Based on record review and interview, the facility failed to ensure adequate supervision and assistance with transfers for one (#3) of five sampled residents reviewed for accidents. The ADON identified 42 residents resided in the facility and 31 residents required assistance with transfers. Findings: The facility's Gait Belt policy, dated 2023, read in part, .Gait Belts promote the safe handling and mobility of residents .Spanish Cove requires a gait belt when assisting all residents with ambulation or transfer .Nursing assistants must wear gait belts at all times . The facility's Safe Lifting and Movement of Residents policy, revised 07/2017, read in part, .Staff responsible for direct resident care will be trained in the use of manual (gait/transfer belts, lateral boards) and mechanical lifting devices .Only staff with documented training on the safe use and care of the machines and equipment used in this facility will be allowed to lift or move residents . An undated facility Policy Statement for Agency Staff policy, read in part, .Gait Belt Policy: Gait belt must be used for all transfers unless otherwise contraindicated and in care plan. Gait belt must be used when assisting a resident with ambulation. You are required to arrive at the facility with your gait belt on your person. Your gait belt should always be on your person . Resident #3 had diagnoses which included orthostatic hypotension, difficulty walking, and unsteady on feet. An admission assessment, dated, 09/02/24, documented the resident was dependent on staff for transfers. Emergency room/hospital notes, dated 09/12/24 through 09/18/24, documented Resident #3 presented to the emergency department with complaint of syncope which resulted in blunt head trauma, and the development of nausea, vomiting, headache, and lightheadedness. It was documented the resident was found to have had a large right subdural hematoma. It was documented the resident progressively became more somnolent in the ER. It was documented the resident had demonstrable neurologic compression and structural issues which caused significant functional impairment in most activities of daily living for which surgery was appropriate. It was documented the resident underwent subdural hematoma evacuation on 09/18/24. A care plan, updated 09/17/24, documented to encourage use of an assistive device. Staff to use walker and gait belt to/from bathroom/dining room. Second staff member was to follow with a chair. On 09/19/24 at 5:15 p.m., OSDH received a Combined Initial and Final state incident report. It was documented CNA #2 was toileting Resident #3 and they wanted to stand to urinate. It was documented CNA #2 did not put a gait belt on resident. It was documented CNA #2 turned away from the resident and the resident fell backwards into the shower and hit their head. It was documented the resident started having nausea and vomiting shortly after fall and was on plavix. It was documented the resident was sent to the ER and diagnosed with a severe brain bleed. It was documented the resident had emergency surgery on 09/18/24. On 09/25/25 at 2:23 p.m., the ADON stated the policy for transfers was to follow the care plan and to use a gait belt for all transfers except for mechanical lift transfers. On 09/25/24 at 2:26 p.m., the ADON stated their expectation for supervision for all ADLs was to always use a gait belt and ensure they held the gait belt the entire time a resident was standing. On 09/26/24 at 10:18 a.m., the ADON stated agency staff were e-mailed the transfer/gait belt policy. They stated the agency staff were to sign the document before they were allowed to work. On 09/26/24 at 11:24 a.m., the ADON stated they did not have a signed policy statement for CNA#2. On 09/26/24 at 3:23 p.m., the home care director of operations stated they did not have a signed policy document from CNA #2. They stated they received the form a few days prior. On 09/27/24 at 9:27 a.m., CNA #2 stated they had never used a gait belt when assisting Resident #3 with their ADLs.