Health inspection·April 5, 2024

F 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy and clinical records and facility documentation, and staff interviews, it was determined that the facility failed to fully investigate an incident with injury of unknown origin for one of 18 residents reviewed (Resident R15). Residents Affected - Few Findings include: Review of a facility policy entitled Investigating Injuries dated 2/20/24, revealed that an Injury of unknown source is defined as an injury that meets both of the following conditions: a. The source of the injury was not observed by any person or the injury could not be explained by the resident; and b. The injury is suspicious because of: (1) The extent of the injury The policy also indicated with the help of the staff and management, the investigator will compile a list of all personnel, including consultants, contract employees, visitors, family members, etc., who have had contact with the resident during the past 48 hours. Review of Resident R15's clinical record revealed an admission date of 1/04/24, with diagnoses that included fractured left hip, pressure ulcer left heel, and atrial fibrillation (abnormal heart rhythm). Review of Resident R15's quarterly Minimum Data Set (MDS-periodic assessment of resident care needs), assessment dated [DATE], revealed that Resident R15 was cognitively impaired and his/her transfer status was an extensive assist, two-person physical assist. Review of a Physical Therapy Treatment Encounter Note dated 3/14/24, revealed Resident R15 was a maximal assist of two for standing. During an interview on 4/4/24, at 10:35 a.m. the Director of Physical Therapy Employee E1 confirmed Resident R15 was a maximal assist of two for all transfers. Page 1 of 6 395594 395594 04/05/2024 Oil City Nursing and Rehab 1293 Grandview Road Oil City, PA 16301

F 0610 Level of Harm - Minimal harm or potential for actual harm Review of a nurse's note dated 3/19/24, at 1:18 p.m. by Assistant Director of Nursing (ADON) revealed that Resident R15 had increased pain, bruising and swelling to the left lower extremity, physician notified, and orders received for x-ray of left foot and ankle. Nursing note written by Registered Nurse (RN) Employee E2 at 5:02 p.m. for x-ray results revealed acute bimalleolar fracture deformity of the left ankle, orders received to send Resident R15 to the emergency room. Residents Affected - Few Review of the Employee Witness Statement Form written on 3/19/24, by Nursing Assistant (NA) Employee E3 revealed that he/she had transferred Resident R15 on 3/17/24, using the sit-to-stand lift in the shower area with only an assist of one. Review of the Employee Witness Statement Form written on 3/19/24, by NA Employee E4 revealed that he/she was providing care at 8:45 a.m. on 3/18/24, and noticed a bruise on Resident R15's ankle. Review of the Employee Witness Statement Form written by the ADON on 3/22/24, revealed that NA Employee E5 was providing care for Resident R15's roommate with the curtain closed and stated that NA employee E6 transferred Resident R15 from chair to bed alone using the sit-to-stand lift. When NA Employee E5 finished caring for the roommate, he/she helped NA Employee E6 with care for Resident R15 who was in bed at this time. Review of the Employee Witness Statement form written on 3/19/24, by NA Employee E6 revealed that he/she transferred Resident R15 into bed with assist of two at approximately 7:15 p.m. and that around 9:55 p.m. Resident R15 wanted out of bed due to foot pain. NA Employee E6 indicated that he/she would inform the nurse regarding the resident's complaint of pain. During an interview on 4/4/24, at 2:45 p.m. NA Employee E6 indicated that he/she transferred Resident R15 from chair to bed using assist of two but could not recall who assisted and NA Employee E6 could also not recall whom he/she notified of Resident R15's complaint of foot pain. Review of Resident R15's clinical record revealed no documentation regarding the resident's complaint of foot pain or any bruising until 3/19/24, at 1:55 p.m. The only other statements in the investigation were written by Licensed Practical Nurse (LPN) Employee E7 who worked the day shift on 3/18/24 and the NA Employee E8 who had never gotten the resident out of bed since the resident's admission. Review of an incident report dated 3/19/24, at 1:21 p.m. revealed that Resident R15 complained of left lower leg pain and had bruising. The resident had no falls or incidents of rolling out of bed. Resident R15 was cognitively impaired and unable to state how the injury happened. Review of an x-ray completed at the hospital on 3/19/24, revealed an acute bimalleolar fracture deformity of the left ankle. Review of information submitted by the facility dated 3/19/24, identified that Resident R15 was identified as a two-person assist with transfers; investigation with staff and resident revealed no inconsistencies of how care was provided, and staff witness statements did not indicate where or how the injury occurred. Review of Resident R15's clinical record and documentation of incident investigation lacked evidence that a full investigation was completed. The information lacked statements from all staff working during the timeframe when the alleged incident may have occurred from 3/17/24 until 3/19/24, at 1:55 395594 Page 2 of 6 395594 04/05/2024 Oil City Nursing and Rehab 1293 Grandview Road Oil City, PA 16301

