**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not ensure each resident receives the necessary care and services in accordance with professional standards of practice (N6, Wisconsin Nurse Practice Act) for 1 of 13 sampled residents (R20) resulting in actual harm. R20 was self-transferring multiple times and on the eighth attempt, suffered an unwitnessed fall. The facility failed to provide an assessment completed by an RN (Registered Nurse) or with RN oversight at the time of the fall. The facility failed to notify the physician timely of the fall, failed to relay all of R20's symptoms to physician and DON B (Director of Nursing) at the time of the fall, and failed to notify physician of changes of condition following the fall. R20 was found to have a left acetabular (hip joint socket) fracture. Evidenced by:Facility policy, titled Change in Condition of the Resident, reviewed 9/20/22, includes, in part: .When a resident presents with a possible change in condition, after a fall or other possible trauma, or noted changes in mental or physical functioning: assess the resident's need for immediate care/medical attention. Provide emergency care as needed. Assessment/evaluation could include, but is not limited to, the following: vital signs, oxygen saturation, blood glucose level .lacerations - amount of bleeding drainage, size/depth of wound, dressings/condition of - if in place.Swelling, edema, discoloration.pain- location, type, intensity, duration, causative factors . alteration in level of consciousness, ability to respond . bowel and bladder control, sensory weakness or change.speech disorder.abdominal spasms or pain . Flushing, cyanosis, blanching.Abduction, adduction, shortening or improper position of extremities.Notify resident's physician.Immediate notification for any symptoms and signs or apparent discomfort, or a marked change in relation to usual symptoms and signs, or unrelieved by measures already prescribed requires a phone call to the provider . Do not fax for issues requiring immediate notification.Non immediate notification: Notifications that do not require immediate consultation with physician . Notify resident's family/responsible party as applicable and in accordance with resident's wishes. Monitor resident's condition frequently until stable or transported to a higher level of care .ensure resident's change in condition is included on the 24 hour report to be reviewed later . Documentation needs to include, but is not limited to the following: description of change in condition noted and assessment or observation of findings, emergency care provided, notification of physician, notification of appropriate party .According to the Wisconsin Nurse Practice Act, N6.03(1), An R.N. (Registered Nurse) shall utilize the nursing process in the execution of general nursing procedures in the maintenance of health, prevention of illness or care of the ill. The nursing process consists of the steps of assessment, planning, intervention, and evaluation. This standard is met through performance of each of the following steps of the nursing process:(a) Assessment. Assessment is the systematic and continual collection and analysis of data about the health status of a patient culminating in the formulation of a nursing diagnosis.(b) Planning. Planning is developing a nursing plan of care for a patient which includes goals and priorities derived from the nursing diagnosis.(c) Intervention. Intervention is the nursing action to implement the plan of care by directly administering care or by directing and supervising nursing acts delegated to L.P.N.s (Licensed Practical Nurse) or less skilled assistants.(d) Evaluation. Evaluation is the determination of a patient's progress or lack of progress toward goal achievement which may lead to modification of the nursing diagnosis.R20 admitted to the facility initially on 10/14/24 and has diagnoses that include paroxysmal atrial fibrillation (irregular rapid heart rate), unspecified fracture of left acetabulum (hip joint socket), acute kidney failure, hypothyroidism, benign prostatic hyperplasia with lower urinary tract symptoms (enlarged prostate gland that can cause urination difficulty), other obstructive and reflux uropathy (abnormality of the urinary tract).R20's Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 4/20/25, indicates R20's cognition is severely impaired with a Brief Interview for Mental Status (BIMS) score of 4 out of 15. Section GG of this assessment indicates R20 needed substantial/maximum assist for toileting, going from sit to stand, and supervision or touching assist for walking.R20's Fall/Risk Management Report titled Un-witnessed Fall, dated 6/29/25 05:00, includes in part: . Nursing description: Resident bed alarm sounding in room. As staff respond to