**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, and facility documentation review for two of three residents (Resident #2, Resident #3) review for abuse, the facility failed to ensure the residents were free from abuse. Residents #2 and #3 had a physical altercation, resulting in both residents with injuries to their faces, and were transferred to the hospital for treatment. The finding includes: 1. a. Resident #2 had a diagnosis of malignant neoplasm of the brain, bipolar disorder, and schizoaffective disorder. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #2 had a Brief Interview for Mental Status (BIMS) score of 13 indictive of an intact cognition and was independent with mobility and had no behaviors. The Resident Care Plan (RCP) dated 10/15/2024 identified Resident #2 had the potential for verbal aggression and accusatory behaviors and ambulated independently. Interventions directed to monitor for accusatory behavior and offer tasks to minimize disruptive behavior. Record review identified no physician orders for behavior monitoring. b. Resident #3 had a diagnosis of dementia, bipolar disorder, and unspecified mood disorder. The quarterly MDS assessment dated [DATE] identified Resident #3 had a BIMS score of 12 indicating moderately impaired cognition, was dependent for mobility, independent with wheelchair mobility, and no had behaviors in the prior seven (7) days. The RCP dated 9/12/2024 identified Resident #3 had dementia. Interventions directed to keep call light within reach and to anticipate and meet the resident's needs. Record review identified no prior aggressive behaviors. Review of the facility incident report dated 10/29/2024 at 9:30 AM identified Residents #2 and #3 had a verbal disagreement followed by a physical altercation. Resident #3 alleged he/she was hit by Resident #2. Resident #2 admitted he/she had hit Resident #3 and stated Resident #3 also hit him/her. Resident #3 was noted to have laceration to the left eyebrow, redness to the left eye and nose swelling. Resident #2 was noted to have redness to her/his right cheek, a 0.5-centimeter (cm) scratch to the right cheek, and a 0.5 cm scratch to the left cheek. Both residents were transferred to the hospital for further evaluation. The report further indicated Resident #3 was identified to have an acute nasal fracture. Facility incident summary dated 11/3/2024 identified Resident #3 entered Resident #2's room and requested Resident #2 pay back $7 that had been borrowed. Resident #2 stated he/she did not have the cash, but would get it, and Resident #3 then hit Resident #2 twice in the face. Resident #2 then hit Resident #3. Hospital emergency department summary CT scan results dated 10/29/2024 identified Resident #3 had an acute, minimally displaced bilateral nasal bone and anterior maxillary spine (upper jaw) fractures. Interview with NA #1 on 10/31/2024 at 2:27 PM identified on 10/29/2024 Resident #2 reported that Resident #3 had entered his/her room asking for $7 to be repaid, and that Resident #3 hit him/her, and Resident #2 responded to defend him/herself. Interview with RN #1 on 10/31/24 at 2:38 PM identified she responded to the unit around 9:30 PM for the altercation between Residents #2 and #3. Resident #2 reported that Resident #3 came into his/her room demanding $7 that was owed to him/her. Resident #2 had a cut on the right cheek, redness on the right cheek, left eye, nose, and on the neck. Resident #3 had blood on his/her face and shirt and a bandage was placed on Resident #3's forehead and both residents were transferred to the hospital for evaluation. Interview and record review with the DNS on 10/31/24 at 3:31 PM identified Residents #2 and 3 were friends prior to the incident, and the incident was over $7 that was owed to Resident #3. Resident #2 had told Resident #3 he/she would have the money the next day and Resident #3 called Resident #2 a liar, stood up and punched Resident #2 twice in the face. Resident #2 indicated he/she then pushed Resident #3 back into his/her chair and punched him/her in the head three (3) times to defend him/herself. The DNS stated although Resident #3 refused to talk about the incident, the allegation of abuse was substantiated. After the incident, Resident #3 wanted to see Resident #2 to say he/she wanted to apologize for the incident. Review of facility Abuse policy dated 3/20/2024 identified residents will not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants, volunteers, and staff of other agencies serving the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, observation, facility documentation, facility policy, and interviews for 1 of 3 residents (Resident #28) reviewed for abuse, the facility failed to ensure a resident was free from physical injury by another resident (Resident #133). The findings include: Resident #28 was admitted on [DATE] with diagnoses that included schizoaffective disorder and a fracture of the pelvis. Resident #28 was responsible for self. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #28 was without cognitive impairment and required physical assist of one with ambulation on and off the unit with wheelchair support. The care plan dated 3/31/22 identified Resident #28 had a concern with Activities of Daily Living (ADL) and fracture of pelvis and sacrum. Interventions included: Occupational Therapy (OT) Physical Therapy /(PT) as ordered, weight bearing as tolerated and toe touch weight bearing to right lower extremity and noted independence in the bedroom with the use of a rolling walker. The nursing progress note dated 4/24/22 at 9:40 PM identified at 3:50 PM the charge nurse was called to the basement for a resident-to-resident altercation. Observation identified Resident # 28 in the hallway bleeding from the mouth, bridge of the nose and arms. Resident # 28 was upset and reported s/he was attacked on the elevator by Resident # 133 as s/he was attempting to get off the elevator for a smoke break. Resident # 28 stated his/her wheelchair got stuck in the elevator and Resident # 133 became upset and started punching her/him in the face and head. Lacerations were noted on Resident # 28's bridge of the nose, chest, and bilateral arms. Following the smoke break, Resident #28 was transferred to an acute care hospital for further evaluation. Resident #133 was admitted on [DATE] with diagnoses that included asthma, acute respiratory failure with hypoxia and schizoaffective disorder. An annual MDS assessment dated [DATE] identified Resident #133 had a severe mental illness, severe cognitive impairment and was independent with ambulation on and off the unit. The care plan dated 3/8/22 identified Resident #133 had a concern related to behavior and a history of taking other residents belongings resulting in verbal and physical altercations. The care plan also noted a history of pushing/bumping through residents to get to the front of the line to smoke. Interventions included: monitoring the resident's status and directed staff to report changes, to provide verbal cues to not to push and to maintain distances from others through staff supervision. The Reportable Event dated 4/24/22 at 4:16 PM identified Resident #28 was involved in a resident-to-resident altercation where Resident #28 reported s/he was assaulted by another resident (Resident #133). Resident #28 reported s/he was attempting to exit the elevator to go to the designated smoking area for smoking time at which time s/he became stuck at threshold. The aggressor, (Resident #133) became impatient. Resident # 28 reported s/he was hit in the face, scratched on both arms, sustained a laceration to the bridge of the nose, chest, and arms. The facility Advanced Practice Registered Nurse (APRN), family and police were notified, and an investigation was initiated. Resident #28 was transferred to the Emergency Department (ED) for further evaluation and was noted to have superficial injuries to the nose and chest. Resident # 28 returned to the facility on 4/24/22. Resident #133 was also transferred to the ED for evaluation following the incident. The APRN progress note dated 4/26/22 noted Resident #28 had an altercation with another resident and had a scratch mark on the left cheek with no other injury. Resident # 28 was transferred to an outside hospital where a Computed Tomography (CT) scan of the chest, abdomen and pelvis were performed and identified unremarkable for acute process then transferred back to the extended care facility. Resident # 28 and Resident # 133 care plans were revised on 4/24/22 to include psychiatric and social work support. Resident #28 and Resident #133 were to have opposite smoke times. Resident #28 was offered a room change. Resident #133 was placed on 1:1 supervision until seen by psychiatry. The Alternate Community Living Center report dated 5/11/22 identified Resident #133 was being referred to alternate community placement secondary to a recent altercation where s/he was the aggressor and punched a peer (Resident #28) in the face, chest and scratched arms and that jewelry on his/ her hands were considered a weapon, therefore requiring removal. The report also noted Resident # 133 had a history of physically assaulting residents and peers. An interview on 6/15/22 at 10:29 AM with Resident #28 identified the incident occurred when both s/he and Resident # 133 were getting off the elevator in the basement region to smoke. There were no other residents or staff around at the time of the incident. Resident #28 reported while s/he was exiting the elevator s/he had trouble crossing the threshold with her/his wheelchair. Resident #133 started yelling at Resident #28 and hitting her/him. Resident #28 screamed for help and other residents came to pull Resident #28 off Resident #133. Staff arrived and brought Resident #28 upstairs. Resident #28 reported s/he was sent to the emergency department (ED) for evaluation. The shift Nursing Supervisor staff told her/him Resident # 133 was also sent out to the ED for an evaluation and would not be returning but s/he observed Resident #133 did return to the unit the following day. Resident # 133 was placed on one-to-one supervision which lasted a couple of days causing her/him to feel fearful. Resident # 28 indicated staff told her/ him s/he (Resident # 28) and Resident #133 would have separate smoke times and offered her/him (Resident #28) a room change. Resident # 28 declined the room