**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure resident was free from abuse for 1 (Resident #1) of 5 residents reviewed for abuse. The facility failed to protect and ensure Resident #1, which resident required extensive assistance for care, was free from receiving multiple injuries of unknown origin. The resident sustained these injuries of unknown origin: left fifth finger fracture, upper femur/thigh fracture, Sacral bone fracture, lower back, and left thigh bruise. These failures placed residents, who resided in the facility, at risk of neglect, not receiving services or care after an injury or fall. Findings included: Review of the Provider Investigation Report dated 02/28/23 reflected an attached Investigation Summary. The summary reflected the investigation was substantial enough to believe an incident occurred and was not reported to the nurse or other administration at the time of occurrence that did result in bodily injury to Resident #1. The facility investigation indicated the injury most likely occurred on 02/19/23 during the 7PM to 7AM shift and no visible signs of injury were present until the morning of 02/21/23, day the injuries were identified and reported. There was no supporting evidence that the incident was done with intent to cause harm to the resident. There was no proof that the aid that was terminated, CNA G, caused the incident or failed to report the incident. The Provider Investigation report further reflected CNA G was terminated out of abundance of caution. Review of Resident Incident/Accident Investigation Worksheet dated 02/21/23, reflected Resident #1 was noted to have an injury of unknown origin. Initial interviews with staff revealed no falls or incidents. The facility-initiated education regarding abuse/neglect, injuries of unknown origin and reporting injuries. The resident was transferred to the emergency room related to hip fracture. Review of Resident #1's electronic face sheet revealed the resident was a [AGE] year-old female admitted to the nurse facility on 01/16/22 with diagnoses of Unspecified Dementia (Primary); Hypertension; Cerebral Infarction (stroke); Hypothyroidism; Lack of Coordination; Altered Mental Status; Aphasia (following stroke); and Vitamin D Deficiency. Review of Resident #1's MDS Assessment on 01/18/23 revealed an active diagnosis of stroke, and the resident had a BIMS score of 99, which indicated a severely impaired cognitive response. The resident required extensive assistance one-person physical assist in bed mobility, dressing, toilet use, personal hygiene; two-person assist with eating. Physical assistance with transfer did not occur during assessment. The MDS also reflected the resident was dependent on functional abilities during admission performance - rolling left and right, sit to lying, lying to sitting on side of bed, toilet transfer, picking up an object, and walking at least 10 feet in a room, activities did not occur. The MDS further indicated the resident received scheduled pain medication and had no falls since admission/entry or reentry or the prior assessment. Review of Resident #1's care plan initiated on 03/29/22, revised 02/22/23 reflected Initial Goals: Resident #1 has history of falling, Fall Risk precautions with the bed in lowest position with brakes locked, call light within reach at all times provide resident with safety device/appliance: wheelchair, and other precautions. Resident #1 has difficulty making self-understood related to Aphasia (disorder that affects how you communicate). Record Review of hospital medical records, Emergency Department notes dated 02/22/23 reflected Diagnoses included: closed 2- part intertrochanteric fracture of left femur and left hip fractur, left hip dislocation. Review of page 19 reflected Resident #1 had a left fifth finger fracture. Review of page 169 of hospital records reflected: Comminuted and minimally displaced left femoral neck fracture (upper femur/thigh fracture). 3 Complex sacral fracture (sacral bone fracture) 4. Acute compression fracture of L2 (lower back) 5 Left thigh contusion (bruise). Review of Resident #1's Clinical Notes entered by LVN B on 02/19/23 at: 5:24 PM reflected a COVID 19 Screening was completed. There was no documentation regarding any other concerns with the resident. Review of Resident #1's Clinical Notes entered by LVN C on 02/20/23 at: 2:33 PM reflected a COVID 19 Screening was completed. There was no documentation regarding any other concerns with the resident. There was no documentation regarding any other assessment conducted at that time. Review of Resident #1's Clinical Notes entered by LVN D on 02/21/23 at: 2:43 AM reflected a COVID screening was completed. The screening revealed no concerns. Review of Resident #1's Clinical Notes entered by LVN C on 02/21/23 at 1:32 PM reflected: CNA reported to this nurse this morning that upon ADL care, resident appeared to have an increase in pain and edema to LLE [left lower extremity] and when CNA attempted to touch extremity for care, resident grimaced and swatted CNA's hand away. This nurse informed DON who assessed resident and advised this nurse to inform NP