure to complete a timely assessment for Resident R29, resulted in harm, when the resident experienced pain and a delay in treatment for one of 17 residents reviewed. (Resident R29) Findings include: Review of facility policy, Abuse Policy - Prevention, Investigation, Reporting dated March 29, 2022, revealed that, The facility must ensure that all alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown source and misappropriation of resident property are reported immediately to the administrator of the facility and to other officials. Review of facility policy Fall Management Program last revised My 13, 2022, revealed: Definition of a Fall per the RAI Manual: Unintentional change in position coming to rest on the ground, floor or onto the next lower surface (i.e. onto a bed, chair, or bedside mat). The fall may be witnessed, reported by the resident or an observer or identified when a resident is found on the floor or ground. Review of facility documentation reported to the Department of Health on February 27, 2023, revealed: . resident had a fall on 2/26/2023 at around 0500am . Review of Resident R29's clinical record revealed that the resident was admitted to the facility on [DATE], with the diagnoses of left femur (hip) fracture, Alzheimer's disease (causes the brain to shrink and brain cells to eventually die), dementia (usually progressive condition marked by the development of multiple cognitive deficits such as memory impairment) with severity and behavioral disturbance, muscle weakness, history of falling. Review of Resident R29's fall assessment, dated December 26, 2022, revealed that the resident was considered a moderate risk for falls. The interventions recommended included a low bed, non-skid footwear, frequent checks, sit in visualization of staff, broad chair, chair locked. Review of Resident R29's quarterly Minimum Data Set (MDS- assessment of resident's care needs) dated February 3, 2023, revealed that the resident had a BIMS (Brief Interview of Mental Status) score of 3 which indicated that the resident was cognitively impaired. Continued review of the MDS revealed that the resident required extensive assistance for bed mobility and limited assistance with transfers and ambulation of one person. Review of Resident R29's care plan, dated February 6, 2023, revealed that the resident had a history of falls/injury and was unaware of safety needs. The interventions developed included half side rails to bed as enablers, encourage and assist to participate in activities or social settings that minimize the potential for falls, ensure that resident was wearing appropriate footwear while out of bed and provide slipper socks or non-skid slippers as indicated for nighttime and hourly checks. Review of nursing note dated February 26, 2023 at 7:00 a.m. [late entry] revealed CNA (nurse aide) called to nurse resident observed laying on floor next to her bed with blankets over her, no s/s (signs and symptoms) of injury, no c/o (complaint) pain. Resident assisted back to bed. Nsg (nursing) supervisor made aware. Review of the next available nursing note dated February 26, 2023, at 1:02 p.m. revealed Resident cried out in pain during assessment of lower extremities. Assessment revealed visually swollen b/l (bilateral) knees, R. (right) L (left), no bruising or erythema noted. Resident medicated for pain. The resident's physician was contacted and orders were obtained for X-ray to bilateral knees and left hip. Review of a Nursing note dated February 26, 2023 at 1:02 p.m. revealed: Resident moaning, pointing to left inner thigh, stating it hurts. Resident cried out in pain during assessment of lower extremities. Assessment revealed visually swollen b/l knees, R>L, no bruising or erythema noted. Resident medicated for pain as per PRN order an lidocaine patches placed to b/l knee with some relief noted. Call out to [Doctor's Office], spoke with on call physician . Order given, readback and verified for X-Ray to B/L knee and Left hip. Resident resting comfortably in chair, will continue to monitor. Continued review of nursing documentation dated February 27, 2023, at 4:10 p.m. noted that the results of the X-ray revealed left hip with acute fracture of the subcaptial left femoral (hip) neck. Orders were obtained for the resident to be transferred to the local hospital for evaluation. Review of nursing documentation dated March 1, 2023, revealed that the resident's daughter was informed that after investigation, the facility determined that the resident had a fall in her room that caused her hip