**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record and facility documentation review, and staff interview, it was determined that the facility failed to ensure that one of four residents reviewed was provided with adequate supervision to prevent accidents which resulted in actual harm to Resident 9 sustaining a fall, requiring transfer to the hospital via emergency medical services and the diagnosis of a fracture to the humerus (long bone of the upper arm). Findings include: Review of Resident 9's clinical record included diagnoses of, but not limited to, Cerebrovascular accident (stroke) with left side hemiparesis (weakness or paralysis on one side of the body), Dementia (decline in cognitive abilities that affects the brain's ability to think, remember, and function normally), and Ambulatory Dysfunction (abnormal gait that makes it difficult or impossible to walk). Review of Resident 9's fall risk assessment dated [DATE], revealed a score of 18. The assessment indicated that if the score is 10 or greater, the resident should be considered high risk for potential falls. Review of Resident 9's quarterly MDS (Minimum Data Set - periodic assessment of resident needs) completed May 19, 2023, revealed resident had a BIMS (brief interview for mental status - structured evaluation aimed at evaluating aspects of cognition in elderly patients) score of 4, indicating severe cognitive impairment. The MDS assessment revealed that the resident required extensive assistance of two persons for transfers and toileting. Review of Resident 9's care plan identified, the resident at moderate risk for falls related to impaired mobility, osteoporosis, unsteady balance, and hemiplegia. The care plan included an intervention initiated April 1, 2017, with a revision date of February 22, 2021, to anticipate and meet the resident's needs. Assist with toileting and do not leave in bathroom unattended. Review of interdisciplinary note dated May 21, 2023, at 2:18 p.m. revealed resident found on bathroom floor laying on left side, head against wall where night light is, hoyer lift used to lift off floor into bed, resident has left shoulder pain and left hip pain. Further review of interdisciplinary note dated May 21, 2023, at 2:30 p.m. revealed fall noted, stat xray shoulder 2 views and stat xray left hip 2 views. Review of interdisciplinary note dated May 21, 2023, at 4:29 p.m. revealed resident's results from x-ray showed the hip was intact but the left shoulder was broken. The humerous (sic) was broken at neck at shoulder joint. Doctor decided to send out due to pain and mobility issues. Resident left at 4:40 p.m. via ambulance. Review of Employee E4's statement obtained on May 21, 2023, revealed resident must have tried to transfer herself. She was on pot with bell, trying to have BM (bowel movement). We heard her yell for help, but she already fell till we ran in there. Review of facility documentation revealed a follow up interview conducted by the Director of Nursing with Employee E4 on May 22, 2023, indicated resident was toileted at 12:40 p.m. and checked approximately one minute before the fall. Resident indicated he/she wanted to stay on the toilet to have a BM. Fall occurred at 12:45 p.m. Interview with Employee E3 on September 29, 2023, at 11:37 a.m. revealed that Resident 9 was not assigned to Employee E3 on the day of the fall. Employee E3 indicated Employee E3 was sitting at the care base with Employee E4 when they heard the resident fall. Interview with the Director of Nursing on September 28 , 2023, at 1:50 p.m. indicated that the resident's care plan was not followed and that staff were in the vicinity at the time of the fall. The facility failed to ensure Resident 9 was provided with supervision during toileting which resulted in actual harm to Resident 9 sustaining a fall, requiring transfer to the hospital via emergency medical services and the diagnosis of a fracture to the left humerus. 28 Pa. Code: 211.5(f) Clinical records Previously cited 10/18/21 28 Pa. Code: 211.12(d)(1) Nursing services 28 Pa. Code: 211.12(d)(5) Nursing services