**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to immediately consult with the resident's physician and notify, consistent with his or her authority, the resident representative when there was an accident with potential for requiring physician intervention for 1 of 6 Residents (Resident #1) whose records were reviewed for accidents. LVN A failed to notify Resident #1's physician and representative when he had a fall on 9/18/23 which resulted in a delay of care. The facility failed to consult the physician when the mobile x-ray did not arrive timely to take the x-ray resulting in Resident #1 waiting 15 1/2 hours for his x-ray to be taken. Resident #1 was hospitalized on [DATE], was diagnosed with a right hip fracture and admitted for surgery. The noncompliance was identified as past noncompliance Immediate Jeopardy (IJ). The noncompliance began on 9/18/23 and ended on 11/30/23. This deficient practice could contribute to residents not receiving the medical care and treatment needed and a decline in physical condition. The findings were: Review of Resident #1's face sheet, dated 9/20/23, revealed he was admitted to the facility on [DATE] with diagnoses including unspecified Dementia (decline in cognitive abilities that impacts a person's ability to perform everyday activities) and Parkinson's (a progressive disorder that affects the nervous system and the parts of the body controlled by the nerves). Further review revealed Resident #1 had a family member who was his Emergency Contact #1. Review of Resident #1's quarterly MDS assessment, dated 8/31/23, revealed he required extensive assistance by 1 person for bed mobility, transfers ambulation and locomotion. He used a walker and wheelchair for locomotion. Further review revealed Resident #1's level of cognition and level of pain was not assessed; he had 1 fall since admission, 2 falls with no injuries and 1 fall with injury but not a major injury. Review of Resident #1's change of condition MDS assessment, dated 10/24/23, revealed his BIMS was 1 of 15 indicative of severe cognitive impairment. Further review revealed Resident #1 used a walker and manual wheelchair for mobility and was admitted with diagnosis which included hip fracture; a pain assessment was not completed, and it reflected that he required major surgery prior to admission to the facility which included a hip replacement. Review of Resident #1's Care Plan revised on 11/28/23 revealed he had self-performance deficit related to Dementia and Parkinson's. He required limited to extensive assistance by 1 or 2 persons with bed mobility and transfers. Further review revealed Resident #1 was a risk for falls reason to unsteady gait/balance, Dementia and Parkinson's. Some of the interventions included to anticipate and meet needs and follow facility fall protocol. Review of Resident #1's fall risk assessment, dated 8/14/23, revealed his score was 16 indicating he was a high fall risk. Review of Resident #1's fall risk assessment, dated 10/18/23, revealed his score was 18 indicating he was a high fall risk. Review of an incident report, dated 9/18/23 at 9:30 AM, revealed that LVN A was passing by Resident #1's room; she saw him sitting on his walker. He bent forward to pick up a wrapper from the floor. The walker started to roll backwards, and she responded, tried to hold him up by his waistline, but was not able to hold him up and lowered him to the floor. LVN A went to get MA B to help transfer Resident #1 safely into his bed. Further review revealed LVN A assessed Resident #1 for range of motion and pain. Assessment was done before and after moving Resident #1 into the bed. Results were within his normal limits. No injuries were observed at the time of incident or post incident. Review of Resident #1's progress note, dated 9/18/23, written by LVN A revealed it was a late entry note. The note reiterated Resident #1 had a fall per the incident report. Further review revealed LVN A did not contact Resident #1's physician or family representative. Review of the SBAR communication form written by LVN A, dated 9/19/23, revealed the change of condition, symptoms or signs observed and evaluated was Pain (uncontrolled). She noted changes in the last week for Resident #1 included mobility decreased and a skin tear (right knee). LVN A conducted a pain evaluation which revealed Resident #1 had a new onset of pain as evidenced by grimacing when attempted to stand, occasional moan and groan, level of speech with negative or disapproving quality, tense, distressed pacing, fidgeting and distracted. Further review revealed a new order for an x-ray of the pelvis and right knee. In addition, it was noted LVN A notified the physician for Resident #1's change of condition on 9/19/23 at 8:35 AM and the family representative on 9/19/23 at 9:00 AM. Review of a an eMAR administration note effective dated 9/19/23 at 12:25 PM revealed LVN A administered Acetaminophen 325 mg., give two tablets every 4 hours as needed for pain. It was noted at 13:27 (1:27 PM) PRN administration