Health inspection·September 29, 2023

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 clinical record and facility documentation review, and staff interview, it was determined that the facility failed to ensure that one of four residents reviewed was provided with adequate supervision to prevent accidents which resulted in actual harm to Resident 9 sustaining a fall, requiring transfer to the hospital via emergency medical services and the diagnosis of a fracture to the humerus (long bone of the upper arm). Findings include: Review of Resident 9's clinical record included diagnoses of, but not limited to, Cerebrovascular accident (stroke) with left side hemiparesis (weakness or paralysis on one side of the body), Dementia (decline in cognitive abilities that affects the brain's ability to think, remember, and function normally), and Ambulatory Dysfunction (abnormal gait that makes it difficult or impossible to walk). Review of Resident 9's fall risk assessment dated [DATE], revealed a score of 18. The assessment indicated that if the score is 10 or greater, the resident should be considered high risk for potential falls. Review of Resident 9's quarterly MDS (Minimum Data Set - periodic assessment of resident needs) completed May 19, 2023, revealed resident had a BIMS (brief interview for mental status - structured evaluation aimed at evaluating aspects of cognition in elderly patients) score of 4, indicating severe cognitive impairment. The MDS assessment revealed that the resident required extensive assistance of two persons for transfers and toileting. Review of Resident 9's care plan identified, the resident at moderate risk for falls related to impaired mobility, osteoporosis, unsteady balance, and hemiplegia. The care plan included an intervention initiated April 1, 2017, with a revision date of February 22, 2021, to anticipate and meet the resident's needs. Assist with toileting and do not leave in bathroom unattended. Review of interdisciplinary note dated May 21, 2023, at 2:18 p.m. revealed resident found on bathroom floor laying on left side, head against wall where night light is, hoyer lift used to lift off floor into bed, resident has left shoulder pain and left hip pain. Further review of interdisciplinary note dated May 21, 2023, at 2:30 p.m. revealed fall noted, stat xray shoulder 2 views and stat xray left hip 2 views. Review of interdisciplinary note dated May 21, 2023, at 4:29 p.m. revealed resident's results from (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: 395631 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 395631 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/29/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE United Zion Retirement Communi 722 Furnace Hill Pike Lititz, PA 17543 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)