Health inspection·September 11, 2025

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interviews, it was determined that the facility failed to provide services consistent with professional standards of practice to ensure the resident's highest level of well-being, which resulted in harm as evidenced by a delay in sending the resident to the hospital following confirmation of a femur fracture, and by failure to provide appropriate pain assessment and management for the fracture, for one of three residents reviewed (Resident 1). Findings include:Review of Resident 1's clinical record revealed diagnoses that included Alzheimer's Disease and Dementia (a progressive cognitive and mental decline that is severe enough to interfere with daily life, affecting memory, thinking, language, and judgment). Resident 1 resided on the locked memory care unit at the facility. Review of the clinical record revealed Resident 1 had a fall on August 26, 2025, at 4:45 PM. Resident 1 complained of pain in her right thigh and had an x-ray (an imaging test that uses a small amount of radiation to create images of internal body structures, such as bones, organs, and soft tissues) completed that same day on Resident 1's right hip, which came back negative for a fracture. Resident 1 was ordered Oxycodone hcl oral tablet (narcotic pain medication) 5 milligrams (mg) by mouth every 4 hours as needed for pain.Review of Resident 1's comprehensive care plan revealed a focus area for falls indicating the Resident is at risk for falls related to confusion, is unaware of safety needs, with an initiation and revision date of September 12, 2024, and an intervention to anticipate and meet the Resident's needs, initiated on September 12, 2024. Review of Resident 1's care plan also revealed a focus area that indicated the Resident has a communication problem related to impaired cognitive status, with an intervention to anticipate and meet needs, initiated and revised on August 21, 2025.Review of Resident 1's August 2025 Medication Administration Record (MAR) revealed an order to monitor for pain from a scale of 0-10, every shift. On August 26, 2025, during the night shift, it was documented that Resident 1 had a pain level of 8. On August 27, 2025, at 6:30 AM, Resident 1 was documented as having a pain level of 5. On August 27, 2025, during the night shift, Resident 1 was documented as having a pain level of 4. On August 28, 2025, at 6:30 AM, Resident 1 was documented as having a pain level of 4. From August 1 to August 25, the resident's pain score was zero. Further review of Resident 1's August 2025 MAR revealed an order for oxycodone hcl oral tablet 5 mg - give 5 mg by mouth every 4 hours as needed for pain. On August 27, 2025, at 2:08 AM, the Resident was documented as having a pain level of 8 and was administered the medication as ordered. On August 27, 2025, at 6:58 AM, the Resident was documented as having a pain level of 5 and was administered the medication as ordered. At 12:35PM, the Resident was documented as having a pain level of 6, and was administered the medication. Further review of Resident 1's August 2025 MAR revealed an order for oxycodone hcl oral tablet 5 mg - give 2.5 mg by mouth every 6 hours as needed for pain. On August 27, 2025, at 4:12 PM, the Resident was documented as having a level 8 pain, and was administered the medication as ordered. Review of Resident 1's clinical record revealed a nursing progress note on August Residents Affected - Few Page 1 of 2 395347 395347 09/11/2025 Oak Hill Center for Rehabilitation and Nursing 1020 North Union Street Middletown, PA 17057

F 0684 Level of Harm - Actual harm Residents Affected - Few 27, 2025, at 2:08 AM, that Resident 1 was yelling and moaning in pain on right hip area, and was administered 5 milligrams of oxycodone oral tablet. Further review of Resident 1's nursing progress notes revealed a note on August 27, 2025, at 6:58 AM, that the Resident was calling out, can't state her pain level, and was administered 5 milligrams of oxycodone oral tablet for pain. Further review of Resident 1's nursing progress notes revealed a note on August 27, 2025, at 12:35 PM, that the Resident was moaning and unable to walk, and received 5 milligrams of oxycodone oral tablet for pain.Review of Resident 1's clinical record revealed a physician note on August 27, 2025, at 4:06 PM, that read, in part, due to ongoing pain and difficulty ambulating, another x-ray will be ordered to check both right and left hip/femur/knee.On August 27, 2025, at 4:12 PM, there was a nursing progress note that Resident 1 was moaning in pain and was administered 5 milligrams of oxycodone oral tablet. At 7:11 PM, on August 27, 2025, a follow up nursing progress note was documented that the Resident still had a pain level of 4. There was no further documentation in Resident 1's clinical record to indicate any pain intervention or assessment was completed.Review of Resident 1's x-ray patient report dated August 27, 2025, at 11:26 PM, revealed the Resident had an acute fracture of the right sub capital femur.Review of Resident 1's clinical record revealed no documentation of the physician being notified of the Resident's fracture.Review of Resident 1's clinical record revealed no physician or nursing progress note after the notification of the fracture. There was no additional PRN (as needed) Oxycodone administered after the dose on August 27, 2025, at 4:12 PM.An interview conducted with the Director of Nursing (DON) on September 8, 2025, at approximately 1:30 PM, revealed x-ray results usually get faxed to the facility, unless it is an unusual finding then they will usually call to confirm it was received by the facility timely. The DON was unable to confirm if a call was received. The DON revealed she would have expected it to be documented on Resident 1's clinical record when the physician was notified of the positive fracture.Review of a written timeline provided by the DON on September 9, 2025, at 3:32 AM, revealed the provider was made aware of the x-ray results on August 28, 2025, at approximately 8:30 AM, assessed the Resident, and gave orders for the Resident to be sent to the hospital, which occurred at approximately 9:00 AM (Approximately 9.5 hours after the X-ray results came back positive for fracture).Review of Resident 1's clinical record failed to reveal any documentation of a time that EMS (Emergency Medical Services) was called or a time that the Resident was sent to the hospital. There was also no progress notes documented showing that Resident 1 was assessed for pain or discomfort throughout the evening and night shift.Review of the hospital records revealed Resident 1 was admitted to the hospital and required surgical intervention for the fracture. Resident 1 was administered IV (intravenous line) morphine for pain management until surgery. Review of the clinical record revealed Resident 1 was readmitted to the facility on [DATE], after having right hemiarthroplasty surgery (partial hip replacement surgery), with no postop complications.During an interview conducted with the Nursing Home Administrator (NHA) and DON on September 11, 2025, at 12:30 PM, revealed that he would have expected staff to monitor Resident 1 for pain and documenting if any pain assessments were completed prior to the Resident being transferred to the hospital. The facility failed to provide timely transfer to the hospital following confirmation of a femur fracture for Resident 1. The facility also failed to monitor and assess Resident 1 for pain and provide as needed pain medication prior to transfer to the hospital. 42 CFR 483.25 Quality of care28 Pa. Code 211.12(d)(1)(3)(5)Nursing services. 395347 Page 2 of 2