alarm, staff hear a loud crash. Find resident on the floor, he had fallen into an old record cupboard along the wall on his roommate's side of the room. Resident lying on his left side, feet were toward the bed, head toward roommate side of room. [NAME] was at heater, facing the door. Seeming resident was walking toward the bathroom and had collapsed and went to the left of walker. [NAME] was left standing by itself. Resident was pale and diaphoretic (excessive sweating). Noted to have some slurred speech at the initial response time. Quick stroke assessment was negative. Tongue came out straight, equal hand grip strength. Resident complaining of pain to left elbow and left shoulder at this time. Resident description: Resident states that he was going to the bathroom. However resident has made the walk multiple times this shift to the bathroom and knows where to go, even in the dark. Resident was walking in the opposite direction at the time of his fall.Immediate Action Taken, Description: Resident VS (vital signs) taken immediately. Stroke assessment completed. Rapid trauma assessment completed. No complaints of pain to chest/ribs, abdomen or hips. No external/internal rotation to feet, no limb shortening of lower extremities present. Resident assisted to the bed with 3 staff members. Skin assessment completed. Skin tear unable to be approximated, wound covered with ABD and wrapped with kerlix at this time. Resident taken to Hospital? NoIt is important to note the nurse who prepared this report and conducted the assessments is a Licensed Practical Nurse (LPN) (LPN H). R20 was moved from the floor without an RN assessment. There is no evidence ROM was evaluated prior to moving R20.Additional information provided by facility via email on 7/23/25 indicates DON B (Director of Nursing) was updated at 6:05 AM regarding the fall incident. (Of note, this is an hour after R20 fell and this is not documented in R20's falls note.)6/29/25 Neuro check form indicates 5:00 AM pain is a 56/29/25 Neuro check form indicates 5:35 AM pain is a 5Surveyor reviewed the fax that was sent to the provider by LPN H dated 6/29/25 and sent at 6:34 AM. Fax states, in part: : .Resident had an unwitnessed fall this morning. Attempting to take self to bathroom for the 8th time tonight. Resident more confused, walking opposite direction from bathroom, resident fell into a cupboard on roommate's side of room. Skin tear to left elbow unable to be approximated. Wound covered with ABD (antibiotic ointment) and Kerlix. C/o pain to tear and left shoulder. Would you like any labs or Xrays of shoulders?It is important to note there is no mention in this fax of resident being pale, diaphoretic, or having slurred speech as it states in the risk management report. There is no mention of the nurse doing a stroke assessment or rapid trauma assessment in the fax.R20's documentation indicated the following:On 6/29/25 at 6:18 AM, Note text: Resident had a fall this morning in room as he was transferring self and taking self to bathroom. Resident had done this same thing 7 other times this shift. This marking his 8th attempt. Resident was walking opposite of bathroom and had fallen into a cupboard on his roommate's side of the room breaking it. Resident has a skin tear to left elbow and left shoulder. Fax sent to PCP (primary care physician) re: pain to areas and multiple attempts.It is important to note that 6/29/25 (date of fall) was on a Sunday. It's also important to note there is no mention of the nurse doing range of motion assessment to upper and lower extremities in this progress note. On 6/29/25 Neuro check form indicates at 7:35 AM (0735) R20 rated his pain at a 5On 6/29/25 at 8:13 AM, Note text: POA/wife (power of attorney) updated of fall at 0800.On 6/29/25 at 8:28 AM, Note text: On call MD [Doctor's name] contacted and updated of resident fall. D/T resident c/o pain to left shoulder and rib area, verbal order given for X-rays. [Doctor's name] asks that resident respiratory status be monitored and report any SOB (shortness of breath) or distress. Verbal order also given for UA (urinalysis) and urine culture d/t resident more frequent urination which results in resident self transferring and more frequent incontinence. Orders placed and POA updated.On 6/29/25 at 10:21 AM, Note text: Floor nurse called into resident room by staff. CNA's (certified nursing assistants) were assisting resident when dried blood was noted on back of shirt. Resident was c/o pain and burning to area. 3 open areas were noted to resident left upper back. One open area was small in size and superficial abrasion. Second measured .75 cm x 1.5 cm. Third measured 8 cm x 1 cm. Area was cleansed. Triple antibiotic ointment applied, and area covered with nonwoven gauze.Of note, there is no mention of contacting