change and felt penalized even though s/he was the victim. Resident #28 spoke to the DNS and Social Worker (SW #1) about his/her concerns and was told this was (Resident #133's) home and that Resident #133 did not have the capacity to understand what s/he did. Resident #28 indicated the event had been traumatizing for him/her. An interview on 6/15/22 at 1:45 PM with SW#1 and corporate [NAME] President of Operations identified SW #1 met with Resident #133 following the incident who was sent to the hospital for further evaluation and placed on a 1:1 supervision. Resident #133 was evaluated by psychiatry, cleared, and placed on every 15 minute checks, separate smoke times and a referral was sent to an outside community agency for possible placement. Resident #133 was evaluated and deemed at appropriate level of care. SW #1 indicated Resident #133 would at times push his/her way to the front of the line to smoke, but not in a malicious manner and indicated the resident had no history of violence towards others. An interview on 6/24/22 at 2:04 PM with the Medical Director identified the behavior was not usual for Resident #133 and indicated his expectation would the facility ensure that a resident was free from any mistreatment. A subsequent interview and clinical record review on 7/12/22 8:47 AM with SW #1 identified Resident #133 baseline behaviors included mumbling, talking about unrealistic events, delusional, would lay on the floor in the basement and stayed in bed. When provoked, Resident #133 would talk loudly and, if observing others wearing jewelry, would make false accusations and state items were his/hers. Resident #133 was also known to squeeze her/his way through residents but not in a malicious manner. SW #1 stated that although she indicated Resident #133 had no previous aggressive behaviors, she documented Resident #133 had a history of assaulting other peers at the facility based on past resident to resident allegations on the referral for alternate community placement. An interview on 7/12/22 at 9:41 AM with NA # 2 identified she was working the second shift on the unit where both residents previously resided on the day of the incident. NA # 2 stated she heard screaming and went downstairs to investigate. When NA # 2 arrived to the area, she observed both Resident #28 and Resident #133 outside the elevator in the basement with the nursing supervisor and other residents. NA # 2 observed bleeding to Resident #28's face. However, it was Resident #133 who reported to NA # 2 that Resident #28 had spit and thrown water at him/her which was the reason s/he hit Resident # 28. Resident #28 denied the allegations. NA #2 removed the other residents from the area while the residents were separated, and she/he believed the nursing supervisor brought Resident #28 upstairs. NA #2 indicated although she had not witnessed aggressive behavior by Resident #133, she had heard there was a history of aggressive behavior towards peers. Attempts to interview Nursing Supervisor were unsuccessful during the survey. The facility policy for Abuse in effect for 4/2022 directs a resident has the right to be free from abuse.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, facility documentation, facility policy and interviews for two of six resident's reviewed for accidents, (Resident #499 and Resident # 500), the facility failed to ensure that a resident was seated in the correct wheelchair and that staff was educated on how to maneuver a wheelchair on an even surface and failed to ensure that intervention were in place to supervise a resident who exhibited restless behaviors to prevent falls with major injuries. The findings included: 1. Resident # 499's diagnoses included a late effect Cerebral Vascular Accident (CVA), acute on chronic renal failure and bilateral carotid stenosis. A re-admission assessment dated [DATE] identified the resident was re-admitted with a diagnosis of a right middle cerebral artery infarct due to an embolism with left sided weakness, was alert and responsive, required total care with Activities of Daily Living ( ADL) and indicated the resident was a high risk for falls. The care plan dated [DATE] identified a risk for falls related to a right sided CVA with left sided weakness and noted the utilization of an Adaptive Wheelchair (AWC) due to impaired mobility. Interventions included to ensure proper positioning, and to assist the resident out of bed via Hoyer Lift with two staff assist to the AWC. The Occupational Therapy (OT) Evaluation dated [DATE] identified Resident #499 was referred for OT services following a hospital stay for an acute CVA. The OT evaluation also noted Resident # 499 presents with a recent onset of left hemiparesis, and left sided upper extremity flaccidity and noted the resident had poor sitting balance. A physician's order dated [DATE] directed to transfer the resident out of bed to an Adaptive Wheelchair (AWC), with a pelvic positioning belt and left arm pad. The Occupational Therapy Progress note dated [DATE] identified an assessment was conducted of Resident # 499's body alignment in the wheelchair, an assessment of the resident's current seating system for appropriate modifications and instruction