**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of clinical records and facility documentation and staff interview, it was determined that the facility failed to ensure appropriate supervision was provided to prevent a fall of one of the eight residents reviewed (Resident 3) Findings include: A review of Resident 3's diagnosis list revealed Parkinson's Disease, repeated falls, and a left humerus fracture. A review of Resident 3's Initial Minimum Data Set (MDS- A standardized assessment tool that measures health status in long-term care residents) dated June 19, 2023, revealed resident required extensive with two people assistance with transferring. A review of Resident 3's ADL (Activity of Daily Living) care plan initiated on June 13, 2023, revealed resident required two-person staff assistance, a handheld stand pivot with transferring. A review of nursing progress notes dated June 20, 2023, at 7:45 p.m., revealed Resident 3 was lowered to the floor by the aide during the transfer from the wheelchair to the recliner chair after night care. The resident landed on her/his bottom and did not hit the head with no injury noted. The resident reported she/he lost her/his balance. Staff educated to follow [NAME]. A review of the facility documentation, Employee E3 revealed that while transferring the resident to the recliner, the resident lost her/his balance, resident was lowered to the floor. The same statement revealed that the report indicated that the resident now required one person's assistance (transferring). x A review of the facility documentation, Employee E4 revealed that a mistake in the documentation was made with transfer status which was supposedly for another resident. An interview with the Director of Nursing on July 6, 2023, at noon, confirmed that the resident was not provided with two-person assistance with transferring which resulted in lowering the resident on the floor. The facility failed to ensure Resident 3 was provided with an appropriate number of staff assistance during transfer. 28 Pa. Code 211.5(f) Clinical records 28. Pa. Code 211.12(c)(d)(1)(1)(3)(5) Nursing services