F 0610 p.m. when Resident R15's left lower leg had bruising and swelling documented. Level of Harm - Minimal harm or potential for actual harm During an interview on 4/5/2024, at 9:45 a.m. the Nursing Home Administrator confirmed that the investigation completed on Resident R15's incident with injury of unknown origin was incomplete and had inconsistent statements that should have been further investigated. The NHA also confirmed that the investigation should have been more thorough with additional staff witness statements. Residents Affected - Few 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 211.12(d)(1)(5) Nursing services 395594 Page 3 of 6 395594 04/05/2024 Oil City Nursing and Rehab 1293 Grandview Road Oil City, PA 16301

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 on review of facility policy, clinical records, and facility documentation, and staff interviews, it was determined that the facility failed to implement appropriate safety measures in a manner that protected a resident from injury of unknown origin and resulted in actual harm when the resident received an ankle fracture that required medical treatment at a hospital for one of 18 residents reviewed (Resident R15). Findings include: Review of a facility policy entitled Investigating Injuries dated 2/20/24, revealed that an Injury of unknown source is defined as an injury that meets both of the following conditions: a. The source of the injury was not observed by any person or the injury could not be explained by the resident; and b. The injury is suspicious because of: (1) The extent of the injury The policy also indicated with the help of the staff and management, the investigator will compile a list of all personnel, including consultants, contract employees, visitors, family members, etc., who have had contact with the resident during the past 48 hours. Review of facility policy entitled Lifting Machine, Using a Mechanical dated 2/20/24, indicated that at least two staff are needed to safely move a resident with a mechanical lift. Review of the Job Description Nurse Aide (NA) revealed that the nurse aide will provide quality routine daily nursing care to residents according to the residents' care plan. Review of Resident R15's clinical record revealed an admission date of 1/04/24, with diagnoses that included fractured left hip, pressure ulcer left heel, and atrial fibrillation (abnormal heart rhythm). Review of Resident R15's quarterly Minimum Data Set (MDS-periodic assessment of resident care needs), assessment dated [DATE], revealed that Resident R15 was cognitively impaired and his/her transfer status was an extensive assist, two-person physical assist. Review of a Physical Therapy Treatment Encounter Note dated 3/14/24, revealed Resident R15 was a maximal assist of two for standing. During an interview on 4/4/24, at 10:35 a.m. with the Director of Physical Therapy Employee E1 confirmed Resident R15 was a maximal assist of two for all transfers. 395594 Page 4 of 6 395594 04/05/2024 Oil City Nursing and Rehab 1293 Grandview Road Oil City, PA 16301

