**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, Xray Portable Service Agreement, medical record review, Emergency Medical Services (EMS) record review, Hospital record review, Facility investigation review, and interview, the facility failed to recognize an injury of unknown origin and notify the Abuse Coordinator timely for 1 of 11 (Resident #2) sampled residents reviewed for abuse. Resident #2, a vulnerable, cognitively impaired resident with left sided Hemiplegia post Cerebral Vascular Accident (CVA), who was dependent for dressing, showering, and bed mobility, and required 2-person, mechanical lift assistance for transfer was found on 5/2/2025 by Family Member (FM) F in significant pain to her right lower extremity and FM F requested Nurse Practitioner (NP) #2 assess Resident #2. NP #2 ordered a one-time dose of Robaxin (medication given for muscle spasms) 500 milligram (mg) per Percutaneous Endoscopic Gastrostomy tube (PEG - a tube inserted through the skin of the abdomen into the stomach). On 5/3/2025, Licensed Practical Nurse (LPN) B noted Resident #2 with severe pain level of 8 (pain scale of 1-10 10 being the highest pain) when moving lower extremities during incontinence care. NP #1 ordered an anti-inflammatory medication injection and an x-ray of the bilateral hips and lower extremities. The x-ray was not ordered STAT (immediate or urgent). On 5/4/2025, Resident #2 was observed to be weak and pale with bruising and scratches to left upper thigh and a rash noted to the left outer lower extremity. NP #1 was notified with new orders noted for antibiotics for 2 days, a STAT chest x-ray, and to obtain lab work. LPN B noted the chest x-ray could not be completed STAT and NP #1 was not notified. On 5/5/2025 at 4:16 PM, x-ray results revealed right and left femur (thigh bone) fractures with displacement (break in the thigh bone where the fractured pieces of the bone are no longer aligned). NP #1 was notified and order given to send Resident #2 out to the hospital. Immediate Jeopardy (IJ) (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) was identified related to the facility's failure to recognize an injury of unknown origin and notify the Abuse Coordinator timely, which resulted in Resident #2 experiencing anxiety, pain, and delay in receiving needed care from 5/2/2025 through 5/5/2025. The Administrator and the Director of Nursing (DON) were notified of the Immediate Jeopardy for F-600 on 9/26/2025 at 1:30 PM, in the Movie room. The facility was cited at F-600 at a scope and severity of J, which constitutes Substandard Quality of Care. A partial extended survey was conducted from 9/26/2025 through 9/30/2025. An acceptable Removal Plan, which removed the immediacy of the Jeopardy for F-600 was received on 9/30/2025. The Removal Plan was validated onsite by the surveyor on 9/30/2025 through audit review, medical record review, observation, review of education records, and staff interviews. The IJ began on 5/2/2025 and was removed on 10/1/2025. The facility's noncompliance at F-600 continues at a scope and severity of D for monitoring of the effectiveness of the corrective actions. The facility is required to submit a Plan of Correction. The findings include: 1. Review of the undated facility policy titled, Abuse Reporting, revealed, .All personnel.are required to immediately report any incident or suspected incident of resident abuse, neglect.including injuries of an unknown source.The incident will be reported to the Abuse Coordinator.FEDERAL REGULATION (42 CFR 483.13) requires the reporting of alleged violations of abuse.neglect.including injuries of unknown origin, immediately to the Abuse Coordinator.and to appropriate state agencies in accordance with state law.The facility must report abuse, neglect.within 24 hours after the reasonable cause threshold (suspicion) is concluded. If serious bodily injury has been sustained by a resident, the incident will be reported immediately but not later than 2 hours after forming suspicion.State public health law requires the reporting of abuse.immediately to state agencies having ‘reasonable cause' to believe that abuse, neglect.has occurred. ‘Reasonable cause' is defined as when, upon review of the circumstances there is sufficient evidence for a prudent person to believe that abuse, neglect.has occurred.The presence of a physical condition.bruise.which is inconsistent with the