**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policies, facility documentation and clinical record, and resident and staff interviews, it was determined that the facility failed to ensure that one of 19 residents reviewed was free of neglect during care (Resident R5). Findings include: Review of facility policy entitled Resident abuse, neglect, exploitation, and misappropriation of resident property policy, last reviewed 12/28/2023, revealed Neglect: The indifference or disregard for resident care, comfort or safety, resulting in or may result in physical harm, pain, mental anguish, or emotional distress. neglect occurs when the facility is aware of, or should have been aware of goods or services that a resident requires but the facility fails to provide them to the resident resulting in, or may result in physical harm, pain, mental anguish, or emotional distress. Review of facility policy entitiled Fall Protocol, with a policy review date of 12/28/2023, revealed that it is the policy of the Pavilion at BRMC to make every attempt at preventing residents from falling. Review of Resident R5's clinical record revealed an admission date 2/14/2011, with diagnoses that included Alzheimer's Disease (a progressive disease that destroys memory and other important mental functions), major depressive disorder (a mental disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), history of seizures, muscle weakness, hearing loss, chronic pain, history of falling, age related physical debility, and macular degeneration (an eye disease that causes vision loss). Review of Resident R5's Activities of Daily Living (ADL) related care plan originally dated 5/4/2020 and last reviewed 7/24/2024, revealed resident has an ADL self-care performance deficit related to confusion, poor vision, and extreme hard of hearing (HOH). Toilet transfer is dependent. Transfers requires extensive assistance of two staff members. Toilet use: is an extensive assist of 1-2 assist for toileting and has stress incontinence. Review of R5's Minimum Data Set (MDS-a periodic assessment of resident care needs) Assessment Section GG Functional Abilities and Goals last updated 7/16/2024, revealed that Section GG0130 Self-care revealed Toileting Hygiene: the ability to maintain perineal hygiene, adjust clothes before and after voiding or having a bowel movement, identified that Resident R5 required Substantial/maximal assistance; Section GG0170 F: toilet transfer: the ability to get on and off a toilet or commode revealed that Resident R5 required partial/moderate assistance. Section C Cognitive Patterns revealed that section C0500 brief interview for mental status (BIMS) summary score revealed a score of 01, indicating cognitive impairment. Review of Resident R5's progress notes from 9/26/2024, at 3:05 p.m. revealed, This writer called to second floor for resident observed on bathroom floor. Resident assessed and found to have bruising to front and back of head, and both knees, with the left knee being significantly swollen. MD [Medical Doctor] notified and orders obtained to send resident to ER [Emergency Room] for evaluation. Son notified and agreeable. Report called to ER, and resident transported to ER via stretcher. Review of Resident R5's CT scan report of the cervical spine without contrast dated 9/26/2024, at 4:24 p.m. revealed an acute nondisplaced (broken bone where pieces of bone didn't move far enough to be out of alignment) type 2 dens fracture (Fracture at the base of the odontoid process [also called the dens] which is a bony projection on the C2 vertebrae in the neck) During an interview with the Director of Nursing (DON) and Nursing Home Administrator (NHA) on 12/5/2024, at approximately 1:30 p.m., it was confirmed that a Nurse Aide (NA) employee assisted Resident R5 into the restroom to use the toilet. Resident R5 was assisted onto the toilet and was left unattended in the restroom. Employees were at change of shift and report was given to the next shift. The resident was found on the floor in the restroom by the next shift staff members. Review of a witness statement to the DON and NHA on 9/27/2024 by NA Employee E1, revealed the following information: it was at the end of the shift and Resident R5 came out from the activity and asked if she could be taken to the bathroom. On coming NA's and off going NA's were at the nurse's station and were giving one another report prior to the end of the shift. NA Employee E1 took Resident R5 to the bathroom and stood in the doorway of the bathroom. NA Employee E1 then proceeded to the room doorway and told the evening shift staff members that Resident R5 was on the toilet in the bathroom and would need assisted