Health inspection·May 16, 2025

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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policies and documents, clinical record review, and staff interview, it was determined that the facility failed to protect residents from neglect that resulted in the actual harm of a hematoma (pooling of blood under the skin) and a facial laceration that required sutures for one of three residents (Resident R1). Findings include: Review of the facility policy, Abuse, Neglect, Exploitation and Misappropriation Prevention Program dated 11/1/24, indicated that residents have the right to be free of neglect. Review of the clinical record indicated Resident R1 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS - periodic assessment of resident care needs) dated 4/7/25, included diagnoses of achondroplasia (a disorder of that prevents the changing of cartilage to bone), muscle weakness, and repeated falls. Review of the MDS dated [DATE], Section GG: Functional Abilities indicated Resident R1 utilized a wheelchair, had lower extremity impairment on both sides, and was dependent on staff for transferring into his wheelchair. Review of a progress note dated 2/11/25, at 7:33 p.m. indicated Resident R1 was found on the floor in front of his wheelchair facing down. Resident R1 had a hematoma on his forehead. Emergency services were called and Resident R1 was transferred to the hospital. Review of a progress note dated 2/12/25, at 6:55 a.m. indicated Resident R1 was returning to the facility, with all testing at the hospital negative for injuries. Review of a facility incident report dated 2/11/25, indicated, Was called to room where pt (patient) was on the floor in front of his wheelchair facing down. Pt denies pain, resident was seen approx. 1 hour prior when trays picked up and no needs were identified at that time. Review of a nurse practitioner note dated 2/14/25, at 11:57 a.m. indicated that after the fall, Resident R1 had been evaluated by occupational therapy, with staff being educated on positioning in the wheelchair, tilt and recline functions of the wheelchair, and the need for leg rests to be on. Review of Resident R1's plan of care for At risk for falls initiated on 6/19/18, included an Page 1 of 6 396003 396003 05/16/2025 Monroeville Post Acute 885 MacBeth Drive Monroeville, PA 15146

F 0600 intervention dated 2/12/25, that indicated, Foot rests on wheelchair when OOB (out of bed). Level of Harm - Actual harm Review of Resident R1's [NAME] as of 2/12/25, included the instruction of OOB to personal chair with leg rests. Residents Affected - Few Review of the document, Inservice for Positioning dated 2/13/25-2/20/25, provided by occupational therapy, revealed eight staff members educated on positioning in wheelchair, use of leg rests when in wheelchair, and how to tilt and recline in the wheelchair for Resident R1. Nurse Aide (NA) Employee E2 signed that she received this education. Review of facility provided education documents dated 3/7/25, revealed education provided to staff on the need to use the [NAME] for appropriate assistance levels and individual resident safety needs. Nurse Aide (NA) Employee E2 signed that she received this education. Review of a progress note created on 3/19/25, at 4:06 p.m. indicated, Staff responded to a call to [Resident R1's] room because he was found on the floor in a pool of blood. I responded immediately and obtained 2 sets of vitals before EMS arrived. The resident, who sustained a head injury, did not provide details about the incident or his intended destination but repeatedly stated that he was fine. When EMS arrived, I assisted with holding his neck and head, as per their instructions. His head was bandaged and neck collar applied. His BP (blood pressure) was slightly elevated but other vitals stable, he has breathing easily on room air. Review of a nurse practitioner note dated 3/19/25, at 12:40 p.m. indicated, Pt was found on the floor by a PT (physical therapy) assistant. I was in the hallway and was able to see him immediately. He was found on the floor in a large pool of blood. He was laying on his right side of the most part with his R (right) shoulder pushed out from under him making his trunk face downward. Review of a nurse's note dated 3/19/25, at 9:24 p.m. indicated, Resident returned from [hospital] with sutures to forehead and a hematoma. Review of facility submitted information dated 3/19/25, indicated, On the morning of 3/19/2025 he [Resident R1] sustained a fall from his wheelchair and was transferred to the hospital. The last time the resident was seen was 20 minutes prior to the fall sitting in his wheelchair watching television. RN (registered nurse) and CRNP (certified registered nurse practitioner) assessed post fall. Upon return from the hospital, he will be evaluated for fall interventions. Review of emergency room documentation dated 3/19/25, at 3:30 p.m. indicated Resident R1 was treated for a fall with a head injury, with the laceration repaired by plastic surgery, and will need suture removal in the plastic surgery clinic in seven days. Review of a nurse practitioner note dated 3/20/25, at 9:52 a.m. indicated that at the hospital on 3/19/25, Resident R1 received five sutures to the laceration on his forehead and that the laceration measured 3.5 centimeters. Review of an update to the submitted information dated 3/25/25, indicated, On return from the hospital, resident was evaluated for seating. Upon investigation, it was noted by CNA (nurse aide) that she did not apply leg rests as indicated. Review of an undated employee statement written by NA Employee E2 indicated, When I got [Resident 396003 Page 2 of 6 396003 05/16/2025 Monroeville Post Acute 885 MacBeth Drive Monroeville, PA 15146

