Inspection·March 27, 2024

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of clinical records, select facility policy and investigative reports, and staff interview, it was determined that the facility neglected to provide one resident with the necessary care and services to prevent injury and maintain physical health out of 16 sampled. (Resident 4). Findings include: A review of the facility's abuse prohibition policy provided on March 27, 2024, revealed that it the policy of the facility to protect their residents from abuse, neglect, misappropriation of property, corporal punishment and involuntary seclusion. A review of Resident 4's clinical record revealed admission to the facility on June 14, 2022, with diagnoses of dementia (a chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning), osteoarthritis, and heart disease. Resident 4's plan of care, last revised by the facility October 30, 2022, indicated that the resident has an ADL (activity of daily living) self-care performance deficit related to activity intolerance related to CHF (congestive heart failure). Planned interventions were to provide the assistance of two staff members to turn and reposition the resident in bed as necessary and that the resident requires a full mechanical lift and assist of two staff members for transfers. A review of a facility investigation report dated February 5, 2024, at 3:30 PM revealed that Employee 3, a nurse aide, rolled the resident in bed, to put a new brief under him. Resident 4 then shifted his hips and rolled off the bed. Employee 3 tried to stop the resident from falling out of bed but was unable to prevent the resident's fall. Resident 4 sustained a large skin tear and abrasion to his head. The physician ordered the resident to be transported to the emergency room for evaluation. The resident returned to the facility with sutures to the right parietal (side) region of his head and right forearm. A review of Employee 3's witness statement dated February 5, 2024, revealed that the employee was assigned to Resident 4 to provide care and services on the day of the fall. According to Employee 3's statement, when he was putting a new brief under the resident, the resident rolled his hip and fell off the bed. He fell onto the floor. Employee 3's statement did not indicate the presence of another staff member while repositioning the resident in bed to provide ADL care. There was no evidence that another staff member was assisting with the resident's turning and (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 9 Event ID: 396148 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 396148 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/27/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Delaware Valley Skilled Nursing & Rehabilitation C 111 Rivers Edge Drive Matamoras, PA 18336 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)