Health inspection·July 9, 2024

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical records and staff interview, it was determined that the facility failed to update a care plan for one of nine residents (Resident R1) to accurately reflect the current status of the resident. Findings include: Review of clinical record indicated Resident R1 was admitted to the facility on [DATE], with diagnoses that included dementia (declining cognitive abilities of remembering, thinking, or making decisions), anxiety and major depressive disorder. Review of Resident R1's Minimum Data Set (MDS-a mandated assessment of a resident's abilities and care needs) assessment, dated 5/16/24, indicated the diagnoses remain current. Review of Resident R1's Resident Care Plan Summary Report (report nurse aides used to know what kind of care to provide) dated 7/1/24, indicated bed mobility as a assist of two. Review of Resident R1's care plan dated 9/6/23, indicated R1 had a bed mobility assist of one and that it was active, current. During an interview on 7/9/24, at 1:30 p.m. Nursing Home Administator confirmed the facility failed to revise care plan for Resident R1 as required. 28 Pa. Code: 211.11(d) Resident Care Plan Page 1 of 2 395164 395164 07/09/2024 St John Specialty Care Center 500 Wittenberg Way Mars, PA 16046

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, incident reports, facility documents, a written employee statement and staff interviews, it was determined that the facility failed to ensure that a resident was free from a preventable accident during care for one of nine resident reviewed (Resident R1). Findings include: Review of clinical record indicated Resident R1 was admitted to the facility on [DATE], with diagnoses that included dementia (declining cognitive abilities of remembering, thinking, or making decisions), anxiety and major depressive disorder. Review of Resident R1's Minimum Data Set (MDS-a mandated assessment of a resident's abilities and care needs) assessment, dated 5/16/24, indicated the diagnoses remain current. Review of Resident R1's care plan dated 9/6/23, indicated R1 had a bed mobility assist of one. Review of facility documents dated 6/26/24, indicated Nurse Aide (NA Employee E1) was providing care. NA Employee E1 remained beside. Resident R1 starting rolling in the opposite direction, NA Employee E1 was unable to stop fall from occuring. Resident R1 was to the hospital with a head laceration and left femoral fracture. Reviewed of NA Employee E1 signed witness statement dated 6/26/24, indicated NA Employee E1 stated she turned Resident R1 away from her, instead of toward her, NA Employee E1 was reaching cream and powder in Resident R1's drawer when Resident R1 rolled out of bed. During an interview on 7/9/24 at 1:30 p.m. the Nursing Home Administrator (NHA) confirmed the facility failed to ensure that a resident was free from a preventable accident. 28 Pa Code 201.14(a) Responsibility of licensee. 28 Pa Code 201.18(b)(1)(e) Management. 395164 Page 2 of 2