**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, facility policy and procedure review, and staff interview it was determined the facility failed to accurately assess and identify a newly admitted resident as a fall risk and develop interventions to prevent falls causing actual harm to Resident 263 who fell causing injuries that required hospitalization for one of 3 residents reviewed (Resident 263) Findings include: Review of facility policy and procedure titled Assessment: Nursing last revised March 2022, revealed A nursing assessment will be performed by a licensed nurse for all patients within 24 hours of admission. Routine and focused assessments will be performed on an ongoing basis as needed. Assessments will be reviewed and certified as completed by an RN within 24 hours and all individuals who complete a portion of the assessment will sign and certify to the accuracy of the portion of the assessment, he/she completed. Review of Resident 263's clinical record revealed the resident was admitted to the facility on [DATE] from the hospital. Review of Resident 263's documentation from the hospital revealed the resident went to the hospital and was admitted after a near syncope (fainting) episode during which she was hypotensive (low blood pressure) and had difficulty getting into her house. Further review of the hospital documentation revealed the resident was discharged with a diagnosis of Hypotension and Syncope. Review of Resident 263's physical therapy documentation while in the hospital revealed the resident was determined to be at risk for falls and to have ambulation deficits, balance deficits, bed mobility deficits, strength deficits, transfer deficits and safety awareness deficits. Review of Resident 263's facility diagnosis list revealed diagnosis of Hypotension (low blood pressure), Syncope (sudden, temporary drop in the amount of blood that flows to the brain), and collapse. Review of Resident 263's Vital Signs revealed a blood pressure on December 17, 2023 at 9:32 P.M. of 102/45 (normal 120/80). Review of Resident 263's admission assessment dated [DATE] revealed the resident was determined to have no risk factors for falls related to history or fear of falls or factors such as current diagnosis or medications that would increase the risk for falls and there was no risk for falls due to the resident's presence or history of gait, strength, or balance factors. Review of Resident 263's progress notes revealed a nursing entry dated December 18, 2023 at 2:53 a.m. that indicated CNA (Certified Nursing Assistant) heard a noise and went into the room to check on patient and found her on the floor face down next to the bed. R (right) facial laceration at smile line measuring 4 cm (centimeters) and one of R eye measuring 1.5 cm. Peri orbital (eye) swelling noted on right side. EMS (Emergency Medical Services) called at 0233 (2:33 a.m.). Review of Resident 263's care plan revealed there was no care plan developed for risk for falls or interventions in place prior to the fall of December 18, 2023. Resident 263 was inaccurately assessed at the time of admission as not being at risk for falls and there were no interventions in place to prevent falls leading to a fall with major injury that required hospitalization on December 18, 2023. This information above was relayed to the Nursing Home Administrator on June 24, 2024 at 1:15 p.m. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(3)(e)(1) Management 28 Pa. Code 201.29(c) Resident rights 28 Pa. Code 211.5(f) Clinical records 28 Pa. Code 211.11(d) Resident care plan 28 Pa. Code 211.12 (c)(d)(1)(5) Nursing services

Based on observations, facility policy review, clinical record review, and interviews with staff, it was determined that the facility failed to ensure residents were free from physical abuse by Resident 88 who previously demonstrated physical aggression towards other residents, which resulted in harm requiring emergency medical treatment of Resident 141. The facility failure resulted in an immediate jeopardy situation for 42 additional residents (Residents 15,18, 22, 23, 24, 29, 33, 38, 39, 40, 41, 42, 45, 47, 60, 65, 66, 73, 75, 76, 77, 81, 89, 94, 99, 105, 110, 112, 115, 119, 120, 121, 127, 131, 135, 138, 139, 141, 146, 150, 154, and Resident 157) who resided on the same unit as Resident 88. Findings include: Review of facility policy titled, Abuse Prohibition with revision date of October 24, 2022 revealed in section 6.3 If the suspected abuse is patient-to-patient, the patient who has in any way threatened or