**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews during the Recertification Survey initiated on 8/14/2024 and completed on 8/20/2024, the facility did not ensure that each resident received adequate supervision and assistance devices to prevent accidents. This was identified for one (Resident #71) of eight residents reviewed for Accidents. Specifically, Resident #71 required the assistance of two staff members for bed mobility as per the Rehabilitation Department screening on 1/4/2024 and 4/4/2024. The resident's comprehensive care plan and nursing care instructions for the Certified Nursing Assistants were not updated to reflect the Rehabilitation Department's recommendations. During the morning care on 6/24/2024, Certified Nursing Assistant #5 turned the resident on their side to clean the resident's back and the resident fell out of the bed. Subsequently, Resident #71 was transferred to the hospital and was diagnosed with a fracture of the right leg. This resulted in actual harm to Resident #71 that is not Immediate Jeopardy. The finding is: The facility's policy titled Rehabilitation Evaluations/Screens/Assessments, last reviewed January 2022, documented the purpose is to ensure the resident receives Physical Therapy, Occupational Therapy, and Speech Therapy evaluation upon admission, quarterly, and as necessary to obtain the resident's baseline function, improve or maintain status, and set appropriate goals/outcome to obtain optimal performance. The undated facility's policy titled Activities of Daily Living documented appropriate care and services will be provided for residents who are unable to carry out Activities of Daily Living independently, in accordance with the plan of care, including appropriate support and assistance with hygiene and mobility. For a dependent resident: the helper does all of the effort; the resident does none of the effort to complete the activity; or the assistance of two or more helpers is required for the resident to complete the activity. Resident #71 was admitted with diagnoses including Dementia, Anxiety Disorder, and Hypertension. The 4/6/2024 Quarterly Minimum Data Set assessment documented a Brief Interview for Mental Status score of 6, indicating the resident had severe cognitive impairment. The Minimum Data Set assessment documented the resident was dependent on staff for rolling from lying on their back to the left or right side. The Rehabilitation Department's quarterly screens dated 1/4/2024 and 4/4/2024 documented the resident required maximum assistance of two people for bed mobility (the ability of the resident to move from their back to the left or right side when in bed). A Comprehensive Care Plan titled Activities of Daily Living All Tasks, effective 8/5/2022 and last updated on 4/4/2024, documented the resident required partial/moderate physical assistance of one staff member for bed mobility (the ability of the resident to move from their back to the left or right side when in bed). There was no documented evidence the Rehabilitation Department updated the Activities of Daily Living All Task care plan to include two person assistance for bed mobility. The Resident Nursing Instructions (care instructions provided to Certified Nursing Assistants) from 6/1/2024 through 6/30/2024 documented Resident #71 required one-person partial/moderate physical assistance for bed mobility. The resident had the behavior of yelling and screaming. A review of the Certified Nursing Assistant Accountability Record for June 2024 documented bed mobility was performed by one staff member through 6/24/2024 as indicated by staff signatures. A nursing progress note dated 6/24/2024 at 2:24 PM, written by Registered Nurse #2 (the Risk Manager), documented this writer was called to assess the resident who was on the floor. While Certified Nursing Assistant #5 was providing care to the resident (at 11:15 AM), the resident began reaching for their stuffed animal, which was on the nightstand table near the bed. The resident reached too far and rolled out of bed onto the floor before Certified Nursing Assistant #5 could reach the resident. Upon assessment, the resident was observed with a deformity to their right lower extremity and was complaining of pain. A Nurse Practitioner who was present in the building, assessed the resident and observed obvious deformity to their right lower extremity. Resident complained of pain from the right hip to the right ankle. 911 was called and the resident was transferred to the hospital. A nursing progress note dated 6/24/2024 at 3:16 PM documented the resident was admitted to the hospital with a diagnosis of a fracture of their right lower extremity. A review of the Accident and Incident Investigation dated 6/24/2024, prepared by Registered Nurse #2 (the Risk Manager) concluded the resident was reaching for a stuffed animal. The resident reached too far and rolled out of bed onto the floor before the Certified Nursing Assistant could prevent the fall. All care plan interventions were investigated to have been in place. The interdisciplinary team and medical services are in agreement that there was no evidence of any abuse, mistreatment, neglect, or exploitation. The hospital Discharge summary dated [DATE] documented the resident was admitted to the hospital on [DATE] with a fracture of their right tibia/fibula (lower leg bones). A Nurse Practitioner readmission note dated 6/27/2024 at 4:06 PM documented the resident was readmitted from the hospital with a right tibia/fibula fracture and the right lower extremity had a cast from mid-femur (bone in thigh) to mid-foot. During an observation on 8/19/2024 at 12:15 PM, Resident #71 was in the day room waiting for lunch. The resident had a cast on their right leg. The resident stated they had a fall; however, could not remember how. During an interview with the Rehabilitation Director on 8/19/2024 at 1:44 PM, the Rehabilitation Director stated Rehabilitation Department screens are completed quarterly and as needed. The quarterly screens dated 1/4/2024 and 4/4/2024 for Resident #71 documented the resident required maximum assistance of two staff members for bed mobility. The care that the Certified