was ineffective. Follow up pain scale was: 6. Review of Radiology report, examination dated 9/20/23 at 01:09 (1:09 AM), revealed Single view of the pelvis. Findings: Acute dislocated fracture involving the right femoral neck (right hip fracture). Ortho consultation recommended. Diffuse Osteopenia present. Right Knee X-ray, 2 views of the right knee. Findings: There are no visualized fracture. Review of Provider Investigation Report, dated 9/27/23, revealed that on 9/18/23 Resident #1 was assessed by LVN A. LVN A found there was no pain immediately post fall. Further assessment shows that ROM was not significantly different than baseline. On 9/19/23, LVN A completed another assessment which revealed Resident #1 was showing signs of guarding his right side. Physician notified; new order given to have x-ray of resident's right side. Results showed fracture in right femoral neck. Provider Response: 1. Incident Report Completed 2. Interview Staff 3. Safe Survey 4. In-service staff - Abuse/Neglect, Pain assessment, Fall Risk Assessment, Incident Report, Documentation, Interventions 5. Notified Family 6. Notified Physician 7. Nurse Suspended pending investigation Summary: Upon investigation and completing staff interviews on 9/19/23, it was discovered the nurse did not report the fall when it occurred on the 18th. The nurse was suspended during investigation. Family was notified on the 19th and an x-ray was ordered. Results of x-ray led to resident being sent to the hospital. Staff was in-serviced on incident reports, pain assessment, fall risk assessment, interventions, reporting falls, fall documentation and on abuse and neglect. Review of an in-service dated 9/21/23 related to reporting falls revealed thirteen staff signatures. Further review revealed the in-service was continued on 9/22/23 which revealed fourteen staff signatures. Review of an in-service dated 9/21/23 related to pain/assessment revealed thirteen staff signatures. Further review revealed the in-service was continued on 9/22/23 which revealed thirteen staff signatures. Review of an in-service dated 9/22/23 related to fall interventions/documentation revealed thirty-two staff signatures. Further review revealed the in-service was continued on 9/22/23 which revealed eight staff signatures. Review of an in-service dated 9/22/23 related to falls assisted and unassisted/documentation revealed thirty-two staff signatures. Further review revealed the in-service was continued on 9/22/23 which revealed nine staff signatures. Review of an in-service dated 9/22/23 related to Abuse, Neglect and Reporting revealed ninety-nine staff signatures. Review of a statement, undated, titled Conversation with [name of LVN A] read: I was walking past the room when I noticed resident was sitting on rolling walker, he was bending down to pick up candy wrapper off the floor, I was worried he was going to fall over so I went to the room, the walker was rolling away and he started falling, I grabbed him from the waistband and assisted him to the floor. He was sitting upright on the floor, so I went to get help and when we returned, he was on the right side stretched out. [name of MA B] the med aide helped assist him get back into bed. Did not verbalize pain. Vitals were taken and charted. On Tuesday, he didn't' want to get up, acted stiff, not moving freely, and moaning. I went to check on him, he was guarding his right side. No visible signs of injuries. No edema (swelling) no bruising. PRN medication given at 8:30 am notified [name of NP C] NP, ordered x-ray. I called [name of Emergency Contact #1) and let her know. 9:30 called x-ray, did not come in during 6 to 2 shift. Results did not come in until overnight. Interview on 1/3/24 at 2:21 PM with MA B, he stated Resident #1 was a fall risk. He stated LVN A asked him to help transfer Resident #1 back into bed after he fell and subsequently was diagnosed with a right broken hip. He stated upon entering Resident #1's room, Resident #1 was on the floor. Resident #1 was grimacing and LVN A conducted an assessment. LVN A then administered PRN pain medication. MA B stated it would be LVN A's responsibility to call the physician and responsible party to inform them of the fall and the details of the incident. MA B verbalized the understanding of the facility fall precautions, preventions and protocols to follow. Interview on 1/3/24 at 4:20 PM with LVN D revealed he worked 2 to 10 PM on 9/18/23. He stated LVN A did not report to him that Resident #1 had fallen. He stated it was the following day that LVN A reported Resident #1 had fallen the day before because on this date, 9/19/23, Resident #1 was complaining of pain to his right side. LVN D stated there was no documentation in the 24-hour report, there was no progress note and he did not know anything about an X-ray order which should be noted in the nursing documentation. LVN D stated after a fall, the charge nurse was responsible for notifying the physician, in-house administrative staff and the resident's responsible party. Further