fracture. By not having a Registered Nurse assess Resident R29 following an unwitnessed fall caused undue pain and a delay in care and treatment. Resident R29 did not have an x-ray report read until 23 hours and 10 minutes from the initial fall. The lack of assessment caused actual harm, undue pain and delay in care to Resident R29 who was diagnosed with a left femoral neck fracture. Review of physician's notes dated March 6, 2023, revealed that the resident was re-admitted to the facility after a fall resulting in left femoral neck fractures. She had a left total hip replacement done on February 28, 2023. Employee E11, Nurse Aide, Witness statement dated February 27, 2023 (11pm-7am) revealed I was doing my rounds and I hard [heard] someone screaming and I stop to listen I didn't hear anything so I kept on to the net [next] room so when I came out the room I hard [heard] screaming again but this time the nurse was out in the hall and I ask her did she hear so we start looking for where the noise was coming from so the nurse whent [sic - went] in [Resident R29] room and i was right behind her at the same time she was laying on the floor with both blankets and her baby on top of her so I start helping her up the nurse start helping me so when I try to put her all the way in the bed she start screaming more so I said your going to have to send her out she said ok the nurse walk out the room told the nurse supervision so I got [Resident R29] back in bed i finish my work so the next night well that night when i came in the nurse came to me and ask can I put [Resident R29] in bed because x Ray was about to come for her but never did and no i didn't say anything to the next shift i thought everyone knew because they said xray was coming. Review of a witness statement, dated February 27, 2023, by Nursing Supervisor, Employee E15, revealed I regret that I did not immediately get up and assess the situation keeping in mind that Resident R29 was confused and may have fallen. My thinking was that she was resting and not getting up wondering through the hall and going into other residents rooms. The Registered Nurse Supervisor confirmed not assessing Resident 29 on February 26, 2023 for possible injuries after being notified of a fall sustained by the resident. Facility staff then then transfered the resident off the ground to the bed without an assessment from a Registered Nurse, causing harm to the resident who screamed out in pain and still continued to demostrate signs and symtoms of pain six hours after the fall. Interview on April 21, 2023, 1:45 p.m. with nurse aide, Employee E11, confirmed that she was a nurse aide assigned to Resident 29 and that she found Resident R29 wrapped up in a blanket rolled over her floor mattress and screaming for help. The resident bed was in low position, Resident R29 complaint of her pain in her leg, there was no bleeding, bruising. I told the nurse we need to send her out. Review of a witness statement dated February 27, 2023, by Licensed Practical Nurse, Employee E9, revealed It was around 5:00 a.m. we both went into the room; it looked like [Resident R29] may have either gotten twisted up and fell from the bed or got up to walk and got twisted. [Resident R29] does get up at night to wonder into other people's room and we have to re-direct her .I did ROM of her legs and then she said something about her arm. I lifted up her gown to see if I could see anything unusual and did passage ROM of her arm, because she was agitated that I was touching her at all, which can be her usual behavior. Then I went to [Registered Nurse Supervisor, Employee E15] I told the [Registered Nurse Supervisor, Employee E15] [Resident R29] was on the floor holding her doll and with her blanket on top of her. [Registered Nurse Supervisor, Employee E15] said were not going to consider that a fall. I went back to [Resident R29's] room and told CNA (nurse aide) that we're going to get her up and put her in the bed. [Registered Nurse Supervisor, Employee E15] did not visit the [Resident R29]. Interview on April 21, 2023, at 10:04 a.m. with Licensed Practical Nurse, Employee E9, confirmed that she was a nurse assigned to Resident 29 on night shift of February 25, 2023. Employee E9 confirmed Resident R29 was laying on stomach, and away from the floor mat on the bare floor. That she did a brief assessment and went to Registered Nurse, Supervisor, Employee R15. I advised her that Resident R29 was found on the floor. The RN, Supervisor, Employee E15 told me that we're not doing an incident report. I went back to