Health inspection·January 11, 2024

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm Based on clinical record review and staff interviews, it was determined that the facility failed to ensure the assessment accurately reflects the resident's status for one of 20 residents reviewed (Resident 28). Residents Affected - Few Findings include: Review of Resident 28's clinical record revealed diagnoses that included pain and unsteadiness on feet. Review of Resident 28's Quarterly Minimum Data Set (MDS-a tool used to assess all care areas specific to the resident), with an Assessment Reference Date of December 8, 2023, revealed under Section J 1900 the Resident had a fall with a major injury since admission/entry or reentry or prior MDS. Review of Resident 28's clinical record revealed a fall dated September 13, 2023. According to the investigation, Resident 28 was found on the floor in her room and stated she fell out of her chair but didn't remember how. Review of Resident 28's progress notes revealed the following documentation, At several points during the shift resident displayed no s/s [signs and symptoms] of any discomfort but as soon as she was asked about her fall she would change her demeanor and state that she was having pain. Approximately 1200 resident stated she was having chest pain again and also stated 'I probably broke a couple of my ribs'. Although no swelling/bruising noted MD ordered CXR [chest x-ray] to rule out injury. Review of the Radiology Report dated September 13, 2023, revealed, in part, There may be residuals of subacute minimally displaced fracture of the sternum. The sternum is a partially T-shaped, vertical bone that forms the anterior portion of the chest wall centrally. An interview with Employee 3 (Resident Nurse Assessment Coordinator) on January 11, 2024, at 10:35 AM, revealed she had not completed the MDS assessment in question and explained Resident 28 had no major injury as documented on the MDS, but instead had a history of possible fracture as noted on the radiology report. An additional interview with Employee 3 revealed the MDS was coded incorrectly and she would be completing a modification of the assessment. An interview with the Director of Nursing on January 11, 2024, at 11:02 AM, revealed Resident 28 had no major injury or fracture from the fall on September 13, 2023, and confirmed the MDS had been coded incorrectly. (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 6 Event ID: 395386 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 395386 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bethany Village Retirement Center 5225 Wilson Lane Mechanicsburg, PA 17055 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)