R20's physician/provider regarding open areas noted to R20's back.6/29/25 Neuro check form indicates at 10:36 AM Pain rated at a 5.On 6/29/25 at 11:03 AM, Nurses note indicates PRN Tylenol given.6/29/25 Neuro check form indicates at 3:35PM pain rated at a 7.6/29/25 Neuro check form indicates at 6:05 PM pain rated at a 4. On 6/29/25 at 6:47 PM, Note text: At 18:30, went into room and resident lying in bed. POA, son and daughter in room. No S/SX (signs and symptoms) of pain when visualizing resident. Lung sounds clear throughout. No SOB noted. O2 sat (saturation) is 92% on RA (room air). Pulse 84 regular. Resident has AROM (active range of motion) to right UE (upper extremities) and LE (lower extremities). When asked to move left arm, resident refuses. When asked to move LLE (left lower extremities), resident is able to move left leg left and right. Unwilling to move or allow writer to move LLE up or down. No internal or external rotation noted to BLE (bilateral lower extremities). No shortening noted. Family states that X ray was for rib and hip. Informed family that the order was for shoulder and rib due to pain after the fall. Family stated, Well maybe they got the hip too with that X ray. When auscultating lung sounds, resident complained of pain when touching left rib area. Questioned if resident would like something for pain and he stated yes. PRN (as needed) Tylenol given. POA questioning results of X ray and informed POA that no results yet from imaging and will call company to see where they are at with the results. POA voiced appreciation for the update. Placed call to mobile imaging at 1845 and spoke with tech stating that results are not in and that they will fax results when available. Confirmed fax number with tech.It is important to note this is the first assessment completed by an RN (Registered Nurse) on R20 since his fall over 13 hours prior. Initial assessment was completed by LPN H. R20 is refusing to move his left arm and leg during ROM assessment, this is a change in R20's status. No evidence a physician/provider was notified.6/29/25 at 7:35 PM (1935) indicates PRN (as needed) Tylenol given, follow up pain evaluation indicated as 0.6/30/25 at 1:16 AM, Note text: The current status is resting in bed. C/o (complains of) pain when moving and touching him PRN Tylenol given. Continue to monitor.Of note: R20 continued to have pain when being moved or touched, no evidence a physician/provider was updated. There is no documentation of an assessment on Night shift. 6/30/25 at 2:04 AM, Note text: Received X ray results from (imaging company name). Left X ray, shoulder. There is no evidence of acute fracture or dislocation. X ray of ribs, unilateral; include PA (posterior anterior) chest. There is no left rib fractures. No evidence of acute cardiopulmonary disease. No pneumothorax. X ray results faxed to PCP.6/30/25 at 0229 (2:29AM) Neuro check form indicates Tylenol ES (extra strength) given Pain rating of a 6 with grimaces and withdraws being marked as yes.6/30/25 at 6:48 AM, Note text: Resident pain level every shift use PAINAD if resident unable to verbalize pain. Yells at the slightest movement. Pain appears to be in left upper leg or hip.It is important to note R20 yells at the slightest movement, there is no evidence of staff contacting a physician with this increase in pain. There is no RN assessment even though there is increased pain noted after R20 sustained a fall on 6/29/25. 6/30/25 at 8:51 AM, Note text: Resident is laying in bed with eyes partly open and readily responds to voice. Resident took his medications this morning but refused breakfast. He refuses to sit up or change position. Resident complains of pain in his left hip, leg, and or heel. Tylenol was ineffective in pain management. Family would like to get X rays of those areas. Resident yells in pain before he even gets touched. Resident has wounds that are draining onto the bed sheets and refuses to let us touch them. Resident is more confused that [sic] usual. Discussed the resident status with POA (wife) and she agreed that he needs to be sent to the ER to get full medical care. POA requests that he should not be given oxycodone (her usual request). Called [Doctors name] at the [NAME] clinic and left message requesting order for transfer to ER.Of note, R20's POA indicated wanting him sent to the ER, facility staff did not send R20 right away, staff waited for an order from the clinic.6/30/25 at 9:01 AM, Note text: Nurse [Nurses name] from [NAME] Clinic called and communicated orders from [Doctors name] for transfer to ER.6/30/25 at 9:28 AM, Note text: Called [NAME] County [NAME] requesting a non-emergent transfer to the ER. Called ER nurse and provided nurse-to-nurse report.6/30/25 at 9:51 AM, Note text: Resident was taken to ER via ambulance. Wife