Health inspection·October 31, 2024

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm Based on facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to ensure care and services were provided in accordance with professional standards of practice to meet each resident's physical, mental, and psychosocial needs for two of three residents reviewed (Residents 1 and 2). Residents Affected - Few Findings Include: Review of facility policy, titled Neurological Checks Policy, revised July 9, 2024, revealed Neurological checks are indicated to monitor for potential irregularities in neurological status in the event of known or unknown head trauma as the result of a resident event, change in resident condition, or physician's order. When triggered by a qualifying event, a neurological check observation in the electronic health record will be initiated to conduct periodic checks and to document the results of the neurological checks. Unless otherwise ordered by the physician, the frequency of neurological assessments will be once every shift for 72 hours post occurrence or change. Review of Resident 1's clinical record revealed diagnoses that included Parkinson's Disease (a disorder of the central nervous system that affects movement, often including tremors) and generalized anxiety disorder (severe, ongoing anxiety that interferes with daily activities). Further review of Resident 1's clinical record revealed that Resident 1 had a fall on October 11, 2024. Review of the fall report revealed that Resident 1 hit her head on the bedside table. Review of Resident 1's nursing progress note dated October 11, 2024, at 10:32 AM, also revealed that Resident 1 hit her head. The progress note further stated that neurological checks at that time were within normal limits. Further review of Resident 1's clinical record revealed no evidence that any additional neurological checks were conducted after the fall on October 11, 2024. Review of Resident 1's clinical record revealed she had an unwitnessed fall on October 27, 2024, at 4:30 AM, and another unwitnessed fall on October 27, 2024, at 6:45 AM. Review of Resident 1's fall report for the 4:30 AM fall revealed Resident 1 was noted with a bruise to her right cheek and neurological checks were initiated and within normal limits. Review of Resident 1's fall report for the 6:45 AM fall revealed that neurological checks were Page 1 of 2 395395 395395 10/31/2024 River's Bend Health & Rehab Center 800 King Russ Road Harrisburg, PA 17109

F 0684 completed at the time of the fall. Level of Harm - Minimal harm or potential for actual harm Review of Resident 1's clinical record revealed that no additional neurological checks were documented on Resident 1 after her falls on October 27, 2024. Residents Affected - Few Review of Resident 2's clinical record revealed diagnoses that included dementia (a group of thinking and social symptoms that interferes with daily functioning) and congestive heart failure (CHF - a chronic condition in which the heart doesn't pump blood as well as it should). Further review of Resident 2's clinical record revealed she had an unwitnessed fall on October 2, 2024. Review of Resident 2's fall report, dated October 2, 2024, revealed that neurological checks were completed at the time of the fall. Review of Resident 2's clinical record revealed that no additional neurological checks were documented after the fall on October 2, 2024. In an email correspondence from the Nursing Home Administrator (NHA) on October 31, 2024, at 9:16 AM, she stated that the facility was unable to find any additional documentation of neurological checks for the aforementioned falls. In a follow-up interview with the NHA on October 31, 2024, at 10:15 AM, she acknowledged the concern of the missing neurological checks. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services 395395 Page 2 of 2