Health inspection·April 6, 2023

F 0600 Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical records, facility documentation review, and resident and staff interview, it was determined that the facility failed to ensure that the resident was free from neglect by not providing two-person assistance needed during transfers or providing the proper equipment during a transport for two of 32 residents reviewed (Residents 14 and 91) causing actual harm to Resident 14. Findings Include: Review of Resident 14's diagnosis list included a diagnosis of intracranial hemorrhage (stroke) and Hemiplegia non-dominate left side (inability to move one side of the body). Review of Resident 14's care [NAME] revealed as of January 30, 2023 Resident 14 was to have the foot pedals of the wheelchair removed while in the room as resident prefers to self-propel independently when in room. Utilize wheelchair foot pedals when assisting resident with mobility in the hallway. Review of Resident 14's care plan revealed interventions to prevent falls including an intervention initiated October 11, 2021, to encourage foot pedals when assisting resident with wheelchair mobility in the hallway. Review of Resident 14's progress notes revealed a nursing entry dated January 30, 2023, at 2:05 p.m. revealed CNA (Certified Nursing Assistant) pushing resident in WC (wheelchair) to dining room. Resident left foot caught on floor causing resident to fall forward, land on floor face down. Resident able to roll on left side to a seated position, resident assisted to WC by three employees, Pressure held to nose d/t (due to) bleed. Further review of Resident 14's progress notes revealed Resident 14 was having nose bleeds but not reporting any pain or discomfort in his/her face. Additional review of Resident 14's clinical record revealed a progress note dated February 6, 2023, at 4:26 p.m. indicating family is requesting [Resident 14] be sent to the ER (Emergency Room) for epistaxis (nosebleed). Review of documentation from the hospital stay of February 6-7, 2023, revealed the resident was admitted with diagnosis of epistaxis due to trauma, closed bilateral (both sides) nasal bone fractures, concussion, fall from wheelchair, acute blood loss anemia (low blood cell count) and coagulopathy (inability of blood to clot). Page 1 of 3 395328 395328 04/06/2023 Brethren Village 3001 Lititz Pike Lancaster, PA 17606

F 0600 Level of Harm - Actual harm Residents Affected - Few Interview with Resident 14 on March 29, 2023, at 1:00 p.m. confirmed when she had the fall on January 30, 2023, she did not have the foot pedals on the wheelchair at the time of the fall. Resident 14 stated she was not asked if she wanted them or not and didn't want to say anything because she thought the CNA was busy at the time. Resident 14 confirmed that the foot pedals have been used every time when transferred outside of her room since her fall. Interview with the Director of Nursing on March 29, 2023, at 11:00 a.m. revealed Nursing Employee E4 resigned from her position and no longer worked at the facility after January 30, 2023. Interview with the Nursing Home Administrator on March 30, 2023, at 9:30 a.m. confirmed Resident 14's foot pedals were not placed on the wheelchair as both the care plan and care [NAME] instructed when transferring Resident 14 in the hallway. Review of documention provided by the facility revealed facility substantiated the allegation of neglect against the nurse aide who failed to follow care [NAME] and care plan by not providing foot pedals to wheelchair during transport. Resident 14 sustained a fall due to the facility staff not following Resident 14's care plan and care [NAME] interventions of placing foot pedals on the wheelchair while transporting the resident in the hallway causing actual harm when Resident 14 was transferred to the hospital and diagnosed with facial fractures. Review of facility audits of foot pedal placement and education provided to all nursing staff revealed the education provided was regarding wheelchair and use of foot pedals but did not address ensuring safety during transfers. Review of Resident 91's diagnosis list revealed Parkinson's Disease (disorder of the central nervous system that affects movement, often including tremors), a history of falls, and a left femur (thigh bone) fracture. Review of Resident 91's Minimum Data Set (MDS- standardized assessment tool that measures health status in long-term care residents) dated January 7, 2023, revealed that the resident had severe cognitive impairment. The MDS also revealed that the resident requires extensive two-people assistance with transferring. Review of Resident 91's current care plan for safety revealed an intervention initiated on July 12, 2022, for two-person assistance with transferring with a rolling walker. Review of Resident 91's nursing progress notes dated February 26, 2023, at 2:09 a.m., revealed resident was lowered by an aide to the knees during the transfer from a recliner to a wheelchair. The resident became weak during the transfer and needed to be lowered to the ground, unable to complete the transfer. The resident had slight redness to the right knee but denied pain/discomfort. The resident was able to stand and was placed in a wheelchair with two staff assistants. Review of the facility documentation, and fall investigation, revealed that on February 26, 2023, at 1:43 p.m., the resident was lowered to their knees during a transfer from a recliner to the wheelchair. Records revealed non-licensed employee E3 transferred the resident by herself/himself. Review of non licensed Employee E3's statement dated March 8, 2023, revealed that she/he was aware 395328 Page 2 of 3 395328 04/06/2023 Brethren Village 3001 Lititz Pike Lancaster, PA 17606

F 0600 of the resident's care plan to have two-person assistance with transferring, but the other aide was not on the unit and the nurse was occupied assisting another resident. Level of Harm - Actual harm Residents Affected - Few Interview with the Director of Nursing on March 30, 2023, at 10:00 a.m., confirmed that the facility failed to ensure Resident 91 was free from neglect by not providing two-person assistance with transferring contributing to the resident's fall. 483.13 - Resident Behavior and Facility Practices, 10-1-1998 edition 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(3)(e)(1) Management 28 Pa. Code 201.18(e)(3) Management 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services 395328 Page 3 of 3