notified.6/30/25 at 2:39 PM, Note text: Hip fracture from fall.6/30/25 at 5:01 PM, Note text: hospitalized . R20's Emergency Department Notes/Hospital Record, dated 6/30/25 at 10:17 AM, includes in part: .Patient presenting to the emergency department following a fall at the nursing home 3 days ago with the patient having persistent severe pain, inability to ambulate, and worsening confusion over the past 2-3 days.Patient given IV pain medications due to concern for underlying hip fracture.Elbow x-ray also obtained prior to obtaining CT scan of the abdomen and pelvis given patient's complaints, however showing no evidence of fracture. CT scan of the abdomen and pelvis returning with concern for bladder thickening and cystitis, new left-sided acetabular fracture of the posterior and anterior pillars, as well as new L3 compression fracture.Patient was discussed with on-call orthopedic surgeon, [surgeon's name], with recommendation for conservative management of acetabular fracture given patient's poor bone quality, not surgical candidate.recommended 6 weeks non weight bearing.Admit for pain management adjustment. With a non-operable hip fracture in a frail 92 year, particularly one who has had poor oral intake in the last two days, the prognosis is concerning. R20's CT (computed tomography) Abdomen Pelvis with contrast Report, dated 6/30/25 at 1:19 PM, includes in part: .Osseous structures: Old healed fracture deformities at the left superior and inferior pubic rami. Acute mildly comminuted and mildly displaced left acetabular fracture with involvement of both the anterior and posterior columns. Stable chronic moderate to severe compression fracture at T11. Newly visualized and likely acute moderate compression fracture at the L3 vertebral body.Of note, R20 went greater than 24 hours with a broken mildly comminuted (bone breaks into 3 or more pieces caused by high forced accidents or trauma i.e. falls) and mildly displaced (bone fragments are not properly aligned) left acetabular (hip socket) fracture.On 7/21/25, Surveyor attempted to contact the 2 CNAs who were on duty the time of R20's fall. Surveyor left voicemail with no return calls.On 7/21/25 at 11:38 AM, Surveyor interviewed CNA J and asked if R20 self-transfers and what interventions are in place for R20 to prevent falls. CNA J indicated yes, R20 self-transfers and he has bed and chair alarms and they take him to the bathroom every 2 hours minimum.On 7/21/25 at 11:41 AM, Surveyor interviewed CNA K and asked if R20 self-transfers and what fall interventions are in place for this resident. CNA K indicated R20 does self-transfer, not as often as he used to before his fall but he does still self-transfer some. CNA K also indicated they take him to the bathroom every 2 hours minimum but he will let staff know when he has to go when he is in common areas. CNA K indicated he has fall alarms, bed in low position, chair at bedside, and stated he likes to sit in the sun in the dayroom.On 7/21/25 at 10:44 AM via phone, Surveyor interviewed LPN I regarding R20's fall. LPN I stated she started her shift after R20's fall. She stated it's common for R20 to self-transfer and he has bed and chair alarms and staff should be doing frequent checks as much as they can. LPN I stated LPN H did hip assessment on lower extremities and nothing hurt R20 at that time. LPN I indicated the assessment should be in R20's progress notes. Surveyor reviewed R20's progress notes and there is no mention of assessments completed in LPN H's progress notes from the fall. Surveyor observed hip assessment in fall report but not progress notes.Surveyor attempted to contact LPN H three times via phone. Surveyor was not successful in reaching LPN H.Surveyor checked the schedules for 6/28/25 (into 6/29) and 6/29/25 (into 6/30) and there were no RNs on duty on night shift either of those days.On 7/17/25 at 2:59 PM, Surveyor interviewed DON B (Director of Nursing) who indicated if no RN is on the schedule, she is on call 24/7. In a follow up interview with DON B and EM L on 7/21/25 at 12:29 PM, DON B indicated she would have expected staff to have increased supervision for R20 after he was self-transferring 7-8 times and temporary interventions. DON B indicated LPN did the assessments on R20 and called DON B after she completed them, they were done without RN oversight. DON B stated LPN H called her after the fall and told her what happened and about rotation and ROM, didn't have concerns. Surveyor asked if LPNs could perform assessments and DON B stated, They can collect data. She would have expected staff to put assessments completed in the resident's progress notes. Surveyor asked DON B how staff got R20 off of the floor after his fall. DON B stated it's not in LPN's documentation but after talking with staff, it was