in body alignment. The resident was assessed in an AWC with lateral support to improve upright positioning and adjusted head rest for comfort with good effect. A Reportable Event (RE) and investigation dated [DATE] identified Resident # 499 was transported to a medical appointment in a wheelchair by Nurse Aide (NA# 3) an escort. The Reportable Event and investigation further indicated as NA #3 and Resident #499 were exiting the medical office building, NA # 3 did not notice that the pavement was uneven, NA#3 turned the wheelchair to the left and Resident # 499's wheelchair tipped sideways causing the resident to fall onto his/her right side, striking his/her head. The resident was then transferred to the emergency room for an evaluation where a Computed Tomography (CT) scan of the head revealed a subarachnoid hemorrhage. Review of the facility fall scene investigation dated [DATE] identified the Root Cause of the fall was that the resident was status post CVA, poor trunk control, and uneven pavement. Following the incident an additional care plan intervention was added to ensure that the resident use his/her own wheelchair for appointments at all times. The emergency room (ER) record dated [DATE] identified Resident #499 was diagnosed with a subarachnoid hemorrhage after a mechanical fall. The hospital physician had a conversation with the Advanced Practice Registered Nurse (APRN) #1 at the skilled nursing facility regarding the resident's condition and indicated that APRN #1 understood that the subarachnoid hemorrhage could be a life threatening bleed. ER record dated [DATE] also indicated that a decision was made to transfer the resident back to the facility to receive a Hospice Evaluation. The progress note written by APRN #2 on [DATE] identified Resident #499 had suffered a fall hitting his/her head while out of the facility at a cardiology appointment. Resident # 499 was taken to the Emergency Department (ED) where he/she was diagnosed with a subarachnoid hemorrhage and his/her condition was deemed to be terminal by the Emergency Department (ED) physician. The Conservator of Estate / Person was contacted and the decision was made to provide comfort care and to obtain a Hospice Evaluation as ordered. Review of the clinical record identified that Resident # 499 expired on [DATE]. Review of the Death Certificate dated [DATE] signed by the Medical Director identified the cause of death as failure to thrive and subarachnoid hemorrhage. Interview with OT #1 on [DATE] at 1:39 P.M. identified Resident # 499 required the use of a tilt in space AWC because he/she would slide forward and lean to the left at times because of his/her poor trunk control due to the right sided CVA. On [DATE] Resident #499 was provided with a tilt in space AWC that was adapted to his/her positioning needs which included a left sided lateral support, to prevent him/her from leaning to the left, a pelvic positioning belt, to prevent him/her from sliding forward, and a tilt in space feature to assist with positioning. OT #1 identified on [DATE] she went to the nursing unit around 10:00 A.M. and noticed Resident # 6 was seated in Resident #499's AWC. OT #1 further indicated she directed NA# 4 to take Resident #6 out of Resident #499's chair so Resident # 499 could be in his/her appropriate chair when it came time for therapy. OT #1 further identified NA#4 seemed a little resistive to the direction, and appeared that she/he (NA# 4) did not want to put the residents' in their appropriate chairs. OT #1 indicated he/she assumed that NA#4 would switch the chairs. When it came time for Resident #499's therapy, OT#1 was informed that the resident was going out for an appointment and was in another resident's chair. OT #1 identified that she went out to the wheelchair van that had arrived to pick up Resident #499 for the appointment, and noted that Resident #499 was in Resident # 501's AWC. OT #1 further stated that she identified that the resident was in the wrong AWC, although she assessed that Resident #501's chair had lateral supports, a pelvic positioning belt and a tilt in space feature and basically had all the same features as Resident #499's AWC. OT #1 informed NA#3 that the resident was not in the correct chair, and to watch for a left lateral lean, and to use the tilt in space feature, because she wanted NA#4 to keep an eye on the positioning, since the resident was not accustomed to this wheelchair as he/she was his/her own chair. Furthermore although OT #1 identified that although Resident #499 should have been in the AWC that was adapted to meet his/her positioning needs, Resident #501's AWC met all of Resident #499's positioning needs, and the resident then left for the doctor's appointment. Interview with NA#4 on [DATE] at 2:00 P.M. identified she had placed Resident #6 in Resident #499's wheelchair that morning because Resident #6's pad was still wet from being washed the night before. NA # 4 stated that OT#1 did ask her to take Resident #6 out of Resident #499's wheelchair, but thought OT #1 would come up and provide Resident #6 with another wheelchair. NA # 4 further indicated that when it was time to get Resident #499 out of bed she went into the shower