and request STAT X-ray to affected areas. NP agreed to STAT X-ray. Pain medication and repositioning Review of Resident #1's Clinical Notes dated 02/21/23 6:57 PM reflected: X-ray results - left fifth finger has acute fracture Review Radiology Report performed dated 02/22/23 at 12:27 AM reflected an X-ray of Left Hip identified Acute intertrochanteric femoral neck fracture; Left femur- acute intertrochanteric femoral neck fracture. Review of Resident #1's Clinical Notes dated 02/22/23 at 7:48 AM reflected x-ray results to lt (left) hip is positive for lt (left) hip fracture don/md POA/daughter notified, will continue to monitor. Review of Resident #1's Clinical Notes dated 02/22/23 at 8:19 AM reflected: LVN E set up transportation to local hospital for further evaluation of left hip fracture. Review of Resident #1's Clinical Notes reflected documentation entered by DON on 02/22/23 at 08:39 AM recorded as Late Entry on 02/22/23 08:39 AM Nurse informed DON that resident was noted to have some bruising to the left-hand 5th digit and swelling and guarding to her left knee. DON and ADON went to assess the resident #1 and noted with left 5th digit bruising. Grimacing noted when attempting to move the hand. Resident #1 also noted with left lower extremity swelling and guarding. Advised the Charge Nurse to notify the MD and request stat x-rays to rule out any fractures or dislocations. Record Review of Resident #1's MAR for pain assessment on 02/19/23-02/21/23 from the Day shift to the Night shift, on each shift, LVN B, LVN E, LVN C and LVN D all enter 0 indicating no pain. But on 2/20/23 and 2/21/23, Resident # 1 showed various signs indicative of pain/discomfort as described by CNA H and LVN C. An Interview on 03/13/23 at 04:43 PM with LVN C, she stated she had worked at the facility on 7A- 7 PM shift on February 20 and 21, 2023. LVN C stated she was the nurse that CNA H had reported to about Resident #1 not behaving like normal, on 02/20/23. When asked about working on February 17th, 18th, and 19th, of 2023, she replied, I think those were the days that I was off that weekend, on Monday (02/20/23) is when I came back. At one point (on 02/20/23), one of the CNA's told me the resident (Resident #1) looked like she was uncomfortable, it was near her scheduled medication time. I thought maybe she was uncomfortable, in pain because it was almost time for it (pain medication). I went back to look at her and she did not look like she was too uncomfortable. I gave her tramadol. LVN C stated she (Resident #1) allowed patient care, no complaints for the rest of the shift from the CNA. Resident #1 was non-verbal, had a g-tube, and no muscle tone. LVN C stated on Tuesday, (02/21/23) the same CNA came and told her, she (Resident #1) was swollen and looked more uncomfortable. She was not allowing patient care. She would not let us touch the left knee or provide care. LVN C said, I noticed the bruise on her left pinky. I was unsure how a resident, who is in bed and normally funny and nice in her non-verbal way, was now not letting us provide care. I went to get the DON then he took a look at her then he had me reach out to the in-house NP (Nurse Practitioner) and she ordered some STAT x-rays. When asked about the results of the x-rays, LVN C said, I just know they had multiple fractures. I went back with the mobile Xray tech (to Resident #1's room). The whole body was done. I was then off Thursday and Friday. There was only one verified fracture at that time, before l left work, of her left hand. It was when I returned Friday (02/24/23) that I learned of the other fractures. On Friday when I came back, I noticed she was out to the hospital, I asked around to see if she went out related to the fall. I learned from one of the other nurses that she had fractures to femur and pelvic region and maybe her tibia. LVN C was asked about the fall she mentioned, and she replied, she had no falls on my shift, nothing was reported to me. I had gotten report from off going nurses and nothing was reported. I cannot say how it happened. LVN C stated they (facility) had an in-service over all protocols and policies, if an incident occurs, new injuries or injuries of unknown origin. She said, it was like 1-hour long meeting on what we need to do if we suspect or see abuse and neglect. So, before I was off Friday- Sunday, there was no signs of any issues with Resident #1. It was only Tuesday (02/21/23) Morning when resident refused care and was showing signs of pain. No one from night shift reported any issues. In an interview on 03/13/23 at 04:06 PM with CNA G, she stated she had worked at the facility for 4 months. She said, honestly, I don't really know what to tell you. I was working that weekend 02/17-19/23). Then that Tuesday, February 20th they (facility) called me and asked if Resident #1 had fell. I was having issues with transportation; the administrator knew that. The Administrator called me and told me I was on suspension (02/23/23) then some days later then he terminated me (02/28/23), because I could not get back to work on Wednesday (02/22/23) so I was suspended because he (ADMN) said it looked weird. He (ADMN) stated he felt like something happened and I did not report it. At no time, the resident (Resident #1) showed signs of pain. Normally, when you change her (Resident #1), she will grab your hand. She grabbed a little more than usual, but she did not scream out or show signs of pain. CNA G stated she had nothing to report because the resident seemed normal. She stated the day (02/22/23) she did her wrote her statement of what she notice during her shift with Resident #1; it was 6:30 PM and her ride was already on his way to work so she could not make it in. She stated ADMN was aware of her transportation issues. She stated that on that Thursday (02/23/23) he told her they were going to continue the suspension then later called and told her they were going to proceed with a termination because he believed she had noticed a change but had not reported it. She said, when we (aides) need help (on the floor/hall) we go get the nurse or the other aide. At the facility, we have one aide on the last 18 rooms in the back and another aide gets the first 3 rooms up front (start/beginning of the hall) and like 10 rooms on another hall, so we just get the nurse because they are always at the nurses' station. CNA G stated no one had explained to her what happened to the resident. She stated she worked the 7P-7A shift on 200 hall normally. She stated she knew Resident #1 well. She said, Depending on what you are doing with her you could do care with 1 person, she was easy to turn and to move, it was like easy to do her care. CNA G was unaware if Resident #1 was 1 or 2 persons assist. She said, when we tried to tell the facility that some residents needed 2 persons, they told us we should be able to take care of it because the residents are in the bed (already in bed by night shift). We have one resident at the front of the hall, and she would put herself on the floor and she had bruises that the nurses would say they already knew about, most of my people were already in the bed. If I had seen anything or notice anything wrong with Resident #1, I would have told the nurse. Interview on 03/14/23 at 12:23 PM with CNA H, she stated she worked at the facility on 7A-7P shift February 20th & February 21st when she noted Resident #1 to not behave at her normal baseline. When asked to describe what happened on February 20, 2023, CNA H said, I came back (from being off the weekend) and went to do my normal rounds. I go into change Resident #1, and I go in and speak to her and let her know I will change her and clean her up. She grabbed my hand when I went to change her. That was unusual and I went to report it to the nurse and let her know that that (Resident #1's behavior) was unusual, for her. She (LVN C) went to go check on her. CNA H was asked if she saw the nurse check on Resident #1, she replied, I saw her go down the hallway, I was going to do something else. CNA H stated LVN C returned after checking on Resident #1 and told her that if the pain continued or if she sees something else to let her (LVN C) know. CNA H said, later on (Resident #1) was still behaving the same way, I could see it in her face. I returned (to Resident #1's Room) the same day (02/20/23) and she was still in pain. Usually, she smiles at you, but she was not doing any of that. She still had that look on her face like she was very uncomfortable, she looked like she was in pain, and I went to tell the nurse (LVN C). CNA H was asked about what occurred on February 21, 2023, during her shift, she said, this day (02/21/23) the nurse went to call someone, one of her (LVN C's) supervisors. The nurse (LVN C) did check the resident (Resident #1) before calling for someone. The nurse asked if I noticed it, the pinky finger. No one reported anything odd or off on either day, during shift change. I first noticed the change in Resident #1, before lunch (on 02/20/23), way before lunch. On Tuesday it was early when I noticed Resident #1 was still in discomfort. She (Resident #1) moves around a lot when I change her normally but on Monday (02/20/23) she did not want me to change her. She had her left leg drawn up to her chest and her hand on her ankle holding it. Tuesday (02/21/23), I went to go do my normal round and she was still holding her left leg. I did not notice anything but when the nurse came in, she saw the finger and asked if I had seen it. I had not, I was just trying to work around her pain and provide care. I was off on Wednesday (02/22/23). When I returned to work on Friday (02/24/23) I asked, my nurse (that day) where is Resident #1 and was told they sent her out. I think I was told it was something about an injury is why she went out. CNA H was asked if she knows when the X-rays were taken and was, she in the room during the x-rays. She replied, as far as Tuesday (02/21/23), I think I remember seeing someone with a machine (mobile x-ray). I was not asked to help hold the resident during x-rays. I know I did see the ADON and DON walk in the patient's (Resident #1's) room. I was told she (LVN C) was going to call someone, but I just kept checking on the resident (Resident #1) throughout the remainder of my shift. CNA