off. Staff acknowledged that Resident R5 was on the toilet in the bathroom and NA Employee E1 stated that she was going to go home. Interviews with staff members by the DON and NHA that worked the evening shift did acknowledge that NA Employee E1 did pass along that Resident R5 was in the bathroom. Review of a witness statement dated 9/26/2024, from NA Employee E2, who found Resident R5 in the bathroom on 9/26/2024, revealed, I came onto the floor got report, and started getting my list of residents up and ready for dinner. When I entered room [ROOM NUMBER], I heard groaning in the bathroom and upon entering saw [Resident R5] on his/her front on the floor with head and shoulders under the wheelchair, not stuck on anything. I called for the nurse without leaving the resident. Found [Resident R5] on the floor at 2:40 p.m. Review of a witness statement dated 9/27/2024, from NA Employee E3, revealed I worked 6-2 Thursday, 9/26/2024. [Resident R5] got up for lunch. She was in the dining room for lunch. Then when bingo began, [Resident R5] told the activities director that she needed to go to the bathroom. [NA Employee E1] said he/she would take [Resident R5] to the bathroom. Second shift came in and was given report and told that [Resident R5] was on the toilet. The day shift NA's left the floor. During interviews on 12/6/2024, at 9:45 a.m. with NA Employee E4, NA Employee E5, NA Employee E6, and NA Employee E3 it was confirmed that the nursing staff was re-educated regarding fall safety and assisting residents when in the restroom. Resident plans of care are reviewed for levels of assistance and care with baths. All employees interviewed revealed that residents are not to be left unmonitored in the restroom for safety purposes. An interview conducted with Licensed Practical Nurse (LPN) Employee E7 on 12/6/2024, at 10:00 a.m. revealed that it is not the practice of the nursing staff to leave residents in the bathroom unattended. Staff should always be aware someone is in the bathroom to watch or monitor resident for safety. Resident plans of care are reviewed for levels of assistance and care with toileting. During an interview with the DON and NHA on 12/5/2024, at approximately 2:30 p.m. it was confirmed that Resident R5 was placed in the restroom unattended by NA Employee E1 and then was left unattended in the bathroom of room [ROOM NUMBER] at change of shift with Resident R5 being found on the floor resulting in a neck fracture. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(3) Management 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(d)(1)(2)(5) Nursing services

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, clinical records, facility documentation, and staff interview, it was determined that the facility failed to provide proper resident supervision during toileting that resulted in a fall with actual harm of a fracture of the neck (C2 vertebrae) for one of 19 residents reviewed (Resident R5). Findings include: Review of facility policy entitiled Fall Protocol, with a policy review date of 12/28/23, revealed that it is the policy of the Pavilion at BRMC to make every attempt at preventing residents from falling. Review of Resident R5's clinical record revealed an admission date of 2/14/2011, with diagnoses that included Alzheimer's Disease (a progressive disease that destroys memory and other important mental functions), major depressive disorder (a mental disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), history of seizures, muscle weakness, hearing loss, chronic pain, history of falling, age related physical debility, and macular degeneration (an eye disease that causes vision loss). Review of Resident R5's Activities of Daily Living (ADL) related care plan originally dated 5/4/2020 and last reviewed 7/24/2024, revealed resident has an ADL self-care performance deficit related to confusion, poor vision, and extreme hard of hearing (HOH). Toilet transfer is dependent. Transfers requires extensive assistance of two staff members. Toilet use: is an extensive assist of 1-2 assist for toileting and has stress incontinence. Review of Resident R5's Minimum Data Set (MDS-a periodic assessment of resident care needs) Assessment Section GG Functional Abilities and Goals last updated 7/16/2024, revealed that Section GG0130 Self-care revealed Toileting Hygiene: the ability to maintain perineal hygiene, adjust clothes before and after voiding or having a bowel movement, identified that Resident R5 required Substantial/maximal assistance; Section GG0170 F: toilet transfer: the ability to get on and off a toilet or commode revealed that Resident R5 required partial/moderate assistance. Section C Cognitive Patterns revealed