with a Hoyer lift. DON B indicated this should have been documented. DON B stated LPN H did not inform DON B of R20's slurred speech, being pale and diaphoretic when she called her at 6:05 AM after R20's fall. DON B indicated she would have expected an immediate phone call to the physician instead of a fax with those symptoms. Surveyor asked DON B who did the stroke assessment on R20 and stated LPN H. DON B indicated an RN should do stroke assessments. Surveyor asked DON B if any staff education was done after this incident, and she indicated not that she's aware of.R20 was self-transferring multiple times in one shift and had an unwitnessed fall. R20 had a change in condition without an RN assessment or continued monitoring. R20's provider was not updated with R20's changes in condition resulting in a delay in treatment and R20 was found to have a left acetabular (hip joint socket) fracture.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not ensure that each resident receives adequate supervision and assistance devices to prevent accidents for 1 of 1 residents (R20) reviewed for falls resulting in actual harm.R20 was self-transferring multiple times and on the eighth attempt, suffered an unwitnessed fall. The facility failed to provide temporary interventions to address the self-transferring. R20 was found to have a left acetabular (hip joint socket) fracture.This is evidenced by:Facility policy, titled Fall Prevention and Management Guidelines, reviewed and revised on 7/18/24, states in part; Each resident will be assessed for fall risk and will receive care and services in accordance with their individualized plan of care to minimize the likelihood of falls or reduce the possibility/severity of injury. A fall is an event in which an individual unintentionally comes to rest on the ground, floor, or other level, but not because of an overwhelming external force. The event may be witnessed, reported, or presumed when a resident is found on the floor or ground, and can occur anywhere . When any resident experiences a fall, the facility will complete a post fall assessment and review: physical assessment with vital signs, neuro checks for any unwitnessed fall or witnessed fall where resident hits their head.alert MD of any abnormal findings from neuro checks - do not wait until series is completed to notify MD of abnormal findings.complete an incident report in Risk Management, notify physician and family/responsible party, review resident's care plan and update with any new interventions put in place to try to prevent additional falls, document all assessments and actions, obtain witness statements from other staff with possible knowledge or relevant information.R20 admitted to the facility initially on 10/14/24 and has diagnoses that include: paroxysmal atrial fibrillation (irregular rapid heart rate), unspecified fracture of left acetabulum (hip joint socket), acute kidney failure, hypothyroidism, benign prostatic hyperplasia with lower urinary tract symptoms (enlarged prostate gland that can cause urination difficulty), and other obstructive and reflux uropathy (abnormality of the urinary tract).R20's Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 4/20/25, indicates R20's cognition is severely impaired with a Brief Interview for Mental Status (BIMS) score of 4 out of 15. Section GG of this assessment indicates R20 needed substantial/maximum assist for toileting, going from sit to stand, and supervision or touching assist for walking.R20's Comprehensive Care Plan states in part: .Focus: At risk for falls .Interventions/Tasks: Bed in low position, date initiated: 10/14/24 . Broda chair by bedside when in bed, date initiated: 7/1/25 .Chair and bed alarms placed and check for proper functioning and placement every shift, date initiated: 5/2/25 .Encourage to transfer and change positions slowly, date initiated: 10/14/24 .FALL RISK (FYI), date initiated: 7/1/25 .Have commonly used articles within easy reach, date initiated: 10/14/24 .Reinforce need to call for assistance, date initiated: 10/14/24 .Reinforce w/c (wheelchair) safety as needed such as locking brakes, date initiated: 10/14/24 .Focus: Urinary Incontinence .Intervention/Tasks: Offer toileting every 2 hours and PRN, date initiated 1/26/25 .R20's Fall/Risk Management Report titled Unwitnessed Fall, dated 6/29/25 05:00 (5:00 AM), includes in part: . Nursing description: Resident bed alarm sounding in room. As staff respond to alarm, staff hear a loud crash. Find resident on the floor, he had fallen into an old record cupboard along the wall on his roommate's side of the room. Resident lying on his left side, feet were toward the bed, head toward roommate side of room. [NAME] was at heater, facing the door. Seeming resident was walking toward the bathroom and had collapsed