Health inspection·May 9, 2024

F 0600 Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Level of Harm - Actual harm Residents Affected - Few Based on review of facility policy, facility documentation and clinical record, and resident and staff interviews, it was determined that the facility failed to ensure that one of three residents reviewed (Resident R1) was free of neglect during care which resulted in actual harm of spiral fractures of the right tibia and fibula (lower leg). This deficiency is cited as past non-compliance. Findings include: A review of facility policy entitled, Resident Abuse & Neglect Prevention Program, dated 1/10/2024, revealed that, Neglect means failure to provide goods and services necessary to avoid physical harm, pain, mental anguish, or emotional distress. Neglect refers to deprivation by a caretaker of goods, or services which are necessary to maintain physical or mental health. A review of Resident R1's clinical record revealed an admission date of 8/5/2021, that included diagnoses of stroke, heart disease, history of falls, and dementia. A review of Resident R1's Quarterly Minimum Data Set assessment (MDS - an assessment tool used to facilitate the management of care) dated 2/28/2024, revealed that Resident R1 required total two-person assistance with transfers. A review of Resident R1's current care plan revealed for transfers resident required, assist of two with front wheeled walker. A review of Resident R1's clinical record revealed a nurse's note dated 4/27/2024, at 9:15 a.m. which indicated that Resident R1 was having some right ankle pain, resident was assessed, and no marks or redness noted, Resident R1 was administered Tylenol (pain medication) and will continue to monitor. A nurse's note dated 4/27/24, at 1:52 p.m. revealed that Resident R1 continued to complain of right ankle pain and was assessed with no swelling or redness noted at that time and was administered Tylenol for pain. A nurse's note dated 4/27/24, at 3:10 p.m. indicated that Resident R1 continued to complain of pain in right leg, resident assessed, and right foot was shiny and slightly swollen and on right shin was a quarter size red area that was tender to touch, right calf was red and warm to touch, also swollen. A nurse's note dated 4/27/2024, at 4:12 p.m. indicated that Resident R1 was sent to the hospital for evaluation. Review of information submitted by facility dated 4/28/2024, revealed Resident R1 was admitted to the hospital with diagnosis of a spiral fracture of the right tibia and fibula. It also revealed that through the investigation that Resident R1 was transferred on 4/27/2024, throughout the day with an assist of one and not an assist of two. (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 3 Event ID: 395341 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 395341 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/09/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Elk Haven Nursing Home 785 Johnsonburg Road Saint Marys, PA 15857 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)