Health inspection·December 31, 2024

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Based on clinical record review and staff interview, it was determined that the facility failed to immediately notify the resident's representative of an accident involving the resident which resulted in an injury for one of three residents reviewed (Resident R1). Findings include: Review of facility policy Change in a Resident's Condition or Status, revised December 2016, revealed that our facility shall promptly notify the resident, his or her Attending Physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status. Unless otherwise instructed by the resident, a nurse will notify the resident's representative when the resident is involved in any accident or incident that results in an injury including injuries of an unknown source. Except in medical emergencies, notifications will be made within twenty-four hours of a change occurring in the resident's medical/mental condition or status. Review of Resident 1's progress note of November 24, 2024, written at 1:47 a.m. revealed that the resident was found on the right side on the floor next to the bed with a pool of blood on the floor at the resident's head and on the resident's hands. The resident was assessed and assisted to bed. A contusion on the right mid forehead with a laceration was noted. The area was cleansed and continued to bleed. Vital signs were taken and 911 called. Resident out to ed (emergency department) at approx (approximately) 0115 (1:15 a.m.) md aware, will call son in am and wait report from hospital. Review of additional progress note of November 24, 2024, written at 5:33 a.m. revealed that son is aware of fall and hospitalization. Interview with the Director of Nursing on December 17, at 1:10 p.m. revealed that the resident's representative was not notified immediately of the resident's fall and hospitalization. 28 Pa. Code: 211.5(f) Clinical records Previously cited 11/21/24, 8/22/24 28 Pa. Code 211.10(d) Resident Care Policies Previously cited 11/21/24 28 Pa. Code: 211.12(d)(1)(5) Nursing services Page 1 of 2 395284 395284 12/31/2024 Phoenix Center for Rehabilitation and Nursing,the 833 South Main Street Phoenixville, PA 19460

F 0580 Previously cited 11/21/24, 8/22/24 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 395284 Page 2 of 2