Health inspection·July 21, 2023

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. Based on a review of facility policy, facility investigative reports, and clinical records, as well as staff interviews, it was determined that the facility failed to provide adequate safety measures to prevent accidents during care for two of three residents reviewed (Resident 2, 3), which resulted in injury. Findings include: The facility's policy regarding fall prevention, dated February 23, 2023, indicated that each resident will be assessed for fall risk and receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls. Staff were to provide additional interventions as directed by the resident's assesment including assistive devices and caregiver education. A significant Change Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated June 14, 2023, indicated that the resident was cognitively impaired, had no speech, was rarely/never understood, and required extensive assistance of two for bed mobility (positioning in bed). Resident 2 was on hospice services and was on an anticoagulant (blood thinning) medication. A care plan for Resident 2, dated January 6, 2020, indicated that the resident required assistance of two staff for bed mobility. A post-fall nursing note for Resident 2, dated July 11, 2023, at 8:15 p.m. revealed that she was assessed for injury. There was a laceration over the left eye brow that measured 3.2 centimeters (cm) by 0.2 cm with jagged edges, a laceration on the left elbow that measured 2.2 cm by 0.1 cm, and an abrasion to the left knee that measured 2 cm by 2 cm. The resident was transferred back to bed with a full-body mechanical lift with the assistance of three staff. The areas were cleansed with normal saline solution, and direct pressure was applied to the left eye brow laceration to stop the bleeding. A nursing note for Resident 2, dated July 11, 2023, at 9:00 p.m., revealed that a registered nurse had been notified by staff that the resident was on the floor. The resident was observed lying on the floor on her left side in a semi-fetal position, with a moderate amount of bleeding noted from a head laceration and left elbow skin tear. Both areas were cleansed with normal saline solution and direct pressure was applied for 15 minutes. The facility's fall investigation, dated July 11, 2023, determined that Nurse Aide 1 was providing incontinence care to Resident 2 by herself at the time of the fall. A witness statement revealed that while moving the resident from one side of the bed to the other side, Resident 2 fell out of the bed. Page 1 of 3 395297 395297 07/21/2023 Embassy of Huntingdon Park 1229 Warm Springs Avenue Huntingdon, PA 16652

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few An interview with the Nursing Home Administrator on July 20, 2022, at 2:30 p.m. confirmed that Resident 2 required a two-person assist with bed mobility, and that Nurse Aide 1 was walking around the bed when the resident fell out. An annual MDS assessment for Resident 3, dated May 2, 2023, indicated that the resident was cognitively impaired and was totally dependent for transfers with the assistance of two staff. A care plan for Resident 3, dated August 4, 2020, revealed a deficit in self-care performance and indicated that the resident required a full-body mechanical lift for transfers. A nursing note for Resident 3, dated July 17, 2023, at 12:40 p.m. revealed that the resident was sitting on a shower chair holding her legs out in front of her. There was blood on the floor and running down the posterior left lower extremity. A hematoma was noted on the posterior left leg with a skin tear in the middle. A hematoma was also noted on the front left lower extremity. The hematoma was dark purple/black on the front and purple/black on the posterior with a skin tear. Resident 3 complained of pain only when cleaning and dressing the hematomas and skin tear. A witness statement from Nurse Aide 2 on July 18, 2023, at 2:45 p.m. indicated that she was aware that Resident 3 required a mechanical lift for transfers, but it was not used because there was another resident on the toilet, and to be quick the staff utilized a stand-and-pivot transfer to the shower chair. A witness statement from Nurse Aide 3 on July 18, 2023, and July 19, 2023, at 10:30 a.m. revealed that he did not know the transfer status for Resident 3, and that the hematoma on the front of the lower leg had previously been there prior to the transfer to the shower chair, but staff failed to report it. The facility's fall investigation, dated July 18, 2023, determined that facility staff failed to use a full body mechanical lift to transfer the resident. An interview with the Regional Director of Nursing on July 20, 2023, at 2:30 p.m. confirmed that the care team that transferred Resident 3 to the shower chair did not use a lift as per care needs due to time restraints. 28 Pa. Code 211.12(d)(1)(5) Nursing services. 395297 Page 2 of 3 395297 07/21/2023 Embassy of Huntingdon Park 1229 Warm Springs Avenue Huntingdon, PA 16652

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Based on clinical record reviews and staff interviews, it was determined that the facility failed to ensure that clinical records were complete and accurately documented for one of three residents reviewed (Resident 1). Findings include: A quarterly Minimum Data Set (MDS) assessment (mandated assessment of a resident's abilities and care needs) for Resident 21, dated July 10, 2023, indicated that the resident was severely cognitively impaired and required extensive assistance from staff for daily care tasks. A licensed practical nurse's note for Resident 2, dated July 7, 2023, indicated that she was sitting on her buttocks on the floor in front of her broda chair near the short hall. A fall investigation, dated July 7, 2023, at 6:30 p.m., revealed that Resident 1 was found sitting on her buttocks on the floor in front of her broda chair near the short hall nurse's station. There was no documented evidence that a registered nurse assessment was documented in the clinical record. Interview with the Director of Nursing on July 20, 2023, 3:18 p.m. confirmed that the resident was assessed by a registered nurse and confirmed that there was no documentation of the assessment in the clinical record. 28 Pa. Code 211.5(f) Clinical records. 395297 Page 3 of 3