attacked another will be removed from the setting or situation, and an investigation will be completed. Further review of facility policy revealed in subsection 6.3.1 the following; the center will provide adequate supervision when the risk of patient-to-patient altercation is suspected. Additional review of the same facility policy revealed in subsection 6.3.2 the center is responsible for identifying patients who have a history of disruptive or intrusive interactions or who exhibit other behaviors that make them more likely to be involved in an altercation. Review of Resident 88's clinical record revealed an admission date of November 1, 2018, which includes, but is not limited to Schizophrenia (severe brain disorder that affects how people perceive and interact with reality, often causing hallucinations, delusions, and social withdrawal), Vascular Dementia (damage to or loss of nerve cells and their connections in the brain affecting memory, thinking, and social abilities), Psychotic Disturbance (condition of the mind that results in difficulties determining what is real and what is not real, including delusions and hallucinations), Mood Disturbance, Anxiety (cluster of mental disorders characterized by significant and uncontrollable feelings of anxiety and fear), and Major Depressive Disorder (persistent feeling of sadness and loss of interest in everyday activities). Review of Resident 88's clinical record including paper chart revealed document History and Physical dated March 25, 2019 indicated Resident 88 had a psychiatric admission to the local hospital March 13 to March 22, 2019. Further review of History and Physical document revealed that Resident 88 was noted to have a history of multiple psychiatric admissions including several involuntary admissions initiated by family member. Review of Resident 88's clinical record revealed a social services note dated September 30, 2022 which indicated, Followed by Psychiatry R/T (Related/To) DX (Diagnosis) Schizophrenia. Thought process is delusional, superimposed upon religious preoccupation. Affect is elevated with pleasant mood to select staff that she knows. She continues to exhibit negative symptoms of Paranoid Schizophrenia, as evidenced by resident refusing medications, assessments, stating God and Jesus have told her she does not need them. She has exhibited episodes of pillaging, hoarding, and has exhibited reactive verbal and physical/violent behavior towards staff when staff have taken the items from her that don't belong to her. Review of Resident 88's clinical record revealed a care plan goal initiated on October 21, 2020 of will not harm self or others. Further review of Resident 88's care plan revealed three physical altercations (November 2022; February 2023; and May 2023) involving other residents. Further review of Resident 88's care plan revealed that on November 25, 2022, resident had a verbal and physical altercation with female (CL1) resident. Resident stated the other resident hit her first, so she kicked over the bed tray table into the other resident hitting the resident in the thigh. Additional review of Resident 88's care plan interventions failed to reveal any interventions that were initiated after the November 25, 2022 physical altercation. Review of the clinical record for Resident 88 revealed on November 25, 2022, a mood behavior progress note indicated, At approx. 1345 EST 11/25/22, undersigned (social worker) approached resident due to undersigned observed and heard 118A (room) resident (CL1) sitting next to resident (Resident 88) in 1 North common area by Nurses' Station, screaming and crying in child-like manner and stating that resident had hit her. The 118A resident (CL1) was receptive to direction and assistance from Unit Nurse to quiet area in 1-North Dining Room. Undersigned interviewed resident (Resident 88). Resident presented as calm. Resident stated, She hit me first, so I hit her back. She hit me in the head with her fist, so I kicked the table [over bed tray table observed in front of resident] in to her thigh. Resident denied any pain or discomfort and did not appear to be in any acute distress. Assistant Administrator and Unit Nurse manager notified. Review of facility documentation including incident report dated November 25, 2022 revealed under section Incident Description and Investigation, At approximately 1:15 pm, another resident (Resident CL1) was trying to get down the hallway and mistakenly hitting (Resident 88)'s table while trying to pass by. So (Resident 88) proceeded to take an empty