**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interviews during the Recertification and Abbreviated Survey (NY00303374) initiated on [DATE] and completed on [DATE] the facility did not ensure that each resident receive adequate supervision and assistance to prevent accidents. This was identified for one (Resident #82) of two residents reviewed for falls. Specifically, Resident #82 required total assistance of two staff members for all areas of Activities of Daily Living (ADLs) including bed mobility as per the Comprehensive Care Plan (CCP). During morning care on [DATE] Resident #82 fell in their room, when the Temporary Nursing Assistant (TNA) #1 turned the resident on their right side away from them (TNA #1) without the assistance of another staff member. Subsequently, Resident #82 fell from their bed and sustained Bilateral Femur (upper leg) Fractures. This resulted in actual harm to Resident #82 that is not Immediate Jeopardy. The finding is: The facility Policy on Fall Prevention was revised in [DATE], documented under the Procedure section (#5) to document care plan directives on the Certified Nursing Assistant (CNA) Accountability Sheet. Under procedure section #7 the policy documented at the time of a fall incident the Registered Nurse (RN) Supervisor is to review the resident's plan of directives to ensure that appropriate interventions were followed, and to revise the care plan to include interventions to prevent reoccurrence of fall incidents. Resident #82 was admitted with diagnoses of Dementia and Cerebral Vascular Accident with Hemiparesis (one side body weakness). Resident #82 was readmitted on [DATE] from the hospital Status Post falls and had diagnoses that included Fracture of Right and Left Femur, Hypertension, and Atrial Fibrillation. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented the resident had short and long term memory problems. The resident required total assistance of two staff members for bed mobility, transfers, toileting, and bathing. The resident has impairment of both upper extremities and on one side of their lower extremity. The resident utilized a wheelchair and had no falls prior to this assessment. The Significant Change MDS dated [DATE] documented the resident had short and long term memory problems and was severely impaired for daily decision making. The resident required total assistance of two staff members for bed mobility, transfers, toileting, and bathing. The resident was always incontinent of both bowel and bladder. The resident has limitations on both sides of the upper and lower extremities. The Nursing Fall Risk assessment dated [DATE] documented the resident's fall risk score was 11 which indicated the resident was at risk for falls and required a Falls/Safety/Injury care plan. The Activities of Daily Living (ADL) Functional/Rehabilitation potential care plan dated [DATE], last updated [DATE] documented the resident required total assistance of two staff members for bed mobility. The At Risk for Falls- Potential/Injury care plan dated [DATE] and was last reviewed on [DATE] documented the resident was at risk for falls with potential for injury related to Dementia, Cerebral Vascular Accident related to Hemiparesis. The interventions included to provide assistance of two staff members for all care including bed mobility. The Resident Nursing Instructions Form (guidance provided to CNAs for resident care needs) dated [DATE]-[DATE] documented Resident #82 required total dependence of two staff members for bed mobility. A Nursing note dated [DATE] at 7:15 AM written by Registered Nurse (RN) #2 documented that at 6:30 AM Resident #82 was turned towards the door by TNA #1 during care. Resident #82 began to roll out of the bed and TNA #1 guided the resident to the floor. Resident #82 was found on the floor in their room lying on their back. The resident complained of right knee discomfort with a pain score of four out of 10 (zero indicating no pain and 10 indicating most severe pain). A Facility Accident and Incident (A/I) Report dated [DATE] at 6:30 AM documented that while TNA #1 was rendering care to Resident #82, TNA #1 turned the resident towards the door and the resident began to roll out of the bed. TNA #1 stated that they guided the resident to the floor. The A/I report documented the resident was found on the floor in their room lying on their back and complaining of right knee discomfort. The Facility A/I Summary dated [DATE] concluded that TNA #1 performed toileting and bed mobility on Resident #82 by themselves without seeking assistance from a Certified Nursing Assistant (CNA) or a nurse. This break in the plan of care resulted in a major injury to the resident. Due to these circumstances, TNA #1 has been relieved from their position. Based on the information provided, there has been evidence of abuse, mistreatment, exploitation, or neglect. The Resident CNA Documentation History Form (documentation of care that was rendered) dated [DATE]-[DATE] revealed at 11:35 PM TNA #1 provided care for Resident #82 utilizing two persons for bed mobility. After 11:35 PM TNA #1 did not document care provision to Resident #82 on [DATE]-[DATE] during the 11:00 PM-7:00AM nursing shift. The Computerized Tomography (CT) scan of the Right Hip, Femur, and Knee dated [DATE] documented there was a right Femur Fracture. The hospital Radiology Report of the Left Knee dated [DATE] documented there was a left Femoral Fracture A Nursing note written by RN #6 dated [DATE] at 2:03 PM documented the x-ray result revealed an Acute Femur Fracture. The Hospital Discharge Instructions dated [DATE] documented that the right Femur fracture was non-operative and the left Femur fracture required surgical intervention on [DATE]. A Medical progress note written by Nurse Practitioner (NP) #1 dated [DATE] documented the resident was evaluated on [DATE] at the bedside. The note documented the resident had a recent hospitalization status post fall resulting in right and left Femur Fractures. TNA #1 was not available for interviews after several