room with NA#3 and found a wheelchair, which she stated that she remembered the chair to be standard wheelchair with a seat belt, and placed Resident #499 in the chair, then asked the supervisor, Registered Nurse (RN) # 2 if it was ok to send the resident in that chair, and indicated they were told it was OK. Attempts to contact RN #2 were unsuccessful. Interview with NA#3 on [DATE] at 12:30 P.M. identified that she came to the facility 15 minutes early on [DATE] to take Resident #499 to the medical appointment, she identified the resident was already in an adaptive, tilt in space wheelchair when she arrived at the facility. OT #1 came onto the van before the van left and told her that Resident # 499 was in the wrong wheelchair. OT #1 tried to adjust the resident in the wheelchair, and shifted the wheelchair a little. NA#3 also indicated that OT #1 did not tell her to watch for the resident's left sided lean or to use the tilt in space feature if the resident was leaning. NA#3 stated that throughout the appointment the residents positioning was poor, and he/she was leaning to the left side therefore she reclined the tilt in space wheelchair as far as it could go back. After the appointment, the wheelchair van called her and told her that they were in the back of the building waiting to pick the resident up. NA#3 identified she went to the back of the building, and although at that time the resident was still leaning towards the left in the chair, and the AWC was fully reclined, she proceeded to exit the building, (a person held the door so she could exit). NA# 3 identified she exited the building with the resident's feet first, and as soon as she exited the building, she hit a threshold and uneven pavement (that she was unable to see because the wheelchair was fully reclined), and attempted to turn left and the wheelchair tipped to the right, and Resident # 499 fell to the ground. She then summoned for help and the resident was sent to the ED. NA#3 stated that after the incident she was educated on ensuring that the resident was in the correct chair prior to a doctor's appointment and safe wheelchair maneuvering. Observation on [DATE] at 4:00 P.M. of the medical office back entrance, identified that the doors to exit were manual, and to exit from the building to the sidewalk there was a threshold, and once you exit the building there was a slight downward pitch to the pavement. Approximately 30 feet to the right of the exit door was a handicapped accessible ramp. Further interview with NA#3 on [DATE] at 12:00 P.M. identified she was not educated regarding the proper position of an AWC if the wheelchair encountered an uneven surface or a surface that is considered a decline that the wheelchair should be turned around, and taken through the doorway backwards. NA#3 further identified that she should have repositioned the resident (who was leaning to the left) prior to moving the wheelchair following the medical appointment to ensure proper positioning. NA #3 was not able to explain how Resident #499 who was in an ACW, leaning to the left tipped over landing on his/her right side. Further interview with OT#1 on [DATE] at 11:30 A.M. identified that a tilt in space wheelchair can be moved when it is reclined, but should not be maneuvered fully reclined because it would make for an awkward transport. OT #1 further stated that if the resident was leaning to the left, he/she should have been repositioned before NA #3 attempted to maneuver the wheelchair, and additionally indicated NA # 3 should have turned the wheelchair backwards to allow for better control of the wheelchair while exiting the building. Interview with the Director of Nurses on [DATE] at 10:30 A.M. identified it is the responsibility of the nurse aides to ensure that Resident #499 was in the correct chair prior to the transport to the physician's office, although the AWC that the resident was transported in met all of Resident #499's positioning needs. The DON further indicated that if the resident was leaning, NA#3 should have repositioned the resident prior to maneuvering the wheelchair. The DON stated that the cause of the fall was NA#3's inability to turn the wheelchair with the uneven pavement, which caused the wheelchair to become off balance. The DNS also indicated that NA#3 may not have seen the uneven surface because of the leg rests on the wheelchair. Interview with the Medical Director on [DATE] at 1:45 P.M. identified that it would be her expectation that if a wheelchair was adapted to meet a resident's positioning needs that the resident be placed in that wheelchair only. The Medical Director further identified that the cause of the Resident #499's death was a failure to thrive which was caused by the subarachnoid hemorrhage sustained in the fall. Review of NA#3's employee file identified that a Job Performance Corrective Action form dated [DATE] identified that NA#3 did not use proper body mechanics when maneuvering the wheelchair over the curb, this action resulted in the wheelchair tipping over and the patient landing face first onto the pavement causing serious injuries, employees are expected to use proper body mechanics and take safety precautions when caring