ensure carton and hit the other resident (Resident CL1) upside the head with it, claiming that the other resident hit (Resident 88) first. Further review of facility documentation including Investigation Report by staff member indicating, both residents were reminded that violent isn't tolerated. Further review of document Investigation Report subsection Action Taken During Investigation revealed the section was blank/empty. Review of facility documentation including Statement by Witness dated February 5, 2023 which revealed (Resident 88) walking in (to dining room) and (Resident 134) said 'God you stink' and (Resident 88) turned around and raised her hand to hit (Resident 134) with the reacher and fell and as (Resident 88) fell (Resident 88) pulled on (Resident 134)'s w/c (wheelchair) and pulled him down with her and then started hitting him with the reacher. Review of Resident 88's clinical record revealed, a Nurse Practitioner Progress note dated February 5, 2023, indicating on February 5, 2023, [Resident 88] was involved in an altercation with another resident (Resident 134), patient striking them [with a reacher] around (Resident 134)'s back and neck. At this time Resident 88 was moved to the secured unit, which houses 40 residents. Review of Resident 88's general progress notes dated February 5, 2023 revealed Resident 134 filed a police report regarding the physical assault by Resident 88. Review of Resident 88's clinical record revealed a progress note dated February 16, 2023 by Certified Registered Nurse Practitioner, indicated Resident 88 refuses treatment for mental health concerns, including medications and counseling, due to his/her belief that God will heal him/ her. Review of Resident 88's clinical record including general progress notes dated May 30, 2023, revealed Called and informed MD (Medical Doctor) that this Resident hit another resident in the head with a cane resulting in a laceration to the other resident's forehead. Review of facility documentation revealed, Resident 88 was in a physical altercation with roommate, Resident 141, during which Resident 88 struck Resident 141 in the head with a cane resulting in a laceration to the forehead requiring emergency hospital treatment. Review of Resident 141's clinical record including progress notes dated May 30, 2023, revealed, Resident came out of (his/her) room to nurses station at approximately 730 am with (his/her) face covered in blood and bleeding profusely from laceration in (his/her) scalp. Pressure was immediately applied to laceration and Resident kept safe. Resident stated that another resident hit her in the head with a cane. Resident requested to be sent out to hospital. Further head to toe assessment revealed no other injuries. VSS (Vital Signs Stable). Management was made aware, then 911 was called. Ice was also applied. Resident refused pain medication.MD was made aware. 911 arrived approximately 20 minutes after call was placed. Bleeding was controlled by the time 911 arrived. Police accompanied 911 to facility and received pertinent information regarding incident. Resident was transported via stretcher accompanied by 2 emergency personnel. (Spouse) made aware. Nursing will follow up for health status updates. The facility's failure to ensure supervision of Resident 88 with known physical aggressive history places Residents 15,18, 22, 23, 24, 29, 33, 38, 39, 40, 41, 42, 45, 47, 60, 65, 66, 73, 75, 76, 77, 81, 89, 94, 99, 105, 110, 112, 115, 119, 120, 121, 127, 131, 135, 138, 139, 141, 146, 150, 154, and Resident 157; who also reside on the secure dementia unit, at risk of immediate jeopardy. An Immediate Jeopardy situation was identified on August 17, 2023, at 4:18 p.m. and an Immediate Jeopardy template was presented to the Nursing Home Administrator, and Director of Nursing at 4:26 p.m. on August 17, 2023. Upon supervisory review dated August 25, 2023 it was determined the facility placed residents in Immediate Jeopardy of abuse on August 17, 2023 concurrently with Immediate Jeopardy of Supervision. The facility was notified on August 25, 2023 at 10:00 a.m. of the supervisory review and presented with the Immediate Jeopardy template for failure to ensure residents on the secured nursing unit were safe from Resident 88 who had a known physical aggression history. The facility submitted and completed an immediate action plan which included an audit to determine residents with verbal or physical aggressive behaviors are identified; Facility staff would audit residents with behaviors to ensure care plans goals