Based on clinical record review, facility documentation review, and staff interview, it was determined that the facility failed to ensure resident safety and prevent an avoidable accident related to a fall for one of four sampled residents which resulted in actual harm of a laceration (a traumatic wound caused by sharp objects or blunt trauma) to the head and a skin tear (a wound caused by blunt force, friction, and/or shear). (Resident 1) Findings include: Clinical record review revealed that Resident 1 had diagnoses that included dementia (a group of symptoms affecting memory, thinking, language, and behavior) and anxiety (condition that involves excessive and persistent worrying that interferes with daily life). The Minimum Data Set (MDS) assessment (a periodic evaluation of resident care needs) dated April 3, 2025, indicated that the resident was cognitively impaired, with a BIMs score (brief interview for mental status tool that is used to get a quick snapshot of how well one is functioning cognitively) of four (zero to seven indicates severe cognitive impairment). The assessment indicated that the resident had physical (hitting, kicking, etc.) and verbal (screaming, cursing, etc.) behavioral symptoms directed towards others. The care plan identified that Resident 1 had a mood and behavior problem related to dementia as evidenced by verbally aggressive behaviors and interventions included for staff to attempt redirection in a calm manner when he was agitated and to ensure resident safety. In addtion, the care plan noted that Resident 1 was at risk for falls related to confusion. On May 27, 2025, a nurse noted that the resident's behaviors began to escalate. The resident started tapping on the medication cart, grabbed the narcotic book (a record-keeping system to track the use of controlled substances such as narcotics) and attempted to throw it. The nurse backed up, grabbed the Dinamap (a device on wheels, designed for precise and reliable measurements of vital signs, including blood pressure, pulse, temperature, and oxygen saturation) and placed it in front of the resident. The resident grabbed the Dinamap and started shaking it. The nurse let go; the cart moved and the resident lost his balance, fell backwards, and hit his head on the closed doors. The nurse noted that the resident appeared to lose consciousness for three to five seconds, and sustained a laceration to the head and a skin tear to the right hand, resulting in a transfer to the hospital. The resident received five staples to close the wound to the back of the head and three Steri-Strips (thin, sticky bandages applied to small cuts or wounds to help them stay closed as they heal) to the right hand. According to facility documentation of the investigation, the nurse used the Dinamap to place in front of the resident, introducing a safety risk to Resident 1 resulting in an avoidable accident related to a fall. In an interview on June 23, 2025, at 1:00 p.m., the Director of Nursing confirmed the facility failed to prevent Resident 1 from an avoidable accident related to a fall, resulting in injury and transfer to the hospital. 483.25(d) Accidents. Previously cited 2/27/25. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1) Management. 28 Pa. Code 211.12(d)(1)(5) Nursing services.