F 0689 Level of Harm - Actual harm Residents Affected - Few Review of Resident R15's physician's orders dated 3/15/24, revealed an order for extensive assist times two, stand and pivot for transfers and showers. The physician orders lacked any orders for the use of any mechanical lift. Review of a nurse's note dated 3/19/24, at 1:18 p.m. by Assistant Director of Nursing (ADON) revealed that Resident R15 had increased pain, bruising and swelling to the left lower extremity, physician notified, and orders received for x-ray of left foot and ankle. Nursing note written by Registered Nurse (RN) Employee E2 at 5:02 p.m. x-ray results revealed acute bimalleolar fracture deformity of the left ankle, orders received to send Resident R15 to the emergency room. Review of the Employee Witness Statement Form written on 3/19/24, by NA Employee E3 revealed that he/she had transferred Resident R15 on 3/17/24, using the sit-to-stand mechanical lift in the shower area with only an assist of one. Review of the Employee Witness Statement Form written on 3/19/24, by NA Employee E4 revealed that he/she was providing care at 8:45 a.m. on 3/18/24, and noticed a bruise on Resident R15's ankle. Review of the Employee Witness Statement Form written by the ADON on 3/22/24, revealed that NA Employee E5 was providing care for Resident R15's roommate with the curtain closed and stated that NA employee E6 transferred Resident R15 from chair to bed alone using the sit-to-stand mechanical lift. When NA Employee E5 finished caring for the roommate he/she helped NA Employee E6 with care for Resident R15 who was in bed at that time. Review of the Employee Witness Statement form written on 3/19/24, by NA Employee E6 revealed that he/she transferred Resident R15 into bed with assist of two at approximately 7:15 p.m. and that around 9:55 p.m. Resident R15 wanted out of bed due to foot pain, NA Employee E6 indicated that he/she would inform the nurse regarding the resident's complaint of pain. During an interview on 4/4/24, at 2:45 p.m. NA Employee E6 indicated that he/she transferred Resident R15 from chair to bed using an assist of two but could not recall who assisted and NA Employee E6 could also not recall whom he/she notified of Resident R15's complaint of foot pain. Review of Resident R15's clinical record revealed no documentation regarding the resident's complaint of foot pain or any bruising until 3/19/24, at 1:55 p.m. The only other statements in the investigation were written by Licensed Practical Nurse (LPN) Employee E7 who worked the day shift on 3/18/24 and the NA Employee E8 who had never gotten the resident out of bed since the resident's admission. Review of an incident report dated 3/19/24, at 1:21 p.m. revealed that Resident R15 complained of left lower leg pain and had bruising. The resident had no falls or incidents of rolling out of bed. Resident is cognitively impaired and unable to state how the injury happened. Review of an x-ray completed at the hospital on 3/19/24, revealed an acute bimalleolar fracture deformity of the left ankle. Review of information submitted by the facility dated 3/19/24, identified that Resident R15 is identified as a two-person assist with transfers. Investigation with staff and resident revealed no inconsistencies of how care was provided, and staff witness statements did not indicate where or how the injury occurred. 395594 Page 5 of 6 395594 04/05/2024 Oil City Nursing and Rehab 1293 Grandview Road Oil City, PA 16301

F 0689 Level of Harm - Actual harm Review of Resident R15's clinical record and documentation of incident investigation lacked evidence that a full investigation was completed. The information lacked statements from all staff working during the timeframe when the alleged incident may have occurred from 3/17/24 until 3/19/24, at 1:55 p.m. when Resident R15's left lower leg had bruising and swelling documented. Residents Affected - Few During an interview on 4/5/2024, at 9:45 a.m. the Nursing Home Administrator confirmed that the investigation completed on Resident R15's incident with injury of unknown origin was incomplete and had inconsistent statements that should have been further investigated. The NHA also confirmed that the investigation did not reveal how Resident R15 sustained an ankle fracture and there was no physician's order for a sit-to-stand lift. The facility failed to provide safety measures that resulted in actual harm of an ankle fracture to Resident R15. 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 201.18(b)(3)(e)(1) Management 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(d)(1)(5) Nursing services 28 Pa. Code 201.14(a) Responsibility of licensee 395594 Page 6 of 6