Health inspection·January 21, 2025

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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews, review of facility policy and the review of clinical records, it was determined that the facility failed to assess, monitor and notify the physician regarding an injury of unknown origin for one of two residents reviewed. (Resident R1) Residents Affected - Few Findings include: Review of facility policy on Assessment revealed that under section POLICY: The Center will conduct initially and periodically a comprehensive, standardized, reproducible assessment of each patient's functional capacity. The assessment must accurately reflect the patient's status at the time of assessment. Routine and focused assessments will be performed on an ongoing basis as needed. The assessment process must include direct observation and communication with the patient, as well as communication with licensed and non-licensed direct care staff members on all shifts. Under section PURPOSE: To determine patient's condition and clinical needs. Under section PRACTICE STANDARDS 4. Conduct a change in condition assessment as needed using the eInteract Change in Condition Evaluation. 5. Utilize assessment data to develop the care plan. 6. Notify physician/advanced practice provider (APP) of assessment results as indicated. 7. Document physician/APP notification and response if indicated. Review of Resident R1's clinical record revealed that Resident R1 was admitted to the facility on [DATE]. Resident R1's diagnoses included Cerebral Infarction, Aphasia, Vascular Dementia with other Behavioral Disturbance, and Anxiety Disorder. Review of Resident R1, most recent MDS (minimum data set- a federally required resident assessment completed at a specific interval) dated November 2, 2024, revealed a BIMS (brief interview for mental status) score of 3, indicating severe cognitive impairment. Review of Resident R1's nursing note dated January 9, 2025, time stamped at 12:03 p.m. reveled that Resident R1 was transferred to local hospital for, new onset strabismus left eye. Progress notes Page 1 of 2 395459 395459 01/21/2025 Crestview Center 262 Toll Gate Road Langhorne, PA 19047

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few dated January 9, 2024, 6:24 p.m. revealed a late entry note revealing that nurse spoke to intensive care unit (ICU). Per ICU nurse, per EMS (Emergency Medical Services) resident had unwitnessed fall with head injury at time unknown. Facility nurse informed ICU nurse that no fall documentation was noted at facility. Further review of Resident R1's nursing note revealed that prior to January 9, 2025, there was no documentation regarding Resident R1's injuries, there was no documented evidence that the physician was notified. Review of nurse's aide, Employee E3's statement dated January 10, 2024, revealed that on January 8, 2025, during the 7 to 3 shift, Employee E3 wrote redness around the left eye and black around the left eye the next day. Interview with nurse's aide, Employee E3 conducted on January 21, 2024, at 12:27 p.m. confirmed that on January 8, 2025, she was in Resident R1's room with the therapist Employee E4 and that Employee E4 and her observed discoloration on Resident R1's left eye. Further, Employee E3 revealed that she did not have to report her observation to licensed nurse Employee E5 who was the nurse on the unit that day, because licensed nurse Employee E5 came into the room and saw the discoloration herself. Review of therapist Employee E4's statement dated January 9, 2025, revealed that on January 8, 2025, Resident R1 was seen at bedside with nursing (nurse aide and licnesed nurse). Resident R1 complained of pain with movement of left lower extremity. Bruising observed on forehead and left eye. On Thursday January 9, 2025, bruising spread to both eyes- no fall was reported. Review of licensed nurse Employee E5's written statement revealed that on January 8, 2025, Resident R1's left eye was slightly puffy, skin color different from the last time I have seen her which was before resident went to the hospital, yellow under the eyes, discoloration, mid upper forehead had yellow spot. On January 9, 2025, noticed left eye bruise with eye brow risen, lump on forehead, yellow color, right eye inverted towards the nose, left eye stayed straight. Telephone interview with therapist Employee E4 conducted on January 21, 2025, at 12:52 pm revealed that she was in room with nurse's aide Employee E3, when she observed the bruise on Resident R1's forehead and left eye. Further, therapist Employee E4 revealed that licensed nurse, Employee E5 came in to give meds. Further therapist Employee E4 also revealed that she reported her observation to licensed nurse Employee E5 at the time and that she talked to licensed nurse Employee E5 about the bruising on the left eye and the forehead. Interview with Facility Administrator Employee E1 conducted on January 21, 2024, at 12:30 pm revealed that Employee E4 was no longer working at the facility. Employee E4 was not available for interview. Review of the resident's clinical record revealed no documented evidence that the physician was notified of Resident R5's injury of unknown origen. 28 Pa Code 201.18 (b)(1) Management 28 Pa. Code 211.10 (c) Resident care policies 28 Pa. Code 211.12 (c)(d)(1)(3) Nursing services 395459 Page 2 of 2