Health inspection·December 30, 2024

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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of clinical records, select resident investigative reports, and staff interview, it was determined the facility failed to consistently provide sufficient staff assistance and implement appropriate interventions based on individual resident needs to promote resident safety and prevent falls with serious injuries for one resident out of 7 sampled residents. (Resident 1). Findings include: A review of clinical records revealed that Resident 1 was admitted to the facility on [DATE], with diagnosis to include muscles weakness, congestive heart failure (condition that occurs when the heart can't pump enough blood to meet the body's needs) and generalized anxiety disorder (condition that involves excessive and persistent worrying that interferes with daily life). A Quarterly Minimum Data Set assessment (MDS is part of the U.S. federally mandated process for clinical assessment of all residents in Medicare or Medicaid certified nursing homes) dated September 14, 2024, revealed the resident was cognitively impaired with a BIMs score (brief interview for mental status tool is used to get a quick snapshot of how well you are functioning cognitively. It is a required screening tool used in nursing homes to assess cognition) of 4 (0-7 indicating severely cognitively impaired). The assessment indicated the resident was independent with wheelchair use. A review of the resident's plan of care initially dated July 22, 2024, revealed the resident was at risk for falls related to a decline in functional status and non-compliance with transfers. A review of a Fall Risk Evaluation dated September 3, 2024, identified Resident 1 as at high risk for falls. A review of a progress notes dated December 19, 2024, at 5:41 PM revealed the resident had a fall in the hallway. The resident was being assisted with transportation to the dining room for dinner when the resident fell forward out of her wheelchair and hit her face on the floor. The fall resulted in a 7 cm x 7 cm hematoma (a pool of mostly clotted blood that forms in an organ, tissue, or body space) over her left eye, a 1cm laceration (cut) under her left eye and complaints of pain when trying to move her left arm and shoulder and subsequent transfer to the hospital. A review of a facility investigative report dated December 19, 2024, at 5:32 PM revealed the resident was being transported by Employee 1 NA (nurse aide) to the dinette for supervised dining. It was indicated the resident pitched herself forward and fell from her wheelchair. Page 1 of 3 395433 395433 12/30/2024 Embassy of Tunkhannock 30 Virginia Drive Tunkhannock, PA 18657

F 0689 Level of Harm - Actual harm Residents Affected - Few A review of a witness statement from Employee 1 dated December 12, 2024, revealed the employee stated she informed the resident that she would help her to the dining room for dinner. The employee indicate that she started pushing her towards the dining room and then noticed the resident started to lean forward which prompted the employee to stop the wheelchair. The employee stated she stopped the wheelchair and the resident lunged forward onto the floor. A review of hospital records dated December 19, 2024, revealed the resident had an X-ray completed on her left shoulder. The results indicated the resident had a dislocation (when bones separate at a joint) of the left humeral head (the rounded end of the upper arm bone, or humerus, that forms the ball of the shoulder joint). Further review of the hospital records dated December 19, 2024, revealed the resident had a CT scan (a noninvasive medical imaging procedure that uses Xray and computers to create detailed pictures of the inside of the body) of the head and brain. The results indicated the resident had a comminuted depressed fracture (a broken bone that has broken into three or more pieces and are pressed downward) of the left orbital floor (bone that surrounds the eye) and a suspected nondisplaced fracture (a broken bone where the pieces of the bone remain aligned and don't move out of place) of the right orbital wall. An interview with the Nursing Home Administrator (NHA) on December 30, 2024, at approximately 1:00 PM revealed all residents should have leg rests in place when being transported by staff in wheelchairs. Furthermore, the NHA stated at the time of the resident's fall leg rests were not in place on the resident's wheelchair. The facility failed to properly utilize leg rests to transport a resident to the dining room resulting in the resident falling from the wheelchair and sustaining a major injury. An interview with the Director of Nursing (DON) and the Nursing Home Administrator (NHA) confirmed the facility failed to implement effective safety measures to prevent Resident 1 from falling, resulting in serious injury and hospital transfer. This deficiency is cited as past non-compliance. The facility's corrective action plan included the following: 1.Facility would be unable to change the outcome of the event that occurred with the resident on December 19, 2024. 2. All residents were assessed to determine if they can self-propel at a wheelchair/other ancillary chair level. Residents were audited to determine if leg rests were available for all wheelchairs/other ancillary chairs in the facility. Leg rests were obtained for all wheelchairs that are being utilized by residents. Leg rests bags have been ordered that will attach to all wheelchairs that will hold bilateral leg rests for immediate transport with leg rests. 3.Policy updates to be completed in cooperation with corporate clinical liaison, IDT (interdisciplinary team) and QAPI (quality assurance performance improvement) teams. Education was completed with all staff on December 21, 2024, and ongoing educations for agency personnel, vendors, and family members next time they are in the building to ensure that no resident is transported within the facility without leg rests on their chair, unless that resident can self-propel their wheelchair with 395433 Page 2 of 3 395433 12/30/2024 Embassy of Tunkhannock 30 Virginia Drive Tunkhannock, PA 18657

F 0689 verbal cues or independently. Level of Harm - Actual harm 4.Audits occur two times weekly by the nursing supervisor/administration to ensure no facility transport is occurring without leg rests to chairs. Audits will also present the ability to educate on the spot and provide supervision in unusual situations of behaviors when residents will not utilize leg rests or are unable to communicate during behavioral outbursts. Audits will continue for 30 days with results to the QA (quality assurance) committee for review, assessment and to ensure compliance with the new policy. Residents Affected - Few The facility's compliance date was December 21, 2024. 28 Pa. Code 211.12 (c)(d)(1)(3)(5) Nursing services 395433 Page 3 of 3