interview revealed LVN D verbalized the understanding of the facility fall precautions, preventions and protocols to follow. Interview on 1/3/24 at 7:54 PM with LVN A revealed she worked 6 AM to 2 PM on 9/18/23. She reiterated the details of the incident report and her statement r/t Resident #1's fall. She stated on the morning of 9/18/23 she saw Resident #1 sitting on the rolling walker as she was passing his room. He bent over to pick up a piece of paper from the floor. He was holding onto the handles which engaged the walker and it started to roll backwards. Resident #1 was very unsteady, and it looked like he was going to fall. She stated she assisted him to the floor, and he did not at any point make contact with the floor. She stated she was able to straddle the walker and held Resident #1 up from under his arm pits. She stated he was too heavy and could not hold him up and lowered him down her legs and he came to a sitting position on her feet. LVN A stated he never hit the floor and at the time she did not perceive it as a fall. She stated she had MA B help her transfer Resident #1 back to bed. She stated Resident #1 was able to stand and lift his legs onto the bed. Resident #1 did not exhibit any signs of pain during assessment. He mumbled no and shook his head when she asked about pain. LVN A further stated Resident #1 did not complain of pain the remaining of the shift. LVN A stated the following day on 9/19/23 Resident #1 was in bed asleep when she rounded on him upon starting her shift at 6 AM. She stated later the same morning, Resident #1 complained of excruciating pain when the aides tried to get him up from bed after breakfast. She stated she tried to give him PRN medication, but he would not take it. She stated she called NP C who ordered mobile X-rays. She then called the responsible party and stated the responsible party did not say anything about sending Resident #1 to the hospital. LVN A stated when she talked to the DON about the incident, the DON was upset with her because she did not report the incident the day before. LVN A stated at this point it was clear to her that an assisted fall was considered a fall. The DON instructed her to complete an incident report, enter late entries into the nurse's progress notes and complete a change of condition risk management form r/t Resident #1 complaining of pain. LVN A stated in retrospect, she believed she mishandled the incident and although she did not perceive it as a fall, it was clearly an incident and should have followed protocol by reporting the incident to the physician, responsible party and administrative staff. Then followed up with documenting the incident. The only person she stated she told about the fall was the 2 to 10 PM shift nurse reporting to work on 2/18/23. LVN A stated on 9/20/23 she learned mobile x-ray did not complete imaging until about 1 AM and then he was sent out later that early morning on the 10 PM to 6 AM shift. LVN A stated the X-Ray confirmed he had a right broken hip. Interview on 1/4/24 at 10:16 AM with the previous DON E revealed LVN A did not report Resident #1's fall on the date of the fall. She learned about it when LVN A was completing a Change of Condition report the day after the fall because he was complaining of pain to his right side. The previous DON E confirmed per LVN A's interview, that LVN A did not report the incident to administrative staff, did not call the physician and did not call the family member on the date of the incident. The previous DON E stated it was necessary to follow fall protocol because the physician might have provided orders on the date of the fall which would then delay care. The previous DON E stated Resident #1 sustained a right hip fracture and required surgery. She stated Resident #1 was transferred to a higher level of care acute post op facility for rehabilitation before transferring back to the nursing facility. Further interview revealed the previous DON E stated staff was provided with extensive training related to facility policy and protocols regarding falls including identifying a fall, reporting the fall, preventions, precautions, assessing pain and documentation. DON E further stated she was terminated as the DON. Attempted telephone call on 1/4/24 at 11:22 AM to Resident #1's Emergency Contact. Left a voicemail requesting she return the call. Interview on 1/4/24 at 11:53 AM with the Interim ADM revealed after Resident #1's fall, facility staff followed protocol when Resident #1 experienced a change of condition; he was experiencing pain on 9/19/23. He stated LVN A called the physician, she obtained an order for X-rays, she administered PRN pain medication and nursing staff sent Resident #1 to the hospital once the X-ray results were obtained. The ADM stated he expected nursing staff to use their best nursing judgement to follow up with a call to the physician when asked about the amount of time it took the X-rays to be completed and provided to the facility. The ADM further stated the previous DON remained