ROM of upper extremity/lower extremity arms and leg and lifted her up to standings position and transferred her to bed. I cannot give an explanation why there's no documentation in the resident's clinical record. I did not notify the coming nurse of the possible unwitnessed fall. On April 20, 2023, at 2:23 p.m. an interview was held with Nursing Home Administrator (NHA) and Director of Nursing (DON) who reported that based on the video footage, Registered Nurse Supervisor, Employee E15 did not go into the resident's room to assess the resident and failed to report the incident, investigated the allegation, and make any documentation in the clinical report of Resident 29. Interview on March 15, 2023, at 9:15 a.m. the Nursing Home Administrator (NHA) confirmed that RN Supervisor, Employee E15, was terminated for neglect related to not reporting and investigating an unwitnessed fall for Resident R29. The facility failed to ensure that Resident R29 was free from neglect related to a Registered Nurse failing to immediately assess the resident after being notified of a fall sustained by the resident. Facility staff transferred the resident off the ground to the bed without an assessment from a Registered Nurse for possible injuries, causing the resident to scream with pain and to continue to experience signs and symtoms of pain 8 hours after the fall incident. The facility's failure to complete a timely assessment for Resident R29, resulted in harm, when the resident experienced pain and a delay in treatment. Refer to F684 and F658 483.13 - Resident Behavior and Facility Practices, 10-1-1998 edition 28 Pa. Code 201.18 (b)(1)(e)(1) Management 28 Pa. Code 211.5(h)Clinical records 28 Pa. Code 211.11(d) Resident care policies 28 Pa. Code 211.12(c) Nursing services 28 Pa. Code 211.12(d)(1)(3) Nursing services 28 Pa. Code 211.12(d)(3) Nursing services 28 Pa. Code 211.12(d)(5) Nursing services

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, review of personnel files, review of facility documentation and interviews with staff, it was determined that the facility failed to ensure that a Licensed Practical Nurse and a Registered Nurse, maintained professional standards of quality care in the implementation and evaluation of nursing care using focused assessment and communication with the health care team members as set forth in the Pennsylvania Code Title 49, Professional and Vocational Standards. This failure resulted in actual harm to a resident related to a lack of a timely nursing assessment and a delay of medical care to a resident who sustained a fall which resulted in fracture of left hip which required medical intervention for one of 17 residents reviewed (Resident R29). Findings include: Review of the Pennsylvania Code Title 49, Professional and Vocational Standards, State Board of Nursing 21.11(a)(1)(2)(4) indicated that the Registered Nurse was responsible for collect complete and ongoing data to determine nursignc are needs, analyze the health status of individuals and comare the datat with the norm norm when determining care needs and carrying out nursing care actions that promote, maintain and restore the well-being of individuals. Review of the Pennsylvania Code Title 49, Professional and Vocational Standards, Chapter 21.145 Functions of the LPN (Licensed Practical Nurse) revealed, The LPN is prepared to function as a member of the health-care team by exercising sound nursing judgement based on preparation, knowledge, experience in nursing and competency. The LPN participates in the planning, implementation and evaluation of nursing care using focused assessment in settings where nursing takes place. Continued review revealed, An LPN shall communicate with a licensed professional nurse and the patient's health care team members to seek guidance when . the patient's condition deteriorates or there is a significant change in condition, the patient is not responding to therapy, the patient becomes unstable, or the patient needs immediate assistance. Review of Licensed Practical Nurse, Employee E9's personnel file revealed a Licensed Practical Nurse Position Description signed and dated by the Employee E9 on June 4, 2021, which indicated that essential job duties included ensuring that documents resident's progress, deterioration, changes in condition etc., as necessary Continued review revealed that, abides by both institutional and State Board of Nursing Examiners requirements in the performing of all duties. Review of Registered Nurse, Employee E15's personnel file revealed a Registered Nurse