Oasis Center For Rehabilitation And Healing

emergency room (ER).Review of Resident #40's progress note dated 02/03/26 at 11:12 A.M. revealed

fractures involving the right superior and inferior pubic rami with medial displacement of the medial

the proximal humeral diaphysis which was similar in position with evidence of healing and a comminuted fracture involving the olecranon of the ulna.

The plan was for the resident to be seen by orthopedic surgery in the emergency room (ER) with a right open reduction internal fixation (ORIF) possibly on 02/04/26 and right elbow brace with possible surgery later.Review of Resident #40's progress note dated 02/04/26 at 12:24 A.M. revealed the son reported that the resident would have surgery on the right arm on 02/05/26 in the afternoon.Review of Resident #40's Orthopedic Surgery Resident Progress Note dated 02/05/26 at 5:55 A.M. revealed the resident had a right hip ORIF.Review of Resident #40's 72-Hour Review Incidents form dated 02/06/26 at 3:43 P.M. revealed bruising to the right elbow started post-fall. X-rays revealed fractures present and the resident was sent to the hospital for surgical repair. A right hip fracture was noted as well.

The resident had osteoporosis and avascular necrosis.Review of Resident #40's progress note dated 02/06/26 at 4:32 P.M. revealed the resident was readmitted to the facility.Review of Resident #40's Quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited moderate cognitive impairment.Interview on 03/26/26 at 11:25 A.M. with the DON confirmed Resident #40's X-rays were not obtained status post fall on 02/02/26 because the X-ray company could not make it to the facility on [DATE] due to inclement weather conditions.

The DON confirmed the X-rays were not obtained until 02/03/26 which showed fractures and the resident was not sent to the ER on [DATE] to obtain the X-rays as an emergency measure due to the X-ray company not being able to drive to the facility in inclement weather.Interview with Resident #40 on 03/26/26 at 11:28 A.M. revealed the resident was in her room sitting in a wheelchair.

She appeared alert and was able to answer questions.

The resident stated she fell in the room from her wheelchair.Interview on 03/26/26 at 11:30 A.M. with Resident #40's brother revealed Resident #40 had a fall prior to admission to the facility and fell going from the wheelchair to the bed again while a resident in the facility.

The brother confirmed the accident happened on 02/02/26 and the resident was not sent out to the hospital until 02/03/26 and it took almost 24 hours to find out the resident had broken bones.

The brother expressed concerns with the delay in treatment.Telephone interview 03/26/26 at 12:27 P.M. with LPN #840 revealed she had heard Resident #40 yell for help and found the resident on the floor.

She stated the resident complained of pain in her right elbow but did not want to go to the hospital.

She stated she had assessed the resident and found bruising to her right elbow with swelling and the resident was assisted to the bed.

While assisting the resident, she stated the resident then complained of right leg and thigh pain. LPN #840 confirmed the physician was notified and immediate X-rays were ordered.Telephone interview on 03/26/26 at 12:35 P.M. with Medical Director (MD) #950 revealed he was aware Resident #40 had sustained a fall and had ordered X-rays for the resident. MD #950 revealed the facility could not control the X-ray company and was aware the X-ray company did not obtain the immediate X-rays until 02/03/26 at which point fractures were identified and the resident was sent to the ER.

Review of the Managing Falls and Fall Risk policy dated 03/2018 revealed based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling.This deficiency represents non-compliance investigated under Complaint Number 2788530.