Inspection·July 16, 2025

F 0689 Level of Harm - Actual harm Residents Affected - Few 0.15 cm. was observed. The resident also had a left upper arm skin tear that measured 6 cm x 1 cm and a left lateral knee skin tear that measured 2 cm x 2cm. It was revealed the resident complained of pain, and the pain was new to the resident. The resident had a temporal injury with pain. The resident's pain was rated 5/10 and described it as hurting. Review of Resident R1's progress note dated 6/29/25, entered by Nurse Practitioner, Employee E2 revealed Resident R1 was assessed via a telehealth visit after a fall. The NA was present at the bedside and reported while changing the resident, the NA went to grab a sheet, and the resident rolled out of bed. The resident had a large 2.5 cm right forehead laceration and a skin tear to the right arm. The resident was ordered to be transferred to the hospital for sutures.Review of Resident R1's hospital records dated 6/29/25, revealed Resident R1 presented to the emergency department secondary to a fall. Resident R1 apparently had fallen out of bed and was found down on the ground. The resident sustained a hematoma/contusion to the right occipital (back of brain) parietal (top and back of brain) portion of the scalp as well as abrasions to the right upper arm and right lower leg. The resident's daughter arrived at the emergency room and was concerned that the facility staff indicated the resident had right leg shortening. On reevaluation, the resident's leg was slightly shorter on the right than the left. An x-ray of the right hip and pelvis was completed and revealed an impacted sub capital fracture (intracapsular neck of femur fracture that typically results from falls or direct trauma to the hip). Surgical options were discussed, and it was decided to not have the resident hospitalized or to undergo surgery. Review of Resident R1's Radiology Report dated 6/29/25, revealed a hip with pelvis x-ray was performed due to a fall. It was revealed the resident sustained a right lateral impacted sub capital fracture. Review of Resident R1's progress note dated 6/30/25, revealed the resident was due to return after receiving sutures but the hospital subsequently found that the resident had a right hip fracture and are awaiting a stretcher to return the resident. Review of information submitted to the Department of Health on 6/30/25, indicated on 6/29/25, Resident R1 was having their draw sheet changed and rolled off the bed onto the floor. The resident was transferred to the hospital. Upon investigation it was determined that Nurse Aide, Employee E3 turned Resident R1 on their side to change their brief.NA, Employee E3 reached for the linen and the resident slid off the mattress onto the floor. The resident received a laceration to the temple. Family and physician were notified, and the resident was transferred to the hospital. It was determined the resident had a fracture right hip. Staff were educated on the importance of using two people for turning as the Kardex indicates. Review of the facility's investigation on 7/16/25, revealed NA, Employee E3's witness statement dated 6/29/25, that stated NA, Employee E3 was doing care on Resident R1. Resident R1 was rolled onto their side, and when NA, Employee E3 turned around to grab a clean draw sheet and a brief, the resident rolled back over and fell on the floor hitting their head and right hip on the ground. RN, Employee E1's witness statement dated 6/29/25, stated around 9:15 p.m. the nurse aide was changing Resident R1's brief and the resident rolled out of bed and sustained a temporal injury measuring about 2.5 centimeters, a 6 cm right upper arm skin tear, and right lateral knee skin tear that measured 2cm x 2cm. A dressing was applied, and the supervisor was informed. The resident was sent to the emergency room for sutures.During a phone interview on 7/16/25, at 10:06 a.m. NA, Employee E3 stated they have been employed since the beginning of May 2025. Around 9:00 p.m. on 6/29/25, NA, Employee E3 stated while doing care, Resident R1 was rolled on their right side towards the window. NA, Employee E3 went to grab a sheet, and the resident rolled back from their right side and Resident R1 hit her head on the floor and hit her right side, her hip. NA, Employee E3 notified the nurse, and the nurse wrapped her up and we waited for the ambulance to come. NA, Employee E3 indicated the resident may have struck the nightstand or bed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395300 If continuation sheet Page 2 of 3 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 395300 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/16/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Perry Health & Rehab Center 9850 Old Perry Highway Wexford, PA 15090 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)

F 0689 Level of Harm - Actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete side table when going down. NA, Employee E3 indicated she was not aware the Resident required an assist of two persons in bed and stated She is like 70 pounds, she is not a heavy lady, I do her by myself all the time. It was literally something that happened. I did not intentionally let her fall or was being negligent. She just rolled. During an interview on 7/16/25, at 10:42 a.m. NA, Employee E4 stated a resident's transfer status can be found in the Kardex. NA, Employee E4 stated if a resident is ordered an assist of two person, to never transfer with only one or leave the resident on their side unattended. During an interview on 7/16/25, 11:01 a.m. NA, Employee E5 stated the level of assistance required for resident's with bed mobility should be in the Kardex, and if not, I ask a nurse for clarification. If a resident requires two people for assistance, two people must always assist the resident and must never be left on their side unattended. During an interview on 7/16/25, 1:10 p.m. RN, Employee E1 stated they were called to Resident R1's room on 6/29/25, and observed Resident R1 on the floor and their head was bleeding on the right side. The supervisor was informed and 911 was notified. The resident was not moved until paramedics arrived. RN, Employee E1 stated according to NA, Employee E3's statement, Resident R1 was put on one side, and as the NA was putting bed sheets on the other side, the NA pulled the bed sheet, then the resident fell down. It was indicated the resident was very small. RN, Employee E1 indicated Resident R1 was asked if she had pain and she said yes but was unable to express the level of pain.During an interview on 7/16/25, at 2:10 p.m. the Nursing Home Administrator and Director of Nursing confirmed the facility failed to ensure the appropriate assistance for bed mobility was provided for one of seven residents (Residents R1), which resulted in actual harm when Resident R1 fell out of bed and sustained a right hip fracture and head contusion. 28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 201.18(e)(1) Management.28 Pa. Code: 207.2(a) Administrator's responsibility.28 Pa. Code: 211.10(d) Resident care policies. Event ID: Facility ID: 395300 If continuation sheet Page 3 of 3