in communication with the family representative who elected to have Resident #1 returned to the facility and the facility completed extensive training for all nursing staff regarding facility fall protocols. Telephone interview on 1/5/24 at 12:38 PM with Resident #1's Emergency Contact revealed LVN A called her the day after Resident #1 fell (9/19/23). LVN A reported to her Resident #1 was in pain and she called the physician and X-rays were ordered. She stated she asked LVN A if she needed to pick Resident #1 up and take him to the hospital and stated LVN A downplayed it and commented, It's not that serious. Resident #1's Emergency Contact stated she was upset that LVN A did not call her on the date of the fall; that LVN A downplayed it and that it took about 16 hours before the X-ray's were completed while he laid in bed in pain. Resident #1's Emergency Contact stated she had told nursing staff Resident #1 had a high tolerance for pain and again stated she was so upset that it took 2 days to send him out to the hospital. She stated she expressed how unhappy she was with how staff handled Resident #1's incident during a discussion with the previous DON and the Operations Manager after he was released from the hospital. She stated she decided not to transfer Resident #1 because he had Dementia, was comfortable and did not want to disrupt his placement. Review of facility policy, Resident Rights, undated, read It is the policy of this facility that all resident rights be followed per state and federal guidelines as well as other regulative agencies. 26. To be informed of any accident involving Resident resulting in injury or requiring physician intervention, any significant change in Resident's condition, or need to alter treatment significantly. Review of facility policy, Quality of Care, Incident Accident Reporting, revised 05/2007, read 3. Incident/Accident Reports involving residents will have notations in the nurses' notes for a minimum of seventy-two (72) hours, or longer as appropriate, until such time as the resident is deemed stable and/or has returned to their previous level of functioning. Report Incident/Accident 1. The charge nurse on the shift when the incident/accident is discovered is required to complete the incident/accident report, before the end of shift. Notification to the resident's appropriate representative and to the attending physician are to be included on this report. Reviews: 1.Fall policy stated Attending physician and Resident Representative shall be notified. 2.Inservice completed on 9/21/23 -The provider either NP or physician and RP will be notified. 3.Inservice completed on 9/22/23-The DON, MD/NP and RP will be notified. 4.NEW DON -Inservice done on 10/16/23- RP, MD and the DON must be notified. 5.Inservice completed on 11/3/203- RP, MD and the DON must be notified. 6.Inservice completed on 11/16/2023- order x-rays, follow up with needed x-rays and calling for reports and follow up. 7.Inservice completed on 11/30/23- RP and MD notified of Change of Condition (COC). Further review of in-services revealed out of 44 nursing employees (nurses and aides) 41 had signed in-service on fall management. Two staff were no longer working at the facility, and 1 was prn and had not worked. The noncompliance was identified as past noncompliance IJ. The noncompliance began on 9/18/23 and ended on 11/30/23 when all staff had been in-serviced on fall management to include notifying the MD and RP. LVN A resigned, and the DON was terminated prior to surveyor entrance. The facility corrected the noncompliance before survey began.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews 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 resident's choices for 1 of 6 Residents (Resident #1) reviewed for treatments and services. LVN A failed to ensure Resident #1 received appropriate assessments and interventions when he had a fall on 9/18/2023, which she did not report as a fall to an oncoming nurse, DON or Administrator. The facility failed to consult the physician when the mobile x-ray did not arrive timely to take the x-ray resulting in Resident #1 waiting 15 1/2 hours for his x-ray to be taken. Resident #1 was hospitalized the following day on 9/19/2023 and diagnosed with a right hip fracture. The noncompliance was identified as past noncompliance Immediate Jeopardy (IJ). The noncompliance began on 9/18/2023 and ended on 11/30/23. This deficient practice could contribute to residents not receiving the necessary medical assessment and treatment and a decline in physical condition. The findings were: Record review of Resident #1's electronic medical record face sheet dated 1/10/2024 revealed a [AGE] year-old male with an initial admission date of 5/10/2023 and a re-admission date of 10/18/2023 with diagnoses to include encounter for closed fracture with aftercare, Parkinson's Disease(a progressive disorder that affects the nervous system and the parts of the body controlled by the nerves.), dysphagia(difficulty with speech), cognitive communication