and interventions current to address specific behaviors; Education provided to nursing staff regarding supervision of residents. The education was held prior to start of work shift and continued until all staff were inserviced. The facility policy on behavior monitoring, supervision, and care plans were reviewed and updated as deemed necessary. Ten resident identified with aggressive behaviors will be audited weekly (x 4 weeks then x 2 months) and the results will be submitted to QAPI for review. The action plan was accepted on August 17, 2023, at 6:09 p.m. On August 18, 2023, a review of audits, documentation of completed employee education, and interviews with 18 licensed and non licensed staff members revealed the facility had completed the interventions developed for the action plan. The Immediate Jeopardy was lifted on August 18, 2023, at 7:25 p.m. after confirmation the immediate action plan was implemented, and the Nursing Home Administrator and the Director of Nursing were informed the residents were no longer in immediate jeopardy. The facility failed to ensure Resident 88 with known physical aggression history from physical abuse towards other residents resulting in an injury to Resident 141 which required emergency hospital treatment. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(3)(e)(1) Management 28 Pa. Code 201.29(c) Resident rights 28 Pa. Code 211.5(f) Clinical records

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, facility policy review, clinical record review, and interviews with staff, it was determined that the facility failed to provide adequate and safe supervision for a resident who demonstrated physical aggression, which resulted in harm to Resident 141 as evidenced by laceration to the forehead requiring emergency hospital treatment. The facility failure resulted in an immediate jeopardy situation for 42 additional residents (Residents 15,18, 22, 23, 24, 29, 33, 38, 39, 40, 41, 42, 45, 47, 60, 65, 66, 73, 75, 76, 77, 81, 89, 94, 99, 105, 110, 112, 115, 119, 120, 121, 127, 131, 135, 138, 139, 141, 146, 150, 154, and Resident 157) who resided on the same unit as Resident 88. The facility failed to ensure interventions were in place to prevent falls for two residents (Residents 67 and 68) reviewed resulting in actual harm to Resident 68 who sustained a fracture. Findings include: Review of facility policy titled, Abuse Prohibition with revision date of October 24, 2022 revealed in section 6.3 If the suspected abuse is patient-to-patient, the patient who has in any way threatened or attacked another will be removed from the setting or situation, and an investigation will be completed. Further review of facility policy revealed in subsection 6.3.1 the following; the center will provide adequate supervision when the risk of patient-to-patient altercation is suspected. Additional review of the same facility policy revealed in subsection 6.3.2 the center is responsible for identifying patients who have a history of disruptive or intrusive interactions or who exhibit other behaviors that make them more likely to be involved in an altercation. Review of Resident 88's clinical record revealed an admission date of November 1, 2018, which includes, but is not limited to Schizophrenia (severe brain disorder that affects how people perceive and interact with reality, often causing hallucinations, delusions, and social withdrawal), Vascular Dementia (damage to or loss of nerve cells and their connections in the brain affecting memory, thinking, and social abilities), Psychotic Disturbance (condition of the mind that results in difficulties determining what is real and what is not real, including delusions and hallucinations), Mood Disturbance, Anxiety (cluster of mental disorders characterized by significant and uncontrollable feelings of anxiety and fear), and Major Depressive Disorder (persistent feeling of sadness and loss of interest in everyday activities). Review of Resident 88's clinical record including paper chart revealed document History and Physical dated March 25, 2019 indicated Resident 88 had a psychiatric admission to local hospital March 13 to March 22, 2019. Further review of History and Physical document revealed that Resident 88 was noted to have a history of multiple psychiatric admissions including several involuntary admissions initiated by family member. Review of Resident 88's clinical record revealed a social services note dated September 30, 2022 which indicated, Followed by Psychiatry R/T (Related/To) DX (Diagnosis) Schizophrenia. Thought