Health inspection·April 17, 2023

F 0600 Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Level of Harm - Actual harm Residents Affected - Few Based on review of facility policy, clinical records, and facility documentation, and staff interviews, it was determined that the facility failed to provide services to create an environment free from neglect by transferring a resident improperly, resulting in actual harm of a left lower leg and ankle fractures for one of four residents reviewed (Resident R1). This deficiency is cited as past non-compliance. Findings include: Review of the facility policy entitled, Resident Abuse Policy and Procedure and Mandatory Reporting of Alleged Abuse dated 2/20/23, revealed, abuse means the willful infliction of injury, .with resulting physical harm, pain, or mental anguish. Willful as used in the definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. A review of Resident R1's clinical record revealed an admission date of 4/30/19, that included diagnoses of stroke, high blood pressure, lung problems, muscle weakness, and seizures. A review of Resident R1's Quarterly Minimum Data Set assessment (MDS- an assessment tool used to facilitate the management of care), dated 2/09/23, revealed that Resident R1 was total dependance and required two-person assist with transfers. A review of Resident R1's Self Care Deficit ADL (Activities of Daily Living) care plan, originally dated 5/09/19, revealed under the category, Transfer Status: Mechanical lift For Transfers assist of two people. A review of Resident R1's clinical record revealed a nursing note written by Registered Nurse (RN) Employee E2, dated 3/28/23, at 7:35 a.m. Summoned to resident room by STNA [State Tested Nurse Aide], reporting fall out of hoyer [mechanical] lift. Resident stated, I slid out of the lift onto my butt, the pad was too short. Resident assessed for injury with none noted. A nursing note dated 3/29/23, at 3:18 p.m. revealed Resident R1 had complaints of pain and swelling noted to left lower leg and ankle. Family and physician notified, orders obtained and x-ray's obtained. Ice applied and Tylenol (pain medication) administered. In-house x-ray's were ordered on 3/29/23, and impression indicated, Multiple Proximal & Distal left TIB/FIB [tibia/fibula-leg bones] fractures and left quadrant Malleolar & Trimalleolar [ankle bones] fractures. Page 1 of 3 395572 395572 04/17/2023 Fairview Manor 900 Manchester Road Fairview, PA 16415

F 0600 Level of Harm - Actual harm Residents Affected - Few A nursing note dated 3/30/23, at 9:46 a.m. revealed that the Orthopedic physician recommended Resident R1 to be transferred to the hospital to be seen. Resident R1 sent to hospital and admitted , resident returned to facility on 4/02/23, with a leg splint / immobilizer to the left leg. Review of information submitted by the facility, dated 3/30/23, revealed that Resident R1 was transferred with a mechanical lift on 3/28/23, around 7:35 a.m. when Resident R1 slid out of the lift pad NA Employee E1 notified nursing staff that Resident R1, fell out of hoyer lift. Nursing staff notified of incident and checked for any injuries. Resident R1 did not complain of any pain until 3/29/23, at 3:20 p.m. which at that time RN supervisor was notified who then notified physician, x-rays ordered and impression indicated, Proximal and distal fractures of the left tibia, fibula and malleolar ankle fractures. Family and physician were notified. An orthopedic physician consult was ordered but the orthopedic physician felt Resident R1 needed to be seen at the hospital, Resident R1 was transferred to the hospital on 3/30/23. A review of documentation submitted by the facility, dated 3/29/23, revealed that the facility initiated an investigation, and the NA was removed from the schedule and would not be returning. Review of the Director of Nursing's (DON) note of the interview conducted with NA Employee E1, dated 3/29/23, reflected that NA, Employee E1, stated that they had been trained on the use of the lift on 12/21/22 and 2/21/23, and was aware that Resident R1 was a two-person lift, however transferred the resident independently without assistance. During an interview on 4/14/23, at 11:00 a.m. the DON confirmed that the NA Employee E1 should not have transferred Resident R1 alone and that there should have been two staff during the transfer. The facility neglected to utilize the appropriate transfer for a resident as care planned which placed the resident at risk for injury from an improper transfer method. As a result, there was actual harm of a lower leg and ankle fractures to Resident R1 requiring medical treatment at the hospital. This deficiency is cited as past non-compliance. On 3/30/23, the facility submitted a plan to include: The NA Employee E1 was removed from the schedule and would not be returning. The facility initiated re-educating all nursing staff, prior to their next shift after the 3/29/23, investigation of the 3/28/23, incident on abuse/neglect, safety education and proper lift transfer procedures. The DON also is in process of monitoring all staff completing transfers. Interviews with Licensed Practical Nurse (LPN) Employee E6, RN Employee E2, and NA Employees E3, E4, E5 and E7 confirmed that they were re-educated on that any time a lift is used, there must be two staff to properly and safely complete the transfer with a lift. The employees stated that the information had been reviewed in February and were re-educated again the last two days of March and beginning of April. The facility continued education for safe proper mechanics of transfer using a lift in April 2023, after the 3/28/23, incident of all staff related to proper mechanics of a transfer, and were observed transferring a resident. The facility Nursing Home Administrator (NHA) stated that the facility was continuing the audits ongoing until compliance is determined. The audit sheets for April were 395572 Page 2 of 3 395572 04/17/2023 Fairview Manor 900 Manchester Road Fairview, PA 16415

F 0600 reviewed. Level of Harm - Actual harm The facility has demonstrated compliance with the mechanical lifts procedure since 4/05/23. Residents Affected - Few 483.13 - Resident Behavior and Facility Practices, 10-1-1998 edition 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(e)(1) Management 28 Pa. Code 210.18(b)(3)(e)(1) Management 28 Pa. Code 211.12(c) Nursing services 28 Pa. Code 211.12(d)(3) Nursing services 395572 Page 3 of 3