Health inspection·April 5, 2024

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. Based on review of facility policies, clinical records, and facility investigative documents, as well as staff interviews, it was determined that the facility failed to ensure that each resident received adequate supervision by failing to ensure that care-planned interventions were in place for one of four residents reviewed (Resident 2). Findings include: A quarterly Minimum Data Set (MDS) assessment (a federally-mandated assessment of a resident's abilities and care needs) for Resident 2, dated March 21, 2024, indicated that the resident could usually understand, was usually understood, was cognitively intact, and required extensive assistance from staff for daily care. Resident 2's care plan, dated June 14, 2023, revealed that she was to have an extensive assist of two when providing care. A witness statement from Nurse Aide 1, dated March 27, 2024, revealed that she provided incontinence care to Resident 2 by herself around 12:00 a.m A witness statement from Licensed Practical Nurse 2, dated March 27, 2024, revealed that Tylenol was administered to Resident 2 at 1:00 a.m. due to the resident complaining of pain. A witness statement from Nurse Aide 3, dated March 27, 2024, revealed that at around 3:30 a.m. to 4:00 a.m. she asked Resident 2 if she needed incontinence care, and the resident refused to roll due to severe pain. A witness statement from Licensed Practical Nurse 4, dated March 27, 2024, revealed that she observed a bruise to Resident 2's forehead during the 7:30 a.m. medication administration and notified the registered nurse. A nursing note for Resident 2, dated March 27, 2024, revealed that the resident had a raised, bruised area on her forehead; the resident stated she rolled out of bed but was not able to tell staff how she got back into bed; the resident's right hip was swollen; and the resident complained of pain to her right hip. The physician and Director of Nursing were notified. New orders were given for the resident to receive an x-ray, and the Director of Nursing notified the resident's responsible party. A nursing note for Resident 2, dated March 27, 2024, revealed that the physician and responsible party were notified of the x-ray results, and the resident was sent to the emergency room for (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 395592 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 395592 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Haida Nursing and Rehab 397 Third Avenue Extension Hastings, PA 16646 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)