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. Page 1 of 3 396102 396102 02/20/2025 Conemaugh Memorial Medical Center Tcu 320 Main Street Johnstown, PA 15901

F 0689 28 Pa. Code 211.12(d)(1)(5) Nursing Services. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 396102 Page 2 of 3 396102 02/20/2025 Conemaugh Memorial Medical Center Tcu 320 Main Street Johnstown, PA 15901

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on review of policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that proper infection control practices were followed during the administration of medications for one of 15 residents reviewed (Resident 116). Residents Affected - Few Findings include: The facility's policy regarding medication administration, dated March 15, 2024, indicated that medications are administered in accordance with professional standards of practice, in a manner to prevent contamination or infection. Staff will follow all infection control practices for hand hygiene and application of personal protective equipment as indicated. Physician's orders for Resident 116 included an order for the resident to receive 8.6 milligrams of Sennosides glycoside two tablets daily for constipation. Observations on February 19, 2025, at 8:45 a.m. revealed that Registered Nurse 1 dropped a tablet of Sennosides glycoside onto the medication cart. She picked the medication up off the cart with her bare hands and placed it into the medication cup and administered the medications to the resident. Interview with Registered Nurse 1 at that time confirmed that she should have wasted the medication. Interview with the Nursing Home Administrator on February 19, 2025, at 3:15 p.m. confirmed that medications that were dropped should have been wasted and were not to be touched with bare hands. 28 Pa. Code 211.12(d)(1)(5) Nursing Services. 396102 Page 3 of 3