Epworth Healthcare And Rehabilitation Center

F-F600 on April 9, 2025.

28 Pa. Code 211.10(c)(d) Resident Care Policies.

28 Pa. Code 201.24(e)(4) Admission Policy.

28 Pa. Code 211.12(d)(1)(5) Nursing Services.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 2 of 4 395393 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 395393 B. Wing 04/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Cedarwood Rehabilitation & Healthcare Center 951 Washington Avenue Tyrone, PA 16686

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 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 38012 Residents Affected - Few Based on review of investigation reports and clinical records, as well as staff interviews, it was determined that the facility failed to provide adequate supervision and assistance to prevent accidents for one of four residents reviewed (Resident 2) who required two staff for bed mobility, resulting in a fall with fractures. This deficiency is being cited as past non-compliance.

Findings include:

Admission paperwork for Resident 2, dated April 4, 2025, revealed that the resident was admitted to the facility on [DATE REDACTED], after having fallen at home and suffering a hip fracture, which required surgery on March 30, 2025. The resident was alert with slight confusion and required extensive assistance from two staff members for care, including bed mobility. The resident's care plan, initiated April 4, 2025, revealed that the resident required two staff members for bed mobility.

An incident note for Resident 2, dated April 7, 2025, revealed that the resident was receiving care from Nurse Aide 1 while in bed. Nurse Aide 1 rolled the resident to do a complete bed change when the resident rolled out of bed and landed face down on the floor. Nurse Aide 1 was the only nurse aide providing care for

the resident at the time of her fall out of bed.

X-ray reports, dated April 7, 2025, confirmed that Resident 2 had a nasal bone fracture, an acute nondisplaced fracture through the base of the odontoid process (also known as the dens, a bony projection of the second cervical vertebra), and a left frontal scalp laceration requiring sutures.

Education records for Nurse Aide 1 revealed that he signed that he received education regarding the facility's policy for reviewing the residents' Kardex (a documentation system that helps nursing staff access key patient information from their care plan) on February 14, 2025.

A written statement by Nurse Aide 1, dated April 7, 2025, revealed that he did not review the resident's Kardex prior to providing care for her and therefore, he did not know that she required two staff for care. He stated that while she was on her side she was holding onto the nightstand; however, she fell to the floor.

An interview with the Director of Nursing on April 17, 2025, at 10:21 a.m. confirmed that Nurse Aide 1 failed to follow Resident 2's care plan for bed mobility resulting in her falling out of bed and sustaining facial and neck fractures.

Following the incident on April 7, 2025, the facility's corrective actions included:

On April 7, 2025, the resident was immediately assessed and transferred to the hospital for further assessment. Nurse Aide 1 was immediately removed from care, interviewed, and suspended. He was then terminated for admitted ly not following the resident's care plan regarding bed mobility.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 3 of 4 395393 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 395393 B. Wing 04/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Cedarwood Rehabilitation & Healthcare Center 951 Washington Avenue Tyrone, PA 16686

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 The alert and oriented residents of the facility were interviewed to determine if they were transferred and received care according to their care plan. Non-interviewable residents were observed and assessed to Level of Harm - Actual harm determine if they had any injuries as a result of improper care with bed mobility.

Residents Affected - Few Education records dated April 8 and 9, 2025, revealed that all of the facility's nursing staff received education regarding reviewing the resident's Kardex/care plan prior to providing resident's with care.

The Director of Nursing or designee will audit five random resident's care to ensure that their plan of care was followed five days a week for one week, and then three days a week for one week, and then weekly for one month. Further audits will be completed as determined by the Quality Assurance Performance Improvement (QAPI) committee.

Review of the facility's corrective actions and interviews completed with staff regarding their re-education revealed that they were in compliance with

F-F689 on April 9, 2025.

28 Pa. Code 201.24(e)(4) Admission Policy.

28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 4 of 4 395393