Health inspection·June 5, 2023

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 review of facility policies, investigation reports, clinical records, and staff education records, as well as staff interviews, it was determined that the facility failed to ensure that residents were free from neglect for one of seven residents reviewed (Resident 2), resulting in harm to Resident 2 due to a fall that resulted in fractures. Findings include: The facility's policy regarding abuse and neglect, dated April 13, 2023, indicated that the facility was to provide protection for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property. An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated March 30, 2023, revealed that the resident was cognitively intact, required the extensive assistance of two staff for transfers, required limited assistance with ambulation (walking), was only able to stabilize and balance herself with staff assistance, and had no recent falls. The resident's care plan, dated March 25, 2023, revealed that she required one staff member and a wheeled walker for transfers. A nursing note, dated May 20, 2023, at 11:09 p.m. revealed that the nurse aide was yelling for help and Resident 2 was found lying on the ground on her stomach, and there was a large amount of blood under her face, which was coming from the resident's nose. The bridge of the resident's nose was swollen with bruising and a laceration, and she was transferred to the hospital. A CT-scan (diagnostic test), dated May 21, 2023, revealed the resident had a fracture of the nasal bone. The facility's investigation dated May 20, 2023, revealed that Resident 2 requested that Nurse Aide 1 walk with her, and Nurse Aide 1 followed the resident with her wheelchair as the resident walked with her rolling walker. When Nurse Aide 1 asked the resident to turn and go back to her room the resident said she was dizzy, and before the resident could be seated, she fell forward. The resident has a history of being dizzy and receives medication three times a day. The investigation determined that Nurse Aide 1 was not using a gait belt at the time of the fall. Nurse Aide 1 stated that she thought the resident did not need a gait belt since it was not care planned. The facility's new employee training checklist, dated January 25, 2023, revealed that Nurse Aide 1 completed training regarding transfer/ambulation with a gait belt. An interview with Nurse Aide 1 on June 5, 2023, at 2:47 p.m. confirmed that she did not use a gait Page 1 of 3 395944 395944 06/05/2023 Chambers Pointe Health Care Center 1425 Philadelphia Avenue Chambersburg, PA 17201

F 0600 belt while walking and transferring Resident 2 because it was not care planned; however, she did confirm that she received education regarding the use of the gait belt. Level of Harm - Actual harm Residents Affected - Few An interview with the Nursing Home Administrator on June 5, 2023, at 2:25 p.m. confirmed that Nurse Aide 1 did not use a gait belt when transferring and ambulating Resident 2 and she should have, and that neglect was substantiated. 42 CFR 483.13 - Resident Behavior and Facility Practices, 10-1-1998 edition. 28 Pa. Code 211.10(c)(d) Resident care policies. 28 Pa. Code 211.11(d) Resident care plan. 28 Pa. Code 211.12(d)(1)(5) Nursing services. 395944 Page 2 of 3 395944 06/05/2023 Chambers Pointe Health Care Center 1425 Philadelphia Avenue Chambersburg, PA 17201

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 Based on review of facility policies, investigation reports, clinical records, and staff education records, as well as staff interviews, it was determined that the facility failed to provide care using adequate assistance devices to prevent accidents for one of seven residents reviewed (Resident 2), resulting in the resident experiencing a fall and fracture. Findings include: The facility's policy regarding gait belt use, dated April 13, 2023, indicated that gait belts were to be used with residents that could not independently ambulate or transfer for the purpose of safety. Each nursing department employee was to be given a gait belt during orientation. All employees would receive education on the proper use of the gait belt during orientation and annually. It would be the responsibility of each employee to ensure they have it available for use at all times when at work. An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated March 30, 2023, revealed that the resident was cognitively intact, required the extensive assistance of two staff for transfers, required limited assistance with ambulation (walking), was only able to stabilize and balance herself with staff assistance, and had no recent falls. The resident's care plan, dated March 25, 2023, revealed that she required one staff member and a wheeled walker for transfers. A nursing note, dated May 20, 2023, at 11:09 p.m. revealed that the nurse aide was yelling for help and Resident 2 was found lying on the ground on her stomach, and there was a large amount of blood under her face, which was coming from the resident's nose. The bridge of the resident's nose was swollen with bruising and a laceration, and she was transferred to the hospital. A CT-scan (diagnostic test), dated May 21, 2023, revealed the resident had a fracture of the nasal bone. The facility's investigation, dated May 20, 2023, revealed that Resident 2 requested that Nurse Aide 1 walk with her, and Nurse Aide 1 followed the resident with her wheelchair as the resident walked with her rolling walker. When Nurse Aide 1 asked the resident to turn and go back to her room the resident said she was dizzy, and before the resident could be seated, she fell forward. The resident has a history of being dizzy and received medication three times a day. The investigation determined that Nurse Aide 1 was not using a gait belt at the time of the fall. Nurse Aide 1 stated that she thought the resident did not need a gait belt since it was not care planned. The facility's new employee training checklist, dated January 25, 2023, revealed that Nurse Aide 1 completed training regarding transfer/ambulation with a gait belt. An interview with Nurse Aide 1 on June 5, 2023, at 2:47 p.m. confirmed that she did not use a gait belt while walking and transferring Resident 2 because it was not care planned. An interview with the Nursing Home Administrator on June 5, 2023, at 2:25 p.m. confirmed that Nurse Aide 2 did not use a gait belt when transferring and ambulating Resident 2 and she should have. 28 Pa. Code 211.12(d)(1)(5) Nursing services. 395944 Page 3 of 3