Health inspection·May 30, 2024

F 0689 right elbow - no LOC [loss of consciousness] and sustained a skin tear to the right elbow. Level of Harm - Actual harm Review of Resident 1's nurses note of May 15, 2024, at 10:59 a.m. revealed UM [unit manager] made this writer aware about resident had fall. this writer came to resident's room and seen resident on the floor between her dresser and her bed. resident said this happen when CNA rolled her on her on her left side, there was no pink pad under me so she told me to stay right there, and went out to the room to get pad and i felt unsteady and try to reached out to the dresser so i could steady myself and then i went down to the floor on my right side. Neuro checks initiated, vitals were taken and entered in PCC [Point Click Care electronic medical record]. resident assessed by RN [registered nurse], OPTUM CRNP [certified registered nurse practitioner] and [attend physician]. resident had skin tear on right elbow, resident C/O [complained of] pain 10/10 to her left knee. PRN [as needed] pain medication given. N/O [new order] for X-ray given by MD. Residents Affected - Few Review of nurses note of May 15, 2024, at 3:06 p.m. indicated x-ray result was negative for any fractures. Review of Resident 1's clinical record including nurses note of May 16, 2024, at 5:58 a.m. revealed right arm x-ray done at 11:00 p.m. Review of clinical record of Resident 1's interdisciplinary note of May 16, 2024, at 8:58 a.m. indicated CRNP made aware of acute right humeral neck fracture. Further review of Resident 1's nurses note of May 16, 2024, at 9:52 a.m. revealed resident sent out to the hospital related to right humeral neck fracture. Additional nursing note at 3:12 p.m. indicated resident was back from the hospital with a sling and orders to follow up with orthopedic surgery. Review of orthopedic surgery consult of May 20, 2024, revealed resident seen for right proximal humerus fracture with recommendations to continue the sling, not use the right upper extremity for transfers, and follow up in two weeks. Review of Employee E3's statement obtained on May 15, 2024, revealed I was doing care on resident, stepped out room to get pad for her. came back patient was on fall [sic]. she told me she was reaching for dresser when falling. Observation on May 30, 2024, at 10:00 a.m. revealed Resident 1 lying in bed with right arm in sling and right hand with edema (swelling) elevated on pillow. Interview with Resident 1 on May 30, 2024, at 10:00 a.m. revealed staff was changing resident and had forgotten the incontinence pad. Resident 1 revealed he/she was on his/her left side when staff left the room to retrieve a pad from the laundry cart. Resident 1 indicated he/she became unsteady, reached for the dresser, and rolled out of the bed onto the right side. Resident 1 stated that he/she continues to have pain, especially when turned on the right side. Review of physician's orders included an order for Oxycodone HCl 5 milligrams (mg) one tablet every eight hours as needed for moderate pain and Oxycodone HCl 10 mg one tablet every eight hours as needed for severe pain. Review of Resident 1's May 2024 Medication Administration Record (MAR) revealed that prior to the fall from May 8-14, 2024, the resident received Oxycodone HCl 5 mg twice and did not receive any Oxycodone HCl 10 mg. Further review of the May 2024 MAR revealed that from May 15-30, the resident received Oxycodone HCl 5 mg twice and received Oxycodone 10 mg HCl 18 times. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395469 If continuation sheet Page 2 of 3 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 395469 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/30/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Emerald Nursing and Rehabilitation 320 South Market Street Elizabethtown, PA 17022 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)

F 0689 Interview with the Nursing Home Administrator on May 30, 2024, at 12:30 p.m. revealed the staff should not have left the resident unsupervised while retrieving supplies. Level of Harm - Actual harm Residents Affected - Few The facility failed to ensure Resident 1 was provided with supervision which resulted in actual harm to Resident 1 sustaining a fall, requiring transfer to the hospital via emergency medical services and the diagnosis of a fracture to the right humerus. 28 Pa. Code: 211.5(f) Clinical records Previously cited 4 /19/24 28 Pa. Code: 211.10(d) Resident care policies 28 Pa. Code: 211.12(d)(1) Nursing services 28 Pa. Code: 211.12(d)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395469 If continuation sheet Page 3 of 3