**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interview, the facility did not ensure that each resident receives adequate supervision and assistance devices to prevent accidents for 2 of 3 residents (R) (R1 and R2) reviewed.The facility did not ensure R2's bed alarm was functioning to alert staff of self-transfer resulting in R2 falling and sustaining an acute fracture involving the left orbital roof, opacified left frontal sinus consistent with fracture involving its lateral wall, and a left nasal fracture. This example is being cited at actual harm.The facility did not ensure that R1 was transferred with assist of 2 and correct sling causing R1 to fall to the floor. Findings:The facility policy titled Plan for the Provision of Nursing Care, undated, states in part under the section Staffing: .E. Nursing assistance provide assistance and care to residents according to the plan of care. The facility policy titled Falls Management Program: Accident Prevention & Investigation, undated, states: It is the mission of the Water's Edge Care Center to prevent falls, prevent accident, and reduce the risk of injuries. Our goal is to ensure the environment remains safe and [NAME] from potential hazards that may lead to an accident, to ensure adequate supervision and ultimately improve the quality of life of our residents. Under the section titled Definition, the policy continues to state: Our facility has adopted the Health Care Association of New Jersey (HCANJ) Best practice evident based Fall Management Guidelines which includes assessments, analysis of risk level, treatment plan, evaluation, education and quality improvement tools.The facility policy states in part: they have specific interventions not included in HCANJ Fall Management Guidelines include but are not limited to: .Risk rounds done before/after shifts assuring obstacles are clear, personal items are within reach, and bed exits are on.We attempt to provide an alarm free facility, we do provide silent bed exits to pager alarms for some residents in an attempt to assist them when they have exited the bed (note this is not to prevent a fall as it has been proven that alarms do not work to prevent a fall, only alert staff that someone has risen). Ours are silent to resident but alert staff via pager.Example 1R2 was admitted to the facility on [DATE] with diagnoses that include cerebral infarction, unspecified symptoms and sign involving cognitive functions following cerebral infarction.R2's quarterly MDS, dated [DATE], indicates a BIMS score of 12/15 indicating mildly impaired cognition and documents R2 requires supervision for transfers.R2's care plan needs, dated 10/23/24, states: I have the potential to fall down and hurt myself, because I am weak, take some medications that can make me dizzy, tired, confused or weak. Approaches include I need my nurses to know that coumadin has a black box warning of Bleeding Risk and can cause major or fatal bleeding.R2's care plan needs, dated 05/07/25, state in part: I can't complete my cares on my own . because I have left facial droop and left sided weakness with a care plan approach dated 01/02/25 that states: I can't transfer safely without help, so I use a bed alarm, page recliner, pager alarm. Check that alarm(s) are applied correctly and turned on.R2‘s nurses notes indicated R2 sustained a major injury on 07/03/25 wherein R2 was found on the floor at 8:00 PM, with head surrounded by a pool of blood and sustained bruising and hematoma over left front skull 3 cm x 4cm, left eye bruised and swollen shut. Alarm not functioning due to the alarm not being plugged in. When staff plugged alarm in, it was noted to be defective and was replaced.R2's physician was contacted and R2 was sent out to emergency room. R2 returned to facility on 07/04/25 at 12:00 AM with diagnoses of left orbital fracture and left nasal fracture.On 08/08/25, Surveyor reviewed emergency room record dated 07/03/25, which stated a CT of Maxillofacial without contrast was completed and impressions of: 1. Moderate left-sided facial soft tissue swelling with moderate left frontotemporal scalp soft tissue swelling. 2. Acute fracture involving the left orbital roof. Opacified left frontal sinus consistent with fracture involving its lateral wall. 3. Left nasal fracture.On 08/08/25 at 11:03 AM, Surveyor interviewed Certified Nursing Assistant (CNA) C regarding expectations of following plans of care and how CNAs are made aware of care plan interventions and changes. CNA C stated care plans are in the computer and are expected to be followed. If there are changes made we receive information during morning rounds, and they are to look up in electronic record. There is a button where staff can view changes using separate buttons for a 1, 3, or 7 day look back period for any changes made based on the last time they worked. CNA C confirmed recently receiving education regarding ensuring following care plans and to ensure correct lifts and 2-person assist is utilized for residents per individual care plans.On 08/08/25 at 11:15 AM, Surveyor interviewed CNA D who confirmed electronic records buttons are to be utilized at the beginning of each shift and CNA D recently received education on following plans of care.On 08/08/25 at 12:30 PM, Surveyor interviewed Nursing Home Administrator (NHA) A and Director of Nursing (DON) B regarding their expectations of following plans of care both related to recent falls of R1 and R2. NHA A and DON B confirmed expectation that staff follow the plans of care.Surveyor asked NHA A and DON B about their expectation of ensuring alarms were applied correctly and functional. DON B stated that CNAs are responsible for applying and ensuring alarms are working. The alarms chirp when the battery is low and facility has been conducting weekly audits on all residents who utilize alarms to ensure alarms are plugged in and if chirping indicating the battery is low, batteries are replaced. Surveyor asked when audits of alarms were started. DON B stated they were in the 4th week of audits. Surveyor asked what prompted the audits; DON B stated as a result of a fall wherein an alarm did not work properly. Surveyor asked DON B if this was due to the fall of R2 on 07/03/25 and DON B stated Yes. Surveyor asked what was the root cause of the alarm not working properly? DON B stated that one alarm box is used per resident and with R2 it is used between the bed and recliner. The alarm box was not changed from the bed to the recliner when R2 was placed in recliner. DON B stated the expectation would be for the CNA to transfer the box to the sensor pad cord in use and ensure the alarm is plugged in.Surveyor asked DON B and NHA A if an investigation was conducted and reported for R2's fall. NHA A stated a Root Cause Analysis (RCA) is being completed through the facility quality department and this usually takes months. Surveyor requested information of audits conducted on alarms. DON B stated she does not have documentation for proof of audits or documentation to support education was provided to staff for the process of checking alarm function. DON B stated the expectation was for them to check during shift to shift rounding. Surveyor asked if this was a process that started following the 07/03/25 fall, DON B stated, No. The expectation was in place prior to R2's fall but was not completed.Example 2R1 was admitted to the facility on [DATE] and has diagnoses that include malignant neuroendocrine tumors and mild cognitive impairment of uncertain or unknown etiology.R1's most recent Minimum Data Set (MDS), was a significant change MDS, with target date of 06/02/25. R1 has a Brief Interview for Mental Status (BIMS) score of 10/15 indicating mildly impaired cognition and is dependent with toileting needs, dressing, and transfers. R1 has an Activated Power of Attorney (POA) as of 07/05/24.R1's care plan needs, dated 05/28/25, state, I can't complete cares on my own. Care plan approaches per facility indicated at time of fall R1 should have been transferred using an Arjo lift (full body lift) and assist of 2 helpers.On 06/26/25, the facility submitted a Misconduct Incident Report wherein R1 sustained minor injuries from a fall that occurred on 06/26/25 as a result of a Certified Nursing Assistant (CNA) failing to follow the plan of care for R1. The CNA transferred R1 with an incorrect mechanical lift and without the assist of another helper. The facility completed an investigation upon reporting the incident and educated all staff regarding following the plan of care to prevent falls/safety. Current non-compliance was discovered during this survey with F689.