Health inspection·January 13, 2025

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of clinical records and staff interview, it was determined that the facility failed to provide adequate supervision transfers for one of six residents (Resident R1), which resulted in a fall. Findings include: Review of Resident R1's admission record indicated she was admitted to the facility on [DATE]. Review of Resident R1's Minimum Data Set (MDS-periodic assessment of a resident's abilities and care needs) dated 11/21/24, indicated diagnoses of right fibula fracture, anxiety and depression. Review of Resident R1's physician orders dated 12/5/24 indicated toilet transfer to be completed assist x 2. Review of Resident R1's profile/preference (tool nursing staff uses for transfer status, ADL assistance) indicated assist x 2 for toileting. Review of a progress note written by Licensed Practical Nurse (LPN) Employee E1 dated 12/29/24, at 9:45 p.m. indicated While Nurse Aid (NA) was transferring resident on to the commode resident slipped and lost her balance and fell in her bathroom, she hit back of her head on railing, no bleeding or lumps noted. Resident has ROM (range of motion) as per usual, no rotation in extremities. POA and MD made aware. Review of facility paperwork dated 12/31/24, indicated that Resident R1 received an x-ray of left shoulder, no fracture or dislocation. Review of facility paperwork dated 1/2/25, Resident R1 went to a orthopedic appointment, x-rays of right obtained indicated impacted proximal humerus fracture. Review of facility paperwork dated 1/6/25, Resident R1 received an x-ray of right shoulder and right humerus indicating no acute fracture or dislocation. Review of facility paperwork dated 1/9/25, Resident R1 received an x-ray of right shoulder and right humerus indicating no definite acute fracture or joint dislocation. Review of an employee statement written by NA Employee E2 dated 12/30/24, stated, Resident R1 asked to go to the bathroom, NA took her into the bathroom, NA proceeded to move wheelchair, Resident R1 Page 1 of 2 395001 395001 01/13/2025 Passavant Retirement and Healt 105 Burgess Drive Zelienople, PA 16063

F 0689 slid, NA was able to break fall, Resident R1 bumped her head. Level of Harm - Minimal harm or potential for actual harm NA Employee E2 is no longer coming to the facility and did not answer the phone or return the message left by the State Agency. Residents Affected - Few Review of an employee statement written by LPN Employee E1 dated 1/8/25, stated, I was at sitting in the team room when (NA) approached the LPN stating Resident R1 was on the floor, while she was transferring resident from wheelchair to commode resident lost balance, fall was broke gently. Employee E2 went immediately into resident's bathroom, Resident R1 was lying on her left side. During an interview on 1/13/2025, at 1:45 p.m. the Nursing Home Administrator confirmed that the facility failed to provide adequate supervision for transfers for one of six residents, which resulted in a fall. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1)(e)(1) Management. 28 Pa. Code 201.20(b)(1) Staff Development. 28 Pa. Code 201.29(a) Resident rights. 28 Pa. Code 211.10(c)(d) Resident care policies. 395001 Page 2 of 2