H stated Resident #1 was a one person-assist, she was an extensive-assist, she could help you turn her. She stated at the end of her shift she gave report to the on-coming shift CNA about what she noticed with Resident #1. Interview on 03/14/23 at 3:54 PM with LVN E revealed he worked the 7P-7A shift on February 17th, 18th, and 19th. He did not notice any changed in Resident #1. The DON asked if she fell over the weekend as far as I know, she did not. She is total care, she cannot walk, she is contracted. The day I came back they told me she had fracture on her left hand- 5th finger and hip on left side. After the x-ray results, transport was set up for Resident #1 to go to hospital on [DATE]. Interview on 03/14/23 at 9:17 AM with the DON revealed if a nurse was told by a CNA that a non-verbal resident was not acting right the nurse should have done a full assessment, but Resident #1 did not really show pain symptoms that well. Resident #1 was able to move her upper extremities and help somewhat with care and she could indicate some things non-verbally. She could not get out of her bed on her own. Interview on 04/03/23 at 9:45 AM with LVN C stated she did not notice any bruising or swelling on 02/20/23. Interview on 04/03/23 at 11:14 AM with CNA H, she stated no side rails were on Resident #1's bed and the bed was in the lowest position with a floor mat. In an Interview on 04/03/23 at 03:55 PM with the DON, he stated they did pain assessments during 02/20/23-02/21/23. Pain assessments were included in the COVID screening and as well as one every shift. He stated from the report he got from the LVN C the medication (tramadol 50 mg) was effective. LVN C did not do a head-to-toe assessment on 02/20/23, after CNA H alerted her to a change in Resident #1's behavior and affect, the DON responded, According to our policy, we would not do a full-head-to toe assessment. Interview on 03/14/23 at 10:57 AM with NP, she said, It was reported to me that Resident #1 may have been able to move around a lot in bed, but she was not able to get out of bed on her own. Resident #1 was able to move off her sheets, but I cannot see that she would have been able to get out of bed on her own, but I agree that she would not have been able to sustain that type of injuries without some type of fall. We see her monthly, so I did order the x-rays. But her injuries definitely indicate, to me, that she experienced some type of fall, especially with an L2 [2nd lumbar vertebrae (lower-mid back)] compression injury. In an Interview on 04/04/23 at 11:22 AM with the NP, she stated that if the resident was more grabby, pushing staff's hands away and/or refusing care when she did not do it before was a change in condition because it was different. The NP stated Resident #1 had Vitamin D Deficiency, but it was being treated. The damage to any bone would have been done before this but the treatment would slow the progression of future bone loss/damage. She also stated that to a degree everyone in a nursing facility has some bone loss. Record Review of Facility's In-service Training reports dated 02/21/23- 02/22/23: Abuse /Neglect/ Misappropriation; Injury of unknown origin reporting Injuries; Fall Prevention/Fall with Major injury. Record Review of Facility's Leadership Policies and Procedures: Complete revision: 11/1/2017, reflected: Section III: Organizational Ethics. Subject: Abuse, Neglect, Exploitation or Mistreatment (continued) . 1. C. To whom the employee can report allegations of abuse including Facility Abuse Coordinator, Administrator, SS (Social Services) Director, Director of Nursing, Charge Nurse, and individual state agency for elder abuse prevention. D. Identification of person who could fall victim to alleged or suspended abuse AND identification of persons who may inflict abuse on another individual. 2. Education/training materials include A. Annual abuse and neglect education are provided as required by regulatory agencies. Education on the rights of the resident and the responsibilities of a facility to properly care for its residents. C. Procedures for reporting incidents of abuse, neglect, exploitation, or the misappropriation of resident property, and mistreatment. D. Dementia management and resident abuse prevention. III: Prevention 1. Abuse Prohibition Handout which includes information on how to and to whom concerns are reported without fear of retribution (located in the Abuse Prohibition binder is: A. Distributed upon Admission; B. Displayed in a prominent place in the facility; and C. Distributed during Resident Council Meeting. D. Distributed annually to covered individuals. 