Health inspection·August 3, 2023

F 0689 Level of Harm - Minimal harm or potential for actual harm Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based on observation, clinical record review, and staff interview, it was determined that the facility failed to implement interventions to prevent falls for two of six residents sampled (Residents 1 and CR1). Residents Affected - Few Findings include: Clinical record review for Resident 1 revealed the resident had dementia (a condition with progressive loss of thinking, memory changes, and personality change) and Parkinson's Disease (a condition that causes unintended tremors and movements such as shaking, stiffness, and difficulty with balance and coordination). Clinical record review for Resident 1 revealed current physician order's that were initiated January 31, 2023, for a standard wheelchair with a coccyx (tailbone) cut-out cushion and Dycem (non-slip pad provided on seating to prevent slipping and provide stabilization) underneath and on-top of the cushion, and bilateral elevation leg rests. If the cut-out cushion is unavailable, use a standard pressure relieving cushion. Review of a nursing progress note dated February 5, 2023, at 9:10 PM for Resident 1 revealed that the resident had fallen. The nurse found the resident lying on the right side at the foot of her bed with the top of her head against the wall. The wheelchair was positioned directly in front of the resident wedged between her and the closet behind it. There was no Dycem on top or under the wheelchair seat cushion. The wheelchair was removed for safety. The resident was wearing non-skid socks with poor tread, and no hipsters (padded underwear to help protect the hips from injury if a resident falls). There resident did not have any injuries. Staff education was provided to ensure Dycem is in place above and below the wheelchair cushion. The responsible party was contacted and reported preventing falls on two occasions when the resident tried to self-transfer, lost her balance, and began falling, and caught the resident to prevent falls. Review of a nursing progress noted dated June 25, 2023, at 8:05 PM for Resident 1 revealed the resident had fallen. The resident was lying on her right side and propped up on the elbow in her room with her head against the wall between the dressers. The resident was wearing non-skid socks, and the wheelchair was behind her. There was no Dycem on top of the wheelchair cushion. There were no injuries. Staff education was provided to ensure Dycem is in place on wheelchair as per care plan. Review of a nursing progress note dated July 18, 2023, at 2:00 PM for Resident 1 revealed that the resident fell in her room. The resident was sitting upright on her buttocks with her legs in front of her and her knees bent, and she was leaning onto the edge of the bed. Staff reported they went to Page 1 of 2 395779 395779 08/03/2023 Centre Care Rehabilitation and Wellness Services 250 Persia Road Bellefonte, PA 16823

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few notify the supervisor and upon their return the resident transferred herself back into bed. The wheelchair cushion was lying on the floor and there was no Dycem on top. Dycem was present on the wheelchair seat below the cushion. There were no injuries. Closed clinical record review for Resident CR1 revealed the resident had dementia, macular degeneration (an eye disease that can blur vision), and legal blindness. Review of facility documentation for Resident CR1 dated July 12, 2023, at 6:15 PM revealed the resident had fallen in another resident's room and the fall was unwitnessed. The resident was found lying on her left side. The resident had a 3-centimeter x 1 millimeter laceration (cut) on her left eyebrow with a moderate amount of bleeding. The resident would not let staff check the range of motion (how much the joint would move) to the right shoulder due to pain. The physician evaluated the resident, and the resident was sent to the hospital. The facility's investigation revealed the resident was wearing improper footwear. Staff were educated to ensure the resident was wearing non-skid socks or shoes with good tread while ambulation or mobilizing in the wheelchair on the unit. Review of a hospital history and physical for Resident CR1 dated July 12, 2023, revealed the resident had a Humerus Fracture (broken bone in upper arm) and a contusion (bruise) of the face. The facility failed to implement interventions to prevent falls related to Residents 1 and CR1. 28 Pa. Code 201.18 (e)(1) Management 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(d)(1)(2)(3) Nursing services 395779 Page 2 of 2