Shift Supervisor job description, signed and dated by the Registered Nurse Supervisor, Employee E15 on March 31, 2023, which indicated that essential job duties included, Investigates all incidents of unknown origin and other incidents and monitors nursing care for accurate assessment and appropriate interventions; supervises the care given to residents on assigned shift. Review of Resident R29's clinical record revealed that the resident was admitted to the facility on [DATE], with the diagnoses of left femur (hip) fracture, Alzheimer's disease (causes the brain to shrink and brain cells to eventually die), dementia (usually progressive condition marked by the development of multiple cognitive deficits such as memory impairment) with severity and behavioral disturbance, muscle weakness, history of falling. Review of Resident R29's fall assessment, dated December 26, 2022, revealed that the resident was considered a moderate risk for falls. The interventions recommended included a low bed, non-skid footwear, frequent checks, sit in visualization of staff, broad chair, chair locked. Review of Resident R29's quarterly Minimum Data Set (MDS- assessment of resident's care needs) dated February 3, 2023, revealed that the resident had a BIMS (Brief Interview of Mental Status) score of 3 which indicated that the resident was cognitively impaired. Continued review of the MDS revealed that the resident required extensive assistance for bed mobility and limited assistance with transfers and ambulation of one person. Review of Resident R29's care plan, dated February 6, 2023, revealed that the resident had a history of falls/injury and was unaware of safety need. The interventions developed included half side rails to bed as enablers, encourage and assist to participate in activities or social settings that minimize the potential for falls, ensure that resident was wearing appropriate footwear while out of bed and provide slipper socks or non-skid slippers as indicated for nighttime and hourly checks. Review of nursing note dated February 26, 2023 at 7:00 a.m. revealed CNA (nurse aide) called to nurse resident observed laying on floor next to her bed with blankets over her, no s/s (signs and symptoms) of injury, no c/o (complaint) pain. Resident assisted back to bed. Nsg (nursing)_ supervisor made aware. Review of the next available nursing note dated February 26, 2023, at 1:02 p.m. revealed Resident cried out in pain during assessment of lower extremities. Assessment revealed visually swollen b/l (bilateral) knees, R. (right) L (left), no bruising or erythema noted. Resident medicated for pain. The resident's physician was contacted and orders were obtained for X-ray to bilateral knees and left hip. Continued review of nursing documentation dated February 27, 2023, at 4:10 p.m. noted that the results of the X-ray revealed left hip with acute fracture of the subcaptial left femoral (hip) neck. Orders were obtained for the resident to be transferred to the local hospital for evaluation. Review of nursing documentation dated March 1, 2023, revealed that the resident's daughter was informed that after investigation, the facility determined that the resident had a fall in her room that caused her hip fracture. Review of physician's notes dated March 6, 2023, revealed that the resident was re-admitted to the facility after a fall resulting in left femoral neck fractures. She had a left total hip replacement done on February 28, 2023. Review of a witness statement, by Nurse aide, Employee E11, dated February 27, 2023, revealed I was doing my rounds and I heard someone screaming and I stopped to listen I didn't hear anything so I kept on to the next room so when I came out the room I heard screaming again but this time the nurse was out in the hall and I asked her did she hear so we start looking for where the noise was coming from so the nurse went into [Resident R29] room . she was laying on the floor with both blankets and her baby on top of her so I start helping her up the nurse start helping me so when I try to put her all the way in the bed she start screaming more so I said of the nurse walk out the room told the nurse supervisor so I got [Resident R29] back in bed. Review of a witness statement dated February 27, 2023, by Licensed Practical Nurse, Employee E9, revealed It was around 5:00 a.m. we both went into the room; it looked like [Resident R29] may have either gotten twisted up and fell from the bed or got up to walk and got twisted. [Resident R29] does get up at night to wonder into other people's