Based on observation, record review, hospital record review and interview the facility failed to provide adequate supervision and intervention to prevent and mitigate a fall with injury for Resident #30. Actual harm occurred on 06/08/23 when Resident #30, who required the assistance of two staff for bed mobility, fell from a bed in high position when receiving incontinence care by one staff member resulting in a right hip dislocation and hospitalization. This affected one resident (#30) of two residents reviewed for accident hazards. The total census was 135. Findings include: Record review for Resident #30 revealed the resident was admitted to the facility 10/11/21 and had diagnoses including cognitive communication deficit, osteoarthritis, and anxiety disorder. Review of the care plan for falls, dated 10/11/21, identified the need to provide a safe environment, including keeping the bed in low position. The plan of care interventions were updated on 06/08/23 for the use of fall mats to be kept on both sides of the resident's bed. Review of a fall assessment, dated 04/07/23 revealed Resident #30 was at high risk for falls. Review the most current occupational therapy assessment, dated 05/09/23, revealed Resident #30 had total dependence on staff for sitting balance, toileting, hygiene, and all other self-care activities of daily living. Review of the Minimum Data Set (MDS) 3.0 assessment, dated 06/03/23 revealed she had moderate cognitive impairment and required total dependence on two or more staff to provide bed mobility, including turns. Review of Resident #30's progress notes revealed a note dated 06/08/23 at 10:38 P.M. indicating State Tested Nursing Assistant (STNA) notified the nurse the resident rolled onto the floor during patient care. The nurse entered and found the resident lying on her side by the bed. The resident said, I rolled out of bed, and denied pain. Assessment at the time showed no sign of injury, however, notes on 06/09/23 revealed the resident complained of pain. An x-ray done the same day revealed the resident had a dislocated hip and was sent to the emergency room. Review of Resident #30's hospital documentation revealed the resident was admitted to the hospital and received a right total hip arthroplasty closed reduction under anesthesia (a procedure to put the hip back in place without need of incision). She was hospitalized until 06/29/23 when she returned to the facility. Review of a facility fall investigation for Resident #30's revealed the resident rolled out of bed on 06/08/23. A skin assessment was (initially) completed with no injuries noted. Bilateral safety mats to the side of the bed were applied in response to the fall. The next day the resident had complaints of pain in the right hip, and an x-ray revealed she had an injury. A witness statement from STNA #816 dated 06/09/23 revealed she rolled Resident #30 onto her right side, then went to the sink to retrieve an extra towel and the resident fell over as soon as she turned back around. STNA #816 received discipline by the facility and education to ensure residents were in a safe position prior to walking away. Observation of Resident #30 on 08/07/23 at 11:43 A.M. revealed she was not interview able and demonstrated no verbal or nonverbal signs of pain. She did not make any motions with her hands or arms nor demonstrate any ability to move around by herself in the bed. Interview with Resident #30's power of attorney on 08/08/23 at 2:13 P.M. revealed that on 06/08/23 at roughly 11:00 P.M. the facility informed her Resident #30 had a fall. The nurse informed her the fall occurred when the aide turned their back on the resident during incontinence care. The nurse said she believed the air mattress might be responsible, which may have shifted beneath the resident and caused her to roll. The next day the facility took x-rays, found had dislocated her hip, and they sent her to the hospital. Resident #30 was admitted to the hospital for 22 days, although she was treated for other conditions besides the dislocated hip during the hospitalization. Resident #30 was not capable of independent positioning in the bed. Interview with Licensed Practical Nurse (LPN) #982 on 08/09/23 at 3:43 P.M. revealed she was Resident #30's nurse at the time of her fall on 06/08/23. The LPN revealed Resident #30 was dependent on staff for bed mobility both before and after the fall and there should have been two staff members present when giving incontinence care. At roughly 10:30 P.M. on 06/08/23, STNA #816 informed her Resident #30 fell. The nurse arrived at the bedside to find the resident laying on her right side next to the right side of the bed. The bed was in a high position due to the fall occurring during incontinence care. The resident denied pain at the time, denied hitting her head, and a skin assessment revealed no evidence of injury. Interview with STNA #816 08/09/23 at 5:18 P.M. revealed on the evening of 06/08/23, Resident #30 had a large bowel movement and STNA #816 provided incontinence care without other staff in the room. She said the resident usually only needed one staff member to provide incontinence care, although sometimes needed two staff if they were unfamiliar with the resident. She stated she ran out of towels while giving care and left the resident on her right side to go to the bathroom to get more. STNA #816 stated she heard the resident fall to the floor while she was in the bathroom and came out to find the resident laying on the floor on her right side. STNA #816 immediately retrieved the nurse. The STNA stated Resident #30 denied pain all throughout that night. The resident could grip the bed 'a little bit' during turns, but otherwise had no ability to contribute to bed mobility both before and after the fall. The surveyor confirmed the above record review findings with the Director of Nursing during an interview on 08/10/23 at 9:55 A.M.