Inspection·April 8, 2024

F 0600 to the facility from the hospital at 2:30 PM, with an immobilizer in place to the right leg. Level of Harm - Actual harm Review of Resident 1's hospital discharge instructions dated April 1, 2024, revealed that Resident 1 was diagnosed with a right femur fracture after falling out of bed. Resident 1 was evaluated by orthopedic surgery, who recommended non-operative management and to follow-up as outpatient. Residents Affected - Few Review of facility's investigation dated March 31, 2024, revealed that Employee 1 was providing Resident 1 with care. Resident 1 was on her left side in bed and, as Employee 1 was attempting to change Resident 1's sheets, Resident 1 rolled out of bed. Review of Employee 1's witness statement dated March 31, 2024, revealed that Employee 1 was providing care to Resident 1, as her bed, sheets, and clothes were wet. Employee 1 stated that as she turned Resident 1 to the other side and started fixing her sheets, Resident 1 fell onto the floor. Review of facility's investigation revealed that there were no additional witness statements obtained and no evidence that any other staff member was present when Resident 1 rolled out of bed. Review of the facility reported incident for the fall on March 31, 2024, revealed that Employee 1 was changing the bed linen and rolled Resident 1 away from her, slightly beyond the perimeter of the mattress, resulting in Resident 1 falling out of bed. Review of the facility reported incident revealed that Employee 1 was suspended, pending investigation, and Employee 1 was immediately educated regarding ensuring that Resident care plans are followed when providing care. Review of the facility's investigation revealed that a written warning was given to Employee 1 dated April 1, 2024, stating, On 3/31/2024 while providing care on a Resident she rolled out of the bed and sustained injury. Resident is care planned for 2 [person] assist for bed mobility. It is important to follow the care plan and to seek clarification if you are unsure. This is for the safety of the Residents. When rolling Residents they should be rolled toward you to prevent falls. During an interview with the Nursing Home Administrator on April 8, 2024, at 12:10 PM, she confirmed that Employee 1 rolled Resident 1 away from her in the bed and did not follow the care plan of two-person assist when Resident 1 rolled out of bed. The facility failed to ensure that Resident 1 was free from neglect when Employee 1 did not follow Resident 1's care planned interventions for two-person assist with bed mobility, resulting in Resident 1 rolling out of bed and sustaining a right femur fracture. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.12(d)(1)(2)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395347 If continuation sheet Page 2 of 4 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 395347 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oak Hill Center for Rehabilitation and Nursing 1020 North Union Street Middletown, PA 17057 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 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few Based on facility policy review, nurse aide job description review, clinical record review, review of facility investigation documentation, and staff interview, it was determined that the facility failed to ensure that each resident received adequate supervision and assistance to prevent accidents, which resulted in a fall and actual harm as evidenced by a right femur fracture, for one of five residents reviewed (Resident 1). Findings Include: Review of facility policy, titled Activities of Daily Living (ADLs), Supporting, undated, revealed Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: .b. Mobility (transfer and ambulation, including walking) . Review of facility's nurse aide job description revealed, Purpose of Your Job Position- To provide each of your assigned residents with routine daily nursing care and services in accordance with the resident's assessment and care plan . Review of Resident 1's clinical record revealed diagnoses that included gastro-esophageal reflux disease (GERD-occurs when stomach acid repeatedly flows back into the tube connecting your mouth and stomach), hypertension (elevated blood pressure), and depression. Review of Resident 1's care plan revealed an intervention initiated on November 29, 2023, for BED MOBILITY: The resident requires (max assistance) by (2) staff to turn and reposition in bed. Review of Resident 1's nursing progress note dated March 31, 2024, revealed that at 3:50 PM, the nurse was notified that Resident 1 rolled out of bed onto the floor. The note stated that Resident 1 was observed laying on the floor on her left side, parallel to her bed. Resident 1 was complaining of right knee and right ankle pain, and was not able to move her right leg due to pain. A hematoma (a collection of blood outside of blood vessels) was also noted on the left side of Resident 1's head. Resident 1 was assisted back to bed via a hoyer lift with the assist of five staff members. A new order was received to send Resident 1 to the emergency department for evaluation and treatment. Resident 1 left the facility for the hospital at 4:20 PM. Review of Resident 1's nursing progress note dated April 1, 2024, revealed that Resident 1 returned to the facility from the hospital at 2:30 PM, with an immobilizer in place to the right leg. Review of Resident 1's hospital discharge instructions dated April 1, 2024, revealed that Resident 1 was diagnosed with a right femur fracture after falling out of bed. Resident 1 was evaluated by orthopedic surgery, who recommended non-operative management and to follow-up as outpatient. Review of facility's investigation dated March 31, 2024, revealed that Employee 1 (Nurse Aide) was assisting Resident 1 with care independently. Resident 1 was on her left side in bed and, as Employee 1 was attempting to change Resident 1's sheets, Resident 1 rolled out of bed. Review of Employee 1's witness statement dated March 31, 2024, revealed that Employee 1 was providing care to Resident 1, as her bed, sheets, and clothes were wet. Employee 1 stated that, as she (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395347 If continuation sheet Page 3 of 4 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 395347 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oak Hill Center for Rehabilitation and Nursing 1020 North Union Street Middletown, PA 17057 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 turned Resident 1 to the other side and started fixing her sheets, Resident 1 fell onto the floor. Level of Harm - Actual harm Review of the facility reported incident for the fall on March 31, 2024, revealed that Employee 1 was changing the bed linen and rolled Resident 1 away from her and outside of the perimeter of the mattress. This resulted in Resident 1 falling off the side of the bed. Residents Affected - Few Review of facility's investigation revealed that there were no additional witness statements obtained and no evidence that any other staff member was present when Resident 1 rolled out of bed. Further review of the facility's investigation revealed a written warning given to Employee 1 dated April 1, 2024, stating, On 3/31/2024 while providing care on a Resident she rolled out of the bed and sustained injury. Resident is care planned for 2 assist for bed mobility. It is important to follow the care plan and to seek clarification if you are unsure. This is for the safety of the Residents. When rolling Residents they should be rolled toward you to prevent falls. During an interview with the Nursing Home Administrator on April 8, 2024, at 12:10 PM, she confirmed that Employee 1 rolled Resident 1 away from her in the bed and did not follow the two-person assist when Resident 1 rolled out of bed. Employee 1 failed to provide the appropriate assistance and technique with bed mobility for Resident 1, resulting in Resident 1 falling out of bed and sustaining a right femur fracture. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.10(c)(d) Resident care policies 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395347 If continuation sheet Page 4 of 4