room and we have to re-direct her .I did ROM (range of motion) of her legs and then she said something about her arm. I lifted up her gown to see if I could see anything unusual and did passage ROM of her arm, because she was agitated that I was touching her at all, which can be her usual behavior. Then I went to [Registered Nurse Supervisor, Employee E15] I told the [Registered Nurse Supervisor, Employee E15] [Resident R29] was on the floor holding her doll and with her blanket on top of her. [Registered Nurse Supervisor, Employee E15] said were not going to consider that a fall. I went back to [Resident R29's] room and told CNA (nurse aide) that we're going to get her up and put her in the bed. [Registered Nurse Supervisor, Employee E15] did not visit the [Resident R29]. Review a witness statement, dated February 27, 2023, by Nursing Supervisor, Employee E15, revealed I regret that I did not immediately get up and assess the situation keeping in mind that Resident R29 was confused and may have fallen. My thinking was that she was resting and not getting up wondering through the hall and going into other residents rooms.' On April 20, 2023, at 2:23 p.m. an interview was held with Nursing Home Administrator (NHA) and Director of Nursing (DON) who reported that based on the video footage, RN Supervisor Employee E15 did not go into the resident's room to assess the resident and failed to report the incident, investigate the allegation, and make any documentation in the clinical report of Resident R29. Registered Nurse, Supervisor, Employee E15 was terminated. Review of documentation by the facility, revealed that Licensed nurse, Employee E9 and CNA, Employee E11 found Resident R29 on her floor on February 26, 2023, approximately at 5:00 a.m. Based on the facility investigation the unwitnessed fall was communicated to the RN, Supervisor Employee E15 who failed to assess the resident, failed to investigate, and document the incident. Resident R29 fell and sustained significant injury of an acute fracture of the sub capital left femoral [NAME] with proximal migration of the distal fragment with no dislocation which required a medical intervention a surgery. Licensed nurse, Employee E9 and Registered Nurse, Supervisor Employee E15 failed to document an unwitnessed fall, investigate the incident which delayed medical treatment from 5:00 a.m. to 1:00 p.m. on February 26, 2023, which resulted in Resident R29 being neglected. Therefore, allegation of neglect is substantiated against Licensed nurse, Employee E9 and Registered Nurse, Supervisor Employee E15 Interview on March 15, 2023, at 9:15 a.m. the Nursing Home Administrator (NHA) confirmed that RN Supervisor, Employee E15 was terminated for neglect related to not reporting and investigating an unwitnessed fall for Resident R29. Licensed Practical Nurse, Employee E9, failed to maintain professional standards of quality care in the implementation and evaluation of nursing care using focused assessment and communication with the health care team members when Resident R29 had a unwitnessed fall as set forth in the Pennsylvania Code Title 49, Professional and Vocational Standards. which resulted in harm to the resident related to a lack of a timely nursing assessment and a delay of medical care to the resident. Registered Nurse Supervisor, Employee E15 failed to maintain professional standards of quality care, established by essential job requirements, to completed an assessment of Resident R29 after receiving a report of an unwitnessed, investigate the accident, and changes in resident condition as set forth by Chapter 21.1 Practice of professional nursing. This failure resulted in actual harm to Resident R29 related to a lack of timely nursing assesment and a delay on medical care to the resident. Refer to F600 and F684. 28 Pa. Code 201.18 (b)(1)(e)(1) Management 28 Pa. Code 211.5(h)Clinical records 28 Pa. Code 211.11(d) Resident care policies 28 Pa. Code 211.12(c) Nursing services 28 Pa. Code 211.12(d)(1)(3) Nursing services 28 Pa. Code 211.12(d)(3) Nursing services 28 Pa. Code 211.12(d)(5) Nursing services