for patients. Subsequent to the incident on [DATE] all staff were educated on ensuring that a resident is in the proper adaptive and or customized wheelchair prior to being transported to a medical appointment, and safe wheelchair maneuvering that included when a hill or incline is encountered to turn the wheelchair around and back down carefully, and to be observant of any curbs, cracks or crevices in the pavement. Audits were also conducted of residents who were in AWC, prior to doctor's appointments. The facility stated that they did not have a policy on AWC. 2. Resident #500 was admitted to the facility on [DATE] with diagnoses that included dementia, a left sided CVA, and Tourette syndrome. An admission assessment dated [DATE] identified that the resident had severely impaired vision, was alert and confused, required assistance with ADL, including transfer, and mobility. Review of a Fall Risk Scale dated [DATE] identified that the resident was at high fall risk. The behavior section of the fall risk assessment identified that the resident had agitation, restiveness to care, poor judgement, poor cognition, and combativeness. A fall care plan dated [DATE] identified that the resident was at risk for falls related to legal blindness with interventions that included to apply gripper socks and education on call bell use. The physician's orders dated [DATE] directed to administer Seroquel 25 (Anti-psychotic) Milligrams (MG) twice a day as needed for agitation, and to transfer and ambulate the resident with assist of one person. The Reportable Event (RE) form dated [DATE] identified that the resident had an unwitnessed fall and was noted on the floor next to the bed with his/her gripper socks on, positive range of motion to the bilateral upper and lower extremities, and no injuries identified. Review of the investigation identified that prior to the fall Resident #500 was confused and yelling out. The investigation further identified in NA#7's statement regarding the fall identified behaviors during the shift that could have contributed the fall which included the resident trying to get up multiple times. The [DATE] Medication Administration Record (MAR) identified that Licensed Practical Nurse (LPN) #4 had signed off that she had medicated the resident with as needed Seroquel on [DATE] (the documentation lacked what time the medication was administered). A RE form dated [DATE] identified that the resident had an injury of unknown origin, with the injury identified as a right displaced closed hip fracture. Review of a summary report dated [DATE] identified that after an investigation it was determined that the right hip fracture is likely due to the fall on [DATE]. Interview with Licensed Practical Nurse (LPN) #4 on [DATE] at 9:01 A.M. identified that she was Resident # 500 charge nurse on [DATE] when the fall occurred. LPN # 4 further identified that during the morning medication pass the resident was agitated and repeatedly standing up from his/her wheelchair. She further indicated that although she/he recalled medicating the resident with Seroquel, she could not recall if it was during the morning medication pass, and could not remember if the medication was effective. LPN # 4 also indicated that although she was aware of the resident's behavior, she could not recall if she had notified the supervisor. LPN#4 further stated that after the fall the staff placed the resident at the nurse's station, where the resident continued to stand from the wheelchair. Interview with NA #7 on [DATE] at 12:00 P.M. identified that Resident #500 was very impulsive, and was attempting to stand all morning prior to the fall, and was non-compliant with requests for him/her to sit down once found standing. NA#7 stated that during the lunch time meal the resident continued to attempt to stand from the wheelchair. After lunch NA#7 brought Resident # 500 to his/her room, and although the resident continue to yell out and attempt to stand, he/she (NA# 7) left the resident unattended in his/her room. He further stated that he could not recall if he had informed the charge nurse of the resident's behavior once Resident # 500 was in the room. NA # 7 also indicated after leaving the resident in the room unattended he/she then left the floor for a few minutes, and when he returned he was informed Resident # 500 was found on the floor. Attempts to contact RN#2 who was supervising on the day of the fall were unsuccessful. Interview with the Director of Nurses (DON) on [DATE] at 2:15 P.M. identified that it would be her expectation that if staff observe a resident continually standing up from the wheelchair and was unable to be redirected that the staff move the resident to a more visible area. The DON further identified that the fall on [DATE] was most likely the cause of the right hip fracture identified on [DATE]. The facility failed to implement additional interventions when Resident #500 exhibited attempts to stand without assistance. Review of the fall policy identified that the facility will maintain a safe environment in order to minimize falls and injuries related to falls, and a fall management plan will be initiated for residents who are at high risk for falls.