Health inspection·January 23, 2024

F 0600 Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Level of Harm - Actual harm Residents Affected - Few Based on observation, clinical record review, review of facility documents, and staff interview, it was determined that the facility failed to protect the rights of a resident to be free from neglect by not providing the services necessary to avoid physical harm resulting in fractures for one of two residents reviewed (Resident 1). Findings include: An observation of Resident 1 on January 23, 2024, at 11:35 AM revealed she was in an activity with her head down. An alarm box was noted on her wheelchair. Clinical record review for Resident 1 revealed that the facility admitted her on September 8, 2023. A progress note date December 29, 2023, at 9:15 PM revealed that the nurse aide (NA) notified the registered nurse (RN) that Resident 1 fell and hit the back of her head. Resident 1was observed by the RN sitting in the hallway on the carpeted floor near the parlor. Resident 1 was bleeding from the back of her head and was noted to have a laceration on the right side of the back of her head. The RN notified the certified registered nurse practitioner and received orders to send Resident 1 to the emergency room. Further clinical record review revealed that Resident 1 returned from the emergency room on December 30, 2023, at 11:03 AM. She was wearing a cervical soft collar. Review of the emergency room report revealed that she had a displaced fracture (bone breaks in two or more places and moves out of alignment) of the left sixth cervical vertebrae (near the base of the neck) and a transverse process remote deformity (a break or crack in one of the wing-like sides at the back of a vertebrae) of the thoracic vertebrae T3 (middle section of your spine, third segment of the 12 thoracic vertebrae). She also had 9 sutures intact to the right posterior (back) scalp laceration. Review of the facility's investigation into Resident 1's fall revealed that Employee 1 forgot to move the alarm box from the resident's chair to her bed on December 29, 2023, at approximately 8:30 PM. A witness statement from Employee 1, NA, indicating that she neglected to move the alarm box from Resident 1's chair onto her bed. Review of Resident 1's care plan entitled Potential for Falls initiated on September 8, 2023, revealed an intervention for Resident 1 to have a silent bed and chair alarm for resident safety. Further clinical record review for Resident 1 revealed a care plan for activities of daily living self-care performance deficit with an intervention that was initiated on September 22, 2023, indicating Resident 1 required the assistance of one to ambulate and transfer in her room and in the hallway Page 1 of 2 395838 395838 01/23/2024 Foxdale Village 500 E. Marylyn Avenue State College, PA 16801

F 0600 Review of Resident 1's fall risk evaluation dated December 12, 2023, indicated her score was 16. The form noted that a score of 10 or higher indicated the resident was a high risk for falls. Level of Harm - Actual harm Residents Affected - Few Review of the nurse aide point of care (POC) documentation (a computerized system where resident care needs are identified and documented) for Resident 1 revealed that Employee 1 had access to the care plan. The care plan indicated that Resident 1 was to have silent bed and chair alarms. Review of the POC task for Resident 1 revealed that she was to have mobility monitors bed and chair alarms for resident safety initiated September 13, 2023. The facility's investigation revealed that Employee 1 was educated on December 29, 2023, at 9:15 PM on following the resident's care plan. She was also educated on January 3, 2024, on abuse and the facility's policy and procedure on abuse. Review of Employee 1's personnel file revealed that she received annual education for falls on November 6, 2023, that included fall prevention. She also received annual education on care plans in December 2023, and that a resident's care plan provides direction to staff on what care and services a resident required. Interview with the Nursing Home Administrator on January 23, 2024, at 9:50 AM revealed that the facility only educated Employee 1 and that they did not educate other staff that would be responsible for fall prevention and following care plans, to prevent this from reoccurring. The above findings were reviewed during an interview with the Nursing Home Administrator and Director of Nursing on January 23, 2024, at 12:00 PM. The facility failed to prevent neglect that resulted in harm for Resident 1. 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 201.29(a) Resident rights 395838 Page 2 of 2