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interview and review of facility documentation, it was determined that the facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice by not having a Registered Nurse assess Resident R29 following an unwitnessed fall causing undue pain and a delay in care and treatment. Resident R29 did not have an x-ray report read until 23 hours and 10 minutes from the initial fall for one of 20 residents reviewed. The lack of assessment caused actual harm, undue pain and delay in care to Resident R29 who was diagnosed with a left femoral neck fracture, for one of 17 residents reviewed. (Resident R29) Findings include: Review of Resident R29's clinical record revealed that the resident was admitted to the facility on [DATE], with the diagnoses of left femur (hip) fracture, Alzheimer's disease (causes the brain to shrink and brain cells to eventually die), dementia (usually progressive condition marked by the development of multiple cognitive deficits such as memory impairment) with severity and behavioral disturbance, muscle weakness, history of falling. Review of Resident R29's fall assessment, dated December 26, 2022, revealed that the resident was considered a moderate risk for falls. The interventions recommended included a low bed, non-skid footwear, frequent checks, sit in visualization of staff, broad chair, chair locked. Review of Resident R29's quarterly Minimum Data Set (MDS- assessment of resident's care needs) dated February 3, 2023, revealed that the resident had a BIMS (Brief Interview of Mental Status) score of 3 which indicated that the resident was cognitively impaired. Continued review of the MDS revealed that the resident required extensive assistance for bed mobility and limited assistance with transfers and ambulation of one person. Review of Resident R29's care plan, dated February 6, 2023, revealed that the resident had history of falls/injury and was unaware of safety need. The interventions developed included half side rails to bed as enablers, encourage and assist to participate in activities or social settings that minimize the potential for falls, ensure that resident was wearing appropriate footwear while out of bed and provide slipper socks or non-skid slippers as indicated for nighttime and hourly checks. Review of nursing note dated February 26, 2023 at 7:00 a.m. revealed CNA (nurse aide) called to nurse resident observed laying on floor next to her bed with blankets over her, no s/s (signs and symptoms) of injury, no c/o (complaint) pain. Resident assisted back to bed. Nsg (nursing)_ supervisor made aware. Review of a Nursing note dated February 26, 2023 at 1:02 p.m. revealed: Resident moaning, pointing to left inner thigh, stating 'it hurts'. Resident cried out in pain during assessment of lower extremities. Assessment revealed visually swollen b/l knees, R>L [right greater than left], no bruising or erythema noted. Resident medicated for pain asper PRN order an lidocaine patches placed to b/l knee with some relief noted. Call out to [Doctor's Office], spoke with on call physician . Order given, readback and verified for X-Ray to B/L knee and Left hip. Resident resting comfortably in chair, will continue to monitor. Continued review of nursing documentation dated February 27, 2023, at 4:10 p.m. noted that the results of the X-ray revealed left hip with acute fracture of the subcapital left femoral (hip) neck. Orders were obtained for the resident to be transfer to the local hospital for evaluation. By not having a Registered Nurse assess Resident R29 following an unwitnessed fall caused undue pain and a delay in care and treatment. Resident R29 did not have an x-ray report read until 23 hours and 10 minutes from the initial fall. The lack of assessment caused actual harm, undue pain and delay in care to Resident R29 who was diagnosed with a left femoral neck fracture. Review of nursing documentation dated March 1, 2023, revealed that the resident's daughter was informed that after investigation, the facility determined that the resident had a fall in her room that caused her hip fracture. Review of physician's notes dated March 6, 2023, revealed that the resident was re-admitted to the facility after a fall resulting in left femoral neck fractures. She had a left total hip replacement done on February 28, 2023. Employee E11, Nurse Aide, Witness statement dated February 27, 2023 (11pm-7am) revealed I was doing my rounds and I hard [heard] someone screaming and I stop to listen I didn't hear anything so I kept on to the net [next] room so when I came out the room I hard [heard] screaming again but this time the nurse was out in the hall and I ask her did she hear so we start looking for where the noise was coming from so the nurse whent [sic - went] in [Resident R29] room and i was right behind her at the same time she was laying on the floor with both blankets and her baby on top of her so I start helping her up the nurse start helping me so when I try to put her all the way