and went to the left of walker. [NAME] was left standing by itself. Resident was pale and diaphoretic. Noted to have some slurred speech at the initial response time. Quick stroke assessment was negative. Tongue came out straight, equal hand grip strength. Resident complaining of pain to left elbow and left shoulder at this time. Resident description: Resident states that he was going to the bathroom. However resident has made the walk multiple times this shift to the bathroom and knows where to go, even in the dark. Resident was walking in the opposite direction at the time of his fall.Immediate Action Taken, Description: Resident VS (vital signs) taken immediately. Stroke assessment completed. Rapid trauma assessment completed. No complaints of pain to chest/ribs, abdomen or hips. No external/internal rotation to feet, no limb shortening of lower extremities present. Resident assisted to the bed with 3 staff members. Skin assessment completed. Skin tear unable to be approximated, wound covered with ABD and wrapped with kerlix at this time. Resident taken to Hospital? No.It is important to note the nurse who prepared this report and conducted the assessments is a Licensed Practical Nurse (LPN) (LPN H) and R20 was moved without an RN assessment. It's also important to note there is no mention of LPN H doing a range of motion assessment to the upper and lower extremities prior to moving R20.Additional information provided by facility via email on 7/23/25 indicates DON B (Director of Nursing) was updated at 6:05 AM regarding the fall incident. (Of note, this is an hour after R20 fell.)R20's Nurses Notes dated 6/29/25 include in part: 6:18 AM, Note text: Resident had a fall this morning in room as he was transferring self and taking self to bathroom. Resident had done this same thing 7 other times this shift. This marking his 8th attempt. Resident was walking opposite of bathroom and had fallen into a cupboard on his roommate's side of the room breaking it. Resident has a skin tear to left elbow and left shoulder. Fax sent to PCP (primary care physician) re: pain to areas and multiple attempts.It is important to note that 6/29/25 (date of fall) was on a Sunday. It's also important to note there is no mention of the nurse doing range of motion assessment to upper and lower extremities in this progress note. This note also indicates staff were aware R20 was self-transferring multiple times already that shift and there is no documentation of temporary interventions being attempted.Surveyor reviewed the fax that was sent to the provider by LPN H dated 6/29/25 and sent at 6:34 AM. Fax states, in part: : .Resident had an unwitnessed fall this morning. Attempting to take self to bathroom for the 8th time tonight. Resident more confused, walking opposite direction from bathroom, resident fell into a cupboard on roommate's side of room. Skin tear to left elbow unable to be approximated. Wound covered with ABD (antibiotic ointment) and Kerlix. C/o pain to tear and left shoulder. Would you like any labs or Xrays of shoulders?It is important to note there is no mention in this fax of resident being pale, diaphoretic, or having slurred speech as it states in the risk management report. There is no mention of the nurse doing a stroke assessment or rapid trauma assessment in the fax.8:13 AM, Note text: POA/wife (power of attorney) updated of fall at 0800.8:28 AM, Note text: On call MD [Doctor's name] contacted and updated of resident fall. D/T resident c/o pain to left shoulder and rib area, verbal order given for X-rays. [Doctor's name] asks that resident respiratory status be monitored and report any SOB (shortness of breath) or distress. Verbal order also given for UA (urinalysis) and urine culture d/t resident more frequent urination which results in resident self transferring and more frequent incontinence. Orders placed and POA updated.10:21 AM, Note text: Floor nurse called into resident room by staff. CNAs (certified nursing assistants) were assisting resident when dried blood was noted on back of shirt. Resident was c/o pain and burning to area. 3 open areas were noted to resident left upper back. One open area was small in size and superficial abrasion. Second measured .75 cm x 1.5 cm. Third measured 8 cm x 1 cm. Area was cleansed. Triple antibiotic ointment applied and area covered with nonwoven gauze.6:47 PM, Note text: At 18:30 (6:30 PM), went into room and resident lying in bed. POA, son and daughter in room. No S/SX (signs and symptoms) of pain when visualizing resident. Lung sounds clear throughout. No SOB noted. O2 sat (saturation) is 92% on RA (room air). Pulse 84 regular. Resident has AROM (active range of motion) to right UE (upper extremities) and LE (lower extremities). When asked to move left arm, resident refuses. When asked