Health inspection·February 27, 2025

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 clinical record review, facility investigation review, and staff interview, it was determined the facility failed to ensure adequate supervision was provided during toileting transfer resulting in a fall of one of 20 residents reviewed (Resident 55). Findings include: A review of Resident 55's diagnosis list includes repeated falls, generalized weakness, abnormalities with gait and mobility, and Congestive Heart Failure (CHF-weakened heart condition that causes fluid buildup in the feet, arms, lungs, and other organs). A review of Resident 55's Quarterly Minimum Data Set (MDS-a standardized assessment tool that measures health status in long-term care residents), dated December 11, 2024, revealed that the resident was cognitively intact. The same MDS revealed that the resident required extensive two-person assistance for both transferring and toileting. A review of Resident 55's care plan, developed on November 18, 2024, revealed an ADL (activities of daily living) care plan for self-performance deficit due to recent falls and left shoulder injury, impaired mobility, muscle weakness, and overall decline. Interventions/tasks included two (person) assists with rolling walker with transfers and two (person) assists with toileting-bathroom grab bars. A review of the nursing progress notes dated December 16, 2024, revealed that at 8:13 p.m., the nurse was notified by an NA (nurse aide) that Resident 55 was lowered to the floor during the transfer from the toilet to a wheelchair. The resident was observed sitting on her bottom with their back against the wheelchair. The resident stated, I just couldn't move. A review of the facility's investigation report revealed a statement from NA Employee E3, dated December 16, 2024, stating: She/he was transferring from the toilet and her knees started to buckle. I did my best to lower her slowly to the ground. A review of the facility's investigation report revealed a statement from NA Employee E4, dated December 18, 2024, stating I had [name of NA- Employee E3] for orientation, I told her/him to get [resident's name] ready to toilet and wait for me to transfer. She/he did not wait and lowered her to the floor. She did not use a gait belt (Also known as a transfer belt. A device put on a patient who has mobility issues, by a caregiver before that caregiver moving the patient) An interview conducted with the Director of Nursing on December 27, 2025, at 10:00 a.m., confirmed Page 1 of 3 395326 395326 02/27/2025 Zerbe Sisters Nursing Center, 2499 Zerbe Road Narvon, PA 17555

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few that Resident 55 required two-person assistance with toileting and transfers. The DON confirmed that the resident was provided with one person's assistance with transfers despite needing two as indicated in the resident's plan of care. The facility failed to ensure Resident 55 was provided with adequate supervision during toileting transfers resulting in a fall. 28 Pa Code 211.12 (c)(d)(1)(3) Nursing Service Previously cited 3/8/24 395326 Page 2 of 3 395326 02/27/2025 Zerbe Sisters Nursing Center, 2499 Zerbe Road Narvon, PA 17555

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, observations, and interviews, it was determined the facility failed to document medication disposition for two of three discharged residents. (Resident 7 and Resident 76) Findings include: Review of facility policy titled Discarding and Destroying Medications, documents disposal of controlled substances must take place immediately (no longer than three days) after discontinuation of use by resident. Disposal must be documented on the medication disposition record, with the signature of at least two witnesses. The medication disposition record will contain the resident's name, date medication disposed, name and strength of medication, name of dispensing pharmacy, quantity disposed, reason for disposition and signature of witnesses. Review of resident 76's clinical records revealed physician orders that included Buspirone (for anxiety) 5mg, Gabapentin (for nerve pain) 900mg, and Zoloft (for depression) 12.5 mg. Review of Resident 76's clinical records revealed a discharge summary date [DATE], documenting the resident expired while hospitalized at Tower Heath Reading Hospital. Resident 76 was transferred to the hospital on [DATE], due to change of mental status and shortness of breath, she was admitted with Congestive Heart Failure exacerbation (impairment in the heart's ability to fill with and pump blood) on [DATE], the facility was notified that Resident 76 ceased to breath while hospitalized . Review of Resident 76's clinical records failed to reveal a medication disposition form. Review of Resident 7's clinical records revealed physician orders that include Duloxetine (for depression) HCI 60mg, Apixaban (for irregular heartbeat) 5mg, and Digoxin (for chronic heart failure) 125mcg. Review of Resident 7's clinical records revealed a Discharge summary dated [DATE], documenting the resident discharged to home on February 21, 2025. The discharge summary documents medication reconciliation of all pre-discharge medications with post discharge medications was completed. Review of Resident 7's clinical records revealed a medication list that did not include the quantity of each medication dispensed. Interview on February 27, 2025, at 1:30 p.m., with Director of Nursing (DON) when the above information was presented, The DON confirmed there was no medication disposition sheet for Resident 76, and Resident 7's medication disposition sheet did not document the quantity of medications disposed. 28 Pa. Code 211.9(j) Pharmacy services. 28 Pa. Code 211.12(d)(1)(5) Nursing services. 395326 Page 3 of 3