F 0600 R1] put him in the chair and didn't put the leg rest on because they cause him pain. So I just sat him up straight and put him in front of the television. Level of Harm - Actual harm Residents Affected - Few Review of the Report Form for Investigation of Alleged Abuse, Neglect, Misappropriation of Property dated 3/28/25, indicated that NA Employee E2 neglected to follow facility recommended safety measures, and was terminated from her employment. Attempts to call and interview NA Employee E2 were unsuccessful. During an interview on 5/7/25, at 11:00 a.m., NA Employee E5 confirmed the use of the [NAME] when caring for residents to provide instruction for additional safety measures or any other needs. During an interview on 5/7/15, at 11:50 a.m., NA Employee E10 confirmed the use of the [NAME] when caring for residents to provide instruction for additional safety measures or any other needs. During an interview on 5/7/25, at approximately 3:45 p.m. the Nursing Home Administrator and the Director of Nursing confirmed NA Employee E2 had two separate educations on the need to use leg rests for Resident R1 and the need to use the [NAME] for appropriate assistance levels and safety information, confirmed that NA Employee E2 did not appropriately position Resident R1 in his wheelchair, and confirmed that the facility failed to provide adequate supervision to prevent falls that resulted in the actual harm of a hematoma and a facial laceration that required sutures for one of three residents (Resident R1). 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(e)(1) Management. 28 Pa. Code 201.29(a) Resident rights. 28 Pa. Code 211.10(c)(d) Resident care policies. 28 Pa Code 211.12(d)(1)(2)(5) Nursing services. 396003 Page 3 of 6 396003 05/16/2025 Monroeville Post Acute 885 MacBeth Drive Monroeville, PA 15146

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 review of facility policies and documents, clinical record review, and staff interview, it was determined that the facility failed to provide adequate supervision to prevent falls that resulted in the actual harm of a hematoma (pooling of blood under the skin) and a facial laceration that required sutures for one of three residents (Resident R1). Findings include: Review of the facility policy, Supporting Activities of Daily Living (ADL) dated 11/1/24, indicated Residents will be provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Review of the clinical record indicated Resident R1 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS - periodic assessment of resident care needs) dated 4/7/25, included diagnoses of achondroplasia (a disorder that prevents the changing of cartilage to bone), muscle weakness, and repeated falls. Review of the MDS dated [DATE], Section GG: Functional Abilities indicated Resident R1 utilized a wheelchair, had lower extremity impairment on both sides, and was dependent on staff for transferring into his wheelchair. Review of Resident R1's plan of care for Requires assistance / potential to restore function for MOBILITY dated 2/9/23, indicated the intervention of a high back w/c (wheelchair) with fitted leg rests and a foot buddy (a stable platform for the wheelchair user's feet). Review of Resident R1's [NAME] (document that outlines the patients' ADLs, continence levels, and behaviors, as well as physician, advanced directives, diet, and allergies) as of 2/10/25, did not include information related to the use of a high back wheelchair or a foot buddy. Review of a progress note dated 2/11/25, at 7:33 p.m. indicated Resident R1 was found on the floor in front of his wheelchair facing down. Resident R1 had a hematoma on his forehead. Emergency services were called and Resident R1 was transferred to the hospital. Review of a progress note dated 2/12/25, at 6:55 a.m. indicated Resident R1 was returning to the facility, with all testing at the hospital negative for injuries. Review of a facility incident report dated 2/11/25, indicated, Was called to room where pt (patient) was on the floor in front of his wheelchair facing down. Pt denies pain, resident was seen approx. 1 hour prior when trays picked up and no needs were identified at that time. Review of Resident R1's plan of care for At risk for falls initiated on 6/19/18, included an intervention dated 2/12/25, that indicated, Foot rests on wheelchair when OOB (out of bed). Review of Resident R1's [NAME] as of 2/12/25, included the instruction of OOB to personal chair with leg rests. 396003 Page 4 of 6 396003 05/16/2025 Monroeville Post Acute 885 MacBeth Drive Monroeville, PA 15146

