**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to assure each resident received adequate assistance to prevent a fall with injury for 1 of 3 residents reviewed (Resident #31). The facility reported a census of 76 residents. Findings include: According to the Minimum Data Set (MDS) assessment dated [DATE] Resident #31 scored 3 on the Brief Interview for Mental Status (BIMS) indicating severe cognitive impairment. The resident had functional limitation in range of motion (ROM) of 1 side, upper extremity. The resident required supervision or touching assistance with transfer and ambulation. The resident's diagnoses included rheumatoid arthritis (RA). The Care Plan identified the resident had an activity of daily living (ADL) self-care performance deficit related to Alzheimer's, disease process, RA, chronic back pain, osteoporosis, hypothyroidism, chronic urinary tract infections (UTI's), depression, impaired balance, but able to stabilize self with walker, and increased risk for falls. The resident had limited ROM of the left hand. The interventions included: a. On 12/8/23 the resident ambulated with a walker to all destinations. The resident ambulated with guidance and direction from staff. Staff were at the resident's side at times. On occasion the resident would walk independently for short distances. The intervention resolved 4/11/24. b. On 4/11/24 the resident ambulated as tolerated to destinations with 1 assist and walker. The resident's bilateral hands had rheumatoid arthritis knuckle contractures, assisted with the walker as needed. The Progress Notes dated 4/23/24 at 11:37 a.m. documented staff were summoned for help in the main nurses station due to the resident on the ground. Staff stated they were assisting the resident up to go to the dining room for lunch. After the resident was in a standing position from the chair she grabbed her walker with her right hand and staff tried to assist the resident's contracted left hand to the walker but the resident let her right hand go from the walker. The resident was lowered to the ground but did end up on her right hip. Vital signs were taken. No shortening noted to bilateral lower extremities. Assisted the resident to a sitting position, then assisted into a standing position with a gait belt and 3 staff members. The resident was wheeled into the dining room in a wheelchair. The resident showed signs of pain by facial expressions and verbally. Interventions included: Updating the Advanced Registered Nurse Practitioner (ARNP), received orders for x-ray of the right hip, sent out via emergent ambulance for x-ray, would no longer use the walker for ambulation. A hospital History and Physical dated 4/23/24 at 12:43 p.m. documented Resident #31 presented to the emergency room (ER) with hip pain following a fall. Hip X-ray results dated 4/23/24 documented an acute appearing right femoral neck fracture in mild varus malalignment. Orthopedic surgery was contacted per their documentation and discussion with the resident's power of attorney (POA). They decided to proceed with surgery the following day. The physical exam revealed the resident's right lower extremity shortened and externally rotated. A Post-hospitalization visit dated 5/1/24 at 10 a.m. documented the resident had right hip hemiarthroplasty (surgery to treat hip fracture) on 4/24/24. Staff reported the resident had increased pain since returning to the facility, noticed with transfers, assisting the resident with daily cares, in the mornings, and in the middle of the night. The resident was cognitively impaired at baseline. Given the resident's cognitive impairment, there was concern she would be unable to express the pain she truly experienced. The resident reported no pain, but even with light palpation over the right hip, she grimaced and stated ouch. New orders included increasing Hydrocodone-Acetaminophen to 7.5/325 mg 3 times a day, and Hydrocodone 5 mg as needed every 6 hours for breakthrough pain. The Progress Notes dated 5/7/24 at 8:42 a.m. documented the resident readmitted on 4/29 post right hip hemiarthroplasty. Appetite very poor, required cues and assistance during meals. Required maximum assist of 2 for transfers, toileting, and bed mobility. Assist of 1 for ADL's and showering. Weight bearing as tolerated to right lower extremity but resident did not allow leg to bear any weight. Left hand remained contracted and painful to the resident. The resident complained of pain in the right lower extremity during any attempts of movement. On 5/14/24 at 10:35 a.m. Staff A Certified Nursing Assistant (CNA) stated (on 4/23/24) she went to assist the resident to go to the bathroom before going to lunch. She said she helped the resident stand up to her walker and one hand was on the walker holding it and the other hand was closed. She opened the hand to put it on the walker and the resident let go of the walker with the one hand, lost her balance and she went to the ground. Staff A was able to hold on to her to ease her down. Staff A stated she did not know they needed to have a gait belt on. She had not seen other staff use a gait belt on the resident. The Director of Nursing (DON), present during the interview, stated the resident had recently changed from independent to a 1 assist prior to the incident. The resident should have had the gait belt on when assisting her. A note dated 4/23/24, Gait belt use, documented discussion of the importance and mandate to use a gait belt with any resident when required an assist of 1 or 2 with any and all transfers and ambulation. Caregivers had to have on their person or within reach a gait belt at all times while on the floor. Failure to follow the protocol could result in disciplinary action. A Summary of the self report on Resident #31: When transferring the resident from the recliner chair the CNA did not have a gait belt on the resident. The resident stood up from the chair, and the CNA was guiding the resident's arthritic hand to grip the walker and the resident's opposite hand, her right hand, let go of the walker. The resident's knees began to buckle, and the CNA slowly guided her to the floor. The resident's Care Plan had recently changed to assist of 1 from independent. Prior to the change the resident had been transferring and ambulating independently. Employee education done with all CNA's and Nurses regarding gait belt use on all residents that were assist of 1 or greater, when not using a manual lift. Education of all nursing staff started on 4/24/24 and completed on on 4/26/24. Each individual CNA or Nurse was given the education on a 1 to 1 basis. Going forward Nursing Administration would conduct audits on all shifts to make sure all were using gait belts properly.