Health inspection·November 29, 2023

F 0656 Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Level of Harm - Actual harm Residents Affected - Few Based on review of policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to develop comprehensive care plans that included specific and individualized interventions to address the care needs of residents for two of three residents reviewed (Residents 1, 3), resulting in a fall with a head injury. Findings include: The facility's policy regarding assistive devices and equipment, dated September 14, 2023, indicated that devices and equipment that assisted with resident mobility, safety and independence were provided for residents, which included wheelchairs, walkers and canes. Recommendations for the use of devices and equipment were based on the comprehensive assessment and documented in the resident's plan of care. The facility's care plan policy, dated September 14, 2023, indicated that the comprehensive, person-centered care plan included measurable objectives and time frames, and described the services that were furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well being. An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated August 23, 2023, revealed that the resident was cognitively impaired, required extensive assistance with transfers, had limited range of motion to his upper extremities, used a wheelchair, had a history of falls, and had diagnoses that included dementia and traumatic brain injury (sudden injury that causes damage to the brain). The resident's care plan, dated September 14, 2023, revealed that he was at risk for falls and used a wheelchair. Investigative documents for Resident 1, dated November 15, 2023, revealed that the resident was on the floor lying in front of his wheelchair with the nurse aide standing beside him. The resident was stabilized, the bleeding was stopped from the laceration, and he was assessed by the registered nurse. A statement from Registered Nurse 1, dated November 15, 2023, revealed that when she came upon the situation to help staff, it was noted that Resident 1's foot rests for his wheelchair were in the bag hanging on the back of the wheelchair. There was no documented evidence that a care plan was developed to address Resident 1's specific and individualized interventions and care needs related to using foot rests on his wheelchair prior to falling from his wheelchair. However, the foot rests were hanging on the back of the chair and Page 1 of 4 395944 395944 11/29/2023 Chambers Pointe Health Care Center 1425 Philadelphia Avenue Chambersburg, PA 17201

F 0656 readily available at the time of Resident 1's fall. Level of Harm - Actual harm A significant change Minimum Data Set MDS assessment for Resident 3, dated November 2, 2023, revealed that the resident was cognitively impaired, used a wheelchair, had a history of falls, and had diagnoses that included dementia and Parkinson's disease (disorder of the central nervous system that affects movement, often including tremors). Residents Affected - Few Observations of Resident 3 on November 29, 2023, at 12:41 p.m. revealed that the resident was in his wheelchair in the dining room, seated at a table, and had leg rests on. There was no documented evidence that a care plan was developed to address Resident 3's specific and individualized interventions and care needs related to using foot rests on his wheelchair. Interview with the Nursing Home Administrator on November 29, 2023, at 2:51 p.m. confirmed that there were no residents care planned for the use of foot rests. 28 Pa. Code 211.12(d)(1) Nursing services. 395944 Page 2 of 4 395944 11/29/2023 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 policies, investigative reports, and clinical records, as well as staff interviews, it was determined that the facility failed to take precautions to prevent injury to a resident caused by not having foot rests on his wheelchair during transport for one of three residents reviewed (Resident 1), resulting in a fall with a head injury. Findings include: The facility's policy regarding assistive devices and equipment, dated September 14, 2023, indicated that devices and equipment that assisted with resident mobility, safety and independence were provided for residents, which included wheelchairs, walkers and canes. Recommendations for the use of devices and equipment were based on the comprehensive assessment and documented in the resident's plan of care. An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated August 23, 2023, revealed that the resident was cognitively impaired, required extensive assistance with transfers, had limited range of motion to his upper extremities, used a wheelchair, had a history of falls, and had diagnoses that included dementia and traumatic brain injury (sudden injury that causes damage to the brain). The resident's care plan, dated September 14, 2023, revealed that he was at risk for falls and used a wheelchair. Investigative documents for Resident 1, dated November 15, 2023, revealed that the resident was on the floor lying in front of his wheelchair with the nurse aide standing beside him. The resident was stabilized, the bleeding was stopped from the laceration, and he was assessed by the registered nurse. A statement from Registered Nurse 1, dated November 15, 2023, revealed that Nurse Aide 2 went to the nurse's desk after she was involved in an incident with Resident 1. She stated that she was assisting another resident in the dining room and Resident 1 was in the dining room as well, and he began asking for help to get back to his room. She continued to help the resident she was with, but Resident 1 continued to ask her for help, so she began pushing him back to his room because he would not stop asking her for help. Nurse Aide 2 did not have foot rests on while she was pushing Resident 1 back to his room. Nurse Aide 2 stated that he was leaning forward and then he put his feet down and fell forward. When Registered Nurse 1 came upon the situation to help staff, it was noted that Resident 1's foot rests for his wheelchair were in the bag hanging on the back of the wheelchair. An emergency room report, dated November 15, 2023, revealed that Resident 1 was being pushed in his wheelchair and fell forward landing on his face and sustained a facial laceration measuring 5.0 centimeters (cm). An e-mail sent from the Director of Nursing to staff, dated November 16, 2023, revealed that Resident 1 had a fall, was transported by the nurse aide without foot rests, and received eight staples on his forehead. Interview with Nurse Aide 2 on November 29, 2023, at 3:11 p.m. confirmed that Resident 1 was in the dining room, needed someone to push him back to his room, and he fell on the floor. She stated that she did not add anything to his wheelchair. 395944 Page 3 of 4 395944 11/29/2023 Chambers Pointe Health Care Center 1425 Philadelphia Avenue Chambersburg, PA 17201

F 0689 Level of Harm - Actual harm Interview with Registered Nurse 1 on November 29, 2023, at 3:05 p.m. confirmed that Nurse Aide 2 was pushing Resident 1 in his wheelchair without foot rests, he fell, and received a laceration to the middle of his forehead, and that he should have had foot rests on his wheelchair before Nurse Aide 2 started to push him. Residents Affected - Few Interview with the Nursing Home Administrator on November 29, 2023, at 2:51 p.m. confirmed that Nurse Aide 2 did not use foot rests on Resident 1's wheelchair when he fell, and she should have put them on prior to pushing Resident 1. 28 Pa. Code 211.10(c)(d) Resident care policies. 28 Pa. Code 211.12(d)(5) Nursing services. 395944 Page 4 of 4