attempts were made to contact them on [DATE]. TNA #1's written statement dated [DATE] documented when they (TNA #1) were providing care for Resident #82 they rolled Resident #82 on their right side to apply the cream to the resident's buttocks. TNA #1 wrote they noticed the resident was rolling more to the right and they tried to intervene, but they were only able to catch the upper part of the resident's body. When the resident's legs fell off the bed, TNA #1 gently placed the resident onto the floor and called for the nurse. Resident #82 told TNA #1 that their right knee hurts. An observation of Resident #82 was conducted on [DATE] at 10:15 AM. Resident #82 was observed sitting in their room in a reclining wheelchair. RN #2, the 11:00 PM - 7:00 AM shift Supervisor on [DATE]-[DATE], was interviewed on [DATE] at 6:36 AM. RN #2 stated they were informed by Licensed Practical Nurse (LPN) #4 that the resident was on the floor. RN #2 stated when they arrived at the unit, they observed Resident #82 on the floor laying on their back between the wall and the right side of the bed. RN #2 stated the resident was complaining of severe pain in the right knee and leg. RN #2 stated that they tried to perform Range of Motion (ROM) to the resident's extremities, however, could not continue due to the resident's complaint of pain. RN #2 stated after they assessed the resident, they transferred the resident back to bed using a Hoyer (mechanical) lift. RN #2 stated the resident required two staff members' assistance for bed mobility and turning and positioning. TNA #1 told RN #2 that they did not request assistance from another staff member when providing care to Resident #82. RN #2 stated that TNA #1 informed them they were unaware that Resident #82 required two-person assistance for bed mobility. CNA #3, who was the 11:00 PM - 7:00 AM CNA on duty on [DATE]-[DATE], was interviewed on [DATE] at 3:12 PM. CNA #3 stated TNA #1 was assigned to Resident #82. CNA #3 stated after providing care to one of the residents on their assignment they were walking in the hallway when they heard TNA #1 calling for help. CNA #3 stated when they got to the resident's room, they saw Resident #82 laying on their stomach on the floor. CNA #3 stated that TNA #1 told them when they rolled Resident #82, the resident was too close to the edge of the bed and the resident continued to roll out of bed. CNA #3 further stated that the resident required two staff members for all ADLs and that TNA #1 did not ask for their assistance to turn Resident #82. LPN #2, who was the medication nurse on duty on [DATE]-[DATE] on the 11 PM-7:00 AM shift, was interviewed on [DATE] at 3:30 PM. LPN #2 stated that they were made aware of the incident by TNA #1 who came to the nurse's station and reported that Resident #82 fell out of bed. LPN #2 stated they called RN #2 then went to Resident #82's room and saw the resident lying face down on the floor. LPN #2 stated TNA #1 reported they rolled the Resident too close to the edge of the bed and the resident rolled off the bed. A subsequent interview with LPN #2 was conducted on [DATE] at 5:16 PM. LPN #2 stated that TNA #1 did not request help from them at any time during the [DATE] - [DATE] 11 PM - 7AM nursing shift. The RN Inservice Coordinator was interviewed on [DATE] at 11:52 AM. The RN Inservice Coordinator stated that all new hires receive training on mandatory policies and procedures upon hire and annually. The RN Inservice Coordinator stated that the TNAs receive the same training and in-services as the CNAs. The RN Inservice Coordinator stated after a one-day classroom training that the TNA is buddied with an experienced CNA and that during this period they receive extensive training on the use of the Electronic Medical Record (EMR) including reviewing the ADL Tasks which includes bed mobility prior to providing care. The Medical Director (MD) was interviewed on [DATE] at 4:43 PM. The MD stated when they were made aware of the resident's fall, they ordered an x-ray of the right leg. The MD stated on [DATE] they were made aware the x-ray results revealed a right Femur Fracture they ordered to send the resident to the hospital for evaluation. The MD stated at the time of transfer that they were not aware of the resident's Left Hip Fracture. The MD stated that based on the fall and x-ray results the resident's fractures were directly related to the fall. The Physician further stated that if the resident's plan of care specified two persons for bed mobility, the expectation would be for the care of the resident to be rendered by two staff members. The Director of Nursing Service (DNS) was interviewed on [DATE] at 9:58 AM. The DNS stated that the resident required two staff members for all aspects of ADLs, especially bed mobility. The DNS stated that there was a break in Resident #82's plan of care because TNA #1 did not follow the resident's plan of care. The DNS stated that TNA #1 did not have a second staff member to assist them with care while the resident was in bed. The DNS stated TNA #1 should have asked for assistance from CNA #3 and if CNA #3 was not available TNA #1 should have asked LPN #2 for assistance. Additionally, the DNS stated that the X-Ray revealed an Acute Fracture of the Right Distal Femur and at the time of the incident they were not aware that the resident had fractured their Left Hip because the resident did not complain of left leg pain. The DNS stated it was upon the resident's return from the hospital that they discovered the resident had fractured the Left Femur (upper leg) as well. The DNS stated the bilateral fractures were directly related to the resident's fall from bed on [DATE]. The Administrator was interviewed on [DATE] at 12:31 PM and stated that TNA #1 did not follow the plan of care when administering care to Resident #82. The Administrator stated they expected the staff to follow each resident's plan of care. If a resident's plan of care requires two-person assistance, then the staff must utilize two staff members to provide care. 10 NYCRR-414.12(h)(2)