deficit, history of falling, and unspecified dementia(decline in cognitive abilities that impacts a person's ability to perform everyday activities). Review of Resident #1's change of condition MDS assessment, dated 10/24/23, revealed his BIMS score was 1 of 15 indicative of severe cognitive impairment. Further review revealed Resident #1 used a walker with a seat and a manual wheelchair for mobility, he had 3 falls since admission with no injuries and 1 fall with injury but not a major injury. Record review of Resident #1's care plan date initiated 7/18/2023 and revision date of 11/28/2023 revealed Resident #1 was at risk for falls. Interventions were adaptive devices as recommended by therapy or the MD. Monitor for risk of falls. Monitor/document ability to perform ADL's. Report any improvement or decline to the MD. Monitor/document/report to the MD PRN signs or symptoms of Parkinson's complications such as poor balance, poor coordination, gait disturbances, and decline in range of motion. Follow the facility fall protocol. Review of Resident #1's fall risk assessment, dated 8/14/23, revealed his score was 16 indicating he was a high fall risk. Review of Resident #1's fall risk assessment, dated 10/18/23, revealed his score was 18 indicating he was a high fall risk. Review of an incident report, dated 9/18/23(no time documented), revealed that LVN A was passing by Resident #1's room; she saw him sitting on his walker. He bent forward to pick up a wrapper from the floor. The walker started to roll back wards and she responded, tried to hold him up by his waistline, but was not able to hold him up and lowered him to the floor. LVN A went to get MA B to help transfer Resident #1 safely into his bed. Further review revealed no injuries were observed at the time of incident or post incident. Record review of Resident #1's EMR revealed documentation authored by LVN A on 9/18/2023 at 9:30 am of Resident #1's fall. There was documentation of an assessment and responsible party and physician were notified of the fall. There was no documentation for the following shifts on 1/18/2024 on the 2:00 PM-10:00 PM shift or the 10:00 PM-6:00 am shift. Review of the SBAR(Situation-Background-Assessment-Recommendation) communication form written by LVN A, dated 9/19/23, revealed that on 9/18/23 Resident #1's mobility decreased and he had a new onset of pain as evidenced by grimacing when attempted to stand, occasional moan and groan; level of speech with negative or disapproving quality, tense, distressed pacing, fidgeting and distracted. Further review revealed a new order for an x-ray of the pelvis and right knee. Review of a medication administration note effective dated 9/19/23 at 13:27 PM (1:27 PM) revealed LVN A administered Acetaminophen 325 mg., give two tablets every 4 hours as needed for pain for Resident #1's right hip pain, PRN administration was ineffective. Follow up pain scale was: 6. Review of the radiology report, examination date 09/20/23 at 01:09 (1:09 AM), revealed Single view of the pelvis. Findings: Acute dislocated fracture involving the right femoral neck(is a break in the bone that connects the hip joint to the thigh bone). Ortho consultation recommended. Diffuse Osteopenia(means your bones are thinner than normal, but not as weak as osteoporosis) present. Right Knee X-ray, 2 views of the right knee. Findings: There are no visualized fracture( a break in the bone.). Review of a statement, undated, titled Conversation with [name of LVN A] revealed: I was walking past the room when I noticed resident was sitting on rolling walker, he was bending down to pick up candy wrapper off the floor, I was worried he was going to fall over so I went to the room, the walker was rolling away and he started falling, I grabbed him from the waistband and assisted him to the floor. He was sitting upright on the floor, so I went to get help and when we returned, he was on the right side stretched out. [Name of MA B] the med aide helped assist him get back into bed. Did not verbalize pain. Vitals were taken and charted. On Tuesday(9/19/2023), he didn't' want to get up, acted stiff, not moving freely, and moaning. I went to check on him, he was guarding his right side. No visible signs of injuries. No edema (swelling) no bruising. PRN medication given at 8:30 am notified [Name of NP C] NP, ordered x-ray. I called [name of Emergency Contact #1) and let her know. 9:30 am called x-ray, did not come in during 6:00 am to 2:00 PM shifts. Results did not come in until overnight(9/19/2023). Interview on 1/3/24 at 4:20 PM with LVN D revealed he worked 2 to 10 PM on 9/18/23. He stated LVN A did not report to him that Resident #1 had fallen. LVN D stated there was no documentation in the 24-hour report, there was no progress note and he did not know anything about an X-ray order which should be noted in the nursing documentation. During an interview on 1/3/24 at 7:54 p.m.LVN A stated the following day on 9/19/23 Resident #1 was in bed asleep when she rounded on him upon starting her shift