process is delusional, superimposed upon religious preoccupation. Affect is elevated with pleasant mood to select staff that she knows. She continues to exhibit negative symptoms of Paranoid Schizophrenia, as evidenced by resident refusing medications, assessments, stating God and Jesus have told her she does not need them. She has exhibited episodes of pillaging, hoarding, and has exhibited reactive verbal and physical/violent behavior towards staff when staff have taken the items from her that don't belong to her. Review of Resident 88's clinical record revealed a care plan goal initiated on October 21, 2020 of will not harm self or others. Further review of Resident 88's care plan revealed three physical altercations (November 2022; February 2023; and May 2023) involving other residents. Further review of Resident 88's care plan revealed that on November 25, 2022, resident had a verbal and physical altercation with female (CL1) resident. Resident stated the other resident hit her first, so she kicked over the bed tray table into the other resident hitting the resident in the thigh. Additional review of Resident 88's care plan interventions failed to reveal any interventions that were initiated after the November 25, 2022 physical altercation. Review of the clinical record for Resident 88 revealed on November 25, 2022, a mood behavior progress note indicated, At approx. 1345 EST 11/25/22, undersigned (social worker) approached resident due to undersigned observed and heard 118A (room) resident (CL1) sitting next to resident (Resident 88) in 1 North common area by Nurses' Station, screaming and crying in child-like manner and stating that resident had hit her. The 118A resident (CL1) was receptive to direction and assistance from Unit Nurse to quiet area in 1-North Dining Room. Undersigned interviewed resident (Resident 88). Resident presented as calm. Resident stated, She hit me first, so I hit her back. She hit me in the head with her fist, so I kicked the table [over bed tray table observed in front of resident] in to her thigh. Resident denied any pain or discomfort and did not appear to be in any acute distress. Assistant Administrator and Unit Nurse manager notified. Review of facility documentation including incident report dated November 25, 2022 revealed under section Incident Description and Investigation, At approximately 1:15 pm, another resident (Resident CL1) was trying to get down the hallway and mistakenly hitting (Resident 88)'s table while trying to pass by. So (Resident 88) proceeded to take an empty ensure carton and hit the other resident (Resident CL1) upside the head with it, claiming that the other resident hit (Resident 88) first. Further review of facility documentation including Investigation Report by staff member indicating, both residents were reminded that violent isn't tolerated. Further review of document Investigation Report subsection Action Taken During Investigation revealed the section was blank/empty. Review of facility documentation including Statement by Witness dated February 5, 2023 which revealed (Resident 88) walking in (to dining room) and (Resident 134) said 'God you stink' and (Resident 88) turned around and raised her hand to hit (Resident 134) with the reacher and fell and as (Resident 88) fell (Resident 88) pulled on (Resident 134)'s w/c (wheelchair) and pulled him down with her and then started hitting him with the reacher. Review of Resident 88's clinical record revealed, a Nurse Practitioner Progress note dated February 5, 2023, indicating on February 5, 2023, [Resident 88] was involved in an altercation with another resident (Resident 134), patient striking them [with a reacher] around (Resident 134)'s back and neck. At this time Resident 88 was moved to the secured unit, which houses 40 residents. Review of Resident 88's general progress notes dated February 5, 2023 revealed Resident 134 filed a police report regarding the physical assault by Resident 88. Review of Resident 88's clinical record revealed a progress notes dated February 16, 2023 by Certified Registered Nurse Practitioner, indicated Resident 88 refuses treatment for mental health concerns, including medications and counseling, due to his/her belief that God will heal him/ her. Review of Resident 88's clinical record including general progress notes dated May 30, 2023, revealed Called and informed MD (Medical Doctor) that this Resident hit another resident in the head with a cane resulting in a laceration to the other resident's forehead. Review of facility documentation