history of course of treatment of the resident.The facility must report to the state agencies.injuries of unknown origin.This might occur without or before the facility investigation into the incident, or it may occur at any time during the investigation.An immediate investigation will commenceand [commence and] a stated and signed statement from the person reporting the incident will be obtained.the Abuse Coordinator.will request social services to follow up with the resident/resident representative and document findings in the medical record.Once the incident has been identified and the investigation initiated, the administrator.will provide the appropriate agencies.with a report of the findings of the investigation within 5 working days.Should the findings reveal that abuse did occur, the report will include the corrective actions taken by the facility to prevent abuse from recurring. 2. Review of the Xray Portable Services Agreement dated 1/1/2023 revealed, .THE PURPOSE of this Agreement is to define the term understandings and respective responsibilities of Customer and Provider with respect to the provision of those portable services .Special Services/On-Call Emergency Provider Services. If requested by Customer and where available, Provider shall be available 24 hours a day, seven (7) days a week for STAT (emergency) requests. A STAT service is provided for critical situations requiring rapid results . 3. Review of the medical record revealed Resident #2 admitted to the facility on [DATE], with diagnoses which included Hemiplegia and Hemiparesis following Cerebral Infarction affecting left non-dominant side, Chronic Obstructive Pulmonary Disease, and Dysphagia. Review of the quarterly Minimum Data Set (MDS) dated [DATE], revealed Resident #2 had a Brief Interview for Mental Status score (BIMS) of 2, which indicated severe cognitive impairment. Resident #2 was dependent for toileting, shower/bathing, dressing, personal hygiene, bed mobility, and sit to stand and walking were not attempted over the assessment period. Resident #2 had no pain present during the assessment period. Review of the Kardex (key information on how to care for a resident) Report as of 5/2/2025, revealed Chair/bed to chair transfer.Dependent x [times] 2 Staff with Mechanical.Lift. Review of the Progress Notes for Resident #2 dated 5/2/2025 at 1:06 PM, revealed, .Resident noted with increased pain and spasms to BLE [both lower extremities]. NP [#2] notified. Review of NP #2's Progress Note for Resident #2 dated 5/2/2025, and signed at 3:09 PM, revealed .Patient [Resident #2's FM F] requesting visit for RLE [right lower extremity] Pain.Patient's [FM F] requested a [I] see her at bedside today. [FM F] reports that patient has been experiencing significant pain over the last hour. Patient's nurse states she received gabapentin [medication given for nerve pain].Generalized weakness.palpation [touch] was identified to the right lower extremity.She feels pain to touch to BLE. Staff.report no new injuries or falls.New Order: Robaxin [medication given for muscle spasms] 500 mg [milligram] via PEG tube x 1 dose Staff to notify provider for.concerns, pain unrelieved by pain medication regimen or new/worsening pain Continue Tylenol 1000 mg via PEG tube 3 times daily.Continue gabapentin [medication given for nerve pain] 100 mg via PEG tube twice daily Continue gabapentin 3 [300] mg via PEG tube daily at bedtime. Review of the Order Summary Report for Resident #2 revealed, .Methocarbamol [Robaxin] Oral Tablet 500 mg.Give 1 tablet.one time only for muscle spasm/pain for 1 Day.Order Date.5/2/2025. Review of the Medication Administration Record (MAR) dated 5/2025, revealed Resident #2 had a pain level of 9 on 5/2/2024 at 4:00 PM, with routine administration of Gabapentin 100 mg capsule. Review of the photographs of Resident #2 provided by complainant (FM A) with a time stamp 5/3/2025 at 12:31 PM, revealed the following wounds: a. Right axillary area (armpit) - purple bruise approximately 2 cm (centimeter) w (width) by 4 cm l (length); b. 2nd toe on the end of left foot - an approximately 1 cm w by 1 cm l open abrasion; c. left calf - red excoriated (damage to the surface of the skin) area approximately 2.5 cm w by 6.5 cm l; d. Outer side of the left leg adjacent to area c- a bruise, green/purple in color approximately 2 cm w by 2 cm l; e. Upper left leg near the left groin - a