Based on interview and record review it was determined the facility failed to provide care in accordance with care planned interventions while pushing a resident in a wheelchair for 1 of 1 sampled resident (#1) reviewed for accidents. This failure resulted in an avoidable fracture to Resident 1's left ankle. Findings include: Resident 1 was admitted to the facility in 2015 with diagnoses including dementia. The 6/2023 Annual MDS revealed Resident 1 had a BIMS of 11 (moderate cognitive impairment). Resident 1's mobility care plan dated 12/9/22 instructed staff to promote Resident 1's independence with locomotion as tolerated without leg rests and revealed Resident 1 needed assistance with leg rests in place for wheelchair mobility when being pushed by staff. A 12/6/23 FRI report revealed on 12/3/23 Resident 1 mobilized her/himself independently while in her/his wheelchair from the dining room toward her/his room. Resident 1 became tired and Staff 11 (CNA) pushed Resident 1 towards her/his room. Staff 11 felt resistance while pushing Resident 1 and immediately stopped while Resident 1 yelled Ow! Staff 12 (LPN) was nearby and told Staff 11 to put Resident 1 into bed so he could look at Resident 1's ankle. Resident 1's ankle had a normal range of motion. Staff 12 administered medication for pain management and applied ice to the resident's ankle. Resident 1's physician was notified and staff were instructed to obtain an X-ray if the resident experienced increased pain or swelling. The FRI revealed Resident 1 had moderate pain and swelling to her/his left ankle, and 12/5/23 X-ray notes revealed she/he sustained an .oblique [slanting] fracture involving the distal fibula [a prominent bone on outside of the ankle] with minimal callus [a temporary development that occurs at the site of a bone fracture and helps the bone move from the inflammatory phase to the repair phase] and mild displacement. The joint alignment is maintained. There is associated soft tissue swelling . The resident was taken to the emergency department for an evaluation. A 12/4/23 5:57 PM progress note by Staff 12 revealed Resident 1 was on alert charting, rested in bed, and her/his behavior was at baseline. Resident 1 stated her/his left ankle hurt when it was moved. The resident's left ankle was noted to be slightly swollen and tender, and she/he complained of pain twice during the shift. Staff 12 administered pain medication. A 12/5/23 3:10 AM progress note by Staff 13 (LPN) revealed Resident 1's left ankle was swollen and painful to touch. The resident requested an ice pack for comfort which was effective. A 12/5/23 10:15 PM progress note by Staff 14 (LPN) revealed a new physician's order was received for a left ankle X-ray to rule out a fracture. A 12/6/23 1:54 AM progress note by Staff 15 (LPN) revealed X-ray results of Resident 1's left ankle found an oblique fracture with mild displacement and soft tissue swelling. Resident 1's physician was notified and orders were provided to offer ice packs and to send Resident 1 to the emergency department in the morning since the resident was stable and effective pain management was in place. Resident 1's 12/6/23 hospital after visit summary and X-ray results revealed she/he had a left foot ankle fracture. The facility obtained a follow up statement from Staff 11 on 12/6/23 at 9:00 AM. Staff 11 stated Resident 1 wheeled her/himself partway down a hall. Staff 11 assisted Resident 1 as she/he sounded out of breath and wanted to go to bed. As they approached the nurses station Resident 1 dropped her/his foot. Staff 11 felt resistance and stopped pushing the wheelchair. Resident 1 cried out and her/his ankle was assessed by another staff. Staff 11 was instructed to assist the resident back to her/his room. Staff 11 stated she then pushed Resident 1 very slowly and reminded her/him to hold her/his legs up. Staff 11 stated she knew how to access care plans and thought she reviewed Resident 1's care plan. An untitled facility document dated 12/8/23 by Staff 16 (former DNS) revealed Staff 11 pushed Resident 1 in her/his wheelchair without leg rests which resulted in Resident 1's fractured left ankle. An interview with the resident found she/he felt safe and comfortable with Staff 11 continuing to provide care. On 8/12/24 at 1:00 PM Resident 1 was observed self propelling slowly in her/his wheelchair with no leg rests. During an interview on 8/12/24 at 2:46 PM Staff 12 stated he assessed the resident at the time of the incident and put ice on her/his foot because she/he complained of pain but there was no swelling or bruising at the time. He indicated the resident was able to identify pain appropriately. Staff 12 stated Resident 1 self propelled in her/his wheelchair independently but when she/he got tired staff placed leg rests on her/his wheelchair before pushing her/him. On 8/13/24 at 10:47 AM Witness 1 (resident representative) stated she was informed of the 12/3/23 incident right away and believed it was a pure accident. She added, Resident 1 would take the leg rests off her/his wheelchair or she/he would ask the staff to remove them. Witness 1 stated Resident 1 was pretty independent and liked to move her/his wheelchair on her/his own but when she/he got tired or was not feeling well she/he asked for help and staff would place the leg rests on the wheelchair before pushing her/him. On 8/14/24 at 3:58 PM Staff 11 confirmed she pushed Resident 1 down the hallway to her/his room without the leg rests on her/his wheelchair, which resulted in Resident 1 sustaining a fractured ankle. Staff 11 stated the resident's foot was not swollen and had no bruising immediately after the accident. On 8/15/24 at 7:18 PM Staff 15 confirmed the incident happened when she was not on shift but she did observe Resident 1's foot on 12/5/24. Staff 15 stated Resident 1 was placed on alert charting, was monitored every shift and received pain medication. Staff 15 stated she observed Resident 1's foot was swollen and the resident said it was slightly painful when she/he moved it. Staff 15 said the day shift nurse ordered the X-ray but she received the X-ray report. Since Resident 1 was stable at the time and it was the middle of the night, a physician's order was received for ice packs if Resident 1 needed it and the on-call doctor gave the okay to go to the hospital in the morning which allowed the resident to sleep. Staff 15 stated if Resident 1 was in a lot of pain she/he would have been sent to the emergency room sooner. Staff 15 added, she believed Resident 1 was care planned to have the footrests on the wheelchair when being pushed by staff before the incident happened and this hasn't happened again to her knowledge. During an interview on 8/16/24 at 9:40 AM Staff 1 (Administrator), Staff 2 (DON), and Staff 3 (Regional Nurse Consultant) were informed of the findings of this investigation. They all confirmed the incident occurred. On 12/8/23, the Past Noncompliance was corrected when the facility completed a root cause analysis of the incident and determined there was a failure to follow Resident 1's care plan to ensure leg rests were on her/his wheelchair before pushing her/him. The Plan of Correction included: 1. Staff education, for all staff, on placing leg rests onto resident wheelchairs, and how to look resident care plans and resident profiles. 2. A notice was created for Resident 1's wheelchair to remind staff to put the leg rests on her/his wheelchair before pushing her/him and what to do if Resident 1 declined the use of the leg rests. 3. Licensed nursing staff monitored use of leg rests on resident wheelchairs for residents who required assistance with mobilizing in wheelchairs.