revealed, Resident 88 was in a physical altercation with roommate, Resident 141, during which Resident 88 struck Resident 141 in the head with a cane resulting in a laceration to the forehead requiring emergency hospital treatment. Review of Resident 141's clinical record including progress notes dated May 30, 2023, revealed, Resident came out of (his/her) room to nurses station at approximately 730 am with (his/her) face covered in blood and bleeding profusely from laceration in (his/her) scalp. Pressure was immediately applied to laceration and Resident kept safe. Resident stated that another resident hit her in the head with a cane. Resident requested to be sent out to hospital. Further head to toe assessment revealed no other injuries. VSS (Vital Signs Stable) . Management was made aware, then 911 was called. Ice was also applied. Resident refused pain medication.MD was made aware. 911 arrived approximately 20 minutes after call was placed. Bleeding was controlled by the time 911 arrived. Police accompanied 911 to facility and received pertinent information regarding incident. Resident was transported via stretcher accompanied by 2 emergency personnel. (Spouse) made aware. Nursing will follow up for health status updates. The facility's failure to ensure supervision of Resident 88 with known physical aggressive history places Residents 15,18, 22, 23, 24, 29, 33, 38, 39, 40, 41, 42, 45, 47, 60, 65, 66, 73, 75, 76, 77, 81, 89, 94, 99, 105, 110, 112, 115, 119, 120, 121, 127, 131, 135, 138, 139, 141, 146, 150, 154, and Resident 157; who also reside on the secure dementia unit, at risk of immediate jeopardy. An Immediate Jeopardy situation was identified on August 17, 2023, at 4:18 p.m. and the Immediate Jeopardy template was presented to the Nursing Home Administrator, and Director of Nursing at 4:26 p.m. on August 17, 2023, regarding the facility's failure to ensure the residents were free from threat of physical violence when staff failed to provide supervision for a resident with a history of violent and aggressive behavior. The facility submitted and completed an immediate action plan which included an audit to determine residents with verbal or physical aggressive behaviors are identified; Facility staff would audit residents with behaviors to ensure care plans goals and interventions current to address specific behaviors; Education provided to nursing staff regarding supervision of residents. The education was held prior to start of work shift and continued until all staff were inserviced. The facility policy on behavior monitoring, supervision, and care plans were reviewed and updated as deemed necessary. Ten resident identified with aggressive behaviors will be audited weekly (x 4 weeks then x 2 months) and the results will be submitted to QAPI for review. The action plan was accepted on August 17, 2023, at 6:09 p.m. On August 18, 2023, a review of audits, documentation of completed employee education, and interviews with 18 licensed and non licensed staff members revealed the facility had completed the interventions developed for the action plan. The Immediate Jeopardy was lifted on August 18, 2023, at 7:25 p.m. after confirmation the immediate action plan was implemented, and the Nursing Home Administrator and the Director of Nursing were informed the residents were no longer in immediate jeopardy. Review of Facility policy and procedure titled Falls Management, revised June 15, 2022 revealed Patients will be assessed for risk of falling as part of the nursing assessment process. Interventions to reduce risk and minimize injury will be implemented as appropriate. Implement and document patient-centered interventions according to individual risk factors in the patient's plan of care. Adjust and document individualized intervention strategies as patient condition changes. Review of Resident 68's demographic sheet revealed the resident was admitted to the facility on [DATE]. Review of Resident 68's admission Evaluation, dated April 8, 2023 revealed in the section titled Fall Risk Factors Resident 68 was identified as having worries about falling or feeling unsteady when standing or walking as well as having incontinence as risk factors for falls. Resident 68 was indicated as requiring a care plan for risk for falls. Further review of the document failed to reveal fall prevention interventions to be included on the care plan. Review of Resident 68's clinical record failed to reveal subsequent fall risk assessments completed until May 20, 2023. Review of Resident 68's admission Minimum