Health inspection·August 24, 2023

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interview, it was determined that the facility failed to ensure that the Minimum Data Set (MDS) assessment was completed to accurately reflect the resident's status for one of 32 sampled residents. (Resident 126) Residents Affected - Few Findings include: Clinical record review revealed that Resident 126 had diagnoses that included a history of falling and repeated falls. A significant change MDS assessment dated [DATE], failed to indicate in section J, Health Conditions, that the resident had experienced falls during the MDS assessment period. Review of nursing documentation revealed that the resident had fallen during the MDS assessment period. In an interview on August 24, 2023, at 9:15 a.m., RN1 stated that the MDS assessment dated [DATE], was incorrect as the resident had two or more falls with minor injuries during the MDS assessment period. Page 1 of 3 395477 395477 08/24/2023 Laureldale Skilled Nursing and Rehabilitation Cent 2125 Elizabeth Avenue Laureldale, PA 19605

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, review of incident reports and staff interview, it was determined that the facility failed to provide adequate supervision and interventions in a timely manner in order to prevent falls for one of six sampled residents who were at risk for falls. (Resident 126) Findings include: Clinical record review revealed that Resident 126 was admitted to the facility on [DATE], and had diagnoses of Parkinson's disease, repeated falls, unsteadiness on his feet and a history of falling. The Minimum Data Set assessments dated May 25, 2023, and August 16, 2023, indicated that the resident required limited to extensive assistance for activities of daily living and had a history of falls. A review of the care plan revealed the resident was at risk for falls due to a history of falls, impaired balance, poor coordination, an unsteady gait and non-compliance with asking for assistance from staff. Review of incident reports revealed that on June 1, 4, 7, 11, and 22, 2023, the resident had been found on the floor in his room at various times during the 3:00 p.m., to 11:00 p.m., shift. On July 6, 2023, and July 11, 2023, facility incident reports indicated that he had slid off of his wheelchair between 6:00 p.m., and 7:00 p.m On July 19, 2023, at 9:45 p.m., he again had fallen out of his wheelchair and was found on the floor in his room. On July 25, 26 and 27, 2023, the resident was found on the floor in his room between 9:00 p.m., and 11:00 p.m On July 28, 2023 and July 29, 2023, the resident had falls on the 11:00 p.m., to 7:00 a.m., shift. Further review of incident reports revealed that the resident was found on the floor in his room on August 1, 5, 6, 8, 14, 21, 22 and 23, 2023, again all during the evening shifts. On August 1 and 22, 2023, the resident had been transferred out to the hospital for evaluation and treatment after he had fallen. Review of the facility incident report for August 23, 2023, revealed that a new intervention was to place the resident on one to one observation on the evening shift. In an interview on August 24, 2023, at 9:15 a.m., RN1 confirmed that the new intervention was to place the resident on one to one observation on the evening shift due to his multiple falls since he was admitted to the facility. Review of incident reports from May 31, 2023, through August 23, 2023, revealed that the resident had experienced 16 falls on the 3:00 p.m.,- 11:00 p.m., shift, three falls on the 11:00 p.m., - 7:00 a.m., shift and six falls on the 7:00 a.m., to 3:00 p.m., shift for a total of 25 falls in three months. The facility failed to provide adequate supervision in a timely manner in order to prevent multiple falls since he had been admitted to the facility. 28 Pa. Code 211.12(d)(1)(5) Nursing services. 395477 Page 2 of 3 395477 08/24/2023 Laureldale Skilled Nursing and Rehabilitation Cent 2125 Elizabeth Avenue Laureldale, PA 19605

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, clinical record review, and staff interview, it was determined that the facility failed to adequately assess bladder incontinence and failed to provide care and services to restore bladder continence for one of 32 sampled residents. (Resident 116) Findings include: Review of the facility policy entitled, Continence Management, dated August 1, 2023, revealed that facility staff was to complete a urinary incontinence assessment upon admission or re-admission and with a change in condition or change in continence status. Clinical record review revealed that Resident 116 was admitted to the facility on [DATE], with diagnoses that included dependence on dialysis, muscle wasting, and chronic obstructive pulmonary disease. According to the Minimum Data Set (MDS) assessment, dated August 7, 2023, the resident was usually understood and needed extensive assistance from staff for toileting. The assessment further indicated that the resident was frequently incontinent of urine and was not on a toileting program. There was no documentation in the clinical record to support that the resident's urinary incontinence was assessed by the facility to determine if normal bladder function could be restored. According to nurse aide documentation, the resident had been frequently incontinent since admission to the facility. In an interview conducted on August 24, 2023, at 9:18 a.m., Registered Nurse 1 (RN1) confirmed Resident 116's urinary incontinence had not been assessed per facility policy. 28 Pa Code 211.12(d)(1)(5) Nursing services. 395477 Page 3 of 3