3. The In-Touch Line is a communication tool which provides all employees, patients/residents, families, friends, etc. with an outlet to express any complaints or concerns they may have to an impartial source. Reports can be made by calling the In-Touch Line . Component IV: Identification 1. Staff members will identify and assess suspected or alleged reports of abuse or neglect, focusing on objective and observable evidence, such as suspicious bruising, witness reports regarding unusual occurrences or patterns or trends of potential abuse or neglect. Types of abuse include BUT ARE NOT LIMITED TO: A. Physical assault/abuse: 1) Hitting 2) Slapping 3) Pinching 4) Kicking 5) Controlling behavior through corporal punishment 6) Physical or chemical restraints (not required to treat a medical condition) . Component V: Reporting/Response 1. All alleged violations concerning abuse, neglect, or misappropriation of property are reported verbally immediately to the Facility Abuse Coordinator, the Administrator and to other officials in accordance with state law including the State Survey and Certification Agency (nurse aide registry or licensing authorities). 2 An analysis is completed to determine what changes are needed, if appropriate, to prevent further occurrences.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for (Resident #1) of five residents reviewed for quality of care. 1.The facility failed to ensure LVN C performed a head-to- toe assessment on 02/20/23 when Resident #1 exhibited a change of condition, of pain with multiple fractures. 2. The facility failed to ensure LVN C monitored or evaluated the resident's response to interventions, and/or revise the interventions as appropriate, causing a negative outcome, or placing the resident at risk for increased pain or further problems. This failure could place residents at risk for harm by not receiving treatment and services by competently assessing and thoroughly addressing the individual's physical, mental, or psychosocial needs. Findings included: Review of Resident #1's electronic face sheet on 01/16/22 revealed the resident was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of Unspecified Dementia (Primary); Hypertension; Cerebral Infarction (stroke); Hypothyroidism; Lack of Coordination; Altered Mental Status; Aphasia (following stroke). Review of Resident #1's MDS Assessment on 01/18/23 revealed an active diagnosis of Stroke. The resident required extensive assistance of one-person physical assist in bed mobility, dressing, toilet use, personal hygiene; two-person assist with eating. The MDS also reflected the resident was dependent on functional abilities during admission performance - rolling left and right, sit to lying, lying to sitting on side of bed, toilet transfer, picking up an object, and walking at least 10 feet in a room, activities did not occur. The MDS further indicated the resident received scheduled pain medication and had no falls since admission/entry or reentry or the prior assessment. Review of Resident #1's care plan initiated on 03/29/22, revised 02/22/23 reflected Initial Goals: Resident #1 has history of falling, Fall Risk precautions with the bed in lowest position with brakes locked, call light within reach at all times provide resident with safety device/appliance: wheelchair, and other precautions. Resident #1 has difficulty making self-understood related to Aphasia (disorder that affects how you communicate). Review of Resident #1's Clinical Notes entered by LVN B on 02/19/23, 02/20/23, and 02/21/23 reflected: COVID 19 Screenings were completed. There was no documentation regarding any other concerns with the resident. Review of Resident #1's Clinical Notes entered by LVN C on 02/21/23 at 1:32 PM reflected: CNA reported to this nurse this morning that upon ADL care, resident appeared to have an increase in pain and edema to LLE [left lower extremity] and when CNA attempted to touch extremity for care, resident grimaced and swatted CNA's hand away. No falls or injuries were reported to this nurse prior to CNA informing of situation. This nurse entered resident #1 room to assess the resident and observed that her left contracted leg did appear edematous, especially in hip and knee region. This nurse palpated area, and the resident once again appeared to be in pain and swatted this nurse's hand away. This nurse assessed the rest of residents left side, observing that left pinky finger was also swollen and bruised. This nurse informed the DON who assessed resident and advised the nurse to inform NP and request STAT Xray to affected areas. NP agreed to STAT X-ray request, and the nurse called orders in to Mobile X-ray Company. Review of Resident #1's Clinical Notes entered by LVN C on 02/21/23 6:57 PM reflected: X-ray results for residents left hand returned this evening. Left fifth finger has acute fracture present at base was found on report. No wrist fracture present. LLE Xray results not available at this time. NP and physician made aware of current results, no new orders at this time while lower extremity X-ray remains pending. This nurse called and spoke with resident's #1's family to inform her of X-ray results. Family stated that she is concerned and does not understand how a fracture could occur to a bed bound patient, nurse assured POA that an investigation into the incident has begun and that management is working on getting statements from all staff who have cared for resident over the last several days, and that as soon as there is any more information available, that POA will be contacted immediately. Review of the Radiology Report dated 02/21/23 at 4:57 PM reflected. Results of