Health inspection·August 15, 2023

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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 clinical records and facility investigation reports and staff interviews, it was determined that the facility failed to provide an environment that was free of accident hazards for residents who were at risk for falls two of four residents (Residents R3 and R4) when they were transferred with assistance of one staff not two as required and sustained a fall with no injuries. Findings include: During an interview on 8/15/23, at 8:35 a.m., with Nurse Aide (NA) Employee E1 and E2 indicated that transfer status of all residents is discussed with staff between shifts with report , it is on the [NAME] at the nurses station and updated as needed and also there are colored blocks of paper above each residents closet indicating transfer status, fluid consistency, and meal consistency. The staff also stated that if a new staff person comes in the staff always go over care of each resident prior to their start of shift. This was confirmed with the Registered Nurse (RN) Employee E3. Review of the clinical record indicated that Resident R3 was admitted to the facility on [DATE], with diagnoses which included abnormal posture, seizures, blindness, closed fracture of the right hip, and cognitive communication deficit. A MDS dated [DATE], indicated the diagnoses remained current. Review of Resident R3's plan of care revised on 3/15/23, indicated that Resident R3 required assistance of the sit to stand lift (lift used to assist residents with limited mobility from sitting to standing position) with two staff. Review of a Resident Family Concern Form dated 6/12/23, indicated that Resident R3 voiced a complaint regarding the daylight Nurse Aide from the previous date (6/11/23), was giving care without telling the resident what she was doing and pulled her arm and moved her about the bed roughly enough to cause her to call out that she was being hurt. Then the resident stated that the NA began to transfer her from the bed without the sit to stand and when she asked the NA about it, the NA stated that she does things two ways, a bear hug or the sit to stand. Then the NA bear hugged the resident and plopped her like a sack of potatoes into the wheelchair. after this the resident went on to state that the NA was not nice and when Resident R3's roommate yelled out when she heard how the NA was treating Resident R3, the NA told the roommate to mind her own business and that it didn't concern her and closed the privacy curtain angrily. The NA refused to tell Resident R3 her name. Resident R3 stated that she wasn't used to being treated that way and was a little sore. from the rough treatment. The staff NA was identified as NA Employee E5. Review of the clinical record indicated that Resident R4 was admitted to the facility on [DATE], Page 1 of 2 395873 395873 08/15/2023 LGAR Health and Rehabilitation 800 Elsie Street Turtle Creek, PA 15145

F 0689 Level of Harm - Minimal harm or potential for actual harm with diagnoses which included Stroke, falls, bladder disorder and difficulty walking. A MDS dated [DATE] indicated the diagnoses remained current. Review of Resident R4's care plan revised on 8/3/21, indicated Resident R4 required transfer with the sit to stand lift and assistance of two staff. Residents Affected - Some Review of an incident report dated 7/7/23, indicated that after transferring Resident R4 to the toilet with the sit to stand and two staff, NA Employee E6 did not call for help to transfer the resident with the sit to stand back to her wheelchair and Resident R4 fell to the floor when she could not hold onto the bar of the sit to stand. Resident R4 was assessed and no injuries occurred due to the unsafe transfer. During an interview on 8/15/23, at 2:15 p.m., the Nursing Home Administrator confirmed that the facility failed to provide an environment that was free of accident hazards. 28 Pa. Code: 201.14(a) Responsibility of licensee. 28 Pa. Code: 201,18(e)(1) Management. 28 Pa. Code: 207.2(a) Administrator's responsibility. 28 Pa. Code: 211.10(d) Resident care policies. 395873 Page 2 of 2