at 6 AM. She stated later the same morning, Resident #1 complained of excruciating pain when the aides tried to get him up from bed after breakfast. During a phone interview on 1/10/24 at 9:20 a.m. with the family member of Resident #1, stated the facility did not know that Resident #1 had a right hip fracture on 09/19/2023 until x-ray results were obtained. She further revealed she did not know how long Resident #1 had a fracture to his right hip. During an interview on 1/10/2024 at 1:45 PM with Medication Aide B revealed he worked on 9/18/2023 with LVN A. He stated he was called to assist her in a resident's room (Resident #1) but couldn't recall time, to help get the resident to back to bed. He stated the resident complained of some pain in his right knee and he left to do his medication pass. Medication Aide B was not asked by the nurse to give any pain medications. All staff receive in-services frequently at the facility on falls reporting abuse and neglect by management. Medication Aide B said (Resident #1) stayed in bed the following day as he was not wanting to get up. During an interview on 1/10/2024 at 1:59 PM with Certified Nurse Aide C revealed he worked on 9/18/2023 during the 2-10 PM shift. He stated he was familiar with Resident #1. He stated during the evening of 9/18/2023 he was sleepy, but he did not recall him complaining of pain. Certified Nurse Aide C stated Resident #1 did not want to get out of bed. He stated he usually would walk with a walker and assistance of one staff, or he could fall as he was a fall risk. Certified Nurse Aide C stated he did not remember anything else and could not recall the next day if the resident was in the hospital or at facility. During an interview on 1/10/2024 at 2:56 PM the Director of Rehabilitation revealed Resident #1 was a fall risk due to Parkinson's Disease and dementia(inability to recall) therefore he used a walker while ambulating. During a phone interview on 1/11/2024 at 1:04 p.m. LVN A revealed she was working as a charge nurse on the 6:00 am to 2:00 PM shift, Monday through Friday on 09/18/2023. She stated she was no longer working at the facility as she decided to resign. She further revealed on 09/18/2023 she was walking past Resident #1's room when she noticed Resident #1 was sitting on the seat of his rolling walker, he was bending down to pick up a candy wrapper off the floor. She stated, I was worried he was going to fall over so I went to the room, the walker was rolling away and he started falling. I grabbed him from the waistband and assisted him to the floor. He was sitting upright on the floor, so I went to get help and when we returned, he was on his right side stretched out. She stated [name of MA B] the med aide helped me assist him get back into bed. LVN A said Resident #1 did not verbalize any pain to her at that time. LVN A further revealed she finished the assessment of checking his body for any injuries on the resident and took his vital signs and she charted them. LVN A stated Resident #1 had no complaints of pain during the rest of her shift. She stated she reported to the oncoming nurse(LVN A stated she could not remember who the nurse was) the resident had not had a fall but to watch him in case he sat on floor again. LVN A confirmed on the following day she was working as the charge nurse on the 6 am to PM shift, when she went to check on Resident #1. LVN A stated, He didn't' want to get up, acted stiff, not moving freely, and moaning. There were no visible signs of injuries, no edema (swelling), and no bruising to his right leg or hip. LVN A further revealed she notified the nurse practitioner who ordered an x-ray. She further revealed she notified Resident #1's responsible party. LVN A revealed she should have reported the incident with Resident #1 as a fall to the DON. She stated, The reason I did not is because I did not think it was a true fall, but thinking back I should have treated it like one. LVN A said if a resident had a fall then nurses were to assess them and then follow up by calling the doctor and follow any new orders, the responsible party, and notify the DON. Documentation was done in the resident's electronic medical record and in the 24-hour report. During an interview on 1/10/2024 at 9:40 am with DON she revealed she was not working at the facility during the time when Resident #1 had a fall on 9/18/2023 During an interview on 1/10/2024 at 9:55 am the facility Administrator confirmed he was the Administrator when Resident #1 had a fall on 9/18/2023. He further revealed that LVN A should have notified the DON and Administrator when the fall occurred on 9/18/2023 Record Review of Provider Investigation Report, dated 9/27/23, revealed that on 9/18/23 Resident #1 was assessed by LVN A. LVN A found there was no pain immediately post fall. Further assessment showed that ROM was not significantly different than baseline. On 9/19/23, LVN A completed another assessment which revealed Resident #1 was showing signs of guarding his right side. Physician notified