Health inspection·April 26, 2024

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 facility documentation, review of clinical record, and staff interview, it was determined that the facility failed to maintain an environment free from hazards related to an unlocked bed wheel brake for one of 20 residents reviewed. (Resident R83) Findings include: A review of clinical record for Resident R83 revealed that the resident was admitted to the facility on [DATE], with diagnoses including anoxic brain damage, abnormal posture, and unspecified mental disorder due to known physiological condition. Review of Resident R83's quarterly Minimum Data Set (MDS- assessment of resident's care needs) date on April 9, 2024, revealed that the resident was assessed a requiring one-person physical assist for bed mobility. Review of Resident R83's care plan on May 5, 2023, revealed that Resident R83 was able to turn and reposition in bed with the assistance one person assist for bed mobility. Review of incident note dated on April 16, 2024, confirmed, and revealed that Resident R83 rolled off side of bed during care and hit head has a laceration to L (left)-forehead. Resident R83 has aphasia-unable to say what happened. Review of facility investigation dated, April 16, 2024, revealed that during incontinence care Resident 83 slid down between the bed and the wall to the floor while nurse aide, Employee E7 was turning resident to the right side to wash her back. Resident was transfer to the hospital. Review nurse aide, Employee E7, statement on April 16, 2024, stated that resident rolled out of bed due to bed moving as I was giving care. I immediately got the nurse and aide. Review of nursing documentation notes on April 16, 2024 3:26 p.m. revealed that Assessed forehead laceration, band-aid removed. 2.7cmx 2.5cm, 100% approximated with steri-strips, dried blood to medial aspect and upper right edge. No drainage, surrounding skin intact. Left open to air. Returned from ER at 12:15 p.m. assisted into bed. Forehead laceration with steri strips and band aid. Abrasion Left shoulder s/p fall. NO CT evidence for acute intracranial hemorrhage or mass effect Interview on April 24, 2024, at 1:41 p.m. with the Director of Nursing, Employee E2, revealed Resident R83 slid down between the wall and bed after nursing assistant turning resident to the right (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 3 Event ID: 395278 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395278 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Saint Joseph Villa 110 West Wissahickon Ave Flourtown, PA 19031 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)