that section C0500 brief interview for mental status (BIMS) summary score revealed a score of 01, indicating cognitive impairment. Review of Resident R5's progress notes from 9/26/2024, at 3:05 p.m. revealed, This writer called to second floor for resident observed on bathroom floor. Resident assessed and found to have bruising to front and back of head, and both knees, with the left knee being significantly swollen. MD [Medical Doctor] notified and orders obtained to send resident to ER [Emergency Room] for evaluation. Son notified and agreeable. Report called to ER, and resident transported to ER via stretcher. Review of Resident R5's CT scan report of the cervical spine without contrast dated 9/26/2024, at 4:24 p.m. revealed an acute nondisplaced (broken bone where pieces of bone didn't move far enough to be out of alignment) type 2 dens fracture (Fracture at the base of the odontoid process [also called the dens] which is a bony projection on the C2 vertebrae in the neck) During an interview with the Director of Nursing (DON) and Nursing Home Administrator (NHA) on 12/5/2024, at approximately 1:30 p.m., it was confirmed that a Nurse Aide (NA) employee assisted Resident R5 into the restroom to use the toilet. Resident R5 was assisted onto the toilet and was left unattended in the restroom. Employees were at change of shift and report was given to the next shift. The resident was found on the floor in the restroom by the next shift staff members. Review of a witness statement to the DON and NHA on 9/27/2024 by NA Employee E1, revealed the following information: it was at the end of the shift and Resident R5 came out from the activity and asked if she could be taken to the bathroom. On coming NA's and off going NA's were at the nurse's station and were giving one another report prior to the end of the shift. NA Employee E1 took Resident R5 to the bathroom and stood in the doorway of the bathroom. NA Employee E1 then proceeded to the room doorway and told the evening shift staff members that Resident R5 was on the toilet in the bathroom and would need assisted off. Staff acknowledged that Resident R5 was on the toilet in the bathroom and NA Employee E1 stated that she was going to go home. Interviews with staff members by the DON and NHA that worked the evening shift did acknowledge that NA Employee E1 did pass along that Resident R5 was in the bathroom. Review of a witness statement dated 9/26/2024, from NA Employee E2, who found Resident R5 in the bathroom on 9/26/2024, revealed, I came onto the floor got report, and started getting my list of residents up and ready for dinner. When I entered room [ROOM NUMBER], I heard groaning in the bathroom and upon entering saw [Resident R5] on his/her front on the floor with head and shoulders under the wheelchair, not stuck on anything. I called for the nurse without leaving the resident. Found [Resident R5] on the floor at 2:40 p.m. Review of a witness statement dated 9/27/2024, from NA Employee E3, revealed I worked 6-2 Thursday, 9/26/2024. [Resident R5] got up for lunch. She was in the dining room for lunch. Then when bingo began, [Resident R5] told the activities director that she needed to go to the bathroom. [NA Employee E1] said he/she would take [Resident R5] to the bathroom. Second shift came in and was given report and told that [Resident R5] was on the toilet. The day shift NA's left the floor. During interviews on 12/6/2024, at 9:45 a.m. with NA Employee E4, NA Employee E5, NA Employee E6, and NA Employee E3 it was confirmed that the nursing staff was re-educated regarding fall safety and assisting residents when in the restroom. Resident plans of care are reviewed for levels of assistance and care with baths. All employees interviewed revealed that residents are not to be left unmonitored in the restroom for safety purposes. An interview conducted with Licensed Practical Nurse (LPN) Employee E7 on 12/6/2024, at 10:00 a.m. revealed that it is not the practice of the nursing staff to leave residents in the bathroom unattended. Staff should always be aware someone is in the bathroom to watch or monitor resident for safety. Resident plans of care are reviewed for levels of assistance and care with toileting. During an interview with the DON and NHA on 12/5/2024, at approximately 2:30 p.m. it was confirmed that Resident R5 was placed in the restroom unattended by NA Employee E1 and then was left unattended in the bathroom of room [ROOM NUMBER] at change of shift with Resident R5 being found on the floor resulting in a neck fracture. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(3) Management 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(d)(1)(2)(5) Nursing services