F 0689 Level of Harm - Actual harm Residents Affected - Few Review of a nurse practitioner note dated 2/14/25, at 11:57 a.m. indicated that after the fall, Resident R1 had been evaluated by occupational therapy, with staff being educated on positioning in the wheelchair, tilt and recline functions of the wheelchair, and the need for leg rests to be on. Review of the document, Inservice for Positioning dated 2/13/25-2/20/25, provided by occupational therapy, revealed eight staff members educated on positioning in wheelchair, use of leg rests when in wheelchair, and how to tilt and recline in the wheelchair for Resident R1. During an interview on 5/7/25, at approximately 2:00 p.m. Director of Therapy Employee E1 confirmed that only eight staff were educated, with the expectation that those staff would disseminate the information to their coworkers. Review of a progress note created on 3/19/25, at 4:06 p.m. indicated, Staff responded to a call to [Resident R1's] room because he was found on the floor in a pool of blood. I responded immediately and obtained 2 sets of vitals before EMS arrived. The resident, who sustained a head injury, did not provide details about the incident or his intended destination but repeatedly stated that he was fine. When EMS arrived, I assisted with holding his neck and head, as per their instructions. His head was bandaged and neck collar applied. His BP (blood pressure) was slightly elevated but other vitals stable, he has breathing easily on room air. Review of a nurse practitioner note dated 3/19/25, at 12:40 p.m. indicated, Pt was found on the floor by a PT (physical therapy) assistant. I was in the hallway and was able to see him immediately. He was found on the floor in a large pool of blood. He was laying on his right side of the most part with his R (right) shoulder pushed out from under him making his trunk face downward. Review of a nurse's note dated 3/19/25, at 9:24 p.m. indicated, Resident returned from [hospital] with sutures to forehead and a hematoma. Review of facility submitted information dated 3/19/25, indicated, On the morning of 3/19/2025 he [Resident R1] sustained a fall from his wheelchair and was transferred to the hospital. The last time the resident was seen was 20 minutes prior to the fall sitting in his wheelchair watching television. RN (registered nurse) and CRNP (certified registered nurse practitioner) assessed post fall. Upon return from the hospital, he will be evaluated for fall interventions. Review of emergency room documentation dated 3/19/25, at 3:30 p.m. indicated Resident R1 was treated for a fall with a head injury, with the laceration repaired by plastic surgery, and will need suture removal in the plastic surgery clinic in seven days. Review of a nurse practitioner note dated 3/20/25, at 9:52 a.m. indicated that at the hospital on 3/19/25, Resident R1 received five sutures to the laceration on his forehead and that the laceration measured 3.5 centimeters. Review of an update to the submitted information dated 3/25/25, indicated, On return from the hospital, resident was evaluated for seating. Upon investigation, it was noted by CNA (nurse aide) that she did not apply leg rests as indicated. Review of an undated employee statement written by NA Employee E2 indicated, When I got [Resident R1] put him in the chair and didn't put the leg rest on because they cause him pain. So I just sat him up straight and put him in front of the television. 396003 Page 5 of 6 396003 05/16/2025 Monroeville Post Acute 885 MacBeth Drive Monroeville, PA 15146

F 0689 Attempts to call and interview NA Employee E2 were unsuccessful. Level of Harm - Actual harm During an interview on 5/7/25, at 11:00 a.m., NA Employee E5 confirmed the use of the [NAME] when caring for residents to provide instruction for additional safety measures or any other needs. Residents Affected - Few During an interview on 5/7/15, at 11:50 a.m., MA Employee E10 confirmed the use of the [NAME] when caring for residents to provide instruction for additional safety measures or any other needs. Review of the Report Form for Investigation of Alleged Abuse, Neglect, Misappropriation of Property dated 3/28/25, indicated that Nurse Aide Employee E2 neglected to follow facility recommended safety measures, and was terminated from her employment. During an interview on 5/7/25, at approximately 3:45 p.m. the Nursing Home Administrator and the Director of Nursing confirmed the facility failed to provide adequate supervision to prevent falls that resulted in the actual harm of a hematoma and a facial laceration that required sutures for one of three residents (Resident R1). 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(e)(1) Management. 28 Pa. Code 201.29(a) Resident rights. 28 Pa. Code 211.10(c)(d) Resident care policies. 28 Pa Code 211.12(d)(1)(2)(5) Nursing services. 396003 Page 6 of 6