Nursing Assistants provide is based on the Rehabilitation Department assessment. The Therapist completing the assessment should update the resident's All-Task Activities of Daily Living care plans based on their assessment. Once the care plan is updated, the recommendations and instructions are automatically documented on the Resident Nursing Instructions. During an interview with Certified Nursing Assistant #5 on 8/19/2024 at 2:22 PM, they stated the resident was dependent on them for bed mobility. On 6/24/2024 they were providing morning care alone for the resident, which included washing their face, changing their brief, combing their hair, and getting them dressed. Resident #71 reached for their stuffed animal on the bedside table when they (Certified Nursing Assistant #5) turned the resident to their left side to clean the resident's back. Certified Nursing Assistant #5 stated they tried to support the resident, but the resident fell out of bed. Certified Nursing Assistant #5 stated the resident required one person's assistance for the bed as per the Resident Nursing Instructions. Certified Nursing Assistant #5 stated they worked with the resident prior to the fall on 6/24/2024 and always provided care by themselves. During an interview with Physical Therapist #1 on 8/19/2024 at 2:30 PM, stated they completed the quarterly Rehabilitation screening for Resident #71 on 1/4/2024 and 4/4/2024. According to their assessment, the resident required the maximum assistance of two staff members for bed mobility. Physical Therapist #1 stated the resident's care plan should have reflected the resident required two persons for the bed mobility as per the recommendations made on the Rehabilitation screens. Physical Therapist #1 stated their recommendation to use two staff for bed mobility was based on their assessment and observation of the resident while the resident was in bed. Physical Therapist #1 stated they were supposed to update the All-Task Activities of Daily Living care plan to reflect their recommendations to use two staff members for bed mobility. Physical Therapist #1 stated they screen many residents a day and try to make sure that everything matches; however, they could not remember why the care plan for Resident #71 was not updated in January 2024 and April 2024 after they completed the Rehabilitation screen. Physical Therapist #1 stated when the Activities of Daily Living care plan is updated, the recommendations are automatically updated on the Resident Nursing Instructions. During a re-interview with the Rehabilitation Director on 8/20/2024 at 8:45 AM, the Rehabilitation Director stated following Resident #71's Rehabilitation screens on 1/4/2024 and 4/4/2024, there was a conversation among the Interdisciplinary Team, which consisted of all Department Heads, during the morning report. The Rehabilitation Director stated even though Physical Therapist #1 documented the resident required two-person assistance for bed mobility, it was not based on the resident's physical needs but because of the resident's behaviors, so the team decided one person was appropriate for bed mobility. The Rehabilitation Director was unable to state the behaviors exhibited by the resident. The Rehabilitation Director stated they were part of the Interdisciplinary Team and were not sure where the discussion regarding the Interdisciplinary Team's decision not to implement the screen findings was documented. The Rehabilitation Director further stated nurses were responsible for updating the care plan related to the Interdisciplinary Team decision. During an interview with Licensed Practical Nurse #5, the unit charge nurse, on 8/20/2024 at 9:57 AM, they stated they attended Interdisciplinary Team meetings for Resident #71 and did not recall any discussions regarding not following the Rehabilitation Department screen assessment recommendation for Resident #71's bed mobility status. Licensed Practical Nurse #5 stated the All-Task Activities of Daily Living care plan is a Rehabilitation Department care plan and only the Rehabilitation Department can update that. Resident #71's medical record review revealed no documentation regarding the Interdisciplinary Team's decision to not implement the Rehabilitation screen assessment recommendations/findings. During a re-interview with Physical Therapist #1 on 8/20/2024 at 10:29 AM, when they completed the resident's Rehabilitation screen in January and April 2024, the resident was exhibiting behaviors of reaching out for things, grabbing, and trying to pinch the staff. Physical Therapist #1 stated the resident's behavior was one of the reasons they recommended two-person assistance with bed mobility for Resident #71. During an interview with Certified Nursing Assistant #6 on 8/20/2024 at 11:31 AM, they stated during the 11:00 PM - 7:00 AM shift, Resident #71 did not help in turning from their back to the left or right side. Certified Nursing Assistant #6 stated they always needed help to turn the resident in bed. During an interview with Certified Nursing Assistant #7 on 8/20/2024 at 12:07 PM, stated during the 3:00 PM - 11:00 PM shift, they always used two people to turn the resident from their back to the left or right side because the resident had a behavior of hitting the staff during care and the resident did not help with turning. During an interview with Physician #1 on 8/20/2024 at 1:00 PM, Physician #1 stated Resident #71's right leg fracture was the result of the fall from bed on 6/24/2024. During an interview with the Director of Nursing Services on 8/20/2024 at 1:38 PM they stated the Rehabilitation Department is responsible for updating the All-Task Activities of Daily Living care plan. The Director of Nursing Services stated based on the Rehabilitation screening evaluation, the resident required two staff members for bed mobility and if there was a discussion by the Interdisciplinary Team to not implement the assessment findings, the reasons should have been documented in the resident's medical record. They stated Certified Nursing Assistant #5 followed the instructions written on the Resident Nursing Instructions and cared for the resident alone on 6/24/2024. 10 NYCRR 415.12(h)(2)