bruise, green/purple in color approximately 4 cm w by 1.5 cm l; f. 2nd elongated area under area e - a bruise, red/faint purple in color approximately 2 cm w by 0.5 cm l; g. 3rd elongated area under area f to the inside of upper left leg -red/faint purple approximately 1 cm w by 1 cm l; h. 4th elongated area adjacent to area g - red/faint purple approximately 3 cm w by 0.5 cm l; i. Left and Right knee area - red petechiae (small red spots found with trauma or clotting disorders) areas. Review of the MAR dated 5/2025, revealed Resident #2 had a pain level of 8 on 5/3/2025 at 9:00 PM, with routine administration of Tylenol extra strength 500 mg tablet. Review of the Progress Notes for Resident #2 dated 5/3/2025 at 10:45 PM, revealed .Resident observed with severe pain when moving lower extremities during incont [incontinence] care. Pain rated 8 using PAINAID [PAINAD] scale [PAINAD scale used to assess pain in patients with dementia].On call NP [NP #1] notified. New orders for ketorolac [anti-inflammatory medication] inj [injection] 30 mg/ml [milliliter] one time only and to obtain x-rays of bilateral hips and lower extremities.Resident received IM [Intramuscular] inj to left hip.Supervisor notified. Review of NP #1's Progress Notes for Resident #2 dated 5/3/2025, revealed .On Call Telemedicine Visit.Nurse called in stating that yesterday [5/2/2025], patient was complaining of her legs hurting really bad. Every times [time] when nurses move her, she screams in pain and states that it is in her legs. She was given muscle spasm medication yesterday. It helped a little bit. She is on Tylenol routine. Chart was reviewed.Bilateral lower extremity pain.X-rays of bilateral hips and lower extremities. IM Toradol [Ketorolac] 30 mg x 1 dose for pain 7-10/10 [7 to 10 on a scale of 1 to 10]. Review of the Order Summary Report for Resident #2 revealed, .x-ray to bilateral hips and lower extremities one time only for pain for 1 day.Order Date.5/3/2025.Ketorolac Tromethamine Injection Solution 30MG/ML.inject 30 mg intramuscular one time only for pain assessed higher than 7 for 1 day.Order Date.5/3/2025. Review of the MAR dated 5/3/2025 at 10:49 PM, revealed LPN B documented Resident #2 had no pain and administered a Ketorolac injection to Resident #2 for pain. LPN B contacted NP #1 to report Resident #2 experienced severe pain with movement. Review of the Progress Notes for Resident #2 dated 5/4/2025 at 8:13 PM, revealed .Upon medication administration, resident observed with weakness and pallor [pale appearance].BP [blood pressure] 134/82 [normal BP reading is less than 120/80 [average range 68-75], RR [respiratory rate] 16 [average range 12-18], and o2 [oxygen] sat [saturation] 94% [percent] [between 95 % to 100%] on room air. Bruising to left upper thigh with scratches on bruising and rash noted to left outer lower extremity. On callprovider [call provider] [NP #1] notified followed with new orders to receive Rocephin [antibiotic] 1 G [gram] IM once daily x2 days. STAT CXR [chest x-ray], and to obtain CBC w diff [Complete Blood Count with differential - common blood test that provides detailed information about the different cells in the blood] and BMP [Basic Metabolic Panel - blood test to check for electrolytes, kidney function, glucose, and calcium].Supervisor notified.To follow up with in house tomorrow. Review of the Order Summary Report for Resident #2 revealed, .STAT CXR one time only for 1 day.Order Date.5/4/2025.cefTRIAXone Sodium [Rocephin antibiotic] Injection Solution .1 GM intramuscularly one time a day for sepsis protocol for 2 Days. Review of the Progress Notes for Resident #2 dated 5/4/2025 at 8:49 PM, revealed .[Named Mobile x-ray] unable to obtain STAT CXR. Rep [Representative] states CXR to be completed tomorrow morning. There was no documentation NP #1 was notified regarding the STAT CXR was delayed until the following day (5/5/2025). Review of the Radiology report dated 5/5/2025 at 3:09 PM, revealed acute appearing left and right displaced femur (thigh bone) fractures with Osteopenia (lower than normal bone mineral density) present. Review of the Progress Notes dated 5/5/2025 at 4:16 AM, revealed .Received x-ray results from bilateral hip and lower extremity x-rays. Results show right and left femur fractures-both noted with displacement. Resident [Resident #2] currently showing sx/s [signs and symptoms] of pain. On call [NP #1] notified with