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. Page 1 of 3 395341 395341 05/09/2024 Elk Haven Nursing Home 785 Johnsonburg Road Saint Marys, PA 15857

F 0600 Level of Harm - Actual harm Residents Affected - Few A review of the facility's investigation revealed that Nursing Assistant (NA) Employee E1 confirmed on a written statement dated 4/28/2024, he/she transferred Resident R1 in and out of bed with assistance of one. A review of documentation submitted by the facility dated 4/28/2024, revealed that the facility initiated an investigation, regarding Resident R1's injury of unknown origin on 4/27/2024. The investigation revealed that the resident was transferred throughout the day with an assist of one on 4/27/24. Following the transfers, the resident's leg had increased swelling and redness. NA Employee E1 did not follow the resident's care plan resulting in harm and employment was terminated. An interview with the NHA on 5/9/2024, at 10:40 a.m. confirmed that NA Employee E1 transferred Resident R1 alone even though resident was an assist of two. The facility failed to ensure that Resident R1 was free from neglect resulting in actual harm of a spiral fracture of the right tibia and fibula. This deficiency is cited as past non-compliance. On 4/28/2024, the facility initiated education for all nursing staff including Registered Nurses (RNs), Licensed Practical Nurses (LPNs), and NAs to ensure that transfer status must be followed on care plan, with review of abuse and neglect and review of following the care plan. This plan included the following: Immediate suspension of NA Employee E1 followed by termination of employment. Immediate education regarding following the resident's care plan for transfers and abuse/neglect was provided to all facility nursing staff which included RNs, LPNs, and NAs, which occurred from 4/28/2024, to 5/2/2024. All staff included in the education also completed competencies conducted by the Director of Nursing (DON) and the RN Supervisor to ensure that they understood the education and could perform the task correctly. All competencies were reviewed during this on-site investigation. Interviews with RN Employees E2, E3, and E5 and LPN Employee E4 and NA Employees E7, E8, E9, and E10 confirmed the facility initiated education starting 4/28/2024, and competencies starting 5/6/2024, which included education on resident transfer status, following the resident's care plan, and review of abuse / neglect, with knowledge of where to find the resident's care plans. Audits were conducted by the DON of following a resident care plan regarding transfers weekly for three weeks, initial audit of nine resident care plans, monthly times three months and quarterly times one since 5/6/2024. Per interview with the NHA and the DON, audits will continue to be completed by the RN Supervisors on each shift as well as the DON. These audits will be reviewed by the Quality Assurance Performance Improvement (QAPI) Committee. The audits will continue until determined otherwise by the QAPI committee. During an interview with the NHA on 5/9/2024, at 10:40 a.m. and review of the facility's immediate actions, education, competencies, audits, and review of the QAPI monitoring process to sustain solutions, it was verified that the facility had implemented a plan of correction to ensure residents are 395341 Page 2 of 3 395341 05/09/2024 Elk Haven Nursing Home 785 Johnsonburg Road Saint Marys, PA 15857

F 0600 free from neglect regarding proper transfers and had achieved substantial compliance. Level of Harm - Actual harm 28 Pa. Code 201.14(a) Responsibility of licensee Residents Affected - Few 28 Pa. Code 201.18(b)(1)(3) Management 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 211.12(c) Nursing services 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services 395341 Page 3 of 3