to move LLE (left lower extremity), resident is able to move left leg and right. Unwilling to move or allow writer to move LLE up or down. No internal or external rotation noted to BLE (bilateral lower extremities). No shortening noted. Family states that X ray was for rib and hip. Informed family that the order was for shoulder and rib due to pain after the fall. Family stated, Well maybe they got the hip too with that X ray. When auscultating lung sounds, resident complained of pain when touching left rib area. Questioned if resident would like something for pain and he stated yes. PRN (as needed) Tylenol given. POA questioning results of X ray and informed POA that no results yet from imaging and will call company to see where they are at with the results. POA voiced appreciation for the update. Placed call to mobile imaging at 1845 (6:45PM) and spoke with tech stating that results are not in and that they will fax results when available. Confirmed fax number with tech.It is important to note this is the first assessment completed by an RN (Registered Nurse) on R20 since his fall over 13 hours prior. Initial assessment was completed by LPN H. 6/30/25 at 1:16 AM, Note text: The current status is resting in bed. C/o (complains of) pain when moving and touching him PRN Tylenol given. Continue to monitor.6/30/25 at 2:01 AM, Note text: Call placed to daughter, (name) in regards of X ray results. Message left.6/30/25 at 2:04 AM, Note text: Received X ray results from (name of imaging company). Left X ray, shoulder. There is no evidence of acute fracture or dislocation. X ray of ribs, unilateral; include PA chest. There is no left rib fractures. No evidence of acute cardiopulmonary disease. No pneumothorax. X ray results faxed to PCP.6/30/25 at 6:48 AM, Note text: Resident pain level every shift use PAINAD if resident unable to verbalize pain. Yells at the slightest movement. Pain appears to be in left upper leg or hip.6/30/25 at 8:51 AM, Note text: Resident is laying in bed with eyes partly open and readily responds to voice. Resident took his medications this morning but refused breakfast. He refuses to sit up or change position. Resident complains of pain in his left hip, leg, and or heel. Tylenol was ineffective in pain management. Family would like to get X rays of those areas. Resident yells in pain before he even gets touched. Resident has wounds that are draining onto the bed sheets and refuses to let us touch them. Resident is more confused that [sic] usual. Discussed the resident status with POA and she agreed that he needs to be sent to the ER to get full medical care. POA requests that he should not be given oxycodone (her usual request). Called [Doctors name] at the [Clinic name] and left message requesting order for transfer to ER.6/30/25 at 9:01 AM, Note text: Nurse [Nurses name] from [name of Clinic] called and communicated orders from [Doctors name] for transfer to ER.6/30/25 at 9:28 AM, Note text: Called [County [NAME]] requesting a non-emergent transfer to the ER. Called ER nurse and provided nurse-to-nurse report.6/30/25 at 9:51 AM, Note text: Resident was taken to ER via ambulance. Wife notified.6/30/25 at 2:39 PM, Note text: Hip fracture from fall.6/30/25 at 5:01 PM, Note text: hospitalized .R20's Emergency Department Notes/Hospital Record, dated 6/30/25 at 10:17 AM, includes in part: .Patient presenting to the emergency department following a fall at the nursing home 3 days ago with the patient having persistent severe pain, inability to ambulate, and worsening confusion over the past 2-3 days.Patient given IV pain medications due to concern for underlying hip fracture.Elbow x-ray also obtained prior to obtaining CT scan of the abdomen and pelvis given patient's complaints, however showing no evidence of fracture. CT scan of the abdomen and pelvis returning with . new left-sided acetabular fracture of the posterior and anterior pillars, as well as new L3 compression fracture.Patient was discussed with on-call orthopedic surgeon, [surgeon's name], with recommendation for conservative management of acetabular fracture given patient's poor bone quality, not surgical candidate.recommended 6 weeks non weight bearing.Admit for pain management adjustment. With a non-operable hip fracture ., particularly one who has had poor oral intake in the last two days, the prognosis is concerning. R20's CT (computed tomography) Abdomen Pelvis with contrast Report, dated 6/30/25 at 1:19 PM, includes in part: .Osseous structures: Old healed fracture deformities at the left superior and inferior pubic rami. Acute mildly comminuted and mildly displaced left acetabular fracture with involvement of both the anterior and posterior columns. Stable chronic moderate to severe compression fracture at T11. Newly visualized and likely acute moderate