Health inspection·June 5, 2025

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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, clinical records and staff interviews, it was determined that the facility failed to provide goods and services resulting in neglect that resulted in the actual harm of a left hip fracture for one of five residents (Resident R1). Findings include: Review of the facility policy, Identifying Types of Abuse dated 2/20/25, indicated that residents have the right to be free of neglect. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Review of Libre Texts Medicine procedure 12.8.5: Procedure- Turning and Positioning the Patient in Bed, indicated to position yourself on the side of the bed that the patient will be turned to. Review of admission record indicated Resident R1 was admitted to the facility 10/31/18, with most recent re-admission on [DATE]. Review of Resident R1's Minimum Data Set (MDS - a periodic assessment of care needs) dated 4/4/25, indicated the diagnoses of hypertension (the force of the blood against the artery walls is too high), heart failure (heart doesn't pump blood as well as it should), and dementia (a general term for loss of memory, language, problem solving and other thinking abilities that are severe enough to interfere with daily life). Section G0110 indicated extensive assist of two for bed mobility. Review of Resident R1's physician order on 5/18/25, indicated fall mats at bedside. Review of Resident R1's care plan on 5/18/25, indicated to minimize risk for injury related to falls, place fall mats bilaterally (both sides). Review of facility provided document dated 5/18/25, indicated while Resident R1 was being changed by Nurse Aide (NA) Employee E1, resident fell from the bed and landed on the left hip on the floor. Care plan was not followed as fall mats were not at the bedside as ordered. Bed was approximately two and a half feet up in the air due to care being provided. The fall resulted in a left hip fracture. Review of Resident R1's X-ray results dated 5/18/25, indicated angulated (a type of displaced fracture where the bone fragments are tilted or angled to each other) left hip fracture. Page 1 of 5 395208 395208 06/05/2025 Hillcrest Rehabilitation & Healthcare Center 100 Little Drive Lower Burrell, PA 15068

F 0600 Level of Harm - Actual harm Residents Affected - Few Review of Registered Nurse (RN) Employee E2's witness statement dated 5/18/25, indicated NA Employee E1 called nurse into Resident R1's room and indicated resident was on the floor. NA Employee E1 stated that while changing Resident R1, resident rolled out of bed and resident complained of pain to the left hip. Foot rotated outward. Physician notified and ordered resident to go to the emergency department. Interventions in place at the time of the occurrence (mark all that apply): included call bell within reach, personal alarm, and bedside table within reach. Fall mat was not marked as being in place. Did the occurrence require staff education? If yes, what education did you provide? Answered - Yes. NA Employee E1 instructed not to leave resident's side. Review of RN Employee E3's witness statement dated 5/18/25, indicated NA Employee E1 said as NA was providing care, NA turned around to grab the brief and Resident R1 rolled out of bed on the right side and onto her left hip. Upon entering the room Resident R1 was in a ball with her head near the dresser lying on her left hip. Interventions in place at the time of the occurrence (mark all that apply): included call bell within reach, personal alarm, and bedside table within reach. Fall mat was not marked as being in place. Did the occurrence require staff education? If yes, what education did you provide? Answered - Yes. NA Employee E1 was instructed not to leave resident's side. Review of NA Employee E1's witness statement unsigned, and undated, indicated when NA arrived to Resident R1's room, resident was shifted sideways and sheets askew as Resident R1 is often sideways. Working on resident's left side (the word right was crossed out in error) first, NA repositioned resident straight and started to re-tuck the draw sheet, got over towards resident's right where resident was a bit higher. NA turned to grab the brief behind them to place on resident and resident moved her hips, shifting resident's knees over the bed enough to cause resident to flip in the air and land on opposite side of left hip. The bed was up over two and a half feet. NA led the turn with the left and couldn't stop resident as NA was trying to get brief. Interview on 6/5/25, at 1:49 p.m. NA Employee E4 indicated You roll a resident towards you in bed. Interview on 6/5/25, at 1:52 p.m. Licensed Practical Nurse (LPN) Employee E5 who was working as a NA, indicated We always roll a resident towards us, so they don't roll off the bed. Interview on 6/5/25, at 1:56 p.m. NA Employee E6 indicated Always roll towards you. Interview on 6/5/25, at 2:15 p.m. NA Employee E7 indicated If I'm by myself, I roll towards me. Interview on 6/5/25, at 2:20 p.m. the Director of Nursing indicated I came in and had NA Employee E1 re-enact what had happened to Resident R1. NA Employee E1 is six feet two inches, and there is no way the event occurred as stated by NA, because NA would have been standing where Resident R1 was found on the floor on the left hip. Further interview on 6/5/25, at 2:20 p.m. the Director of Nursing confirmed that NA Employee E1 was neglectful in following the care plan for floor mats and assist of two staff was not followed. Interview on 6/5/25, at 2:45 p.m. the Nursing Home Administrator and Director of Nursing confirmed the facility failed to provide goods and services resulting in neglect that resulted in the actual harm of an angulated left hip fracture for one of five residents (Resident R1). 28 Pa. Code 201.14(c) Responsibility of licensee. 395208 Page 2 of 5 395208 06/05/2025 Hillcrest Rehabilitation & Healthcare Center 100 Little Drive Lower Burrell, PA 15068