order to send resident to ER [Emergency Room] for eval [evaluation]. [Named FM F] notified.Supervisor notified. Review of the Order Summary Report for Resident #2 revealed, .Send to ER d/t [due to] left and right femoral fracture.Order Date.5/5/2025. Review of the Progress Notes completed by LPN D for Resident #2 dated 5/6/2025 at 5:43 PM, revealed .this nurse spoke with [FM F] this date to follow up on resident condition. [FM F] states that resident has cast placed to left leg and ortho [orthopedic] wanting to complete right total knee however [FM F] unsure that is the best thing at this time. [FM F] questioned this nurse about injury and states he does not understand how this can happen. this nurse educated on osteopenia, osteoarthritis and possible causes of pathological fractures.[FM F] requested meeting with this nurse and DON [Director of Nursing] later this week. Review of the Progress Notes for Resident #2 dated 5/9/2025, revealed .re-admitted to the facility today at 11:32 AM via EMS stretcher. Assistance of 4 people transferred from stretcher to bed.cast on BLE r/t [related to] fractures.[FM F] at bedside after admission. Review of the MAR for 5/2025, revealed Resident #2 had a pain scale of 10 on 5/10/2025 at 12:57 PM and 5/11/2025 at 11:00 AM, with administration of PRN Oxycodone 5 mg tablet. Review of NP #2's Progress Note for Resident #2 dated 5/13/2025, revealed .Staff report concerns including uncontrolled pain. Physical therapy notified me today that patient is experiencing frequent pain despite pain medication regimen especially with rolling/turning/personal care. Patient endorses [acknowledges]on exam that she is experiencing frequent pain as well.New Order: Oxycodone 5 mg/5 mL. Administer 5 mL via Peg tube every 6 hours.Oxycodone 5 mg/5 mL. Administer 5 mL via PEG tube daily as needed x 14 days for breakthrough pain.Robaxin 500 mg via PEG tube 4 times daily. 4. Review of the Emergency Management Services (EMS) #1's Patient Care Record for Resident #2 dated 5/5/2025 at 4:23 AM, revealed, .Extremity Pain.Signs & Symptoms Leg Pain (Primary).04:39 [4:39 AM].BP 93/55.04:41 [4:41 AM].BP 89/55.Pulse 102.04:44 [4:44 AM].BP 81/52.04:51 [4:51 AM] 79/64.Left Leg.Pain.Right Leg.Pain.dispatched emergent to [Named Facility #1].for pain, arrival on scene, staff states that the pt [Patient] was complaining of pain sat [Saturday] morning when they moved them [Resident #2].an x-ray.came back with both femurs displaced.states that the pt had recently gotten a Toradol [Ketorolac] shot along with a shot for Rocephin unable to determine why. staff states that the pt has been more pale then [than] normal unable to determine how long it has been for staff denied any recent trauma, pt does not normally ambulate, bed bound and has left sided deficits from previous stroke. staff also states the pt has a PEG tube and has been NPO [nothing by mouth]. during initial assessment the pt is repeating what sounds like please help me over and over. pt speech is normally difficult to understand and is normal for her baseline. pt was moved to stretcher with a 5 person sheet drag and secured with all available seatbelts and guard rails up.secondary assessment, and transport the pt is repeating please help me. unable to determine pain scale of specifically where the pt is hurting due to baseline AMS [Altered Mental Status].pt was hypotensive [low blood pressure] during care.while reading printed Hx [History] of pt from NH [Nursing Home] the x-ray states that bilateral femurs are fractured distally.arrival at er, pt was moved to ER bed with a 3 person sheet drag and secured with bed rails up. gave short report to rn [Registered Nurse] and doctor, told staff the story as told above.Emergency Response.Emergent.Lights and Sirens. 