Health inspection·November 15, 2024

F 0600 Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Level of Harm - Actual harm Residents Affected - Few Based on a review of select facility policies and procedures, clinical record review, and resident and staff interview, it was determined that the facility failed to protect a resident's right to be free from neglect by staff that resulted in actual harm with a serious injury of an ankle fracture for one of 10 residents reviewed (Resident 1). Findings include: The facility policy entitled, Resident Abuse and Neglect Prevention Program, last reviewed July 24, 2024, revealed that each resident has the right to be free from verbal, sexual, physical, and mental abuse. Management and staff are jointly and individually responsible to ensure each resident will be free from abuse, neglect, and misappropriation of property. The facility has a plan in place to assure appropriate steps are taken to protect each resident from mistreatment, neglect, abuse, and misappropriation of property. The policy defines neglect as the failure to provide goods and services necessary to avoid physical harm. Clinical record review for Resident 1 revealed nursing documentation dated October 7, 2024, at 9:27 PM that she was lowered to the floor in the shower room. Resident 1 complained of left leg discomfort at this time. Nursing documentation dated October 9, 2024, at 2:52 PM revealed that Resident 1 was requesting to get an x-ray of her left foot. The facility received a physician's order for Resident 1 to get an x-ray on October 11, 2024, which showed a nondisplaced fracture of her left ankle. Nursing documentation dated October 16, 2024, at 10:34 PM revealed that Resident 1 returned from her orthopedic appointment with new orders to wear a left leg immobilizing boot. Resident 1 is to return for an orthopedic appointment in six weeks. Review of Resident 1's clinical record revealed that the facility admitted her on May 28, 2024. A Minimum Data Set Assessment (MDS, a form completed at specific intervals to determine care needs) dated September 2, 2024, indicated that the facility determined that she was cognitively intact. Review of Resident 1's task list (a list of care tasks to be performed) indicated that starting May 31, 2024, Resident 1 was assessed to require the assistance of two staff members for all care every shift. Review of Resident 1's plan of care dated June 3, 2024, indicated that Resident 1 required the assistance of two staff members for all care. Page 1 of 2 395045 395045 11/15/2024 Mountain View Rehabilitation and Senior Living Ctr 2050 Trevorton Road Coal Township, PA 17866

F 0600 Level of Harm - Actual harm Residents Affected - Few Interview with Resident 1, on November 15, 2024, at 10:00 AM revealed that Employee 1, nurse aide, insisted on completing her shower by herself despite Resident 1 telling Employee 1 several times that she required the assistance of two caregivers. Resident 1 indicated that Employee 1 said, It will be okay, let's just get it done. Resident 1 indicated that Employee 1 transferred her to a shower chair by herself, and when the shower was completed, Employee 1 asked Resident 1 to stand to dry her off. Resident 1 indicated that as soon as she tried to stand, she fell to the ground. Resident 1 indicated that is when Employee 1 went to get help. Resident 1 also indicated that she feels like the pain in her ankle is getting worse and not better. Review of the facility's investigation into Resident 1's fall on October 7, 2024, revealed a witness statement by Employee 1 dated October 10, 2024, indicating that she was aware Resident 1 required the assistance of two staff members but provided Resident 1 a shower on her own anyway. Interview with the Director of Nursing and Employee 2 (assistant director of nursing) on November 15, 2024, at 12:45 PM confirmed that the facility could not provide evidence that the facility implemented any measures after Resident 1's incident that occurred on October 7, 2024, to ensure that staff received training on the number of staff members needed to ensure the physical health of all its residents. The facility only indicated that Employee 1 could not return to the facility for assignments. The facility failed to ensure care was provided in a safe manner to Resident 1, resulting in a fracture. 483.12 Freedom from Abuse, Neglect and Exploitation Previously cited 7/24/24 28 Pa. Code 201.14 (a) Responsibility of licensee 28 Pa. Code 201.18 (b)(1)(2)(e)(1) Management 28 Pa. Code 201.19(6)(7)(8) Personnel policies and procedures 28 Pa. Code 201.29 (a)(c) Resident rights 28 Pa. Code 211.12(c)(d)(1)(5) Nursing services 395045 Page 2 of 2