Inspection·May 16, 2023

F 0689 resident had a self-care deficit and to encourage wheelchair mobility, was at risk for falls. Level of Harm - Actual harm A review of a progress note dated 5/8/23, at 12:28 p.m., indicated Licensed Practical Nurse (LPN) Employee E1 entered Resident R1's room to take her to the dining room, while pushing her wheelchair through the doorway, the resident fell forward as she put her feet on the floor and hit the front of her head when she fell at 11:40 a.m. Bright red blood noted to resident ' s face and floor from nose due to split at the bridge and the right side from resident ' s glasses making impact with the skin. Large hematoma (a pocket of blood inside the body caused by hemorrhage, rapid blood loss) was noted to the right side of the head. 911 was called and Resident R1 was sent to the local emergency room for evaluation. Residents Affected - Few A review of a progress note dated 5/8/23, at 1:00 p.m. indicated Resident R1 was assessed by the Nurse Practitioner and due to the extent of injury and fraility and concern for nasal deformity; post nasal bleed and inability to pass air through the right nasal passage the resident was sent to the local emergency room for further imaging and treatment. A review of the hospital record CT scan report dated 5/8/23, indicated bilateral nasal bone deformities and fracture deformities involving the nasal septum, nondisplaced bilateral posterior C1 vertebra arch fractures (C1 vertebra arch is a closed ring of the first spinal bone that supports the skull, fracture of a closed ring necessarily results in at least two areas ) and Type II dens fracture (fracture occurring at the base of the odontoid [toothlike projection from the second cervical vertebra on which the first vertebra pivots] as it attaches to the body of C2) and mild translocation (describes the movement of fractured bones away from each other). Resident R1 was required to wear a soft cervical collar on return to the facility. During an interview on 5/16/23, at 11:50 a.m. LPN Employee E2 stated when she pushes a resident that self-propels their wheelchair, she uses leg rests. During an interview on 516/23, at 11:55 a.m. Nurse Aide (NA) Employee E3 stated she would look on the kiosk or in the Kardex to find residents transfer status, and she uses leg rests for residents that self-propel their wheelchair if she is going to push them. During an interview on 5/16/23, at 11:56 a.m. LPN Employee E1 stated the long hall nurse (LPN Employee E1's shift assignment) goes into the dining room to assist with feeding residents. Resident R1 was the only resident not in the dining room so she offered to go get her and bring her to the dining room. Resident R1 was already in her wheelchair as she usually brings herself to the dining room. She offered to help Resident R1 and she agreed to the assistance. She did not place the leg rests on the wheelchair, she instructed the resident to lift her legs. As she was pushing Resident R1 through the doorway out of her room, Resident R1 planted her feet on the floor. She is unable to walk. When she put her feet down, she went forward and fell on her face. She twisted herself over on the floor and noticed the blood. LPN Employee E1 stated she was unsure if leg rests were in Resident R1's room, and it slipped my mind to use the leg rests. During an interview on 5/16/23, at 12:05 p.m. NA Employee E4 stated she looks in the Kardex or asks a nurse if she does not know the transfer status of a resident, and if she pushes a resident in a wheelchair, she uses leg rests. During an interview on 5/16/23, at 12:06 p.m. Registered Nurse (RN) Employee E5 stated some residents are able to hold legs up and some need the leg rests. She just knows them to determine who needs (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395783 If continuation sheet Page 2 of 4 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 395783 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Peters Township Post Acute 113 West McMurray Road McMurray, PA 15317 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)

F 0689 and who does not need the leg rests. Level of Harm - Actual harm During an interview on 5/16/23, at 12:07 p.m. NA Employee E6 stated they look at the Kardex to find the transfer status of a resident, and they use leg rests when pushing a wheelchair. Residents Affected - Few During an interview on 5/16/23, at 12:09 p.m. NA Employee E7 stated they look at the Kardex, ask the supervisor, director of nursing, or therapy about the resident's transfer status, and they always use leg rests when pushing a wheelchair. During an interview on 5/16/23, at 12:10 p.m. LPN Employee E8 stated they use leg rests when pushing a wheelchair. During an interview on 5/16/23, at 12:11 p.m. NA Employee E9 stated they look in the Kardex to find the transfer status of a resident, they don't always use leg rests if the resident is high functioning and can keep their legs lifted up. During an interview on 5/16/23, at 12:12 p.m. RN Employee E10 stated she never pushes the wheelchairs without leg rests because too many times they put their legs down. During an interview on 5/16/23, at 12:13 p.m. NA Employee E11 she asks a nurse or looks in the Kardex to find the resident's transfer status, and she would assist a resident in a wheelchair without putting leg rests on first. During an interview on 5/16/23, at 12:15 p.m. NA Employee E12 stated they look in the Kardex to find the transfer status, and they never push a wheelchair without leg rests. During an interview on 5/16/23, at 12:16 p.m. NA Employee E13 stated they look in the Kardex or care plan to find resident's transfer status, and it depends on the resident whether they would use leg rests when pushing a wheelchair. During an interview on 5/16/23, at 12:20 p.m. LPN Employee E14 stated she uses leg rests even if she knows the resident because she worked somewhere else and it was a big deal so she always uses the leg rests. During an interview on 5/16/23, at 12:20 p.m. NA Employee E15 stated she looks at the Kardex to find the transfer status, and she only pushes wheelchairs with leg rests unless the resident can hold their feet up for a long time. During an interview on 5/16/23, at 12:23 p.m. Rehab Director Employee E16 stated the residents are assessed for wheelchair use on admission and the chair is positioned so the resident can place their feet flat on the floor. If staff are pushing a self-propelling resident in their wheelchair, they should have leg rests on. Every resident should have leg rests in their room unless they are confused and try to stand on them. During an interview on 5/16/23, at 4:00 p.m. the Director of Nursing confirmed the facility failed to prevent injury while transporting a resident in a wheelchair resulting in actual harm for Resident R1. 28 Pa Code: 201.14 (a)(c)(d)(e) Responsibility of licensee. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395783 If continuation sheet Page 3 of 4 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 395783 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Peters Township Post Acute 113 West McMurray Road McMurray, PA 15317 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)

F 0689 28 Pa Code: 201.18(b)(1)(3) (e)(1) Management. Level of Harm - Actual harm 28 Pa Code: 211.10 (a) Resident care policies. Residents Affected - Few 28 Pa Code: 211.12 (d)(1)(2)(5) Nursing services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395783 If continuation sheet Page 4 of 4