Inspection·July 24, 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, review of clinical records, facility documentation, and staff interviews, it was determined that the facility failed to protect residents from an accident of a roll out of bed for one of three residents (Resident R1). Findings include: Review of the facility policy Accidents/ Incidents last reviewed on 6/26/24, with a previous review date of 10/4/23, indicated that the Center will report, review and investigate all accidents/incidents which occur. Any accident/incident that may be considered an allegation of abuse/neglect, etc. will be managed in accordance to the Abuse Prohibition Policy. An accident is defined as an unexpected incident that may result in injury. Review of the clinical record indicated that Resident R1 was admitted to the facility on [DATE], with diagnoses which included severe unspecified dementia without behavioral disturbance, bacteremia, sepsis, a stroke, speech and language deficits and other brain infarcts. A Minimum Data Set (MDS - periodic assessment of a resident's abilities and care needs) dated 7/7/24, indicated the diagnoses remained current. Section GG of the MDS also indicated that Resident R1 was dependent for rolling left to right. Dependent on staff (meaning that the helper does all of the effort. Resident does none of the effort to complete the activity, or the assistance of two or more helpers is required for the resident to complete the activity). Review of Resident R1's plan of care for ADL Self Care Performance Deficit related to Dementia active on 7/3/24, failed to include in the interventions what level of staff assistance Resident R2 required for transferring to bed from her wheelchair and for dressing/undressing. The care plan was not updated to reflect the physician's order for transfer and assistance. Review of the facility provided documentation dated 7/8/24, indicated Licensed Practical Nurse(LPN) Employee E1 turned Resident R1 onto her side towards her, then left her to go into the hall to look for Registered Nurse(RN) Employee E2 who was bringing in wound care supplies, leaving Resident R1 on her side and unassisted and Resident R1 rolled onto the floor. Review of a written statement by LPN Employee E1 dated 7/8/24, indicated, I was doing last rounds, RN Employee E2 came into the room and was going to do Resident R1's coccyx treatment. I had positioned Resident R1 on her left side towards me. I was waiting for RN Employee E2 to return and I stepped away from the bed and looked back to see Resident R1 sliding off the bed. I hurried back to attempt to catch her but she rolled out of bed. (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: 395783 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 07/24/2024 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)