in the bed she start screaming more so I said your going to have to send her out she said ok the nurse walk out the room told the nurse supervision so I got [Resident R29] back in bed i finish my work so the next night well that night when i came in the nurse came to me and ask can I put [Resident R29] in bed because x Ray was about to come for her but never did and no i didn't say anything to the next shift i thought everyone knew because they said xray was coming. Review of a witness statement, dated February 27, 2023, by Nursing Supervisor, Employee E15, revealed I regret that I did not immediately get up and assess the situation keeping in mind that Resident R29 was confused and may have fallen. My thinking was that she was resting and not getting up wondering through the hall and going into other residents rooms. The Registered Nurse Supervisor not assessing the Resident after a fall for possible injuries and as a result facility staff then transferring the resident off the ground to the bed without an assessment from a Registered Nurse for possible injuries, caused the resident to scream out in pain causing harm to the Resident. Interview on April 21, 2023, 1:45 p.m. with nurse aide, Employee E11, confirmed that she was a nurse aide assigned to Resident R29 and that she found Resident R29 wrapped up in a blanket rolled over her floor mattress and screaming for help. The resident bed was in low position, Resident R29 complaint of her pain in her leg, there was no bleeding, bruising. I told the nurse we need to send her out. Review of a witness statement dated February 27, 2023, by Licensed Practical Nurse, Employee E9, revealed It was around 5:00 a.m. we both went into the room; it looked like [Resident R29] may have either gotten twisted up and fell from the bed or got up to walk and got twisted. [Resident R29] does get up at night to wonder into other people's room and we have to re-direct her .I did ROM of her legs and then she said something about her arm. I lifted up her gown to see if I could see anything unusual and did passage ROM of her arm, because she was agitated that I was touching her at all, which can be her usual behavior. Then I went to [Registered Nurse Supervisor, Employee E15] I told the [Registered Nurse Supervisor, Employee E15] [Resident R29] was on the floor holding her doll and with her blanket on top of her. [Registered Nurse Supervisor, Employee E15] said were not going to consider that a fall. I went back to [Resident R29's] room and told CNA (nurse aide) that we're going to get her up and put her in the bed. [Registered Nurse Supervisor, Employee E15] did not visit the [Resident R29]. Interview on April 21, 2023, at 10:04 a.m. with Licensed Practical Nurse, Employee E9, confirmed that she was a nurse assigned to Resident 29 on night shift of February 25, 2023. Employee E9 confirmed Resident R29 was laying on stomach, and away from the floor mat on the bare floor. That she did a brief assessment and went to Registered Nurse, Supervisor, Employee R15. I advised her that Resident R29 was found on the floor. The RN Supervisor, Employee E15 told me that we're not doing an incident report. I went back to ROM of upper extremity/lower extremity arms and leg and lifted her up to standings position and transferred her to bed. I cannot give an explanation why there's no documentation in the resident's clinical record. I did not notify the coming nurse of the possible unwitnessed fall. Review a witness statement, dated February 27, 2023, by Nursing Supervisor, Employee E15, revealed I regret that I did not immediately get up and assess the situation keeping in mind that Resident R29 was confused and may have fallen. My thinking was that she was resting and not getting up wondering through the hall and going into other residents rooms. The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice by not having a Registered Nurse assess Resident R29 following an unwitnessed fall causing undue pain and a delay in care and treatment. Resident R29 did not have an x-ray report read until 23 hours and 10 minutes from the initial fall. The lack of assessment caused actual harm, undue pain and delay in care to Resident R29 who was diagnosed with a left femoral neck fracture. Refer to F600 and F658. 28 Pa. Code 201.18 (b)(1)(e)(1) Management 28 Pa. Code 211.5(h)Clinical records 28 Pa. Code 211.11(d) Resident care policies 28 Pa. Code 211.12(c) Nursing services 28 Pa. Code 211.12(d)(1)(3) Nursing services 28 Pa. Code 211.12(d)(3) Nursing services 28 Pa. Code 211.12(d)(5) Nursing services