Health inspection·September 26, 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 observations, review of clinical records, facility policies and facility documentation, and staff and resident interviews, it was determined that the facility failed to provide adequate supervision that resulted in actual harm including a laceration requiring seven sutures (stitches to close a wound), head injury, and skin tear of forearm, to one of two residents reviewed (Resident R1). Findings include: Review of the facility policy entitled, Comprehensive Care Plan dated 3/13/23, revealed that the care plan will describe at a minimum, the following: (a) the services that are to be furnished to attain or maintain the Resident's highest practical physical, mental and psychosocial well being . 6. Qualified staff responsible for carrying out interventions specified in the care plan will be notified of their roles and responsibilities for carrying out the interventions, initially and when changes are made. Review of the facility policy entitled, Fall Prevention Program dated 3/13/23, revealed that residents that have a fall history will be placed on the fall prevention precautions, .6. fall risk interventions will at a minimum: include educating staff, resident, and family to increase the awareness of residents risk for falling and possible interventions to minimize the risk .8. Certified Nursing Assistants may assist with fall prevention as follows: 9a) follow the interventions as outlined on the care plan and [NAME] [system for resident care information to be relayed to staff] . Review of Resident R1's clinical record revealed an original admission date of 12/14/2017, with diagnoses that included heart failure, weakness of the right side of the body following a stroke, diabetes, difficulty walking, obesity, low back pain, legal blindness, Alzheimer's disease and dementia (condition characterized by progressive, persistent severe impairment of intellectual capacity, including memory loss and confusion). Review of the physician order sheet, dated 9/26/23, revealed that on 1/03/23 an order was written Do Not leave unattended in bathroom. Review of a care plan entitled I am at high risk for falls care plan, revealed don't leave me unattended in the bathroom and was created on 1/03/23. Review of nursing documentation, dated 9/11/23, written by Registered Nurse (RN) Employee E1, stated that Resident R1 experienced leaning back on the toilet for about 20 seconds with some tremors but was still alert and talking. (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 3 Event ID: 395793 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 395793 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Orchard Manor 20 Orchard Drive Grove City, PA 16127 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)