5. Review of Hospital #1's photographs of Resident #2 upon admission on [DATE], revealed the same area of injuries as the complainant's photographs and additional areas noted. An area of green bruising noted to the left of pubic area approximately 1 cm wide x 0.5 cm long and an excoriated open area with dried blood under the fold of the right breast approximately 3 cm wide x 1 cm long. Review of Hospital #1's History and Physical for Resident #2 dated 5/5/2025 at 5:26 AM, revealed, .TRAUMA SERVICE HISTORY AND PHYSICAL .Chief complaint/Reason for admission: Mechanism of Injury Details: unknown mechanism.Per EMS report, x-rays at the facility revealed bilateral femur fractures. Staff reports that patient complained of leg pain after using a lift to transfer the patient from bed to chair. Patient is bedbound previous stroke with residual left-sided deficit.Patient was a level 1 trauma activation [generally includes Mechanism of Injury: High-speed motor vehicle collision.Fall from significant height.crush injury.Extremity trauma.multiple fractures] secondary to hypotension and [en] route .She was noted on radiographs [x-rays] to have evidence of bilateral distal femur fractures. The patient has had.report from the hospital that I [Medical Doctor #2] have received directly .no falls and no history of any trauma.The patient does have some occupational therapy that was being tried and apparently the patient had made some progress. The patient did however on Friday according to the report I received from the family [have] pain in her knee area.It is notable that the patient [referring to FM F] does have concerns about the causation of which I [Medical Director #2] have no other information as to any cause. The patient does have a displaced right distal femur fracture.supracondylar fracture [break in the thighbone that occurs just above the knee joint] of course is comminuted [breaks into multiple pieces]. There is a left supracondylar femur fracture which is also identified and is comminuted but is not as far displaced.Current Facility [Hospital #1] - Administered Medications.fentanyl [medication used for severe pain] 50 mcg [micrograms] intraVENOUS Q20 [every 20] Min [Minutes] PRN [as needed].HYDROmorphine [medication used for moderate to severe pain] 0.5 mg intraVENOUS Q4H [every 4 hours] PRN.oxyCODONE [medication given for moderate to severe pain] 5 mg.Q6H [every 6 hours] PRN.Lower extremities are noted to have bilateral splints applied. Swelling is present over both the right and left distal thigh.x-ray femur right.Acute fracture of the distal femur with approximately one half bone width posterior [back] and lateral [side to side] displacement of the distal segment [a bone fracture in which the part of the bone farthest from the body has been shifted backward and to the side, by an amount equal to half the bone's width].X-ray femur left.Acute comminuted, impacted fracture [where the bone breaks into multiple pieces (three or more) and one bone fragment is driven into another bone fragment] of the distal femur.MUSCULOSKELETAL.Intramuscular hematoma [a collection of blood that clots within a muscle] in the medial left thigh.PROCEDURE: Indications: Closed fracture left distal femur.Procedure Description May 5,2025 Patient is brought to the operating room.The leg is then elevated.There is some bruising posteriorly to the distal thigh.A long-leg cast is applied.The patient did have radiographs taken showing improved position of the distal femur relative to the shaft on both AP [Anterior Posterior] lateral views.Patient's condition remains critical, requires frequent assessment and interventions, and/or is unstable with conditions that pose a significant threat to life or risk of prolonged impairment.S/p [status post] OR [operating room] yest [yesterday] for LLE [Left Lower Extremity] cast. S/p 2u [2 units] PRBC [packed red blood cell] transfused yest for Hgb [hemoglobin] 6.9 [Normal range 12.0 to 15.5 g/dL [grams/deciliter].and hypotension. admitted to ICU [Intensive Care Unit] postop [postoperatively] for monitoring. Review of Hospital #1's Procedure Description dated 5/7/2025, revealed .Application of long-leg cast right lower extremity.The patient was brought to the operating room.The patient has the area of the fracture identified and I [Medical Doctor #2] have been able to manipulate it and reduce it back into better alignment.The patient has the long-leg cast applied.The patient is awakened from the anesthetic and taken to the recovery room. 6. Review of the facility's investigation revealed an undated signed written statement completed by Certified Nursing Assistant (CNA) M which revealed, .Friday night/Sat [Saturday] [5/2/2025-5/3/2025] morn [morning] approx [approximately] midnight while attempting to change resident [Resident #2] , I noticed resident acting as if rolling side to side was more painful then [than] normally [normal]. When rolling back over I noticed marks on left side and notified the charge nurse. Review of the Facility's investigation revealed a typed statement