compression fracture at the L3 vertebral body.On 7/21/25, Surveyor attempted to contact LPN H three times via phone. Surveyor was not successful in reaching LPN H.On 7/21/25, Surveyor attempted to contact the 2 CNAs who were on duty at the time of R20's fall. Surveyor was unsuccessful in reaching the 2 CNAs. On 7/21/25 at 11:38 AM, Surveyor interviewed CNA J (Certified Nursing Assistant) and asked if R20 self-transfers and what interventions are in place for R20 to prevent falls. CNA J indicated yes, R20 self-transfers and he has bed and chair alarms and they take him to the bathroom every 2 hours minimum.On 7/21/25 at 11:41 AM, Surveyor interviewed CNA K and asked if R20 self-transfers and what fall interventions are in place for this resident. CNA K indicated R20 does self-transfer, not as often as he used to before his fall, but he does still self-transfer some. CNA K also indicated they take him to the bathroom every 2 hours minimum, but he will let staff know when he has to go when he is in common areas. CNA K indicated he has fall alarms, bed in low position, chair at bedside, and stated he likes to sit in the sun in the dayroom.On 7/21/25 at 10:44 AM, via phone, Surveyor interviewed LPN I regarding R20's fall. LPN I stated she started her shift after R20's fall. She stated it's common for R20 to self-transfer and he has bed and chair alarms and staff should be doing frequent checks as much as they can. LPN I stated LPN H did hip assessment on lower extremities and nothing hurt R20 at that time. LPN I indicated the assessment should be in R20's progress notes.Surveyor reviewed R20's progress notes and there is no mention of assessments completed in LPN H's progress notes from the fall. Surveyor observed hip assessment in fall report but not progress notes.Surveyor checked the schedules for 6/28 into 6/29 and 6/29 into 6/30. There were no RNs on duty on night shift either of those days.On 7/17/25 at 2:59 PM, Surveyor interviewed DON B (Director of Nursing) who indicated if no RN is on the schedule, she is on call 24/7. In a follow up interview with DON B and EM L (Executive Manager) on 7/21/25 at 12:29 PM, DON B indicated she would have expected staff to have increased supervision for R20 after he was self-transferring 7-8 times and temporary interventions. DON B indicated LPN H did the assessments on R20 and called DON B after she completed them, they were done without RN oversight. DON B stated LPN H called her after the fall and told her what happened and about rotation and ROM, didn't have concerns. Surveyor asked if LPNs could perform assessments and DON B stated, They can collect data. She would have expected staff to put assessments completed in the resident's progress notes. Surveyor asked DON B how staff got R20 off of the floor after his fall. DON B stated it's not in the LPN's documentation but after talking with staff, it was with a Hoyer lift. DON B indicated this should have been documented. DON B stated LPN H did not inform DON B of R20's slurred speech, being pale and diaphoretic when she called her at 6:05 AM after R20's fall. DON B indicated she would have expected an immediate phone call to the physician instead of a fax with those symptoms. Surveyor asked DON B who did the stroke assessment on R20 and DON B stated LPN H. DON B indicated an RN should do stroke assessments. Surveyor asked DON B if any staff education was done after this incident and she indicated not that she's aware of.Additional information received from the facility on 7/24/25 via email with two staff statements that state in part the following: 7-23-24 Resident was up to the bathroom multiple times. Resident was offered to get up in chair but would turn look at the clock on the way back from bathroom and said it was to early. Resident had snacks at bedside also. Resident was offered to come sit in living room area resident wanted to go back to bed. (Signature). Second statement states in part: 7/24/25. 6/29/25 on the night in question, (R20's name) was up multiple times to the bathroom. Ambulated to and from bathroom (with) no c/o (complaints of) pain or discomfort. Resident also denied pain. Also refused suggestion of sitting in broda chair to come out by us. Would check his clock on his walk back from the bathroom, and state it was too early. Resident had graham crackers and H2O (water) @ (at) bedside . (Of note, no temporary interventions for increased supervision due to getting up multiple times was implemented when R20 did not agree to get up into his chair to prevent a fall.)R20 was self-transferring multiple times in a shift, the facility failed to provide temporary interventions to address the self-transferring, and on the 8th attempt, R20 had an unwitnessed fall. R20 was found to have a left acetabular (hip joint/socket) fracture.