Health inspection·April 3, 2024

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon clinical record and facility documentation review, it was determined the facility failed to ensure adequate supervision of a resident to prevent resident from falling from a facility window resulting in physical harm and hospitalization for Resident 1. Findings include: Review of Resident 1's diagnosis list revealed diagnoses including left side Hemiplegia (paralysis or weakness to one side of the body), difficulty in walking, Vascular Dementia (irreversible, progressive degenerative disease of the brain resulting in loss of reality contact and functioning ability), muscle weakness, Psychotic Disturbance (condition of the mind that results in difficulties determining what is real and what is not real.[3] Symptoms may include delusions and hallucinations), Alcohol abuse with Alcohol induced sleep disorder, and Alcohol Dependence with Alcohol-induced persisting Dementia. Review of Resident 1's Quarterly Minimum Data Set (MDS - periodic assessment of resident needs) dated February 2, 2024, revealed Resident 1 had a Brief Interview for Mental Status Score of 5 indicating severe cognitive impairment. Review of Resident 1's Elopement Risk assessment dated [DATE], revealed Resident 1 was a moderate wander risk. Review of Resident 1's Fall Risk Assessment/Evaluation dated March 26, 2024, revealed Resident 1 was a high risk for falls. Review of Resident R 1's care plan initiated on Sepember 26, 2022 revealed a focus goal of [Resident] has adjustment issues to admission distractibility r/t (related/to) cognitive deficits, feelings of loss of independence/phsysical decline. Further review of same care plan revealed interventions of a Consult with [community provider] to monitor medications, Encourage [Resident 1] to participate in conversation with staff and other residents daily, Encourage ongoing family involvement, and Help [Resident 1] to identify stressors which may be early warning signs of problem behavior. Intervene and remove stressors as possible. Further review of Resident 1's care plan revealed a care plan related to risk of falls and notation of recent falls occurring on March 1, 2023; March 25, 2023; May 25, 2023; November 14, 2023 and March 26, 2024 during which resident was identified as self ambulating. Interventions included but not limited to Anticipate and meet [Resident 1]'s needs, Assist of 1 for transfers and ambulation with Page 1 of 3 395575 395575 04/03/2024 Gardens at Stevens, The 400 Lancaster Avenue Stevens, PA 17578

F 0689 RW (rolling walker). Level of Harm - Actual harm Review of Resident 1's care plan revealed a focus goal initiated November 22, 2022 for Elopement and associated injury related to exit seeking behavior. Further review of same care plan revealed interventions including; Assist in orientation to room and facility using verbal cues and reminders, Encourage group activity and attempt to keep occupied, Notify social services for persistent attempts to leave building and not responding to redirection, provide diversional activities when exit seeking, and wanderguard function checked each night shift and placement checked each shift. Residents Affected - Few Review of Resident 1's clinical record including progress notes dated April 2, 2024, revealed CNA [certified nurse aide] for night shift entered unit at 2211 [10:11 p.m.] stating to other RN [registered nurse] supervisor that she saw a man outside the kitchen a minute before. This RN followed other RN down hall to check on situation. Exiting back kitchen door we observed [Resident 1] standing and leaning against stair wall. Resident noted he fell but could not determine how he got outside. Another staff member found resident glasses on ground around the other side of the building next to air conditioner units. No alarms had gone off in building. Staff had last seen [Resident 1] at 2155 [9:55 p.m.] in hallway in wheelchair. Wheelchair was not with resident when he was observed outside. Resident taken inside and placed in wheelchair. This RN assessed resident for injuries and notified [director of nursing, nursing home administrator and on call provider]. Resident with multiple abrasions to head, ankles, and knees. Decision to send to ED [emergency department] for evaluation since resident stated he fell and it was unwitnessed. Call placed to EMS. Resident's son notified of situation and ongoing investigation of events. Staff continued to search for resident's wheelchair which was found in 2nd floor restorative dining room where a window was noted to be open. EMS arrived with [police officer]. Resident transported to [acute care facility]. Resident left facility vital signs stable though not within residents normal limits, resident awake though more hypoactive, verbalized no complaints of pain however resident appeared pale and facial expressions and body language indicative of pain, injuries as noted above. Review of Resident 1's emergency room record dated April 2, 2024, revealed patient admitted following a fall out of window at [facility], Patient found to have two left facial fractures, left 3-6 rib fractures, left pneumothorax [air leakage between lungs and chest wall] and subarachnoid hemorrhage [type of brain bleed]. Further review of Resident 1's acute care facility records indicate the following injuries as of April 2, 2024: traumatic fracture of ribs of left side with pneumothorax required chest tube insertion; left zygomatic arch [portion of jaw/mandible] fracture; left orbital wall [bone around eye] fracture; left maxillary [portion of jaw] fracture and left third through six rib fractures. Review of facility documentation and witness statements dated April 1, 2024, revealed Resident 1 was observed at 9:30 p.m. near the nurses' station and last observed at 9:55 p.m. near or in resident's room in a wheelchair. Resident 1 was next observed at approximately 10:11 p.m. outside the building near a set of stairs leading to the kitchen entrance. Observation of the activity room windows on April 3, 2024, at approximately 9:30 a.m. revealed all windows in the activity room to have two window stop brackets on each window. Further observation of the window on the left side of the activity room revealed two window stop 395575 Page 2 of 3 395575 04/03/2024 Gardens at Stevens, The 400 Lancaster Avenue Stevens, PA 17578

F 0689 brackets secured in the upper portion of the window. Level of Harm - Actual harm Interview with the Nursing Home Administrator on April 3, 2024, at 11:00 a.m. revealed Resident 1's wheelchair was found approximately four feet from the window on the left side of the activity room on the night of the fall and the window was observed to be open at that time. Residents Affected - Few Further interview with the Nursing Home Administrator revealed no staff members were present in the activity room at the time Resident 1 opened the window or in the hours preceding the fall. The facility failed to provide adequate supervision by facility staff to prevent accidents to a resident noted to be a High fall risk and moderate elopement risk resulting in harm and hospitalization to Resident 1. 28 Pa. Code 201.18(a)(b)(1) Management Previously cited 3/10/2022, 3/15/2023, 10/5/2023, 2/1/2024 28 Pa. Code 211.12(a)(d)(4)(5) Nursing Services Previously cited 3/10/22, 3/15/2023, 5/13/2023, 8/8/2023, 2/1/2024 395575 Page 3 of 3