signed by LPN D dated 5/5/2025, revealed .I called and spoke with [MD #2] about an update on [Named Resident #2] concerning recent admission to hospital regarding fractures to bilateral femurs. [MD #2] stated the fractures were likely due to osteoporosis because her bones were so bad and there is no known trauma. Continued review of the Facility's investigation revealed a typed form with question asked Any issues or incident with [Named Resident #2] with staff names typed with staff answer No. No staff members who were interviewed or staff member performing the interviews signed the form. 7. The surveyor attempted to contact FM A by telephone on 9/23/2025 at 1:51 PM. FM A did not return phone call. During a telephone interview on 9/23/2025 at 7:09 PM, Registered Nurse (RN) C was asked if she knew how Resident #2 sustained femur fractures to the left and right leg. RN C stated, .I don't know how that happened. I was actually just stepping in for a floor nurse [referring to 5/2/2025]. I don't know the information about that case. During a telephone interview on 9/23/2025 at 7:15 PM, LPN D was asked if she knew how Resident #2 sustained femur fractures to the left and right leg. LPN D stated, .I am not 100 percent sure, I think bone mass, Osteoporosis [bones become weak and brittle] . LPN D was asked how she was made aware Resident #2 had a diagnosis of Osteoporosis. LPN D stated, .probably came off of an x-ray in the conclusion at the bottom of the report.No other injuries I know of. LPN D was asked if the staff ever transferred Resident #2 without the use of the lift. LPN D stated, .not with her, we always used the lift. During a telephone interview on 9/23/2025 at 7:25 PM, LPN B was asked if she knew how Resident #2 sustained femur fractures to the left and right leg. LPN B stated, .I don't know how the fractures occurred. During an interview on 9/24/2025 at 1:25 PM, FM F was asked about Resident #2's femur fractures to left and right leg. FM F stated, .we [referring to FM A] had a talk with the head nurse.she said Osteoporosis, I disagreed.[MD #2] called me and said the only time he seen this type of injury was with a head on car crash.I got a call about 3:00 [AM] in the morning on Monday [5/5/2025] and the nurse said she has to go to the hospital.2 broken legs, I was here on Wednesday [4/30/2025], off on Thursday [5/1/2025].back on Friday [5/2/2025] they were broken.I got the NP to see her on Friday.she was in pain when I touched her legs it hurt, her legs were swollen.my wife couldn't tell me what happened.before the pain she could move her legs some.the head nurse asked around nobody [referring to staff] said anything. During a telephone interview on 9/24/2025 at 1:30 PM, Radiologist #1 was asked if Resident #2's fractures were caused by trauma. Radiologist #1 stated, .I can tell you this Osteoporosis does not cause fractures, there has to be a cause for the injury.having Osteoporosis or Osteopenia doesn't have anything to do with how it happened.something has to cause the fracture.Yes she did have Osteopenia and Demineralization [loss of mineral content from a bone] but something has to cause the injury. During an interview on 9/24/2025 at 2:52 PM, NP #2 was asked about his visit with Resident #2 on 5/2/2025 and if Resident #2 had a diagnosis of Osteoporosis. NP #2 stated, .No, I believe it [diagnosis] was identified on the x-ray over the weekend [5/4/2025].Osteopenia on the x-ray.I performed a physical assessment on her [5/2/2025].pain was reported, I can't relate the pain had to do with the fracture.I can only speak on the note.I have seen her various times, she could not walk.occurred over the weekend not present per my note [NP #2 was referring to the injury]. NP #2 was asked if Osteopenia can cause a fracture. NP #2 stated, .it can contribute to it.It was noted on the x-ray for Osteopenia, to my knowledge that is the 1st time it was diagnosed. During an interview on 9/25/2025 at 8:30 AM, the Administrator (Abuse Coordinator) was asked if the facility determined how Resident #2 sustained femur fractures to left and right leg. The Administrator stated, .It's spontaneous, pathological, she was sent to the hospital, I called [Named MD #2], he confirmed my thoughts, we investigated and there was no incident.I did not feel it was an injury of unknown source, immobility, how long she had been immobile, therapy had started sitting her on the