Data Set (MDS- periodic assessment of resident needs) dated April 14, 2023 revealed the resident had a fall in the last 2-6 months prior to admission and triggered for a falls care plan. The assessment was coded as being completed on April 20, 2023. Review of Resident 68's admission care plan failed to reveal a care plan for the prevention of falls. Review of Resident 68's Progress Notes revealed a nursing entry dated April 26, 2023 at 6:23 p.m. stating resident was found on the floor next to her bed five or six feet from her wheelchair at 3:45 p.m. states 'my foot slipped' when asked what happened. No injuries were noted and denies pain anywhere. Further review of Resident 68's progress notes revealed a note dated April 26, 2023 at 6:54 p.m. indicating, Resident had just finished up with visit from her daughter, resident trying to go out of the dinning room and back to her room. Resident had a previous fall and was being closely monitored. CNA (certified nurse aide) on shift was pushing resident in wheelchair back into the dinning room when resident removed her feet from the leg rest and tried to stop the chair. Resident placed her feet on the floor to stop the wheelchair and fell front. When falling the resident did strike the left side of her head. Resident had a small bruise to the chest area along with an abrasion to the left side of her head. MD (medical doctor) gave order to send resident out for cat (Computed Tomography-diagnostic cross-sectional X-ray images of the body) scan and to be evaluated. Further review of Resident 68's progress notes revealed a nursing entry dated April 27, 2023, at 1:22 a.m. indicating resident returned to the facility after being sent to the hospital for a fall with a diagnosis that included a fracture of the left clavicle (collar bone). Review of Resident 68's current care plan revealed a care plan for falls wasn't developed until April 28, 2023. Interview with the Nursing Home Administrator and the Director of Nursing on August 2, 2023 at 12:30 p.m. confirmed there was no comprehensive assessment of Resident 68's falls risk and no care plan developed upon admission to prevent falls. The facility failed to comprehensively assess Resident 68 and develop interventions to prevent falls for Resident 68 resulting in actual harm to Resident 68 when Resident 68 had two falls on April 26, 2023 requiring evaluation and treatment for a fractured clavicle at the hospital. Observation of Resident 67 on July 31, 2023 at approximately 11:00 a.m. revealed the resident was nonverbal with bilateral contractures (permanent tightening of the muscles, tendons, skin, and surrounding tissues that causes the joints to shorten and stiffen) to both the upper and lower extremities. Review of Resident 67's clinical record revealed a diagnosis of Anoxic Brain Injury (brain injury from lack of oxygen). Review of Resident 67's care plan revealed the resident was identified as requiring assistance for mobility with an intervention added March 25, 2022, for the resident to have two staff person assistance with repositioning in bed. Review of Resident 67's progress notes revealed a nursing note dated July 20, 2023, which indicated; [Staff person] was changing resident and since the bed was saturated she was trying to change the sheets. Resident kicked and when she kicked she rolled out of bed and hit the floor. When she hit the floor she hit her head on either the dresser or the floor resulting in bleeding. Further review of Resident 67's progress notes revealed the resident was sent to the hospital and returned a few hours later when the CT scan showed no injuries, and the resident did not require sutures. Review of facility documentation including incident report dated July 20, 2023 revealed there was only one staff person assisting Resident 67 to turn in bed. Interview with the Director of Nursing on August 3, 2023, at 10:30 a.m. confirmed Resident 67 should have had two staff people present when repositioning in bed. F 0689 Free of Accidents/Hazards/Supervision/devices was previously cited on November 16, 2022 at scope and severity level J. 28 Pa. Code 201.14(a) Responsibility of licensee Previously cited on 11/16/22 28 Pa. Code 201.18(b)(1)(3)(e)(1) Management Previously cited on 04/04/23; 11/16/22 28 Pa. Code 201.29(c) Resident rights 28 Pa. Code 211.5(f) Clinical records 28 Pa code 211.10 (d) Resident care policies 28 Pa. Code 211.11(d) Resident care plan 28 Pa. Code 211.12 (c)(d)(1)(5) Nursing services Previously cited on 4/4/23, 11/16/22, 2/10/22, 8/23/21, 7/8/21, and 4/20/21