the left hand identified an acute oblique 5th, proximal phalanx (finger) base fracture with mild displacement seen. Review of the Radiology Report performed on 02/22/23 at 12:27 AM revealed Acute intertrochanteric femoral neck fracture; Left femur- acute intertrochanteric femoral neck fracture. Review of Resident #1's Clinical Notes, entered by LVN E on 02/22/23 at 7:48 AM reflected: x-ray results to lt (left) hip is positive for lt (left) hip fracture don/md/ [Resident #1's POA/notified, will continue to monitor. Review of Resident #1's Clinical Notes, entered by LVN E on 02/22/23 at 8:19 AM reflected: Set up transportation to local hospital for further evaluation of left hip fracture. Review of Resident #1's Clinical Notes reflected documentation entered by DON on 02/22/23 at 8:39 AM for 02/21/23 at 11:39 AM: [Recorded as Late Entry on 02/22/23 8:39 AM] Nurse informed DON that resident was noted to have some bruising to the left-hand 5th digit and swelling and guarding to her left knee. DON and ADON went to assess the Resident #1. Resident #1 noted with left 5th digit bruising. Grimacing noted when attempting to move the hand. Resident #1 also noted with left lower extremity swelling and guarding. Advised the Charge Nurse to notify the MD and request stat x-rays to rule out any fractures or dislocations. Record Review of Resident #1's MAR for pain assessment on 02/19/23-02/21/23 from the Day shift to the Night shift, on each shift, LVN B, LVN E, LVN C and LVN D all enter 0 indicating no pain. But on 2/20/23 and 2/21/23, Resident # 1 showed various signs indicative of pain/discomfort as described by CNA H and LVN C. Interview on 03/13/23 at 9:35 AM with ADMN, he stated Resident #1 was discharged to another facility aftr the hospialization. Interview on 03/14/23 at 12:23 PM with CNA H, she stated she worked at the facility on 7A-7P shift February 20th & February 21st when she noted Resident #1 to not behave at her normal baseline. When asked to describe what happened on February 20, 2023, CNA H said, I came back (from being off the weekend) and went to do my normal rounds. I go into change Resident #1, and I go in and speak to her and let her know I will change her and clean her up. She grabbed my hand when I went to change her. That was unusual and I went to report it to the nurse and let her know that that (Resident #1's behavior) was unusual, for her. She (LVN C) went to go check on her. CNA H was asked if she saw the nurse check on Resident #1, she replied, I saw her go down the hallway, I was going to do something else. CNA H stated LVN C returned after checking on Resident #1 and told her that if the pain continued or if she sees something else to let her (LVN C) know. CNA H said, later on (Resident #1) was still behaving the same way, I could see it in her face. I returned (to Resident #1's Room) the same day (02/20/23) and she was still in pain. Usually, she smiles at you, but she was not doing any of that. She still had that look on her face like she was very uncomfortable, she looked like she was in pain, and I went to tell the nurse (LVN C). CNA H was asked about what occurred on February 21, 2023, during her shift, she said, this day (02/21/23) the nurse went to call someone, one of her (LVN C's) supervisors. The nurse (LVN C) did check the resident (Resident #1) before calling for someone. The nurse asked if I noticed it, the pinky finger. No one reported anything odd or off on either day, during shift change. I first noticed the change in Resident #1, before lunch (on 02/20/23), way before lunch. On Tuesday it was early when I noticed Resident #1 was still in discomfort. She (Resident #1) moves around a lot when I change her normally but on Monday (02/20/23) she did not want me to change her. She had her left leg drawn up to her chest and her hand on her ankle holding it. Tuesday (02/21/23), I went to go do my normal round and she was still holding her left leg. I did not notice anything but when the nurse came in, she saw the finger and asked if I had seen it. I had not, I was just trying to work around her pain and provide care. I was off on Wednesday (02/22/23). When I returned to work on Friday (02/24/23) I asked, my nurse (that day) where is Resident #1 and was told they sent her out. I think I was told it was something about an injury is why she went out. CNA H was asked if she knows when the X-rays were taken and was, she in the room during the x-rays. She replied, as far as Tuesday (02/21/23), I think I remember seeing someone with a machine (mobile x-ray). I was not asked to help hold the resident during x-rays. I know I did see the ADON and DON walk in the patient's (Resident #1's) room. I was told she (LVN C) was going to call someone, but I just kept checking on the resident (Resident #1) throughout the remainder of my shift. CNA H stated Resident #1 was a one person-assist, she was an extensive-assist, she could help you turn her. She stated at the end of her shift she gave report to the on-coming shift CNA about what she noticed with Resident #1. In an interview on 03/13/23 at 04:06 PM with CNA G, she stated she had worked at the facility for 4 