Health inspection·February 20, 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 a review of facility policies, clinical records, and facility investigation reports, as well as observations and staff interviews, it was determined that the facility failed to ensure resident safety during transportation in a wheelchair for one of 40 residents reviewed (Resident 216). Findings include: A facility policy regarding safe mobility, dated March 15, 2024, indicated that the facility would promote safe mobility for all residents in their care. Yellow code was caution, the resident needs assistance with mobility. A review of the clinical record for Resident 216 indicated that the resident was admitted to the facility on [DATE], with a diagnosis of a closed non-displaced intertrochanteric fracture of the right femur. Resident 216 was coded yellow. A mobility care plan for Resident 216, dated February 12, 2025, indicated that the resident was to have therapeutic exercise, bed mobility gait training, and transfer and ambulation devices as ordered. The resident was weight bearing as tolerated to the right lower extremity. A certified physician's assistant note for Resident 216, dated February 12, 2025, revealed that the resident had active problems that included a distal radius fracture of the right upper extremity with splint and a right femur fracture. The resident had an open reduction and internal fixation (surgical procedure used to treat broken bones) on February 8, 2025. Observations on February 20, 2025, at 1:15 p.m. in the therapy room revealed that Occupational Therapist 2 pushed Resident 216 into the therapy room. Resident 216's wheelchair did not have foot rests in place and her feet were approximately one inch off the ground. Resident 216 was pushed to the table to work on a hand coordination activity with a board and plastic pins. Interview with the Occupational Therapist 2 at the time of the observation revealed that Resident 216 had foot rests and they should be in use. Interview with Director of Nursing on February 20, 2025, at 12:44 p.m. confirmed that the staff should always use leg/footrests on wheelchairs when residents are being transported in their wheelchairs but indicated that therapy staff have their own procedure. 28 Pa. Code 201.14(a) Responsibility of Licensee. 28 Pa. Code 201.18(b)(1)(e)(1) Management. (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 3 Event ID: 396102 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 396102 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/20/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Conemaugh Memorial Medical Center Tcu 320 Main Street Johnstown, PA 15901 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)