Based on observation, interview and record review, the facility failed to ensure a CNA (Certified Nursing Aide) followed the resident's comprehensive care plan regarding fall prevention for 1 of 3 residents reviewed for falls. (Resident B) This resulted in the resident falling to the floor, fracturing both femurs (thigh bones) and required surgical repair of the fractures and hospitalization after the staff member left the resident seated on the side of their bed, without supervision. (Resident B) Finding includes: A facility self-reported incident #300, dated 5/30/25 at 10:39 A.M., indicated Resident B was .sitting on bed and attempted to transfer unassisted and fell on her side. Resident was immediately assessed by nurse and pain in torso was reported .order received to send to ED [Emergency Department] X-rays show acute displaced longitudinal oblique fracture of the distal diaphysis and distal metaphysis of the femur with a mild amount of hemorrhage at the fracture site On 6/26/25 at 10:22 A.M., Resident B was not observed in her room, the bed had been made, and a mat was folded up against the wall. A bolster/perimeter mattress ( a mattress with elevated sides) was observed with bilateral bolsters on the sides of the bed. The resident was observed in the hallway, near the nurses station, in a high back wheelchair. She did not respond to her name or other questions. She was observed to stare but made no vocal sounds. On 6/24/25 at 10:46 A.M., a review of the clinical record for Resident B was conducted. The resident's diagnoses included, but were not limited to: dementia, unsteadiness on feet, muscle weakness, abnormalities of gait/mobility and depression. The Annual Minimum Data Set (MDS) Assessment, dated 4/15/25, indicated the resident had inattention with disorganized thinking, required substantial/maximal assistance from a staff member when she went from a lying to a standing position and when she went from a seated to standing position. The resident's current care plan, initiated on 11/18/24, indicated the resident had .impaired cognition with associated short term memory impairment and risk for confusion, disorientation, altered mood, impaired or reduced safety awareness & communication r/t [related to] Dementia. Sometimes understood/understands The interventions included, but were not limited to: pay attention to basic needs, provide cues and supervision for decision making. A current fall care plan, initiated on 10/4/23, indicated Resident B was at risk for falls related to a history of falls, poor safety awareness due to a diagnosis of dementia and decreased mobility. The interventions included, but were not limited to: fall mat next to bed, bed in the low position, staff to assist with transfers and a perimeter mattress to define edges of the bed. A facility Profile Care Guide ( information that directed resident care for CNA's), dated 9/18/24, indicated the resident required one staff member for transfer assistance. A Nursing Progress Note, dated 5/30/25 at 10:39 A.M., indicated CNA 3 had called LPN 2 into Resident B's room to have the resident assessed after a fall. CNA 3 indicated the resident had been seated at the side of her bed and CNA 3 had walked away from the resident to grab something. CNA 3 had heard a thump and found the resident lying on her left side, in a seated position. The resident had complained of bilateral hip and knee pain, but was unable to verbalize the severity of pain per a pain scale. An emergency room Report, dated 5/30/25 at 12:32 P.M., indicated the resident had presented to the emergency room with a left leg deformity after a fall from the edge of the bed.She was reportedly at the edge of the bed and fell to the ground, sustained an injury to the left leg and has some swelling above the knee along with some deformity and tenderness An X-ray indicated the resident had a comminuted distal femur fracture. The report indicated at 2:54 P.M., a re-examination was conducted due to the resident's pain and swelling of the right knee area. Another x-ray was obtained which revealed a fracture of the right distal femur. The Assessment/Plan from the emergency room indicated the following: fall from ground level, left femur fracture, periprosthetic (fracture associated with an orthopedic implant-history of femur fracture with internal fixation) and acute traumatic fracture right distal femur. admitted to the hospital in stable condition. The hospital Computerized Tomography (CT) results indicated the following: .right acute displaced oblique fracture of the distal femur. (The long bone in the thigh area, when it breaks in a diagonal pattern it could be related to traumatic injury-forceful blow or twisting of the leg) . The hospital CT results of the left leg revealed an old proximal femur fracture with an internal fixation (previous fracture repair) with a .left comminuted, obliquely oriented fracture of the distal femur. The distal fracture fragment is medially displaced by 1 full shaft width at time of the CT. Bones severely demineralized (When a fracture is displaced, it means that the broken ends of the bone are not aligned correctly and have shifted our of their normal pattern) A form titled, Statement of Witness Form, dated 6/1/25, indicated the Administrator and the Director of Nursing (DON) had spoken to CNA 3 regarding the incident. The statement indicated CNA 3 had moved the floor mats to position the wheelchair next to the resident's bed, for a transfer. There were no other statements regarding the investigation of the fall. CNA 3 was terminated due to misconduct and policy violation, unrelated to incident, on 6/11/25. A form titled, Disservice/Training Log, dated 6/1/25, indicated CNA 3 had been in-serviced on transfer training. Resident B returned from the hospital, on 6/4/25 at 9:44 P.M. An Interdisciplinary Team (IDT) Progress Note, dated 6/2/25 at 9:41 A.M., indicated Resident B had a fall.Resident was sitting on the edge of bed, aide was getting ready to transfer resident to w/c [wheelchair] while getting a washcloth resident attempted to transfer self and fell to the floor. Resident has severe cognitive deficits r/t [related to] dx [diagnosis] of dementia and does not remember that she requires assistance with transfers .Immediate intervention resident sent to ER [Emergency Room] for eval [evaluation] and treat, ghost alarm place to bed During an interview, on 6/24/25 at 12:02 PM. the Administrator indicated when he had documented, on the incident report, he had only observed one of the CT results and was unaware there were actually two femur fractures when he reported the incident. On 6/24/25 at 2:17 P.M., the Administrator provided a policy titled, Fall Management Program Guidelines, dated 5/31/17 and last reviewed on 12/17/24 and indicated the policy was the one currently used by the facility. The policy indicated .[Name of Corporation] strives to maintain a hazard free environment, mitigate fall risk factors and implement preventative measures. [Name of Corporation] recognizes even the most vigilant efforts may not prevent all falls and injuries. In those cases, intensive efforts will be directed toward minimizing or preventing injury This citation relates to Complaint IN00460706. 3.1-45(a)(2)