and new order given to have x-ray of residents right side. Results showed fracture in right femoral neck. Provider Response: 1. Incident Report Completed 2. Interviews of Staff 3. Safe Survey with residents 4. In-service staff - Abuse/Neglect, Pain assessment, Fall Risk Assessment, Incident Report, Documentation, Interventions 5. Notified Family 6. Notified Physician 7. Nurse Suspended pending investigation. Summary: Upon investigation and completing staff interviews on 9/19/23, it was discovered that the nurse did not report the fall when it occurred on the 18th. The nurse was suspended during investigation. Family was notified on the 19th and an x-ray was ordered. Results of x-ray led to resident being sent to the hospital. Staff was in-serviced on incident reports, pain assessment, fall risk assessment, interventions, reporting falls, fall documentation and on abuse and neglect. Review of the facility policy titled Significant Change of Condition, Response, dated 05/2007 with revision dates of 06/2019, 01/2022, and 12/2023 revealed: It is the policy of this facility to ensure each resident receives quality of care and services to attain and maintain the highest practible physical mental and psychological well-being in accordance with the interdisciplinaty comprehensive assessment and plan of care. 4. The Medical Director shall be notified in the evenrt that the Attending Physician or on-call Physician cannot be reached. Review of the facility policy titled Fall Management System, dated 06.2018 with revision dates of 1.2022; and 12.2023, revealed: Policy: It is the policy of the facility to provide an environment that remains as free of accident hazards as possible. It is also the policy of this facility to provide each resident with appropriate assessment and interventions to prevent falls and to minimize complications if a fall occurs. Definition: Fall: refers to unintentionally coming to rest on the ground, floor, or other lower level, but not as a result of an overwhelming external force (e.g., resident pushes another resident).An episode where a resident lost his/her balance and would have fallen, if not for another person or if he or she had not caught him/herself, is considered a fall. Procedure section 3. When a resident sustains a fall, a physical assessment will be completed by a licensed nurse, with results documented in the medical record. b. Follow up documentation will be completed for a minimum of 72 hours following the incident. The facility course of action prior to surveyor entrance included: LVN A resigned before she was terminated. The previous DON was terminated. Review of in-services on notifying the MD in the event of a fall, change of condition, and ordering x-rays, follow up with needed x-rays and calling for reports and follow up were completed between 9/21/2023-11/30/23. Review of an in-service, dated 9/21/23 related to reporting falls revealed thirteen staff signatures. Further review revealed the in-service was continued on 9/22/23 which revealed fourteen staff signatures. Review of an in-service, dated 9/21/23 related to pain/assessment revealed thirteen staff signatures. Further review revealed the in-service was continued on 9/22/23 which revealed thirteen staff signatures. Review of an in-service, dated 9/22/23 related to fall interventions/documentation revealed thirty-two staff signatures. Further review revealed the in-service was continued on 9/22/23 which revealed eight staff signatures. Review of an in-service, dated 9/22/23 related to falls assisted and unassisted/documentation revealed thirty-two staff signatures. Further review revealed the in-service was continued on 9/22/23 which revealed nine staff signatures. Review of an in-service, dated 9/22/23 related to Abuse, Neglect and Reporting revealed ninety-nine staff signatures. Review of an in-service , dated 10/16/23 related to reporting falls revealed fourty-eight staff signatures. Review of an in-service , dated 11/3/2023 related to falls and pain management revealed twenty-nine staff signatures. Review of an in-service , dated 11/16/2023 related to order xrays, follow up with needed xrays and calling for reports and follow up revealed fourteen staff signatures. Review of an in-service , dated 11/30/23 related to RP and MD notified of COC revealed nineteen staff signatures. Interviews with 27 employees who consisted of LVNs, RNs, MA, and CNAs from 1/23/24 at 10:00 a.m. to 1/25/24 at 10:30 a.m. revealed that had received in-services on fall management, identifying change of conditions to include pain and behavior, who to notify (DON, doctor, and RP), delay in tests, and abuse and neglect. The noncompliance was identified as past noncompliance IJ. The noncompliance began on 9/18/2023 and ended on 11/30/23 when all staff had been in-serviced on fall management, notifying the MD and RP, pain management, and x-ray ordering/follow-up. LVN A resigned and the DON was terminated before surveyor entrance. The facility had corrected the noncompliance before the survey began.