Inspection·October 3, 2023

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 facility policy, clinical records, facility investigation records, and staff interview it was determined that the facility failed to provide fall interventions for two of three residents ( Resident R1 and Resident R2). Findings include: Review of facility policy Incidents and Accidents dated 1/19/23, indicated: The purpose of incident reporting can include: Assuring that appropriate and immediate interventions are implemented and corrective actions are taken to prevent recurrences and improve the management of resident care. Review of Resident R1 clinical record indicated resident was admitted on [DATE]. Review of Resident R1 MDS (minimum data set - a brief periodic assessment of resident needs) dated 8/11/23, indicated diagnosis of hypertension (a condition in which the force of the blood against the artery wall is too high) and anxiety disorder (mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere in one's daily activities). Review of incident report dated indicated that Resident R1 had a fall on 8/7/23, one of the assessments/recommendations on the incident report predisposing situation factors indicated improper footwear, dated 8/7/23, Resident R1 to wear non-skid footwear (which they did not have on at the time of the fall). Review of an incident report dated 8/11/23, indicated that Resident R1 had fallen and the assessment/recommendations for Resident R1 to wear non-skid footwear (which they did not have on at the time of the fall), predisposing situation factors indicated improper footwear. Review of Resident R1 clinical record failed to include other information about Resident R1 non-skid footwear. Review of Resident R2 clinical record indicated that resident was admitted on [DATE]. Review of Resident R2's MDS dated [DATE], indicated diagnosis of hypertension and history of falling ( a sudden loss of gait causing the hitting of any part of the body to the floor). (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 2 Event ID: 396138 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 396138 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harmony Physical Rehabilitation 4365 Northern Pike Monroeville, PA 15146 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)