edge of the bed.bones, larger woman contributing factors, lying in bed for excessive amount of time.she was getting up in the Broda chair [chair designed for individuals who require long-term seating and complex positioning for comfort and safety].she got up for a shower with the use of the lift on Thursday [5/1/2025]. The Administrator was asked about the hospital admission paperwork that noted Resident #2 had experienced pain after being transferred with the use of the lift. The Administrator stated, .I checked with staff no one reported any issues with the lift. During a telephone interview on 9/25/2025 at 9:50 AM, FM A stated, .went to visit her on Saturday [5/3/2025] usually when I go, I like to look at her skin and lotion her feet down.when I sat on the side of her bed she just started screaming, She was anxious. I checked for marks on her body, anything abnormal, I noticed little red spots on both her legs.I took pictures of all her injuriesst toe next to big toe with dried blood on the blanket, back of her leg at top of her thigh, and all the way down the calf it looked like her skin had been rubbed against something.looked like a carpet burn, under her right arm was a bruised area.the color was purple and red like she had been pulled in that area.I called the staff down there.I am not sure who it was because I was so upset.I asked them to explain to me how those injuries happened and why she was screaming in pain.this was on Saturday.he [FM F] finds out on Monday [5/5/2025] she [Resident #2] has 2 broken femurs.when we got to the hospital the nurse took pictures of her injuries.the doctor comes in and says he doesn't see those injuries accept with a motor vehicle accident.the [Named MD #2] gave us options and we decided the cast to both legs would be the best.I know the staff took her for a shower on Thursday [5/1/2025] it had to have happened between Wednesday and Friday [4/30/2025-5/2/2025].she [Resident #2] was yelling and grabbing at her legs.the person I reported the injuries to on Saturday [5/3/2025] just blew me off and said we will have to do blood work. During a telephone interview on 9/25/2025 at 11:47 AM, CNA M [CNA who cared for Resident #2 on Saturday 5/3/2025] stated, .I work night shift I will call you back. CNA M never returned this Surveyor's call. During a telephone interview on 9/25/2025 at 12:26 PM, NP #1 was asked when she was notified about Resident #2 experiencing pain on 5/3/2025, 5/4/2025, and 5/5/2025, did the nurse allow her to visualize the resident or if any bruising was reported. NP #1 stated, .if it is in my note. NP #1 was asked if an accident was reported to her related to Resident #2. NP #1 stated, .yeah.same thing if an accident it would be in my note.if I had seen a picture of the resident, it would be in my note. On 9/25/2025, an email was sent to [Named Radiology Representative] to verify if Resident #2's x-ray to her bilateral hips and lower extremities were ordered as STAT [immediately or urgent]. [Named Radiology Representative] emailed this Surveyor back and noted we received the order as a normal routine case. It was not ordered as a STAT x-ray. During an interview on 9/25/2025 at 2:16 PM, LPN H stated, .She [Resident #2] complained of pain and the NP ordered an x-ray.She was anxious and crying that is why we called the NP on Sunday [5/4/2025] to see if we should increase her pain medications. During an interview on 9/25/2025 at 3:09 PM, the Administrator and DON were asked when they were notified of the injury with Resident #2. The DON stated, .I think [Named LPN B] notified us on Monday [5/5/2025] morning. The DON was asked when Resident #2 started experiencing pain, did she physically assess the resident. The DON stated, No. The DON was asked if she was notified of any bruises on Resident #2. The DON stated, .talked about bruise around the injection site [referring to the IM medications given for pain].no nurses reported any concerns with Resident #2 over the weekend. The DON was asked what she would expect nursing to do if a bruise of unknown origin was found on a resident. The DON stated, .bruises would be reported to a charge nurse, put on a shower sheet if CNA finds one.the nurse would report it to Administrator and myself, call on call staff, and notify family, complete a skin assessment. The Administrator was asked if a timeline was completed with Resident #2's injury, if staff members