Health inspection·June 6, 2023

F 0685 Assist a resident in gaining access to vision and hearing services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of select facility policies and procedures, clinical record review, observation, and staff interview, it was determined that the facility failed to provide hearing assistive device treatment and services for one of six residents reviewed (Resident 1). Residents Affected - Few Findings include: Interview with the Nursing Home Administrator and the Director of Nursing on June 6, 2023, at 3:35 PM revealed that the facility could not provide a policy/procedure to address the care and treatment planning for a resident who required the use of a hearing aid (e.g., assist in making appointments with a hearing device professional, planned storage, responsible person to ensure the application of the device, and steps taken if the device is determined missing, etc.). Observation of Resident 1 on June 6, 2023, at 9:45 AM revealed she was in the hallway while Employee 1 (licensed practical nurse) positioned herself closely to Resident 1's face while repeatedly asking the same questions while Resident 1 exhibited difficulty with the communication. Resident 1 repeatedly asked, What? Interview with Employee 1 on the date and time of the above observation indicated that she could not find Resident 1's hearing aid that morning, and that it was, gone. Employee 1 indicated that Resident 1 was to wear a hearing aid in her left ear, but, that she only did so when she wanted. Interview with Employee 1 and Employee 2 (assistant director of nursing) on June 6, 2023, at 9:50 AM indicated that Resident 1's [NAME] (electronic documentation of resident care needs to include hearing devices) indicated that she wore a hearing aid only in her left ear. Resident 1's [NAME] printed June 6, 2023, at 9:56 AM indicated that Resident 1 required a hearing aid in her right and left ears. A plan of care developed by the facility to address Resident 1's leisure activity listed interventions that included Resident 1 wore bilateral hearing aids most of the day, and that staff would remind Resident 1 to utilize her hearing aids. Interview with the Nursing Home Administrator, the Director of Nursing, Employee 2, and Employee 3 (assistant nursing home administrator) on June 6, 2023, at 1:45 PM revealed that staff determined Resident 1 was missing a hearing aid on May 1, 2023; however, staff did not document this in her medical record and did not update her [NAME] or plan of care to reflect that she was not wearing her right hearing aid. The interview confirmed that the facility could not provide evidence that staff took Page 1 of 4 395571 395571 06/06/2023 Muncy Place 215 East Water Street Muncy, PA 17756

F 0685 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few any steps to arrange for Resident 1's hearing aid replacement (e.g., determine if she or her responsible party wanted to have the device replaced or arrange for an appointment with a hearing device professional). Late entry social services documentation dated June 6, 2023, at 1:46 PM (for an effective date of May 1, 2023), revealed that Resident 1's daughter reported that her mother's hearing aid was missing, and staff were instructed to, keep an eye out for missing item and to notify IDT (interdisciplinary team) of its return. Social services documentation dated June 6, 2023, at 2:09 PM revealed that facility staff left a message with Resident 1's primary contact to inquire about scheduling an appointment for the missing hearing aid. 28 Pa. Code 211.10(a)(d) Resident care policies 28 Pa. Code 211.11(d) Resident care plan 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services 395571 Page 2 of 4 395571 06/06/2023 Muncy Place 215 East Water Street Muncy, PA 17756

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 review of select facility policies and procedures, clinical record review, and staff interview, it was determined that the facility failed to implement interventions to prevent resident falls for two of six residents reviewed (Residents 1 and 2). Findings include: The facility policy entitled, Fall Prevention and Management, last revised June 2023, revealed that the licensed nurse is responsible to initiate safety interventions to prevent or minimize falls based on the fall risk evaluation and communicate interventions initiated on the resident care plan. The licensed nurse is responsible to develop and periodically update the fall related care plan. The licensed nurse is responsible to review the resident care plan and revise (add/delete) interventions to prevent/minimize subsequent falls. Clinical record review for Resident 1 revealed nursing documentation dated May 26, 2023, at 1:46 PM that Resident 1 sustained a fall at 8:30 AM. The documentation indicated that staff followed guidelines when providing care with the assistance of one staff and a gait belt. Resident 1 was sent to the emergency room for an evaluation and treatment and returned from the emergency room with a diagnosis of a fractured nose. The documentation indicated that staff updated Resident 1's [NAME] (electronic documentation of resident care needs, to include level of staff assistance required, utilized by nurse aide staff caring for a resident) to reflect a downgraded transfer status. Review of Resident 1's active plan of care developed by the facility to address Resident 1's potential for injury, trauma, and falls related to her debility indicated an active intervention, dated April 5, 2023, that Resident 1 required the assistance of two staff and a gait belt for transfers. Review of Resident 1's [NAME] dated March 17, 2023 (active at the time of Resident 1's fall on May 26, 2023) revealed that the physical therapist instructed staff to provide the assistance of one staff person for transfers; and that Resident 1 could ambulate to the bathroom and in the halls with the assistance of one staff person and a roller walker. Resident 1's plan of care and [NAME] provided different instructions pertaining to transfer status at the time of her fall on May 26, 2023. Review of Resident 1's [NAME] dated May 26, 2023, indicated that a physical therapist documented a downgraded transfer status as Resident 1 required the assistance of two staff with a gait belt for transfers at that time. Clinical record review for Resident 1 revealed nursing documentation dated June 1, 2023, at 8:34 AM that the registered nurse (RN) was walking down the hall when the licensed practical nurse (LPN) reported Resident 1 had fallen. The RN noted Resident 1 on the floor in her bathroom. Resident 1 sustained a skin tear to her left forearm measuring 2.5 cm (centimeters) by 1 cm by less than 0.1 cm and an abrasion to the left side of her back measuring 19 cm by 1.5 cm by 0 cm. The documentation indicated that one staff member attempted to transfer Resident 1 at the time of the fall. Review of the facility's investigation of Resident 1's fall on June 1, 2023, confirmed that nurse 395571 Page 3 of 4 395571 06/06/2023 Muncy Place 215 East Water Street Muncy, PA 17756

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few aide staff failed to obtain the assistance of additional staff when transferring Resident 1 to provide toileting care. Clinical record review for Resident 2 revealed a plan of care developed by the facility to address his risk for falls that listed interventions that included two staff to provide assistance with bed mobility (dated March 31, 2023). Nursing documentation dated May 2, 2023, at 4:55 PM revealed that a nurse aide reported that while she was providing care, Resident 2 became combative (pushing and pulling away from her) when he rolled off the other side of the bed. Resident 2 did not sustain any injuries. Review of Resident 2's [NAME] in effect at the time of Resident 2's fall instructed staff to ensure the assistance of two staff for bed mobility. The facility's investigation of Resident 2's fall on May 2, 2023, confirmed that staff failed to follow his plan of care and ensure the assistance of two staff for bed mobility as per his [NAME]. Interview with the Director of Nursing, the Nursing Home Administrator, Employee 2 (assistant director of nursing), and Employee 3 (assistant nursing home administrator), on June 6, 2023, at 1:45 PM confirmed the above findings for Residents 1 and 2. 28 Pa. Code 211.11(d) Resident care plan 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services 395571 Page 4 of 4