months. She said, honestly, I don't really know what to tell you. I was working that weekend 02/17-19/23). Then that Tuesday, February 20th they (facility) called me and asked if Resident #1 had fell. I was having issues with transportation; the administrator knew that. The Administrator called me and told me I was on suspension (02/23/23) then some days later then he terminated me (02/28/23), because I could not get back to work on Wednesday (02/22/23) so I was suspended because he (ADMN) said it looked weird. He (ADMN) stated he felt like something happened and I did not report it. At no time, the resident (Resident #1) showed signs of pain. Normally, when you change her (Resident #1), she will grab your hand. She grabbed a little more than usual, but she did not scream out or show signs of pain. CNA G stated she had nothing to report because the resident seemed normal. She stated the day (02/22/23) she did her wrote her statement of what she notice during her shift with Resident #1; it was 6:30 PM and her ride was already on his way to work so she could not make it in. She stated ADMN was aware of her transportation issues. She stated that on that Thursday (02/23/23) he told her they were going to continue the suspension then later called and told her they were going to proceed with a termination because he believed she had noticed a change but had not reported it. She said, when we (aides) need help (on the floor/hall) we go get the nurse or the other aide. At the facility, we have one aide on the last 18 rooms in the back and another aide gets the first 3 rooms up front (start/beginning of the hall) and like 10 rooms on another hall, so we just get the nurse because they are always at the nurses' station. CNA G stated no one had explained to her what happened to the resident. She stated she worked the 7P-7A shift on 200 hall normally. She stated she knew Resident #1 well. She said, Depending on what you are doing with her you could do care with 1 person, she was easy to turn and to move, it was like easy to do her care. CNA G was unaware if Resident #1 was 1 or 2 persons assist. She said, when we tried to tell the facility that some residents needed 2 persons, they told us we should be able to take care of it because the residents are in the bed (already in bed by night shift). We have one resident at the front of the hall, and she would put herself on the floor and she had bruises that the nurses would say they already knew about, most of my people were already in the bed. If I had seen anything or notice anything wrong with Resident #1, I would have told the nurse. An Interview on 03/13/23 at 04:43 PM with LVN C, she stated she had worked at the facility on 7A- 7 PM shift on February 20 and 21, 2023. LVN C stated she was the nurse that CNA H had reported to about Resident #1 not behaving like normal, on 02/20/23. When asked about working on February 17th, 18th, and 19th, of 2023, she replied, I think those were the days that I was off that weekend, on Monday (02/20/23) is when I came back. At one point (on 02/20/23), one of the CNA's told me the resident (Resident #1) looked like she was uncomfortable, it was near her scheduled medication time. I thought maybe she was uncomfortable, in pain because it was almost time for it (pain medication). I went back to look at her and she did not look like she was too uncomfortable. I gave her tramadol. LVN C stated she (Resident #1) allowed patient care, no complaints for the rest of the shift from the CNA. Resident #1 was non-verbal, had a g-tube, and no muscle tone. LVN C stated on Tuesday, (02/21/23) the same CNA came and told her, she (Resident #1) was swollen and looked more uncomfortable. She was not allowing patient care. She would not let us touch the left knee or provide care. LVN C said, I noticed the bruise on her left pinky. I was unsure how a resident, who is in bed and normally funny and nice in her non-verbal way, was now not letting us provide care. I went to get the DON then he took a look at her then he had me reach out to the in-house NP (Nurse Practitioner) and she ordered some STAT x-rays. When asked about the results of the x-rays, LVN C said, I just know they had multiple fractures. I went back with the mobile Xray tech (to Resident #1's room). The whole body was done. I was then off Thursday and Friday. There was only one verified fracture at that time, before l left work, of her left hand. It was when I returned Friday (02/24/23) that I learned of the other fractures. On Friday when I came back, I noticed she was out to the hospital, I asked around to see if she went out related to the fall. I learned from one of the other nurses that she had fractures to femur and pelvic region and maybe her tibia. LVN C was asked about the fall she mentioned, and she replied, she had no falls on my shift, nothing was reported to me. I had gotten report from off going nurses and nothing was reported. I cannot say how it happened. LVN C stated they (facility) had an in-service over all protocols and policies, if an incident occurs, new injuries or injuries of unknown origin. She said, it was like 1-hour long meeting on what we