Health inspection·May 1, 2023

F 0658 Ensure services provided by the nursing facility meet professional standards of quality. Level of Harm - Minimal harm or potential for actual harm Based on review of The Pennsylvania Code, Professional and Vocational Standards, State Board of Nursing, facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that a registered nurse assessment was completed with a change in condition for one of three residents reviewed (Resident 2). Residents Affected - Few Finding include: The Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.11 (a)(1)(2)(4) indicated that the registered nurse was to collect complete and ongoing data to determine nursing care needs, analyze the health status of individuals and compare the data with the norm when determining nursing care needs, and carry out nursing care actions that promote, maintain and restore the well-being of individuals. The facility's current policy for falls indicated that a registered nurse would assess any resident after a fall prior to the resident being moved. A comprehensive Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated April 5, 2023, revealed that the resident had severe cognitive impairment, was sometimes understood, could sometimes understand, was dependent on staff for her locomotion on and off the unit, and had diagnoses of dementia. Resident 2's care plan, dated February 16, 2023, indicated that the resident required two staff to pivot with a gait belt and a wheeled walker for transfers. Nursing note for Resident 2, dated April 26, 2023 at 6:06 a.m., revealed that the resident was walking with Nurse Aide 1 when she stated that she was going down. The nurse aide then lowered the resident to the floor. The resident was then lifted from the floor with a full body mechanical lift by a licensed practical nurse and nurse aide and placed in bed. Interview with the Director of Nursing on May 1, 2023, at 1:50 p.m. confirmed that a registered nurse did not assess the resident prior to the staff picking her up off the floor and putting her back in bed and should have. 28 Pa. Code 211.12(d)(1)(5) Nursing services. 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: 395050 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 395050 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Garvey Manor 1037 South Logan Boulevard Hollidaysburg, PA 16648 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)