Health inspection·June 30, 2025

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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 record, review of policy and procedures, interviews with staff, and review of hospital records, it was determined that the nursing staff failed to properly supervise one of five residents reviewed during transfer and ambulation. (Resident R1) Findings include:A review of the facility policy titled fall management dated February, 2023 revealed that it was the responsibility of the facility staff to assess residents who were at risk for falls and identify the reason for the fall to prepare a care plan to reduce the potential for future falls. This policy indicated that a plan of care would be developed and initiated to address fall risk factors and measures to prevent falls. A facility incident report will be completed post fall and witness statements/information would be documented and used to develop care plan approaches to prevent falls.A review of the facility's policy titled incident and accident investigation dated January, 2022 revealed that the purpose of the investigation of an incident was to complete a prompt and thorough review and report of all falls to promote resident safety and quality of care. The policy indicated that the registered nurse (ADON- Assistant Director of Nursing) was responsible for the investigation and obtaining employee statements of the circumstances surrounding the fall. The ADON was also responsible for determining new interventions that would be effective to prevent falls. The ADON was also responsible for conducting interviews with the resident involved in the fall. The ADON was responsible for training of tasks to staff to prevent further falls. The ADON was responsible for providing a summary of the investigation into the fall/incident. Review of Resident R1's clinical record revealed that the resident was admitted to the facility on [DATE] with the diagnosis of Anemia, Atrial Fibrillation (irregular heart beat) and generalized weakness. Review of physical therapist's assessment dated [DATE] indicated Resident R1 had a diagnosis of BPPV (vertigo or sudden onset of asensation of spinning or moving). The therapist's assessment also indicated that Resident R1 had kyphosis (an excessive forward curve of the spine) and inadequate hip extension, unsteadiness on the feet and inadequate toe clearance; which was associated with muscle weakness in the resident's gait. The therapist assessed Resident R1 to be at risk for falls; because of the resident reduced balance. The physical therapy care plan for Resident R1 was to provide Resident R1 with partial/moderate assistance with walking to prevent falls. Review of the occupational therapist assessment dated [DATE] indicated Resident R1 required care giver assist to walk with cues from staff to perform proper/safe walking techniques for a distance of 15 feet with a roller walker. The occupational therapist indicated that Resident R1 required the support of a staff member to stand from a seated position.Clinical record review revealed a physicial therapy progress note dated April 24, 2025 that indicated Resident R1 had decreased cadence (balance or movement), decreased step/stride length and decreased toe clearance and flexed posture. The progress indicated that Resident R1 was ambulating with a roller walker and care giver assist with a wheelchair following. Review of Resident R1's admission comprehensive assessment (MDS-an assessment of care needs) dated April 28, 2025 indicated that this resident was cognitively intact. Resident R1 was assessed with bilateral lower extremity impairments on both sides of the body. The assessment indicated for toileting hygiene Resident R1 required supervision or touching assistance in which the staff provides verbal cues and/or touching and/or contact guard assistance as resident completes the activity. The resident had functional mobility impairments from chair/bed to chair transfers; required supervision or touching assistance provided by staff. Resident R1 required partial/moderate assistance from staff for ambulation. The staff member was required to lifted, hold or support the trunk or limbs of the resident for ambulation or transfers. The resident was dependent for walking 50 feet (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 396101 If continuation sheet Page 2 of 3 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 396101 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/30/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rehab at Shannondell 5000 Shannondell Drive Audubon, PA 19403 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete with assist of two for ambulation 50 feet. The comprehensive assessment identified Resident R1 as occasionally incontinent of urine. Review of Resident R1's care plan dated April 22, 2025 revealed that the resident was care planned for falls. Interventions included to assist with transfers as needed and resident is supervision.Review for Resident R1's nursing notes dated April 24, 2025 at 10:25 a.m. indicated This nurse was called by therapy and was notified that this patient had fallen with therapy out of the balcony. This nurse went to the balcony right away. The patient was found lying face down with her head towards the ceiling. She was immediately assessed for injuries by this nurse .This nurse notice bleeding form her right hand and right knee .CRNP noticed. Continued review of nursing notes dated April 24, 2025 at 11:04 a.m. revealed that the resident reported discomfort of bilateral knees and left side.Nursing note dated April 25, 2025 indicated that continued care from the occupational and physical therapy departments were necessary for gait training, transfer training and dynamic balance to help prevent further falls for Resident R1.Interview with the physical therapist, Employee E6, at 1:00 p.m., on June 30, 2025 confirmed that in order to promote safe transfers and ambulation, Resident R1 required moderate supervised assistance of a staff member to use a rolling walker for transfers as demonstrated for 15 feet. The physical therapist also confirmed that Resident R1 required cueing and physical support from staff to go from a seated position to standing position and standing position to seated position for safety reasons. Review of nursing note dated April 26, 2025 indicated Resident R1 required assist of one staff member for transfers. The nursing note also indicated that this resident required assist of one staff person to use a rolling walker for ambulation. Review of nursing note dated April 28, 2025 revealed that the resident self reported to a licensed nurse, Employee E5, that she had a fall at 5:00 a.m., while standing to walk to the bathroom. The nursing assistant, Employee E7, responsible for the care of Resident R1 at 5:00 a.m., was contacted and reported that walker was placed in front of Resident R1. The nursing assistant, Employee E7 reported that during this transfer with Resident R1, he turned away from the resident to grab her trash to empty it, as it was full. The nursing assistant, Employee E7, reported that Resident R1 fell, when he turned away from her to empty the trash, as it was full. Clinical record review for April 28, 2025 indicated that Resident R1 was found to have a weeping open area on the left shin, that required treatment as ordered by the physician.Interview with the Director of Nursing, Employee E2, on June 30, 2025 at 10:45 a.m., confirmed that there was no documentation to indicate a written statement had been obtained from the nursing assistant, Employee E7 that indicated he turned his head for a split second to empty her trash can, on April 28, 2025. Review of the incident documentation indicated that Resident R1 was walking to the bathroom with her walker when she fell. There was no documentation to indicate that the nursing assistant provided contact guard, moderate supervised assistance and cueing to keep both hands on the walker as required for safe transfers for Resident R1 at 5:00 a.m., on April 28, 2025.28 PA. Code 211.10(d) Resident care policies28 PA. Code 211.12(d)(1) Nursing services Event ID: Facility ID: 396101 If continuation sheet Page 3 of 3