need to do if we suspect or see abuse and neglect. So, before I was off Friday- Sunday, there was no signs of any issues with Resident #1. It was only Tuesday (02/21/23) Morning when resident refused care and was showing signs of pain. No one from night shift reported any issues. Interview on 03/14/23 at 3:54 PM with LVN E revealed he worked the 7P-7A shift on February 17th, 18th, and 19th. He did not notice any changed in Resident #1. The DON asked if she fell over the weekend as far as I know, she did not. She is total care, she cannot walk, she is contracted. The day I came back they told me she had fracture on her left hand- 5th finger and hip on left side. After the x-ray results, transport was set up for Resident #1 to go to hospital on [DATE]. Interview on 03/14/23 at 9:17 AM with the DON revealed if a nurse was told by a CNA that a non-verbal resident was not acting right the nurse should have done a full assessment, but Resident #1 did not really show pain symptoms that well. Resident #1 was able to move her upper extremities and help somewhat with care and she could indicate some things non-verbally. She could not get out of her bed on her own. DON said, On Monday (02/20/23) she (LVN C) did do an assessment, she did a COVID Screening. He stated that LVN C did a head-to-toe assessment on 02/21/23 because the symptoms warranted it, but Resident #1 vital signs did not warrant it a head-to-toe assessment on 02/20/23. In an Interview on 04/03/23 at 03:55 PM with the DON, he stated they did pain assessments during 02/20/23-02/21/23. Pain assessments were included in the COVID screening and as well as one every shift. He stated from the report he got from the LVN C the medication (tramadol 50 mg) was effective. LVN C did not do a head-to-toe assessment on 02/20/23, after CNA H alerted her to a change in Resident #1's behavior and affect, the DON responded, According to our policy, we would not do a full-head-to toe assessment. Interview on 03/14/23 at 10:57 AM with NP, she said, It was reported to me that Resident #1 may have been able to move around a lot in bed, but she was not able to get out of bed on her own. Resident #1 was able to move off her sheets, but I cannot see that she would have been able to get out of bed on her own, but I agree that she would not have been able to sustain that type of injuries without some type of fall. We see her monthly, so I did order the x-rays. But her injuries definitely indicate, to me, that she experienced some type of fall, especially with an L2 [2nd lumbar vertebrae (lower-mid back)] compression injury. In an Interview on 04/04/23 at 11:22 AM with the NP, she stated that if the resident was more grabby, pushing staff's hands away and/or refusing care when she did not do it before was a change in condition because it was different. The NP stated Resident #1 had Vitamin D Deficiency, but it was being treated. The damage to any bone would have been done before this but the treatment would slow the progression of future bone loss/damage. She also stated that to a degree everyone in a nursing facility has some bone loss. Record Review of hospital medical records, Emergency Department notes dated 02/22/23 reflected Diagnoses included: closed 2- part intertrochanteric fracture of left femur and left hip fractur, left hip dislocation. Review of page 19 reflected Resident #1 had a left fifth finger fracture. Review of page 169 of hospital records reflected: Comminuted and minimally displaced left femoral neck fracture (upper femur/thigh fracture). 3 Complex sacral fracture (sacral bone fracture) 4. Acute compression fracture of L2 (lower back) 5 Left thigh contusion (bruise). Record Review of Facility's In-service Training reports dated 02/21/23- 02/22/23 revealed: Abuse /Neglect/ Misappropriation; Injury of unknown origin reporting Injuries; Fall Prevention/Fall with Major injury. Record Review of Facility's Nursing Policies and Procedures: Complete revision: 7/01/16 Subject: Physician and other Communication/Change in condition reflected: .provide nursing staff with guidelines for making decisions regarding appropriate and timely notification of medical staff regarding changes in a patient's/resident's condition and provide guidance for the notification of patients/residents and their responsible party regarding changes in condition. Complete assessment of the patient/resident which may in [NAME] but is not limited to: .Current physical condition. C. Patient's pious condition (declining, improving, stable). D. Previous and current mental status. E. Vital signs, TPR, BP, I/O, Lung Sounds, N/V (nausea/vomiting) Abdominal Assessment, Pain, Last BM, Blood Glucose. F. Recent labs, x-ray results. G. Medications. H. Allergies. I. Code Status, J. Hospital of choice, K. Patient. Resident/family wishes. L. Any interventions/first aide provided to the patient/resident. 2 Complete SBAR (Situation, Background, Assessment, Recommendation- a verbal/written nursing communication tool). 3. Notify the physician of the change in medical condition The nurse will document all assessments and changes in the patient's/residents condition it he medical record.