F 0600 28 Pa. Code 201.18(b)(1)(3)(e)(1) Management. Level of Harm - Actual harm 28 Pa. Code 211.10(a)(d) Resident care policies. Residents Affected - Few 28. Pa. Code. 211.12(d)(1)(2)(5) Nursing Services. 395208 Page 3 of 5 395208 06/05/2025 Hillcrest Rehabilitation & Healthcare Center 100 Little Drive Lower Burrell, PA 15068

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, clinical records and staff interviews, it was determined that the facility failed to make certain each resident received adequate supervision and assistance to prevent accidents which resulted in actual harm of a left hip fracture for one of five residents (Resident R1). Findings include: Review of the facility policy Accidents and Incidents-Investigating and Reporting dated 2/20/25, indicated all accidents occurring on our premises must be investigated and reported to the administrator. Review of facility policy Activities of Daily Living dated 2/20/25, indicated appropriate care and services will be provided for residents who are unable to carry out ADLs (activities of daily living) independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: a. Hygiene (bathing, dressing, grooming, and oral care); b. Mobility (transfer and ambulation, including walking); c. Elimination (toileting); d. Dining (meals and snacks); and e. Communication (speech, language, and any functional communication systems). Review of admission record indicated Resident R1 was admitted to the facility 10/31/18, with most recent re-admission on [DATE]. Review of Resident R1's Minimum Data Set (MDS - a periodic assessment of care needs) dated 4/4/25, indicated the diagnoses of hypertension (the force of the blood against the artery walls is too high), heart failure (heart doesn't pump blood as well as it should), and dementia (a general term for loss of memory, language, problem solving and other thinking abilities that are severe enough to interfere with daily life). Section G0110 indicated extensive assist of two for bed mobility. Review of Resident R1's physician order on 5/18/25, indicated fall mats at bedside and failed to have an order for bed mobility assistance required. Review of Resident R1's care plan on 5/18/25, indicated to minimize risk for injury related to falls, place fall mats bilaterally (both sides). The care plan failed to indicate extensive assistance for bed mobility. Review of facility provided document dated 5/18/25, indicated while Resident R1 was being changed by Nurse Aide (NA) Employee E1, resident fell from the bed and landed on her left hip on the floor. Care plan was not followed as fall mats were not at the bedside as ordered. Bed was approximately two and a half feet up in the air due to care being provided. The fall resulted in a left hip fracture. 395208 Page 4 of 5 395208 06/05/2025 Hillcrest Rehabilitation & Healthcare Center 100 Little Drive Lower Burrell, PA 15068

F 0689 Level of Harm - Actual harm Residents Affected - Few Review of Registered Nurse (RN) Employee E2's witness statement dated 5/18/25, indicated NA Employee E1 called nurse into Resident R1's room and indicated resident was on the floor. NA Employee E1 stated that while changing Resident R1, resident rolled out of bed and resident complained of pain to the left hip. Foot rotated outward. Physician notified and ordered resident to go to the emergency department. Interventions in place at the time of the occurrence (mark all that apply): included call bell within reach, personal alarm, and bedside table within reach. Fall mat was not marked as being in place. Did the occurrence require staff education? If yes, what education did you provide? Answered - Yes. NA Employee E1 instructed not to leave resident's side. Review of RN Employee E3's witness statement dated 5/18/25, indicated NA Employee E1 said as NA was providing care, NA turned around to grab the brief and Resident R1 rolled out of bed on the right side and onto her left hip. Upon entering the room Resident R1 was in a ball with her head near the dresser lying on her left hip. Interventions in place at the time of the occurrence (mark all that apply): included call bell within reach, personal alarm, and bedside table within reach. Fall mat was not marked as being in place. Did the occurrence require staff education? If yes, what education did you provide? Answered - Yes. NA Employee E1 was instructed not to leave resident's side. Review of NA Employee E1's witness statement unsigned, and undated, indicated when NA arrived to Resident R1's room, resident was shifted sideways and sheets askew as Resident R1 is often sideways. Working on resident's left side (the word right was crossed out in error) first, NA repositioned resident straight and started to re-tuck the draw sheet, got over towards resident's right where resident was a bit higher. NA turned to grab the brief behind them to place on resident and resident moved her hips, shifting resident's knees over the bed enough to cause resident to flip in the air and land on opposite side of left hip. The bed was up over two and a half feet. NA led the turn with the left and couldn't stop resident as NA was trying to get brief. Interview on 6/5/25, at 2:20 p.m. the Director of Nursing indicated I came in and had NA Employee E1 re-enact what had happened to Resident R1. NA Employee E1 is six feet two inches, and there is no way the event occurred as stated by NA, because NA would have been standing where Resident R1 was found on the floor on the left hip. Further interview on 6/5/25, at 2:20 p.m. the Director of Nursing confirmed that NA Employee E1 failed to make certain each resident received adequate supervision and assistance to prevent accidents which resulted in actual harm of a left hip fracture for one of five residents (Resident R1). 28 Pa. Code 201.14(c) Responsibility of licensee. 28 Pa. Code 201.18(b)(1)(3)(e)(1) Management. 28 Pa. Code 211.10(a)(d) Resident care policies. 28. Pa. Code. 211.12(d)(1)(2)(5) Nursing Services. 395208 Page 5 of 5