Inspection·August 4, 2023

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Based on clinical record review, review of facility documents, and staff and resident interview, it was determined that the facility failed to protect the rights of a resident to be free from neglect by not providing the services necessary to avoid a fall out of bed resulting in injury for one of one resident reviewed for neglect related to a fall (Resident 60). Findings include: Clinical record review for Resident 60 revealed a nursing progress note dated July 13, 2023, at 9:53 PM that indicated he was witnessed by staff to roll out of bed onto the floor. The note indicated that he landed on the floor face first and that he denied pain other than his knees. His knees were red from laying on the floor and he had an abrasion on his left elbow. Further clinical record review for Resident 60 revealed a nursing progress note date July 13, 2023, at 10:09 PM that revealed a nurse aide was performing incontinence care on him and had him propped on his left side holding himself up with his right hand. The nurse aide turned his head for a second and the resident rolled onto the floor. The resident was assessed by the registered nurse, and it was noted that he had a small skin tear on his left elbow and an abrasion on his left knee with redness to his right knee. Resident 60 stated that his knees were slightly sore, but he was ok. Review of Resident 60's care plan for activities of daily living that was last revised on September 8, 2021, indicated that he required two staff for bed mobility (moving to and from lying position, turns side to side, and positions body while in bed) and assist of two staff for toilet use (how resident cleanses self after elimination, changes pad, adjusts clothing). Review of the facility investigation into Resident 60's fall dated July 13, 2023, at 10:02 PM revealed that there was no witness statement from the nurse aide that was present in the room during the fall. There was no evidence that the facility investigated the fall to rule out neglect. Interview with the Director of Nursing, (DON) and Employee 5, corporate nurse consultant, on August 3, 2023, at 11:23 AM revealed that when the fall occurred, there was only one nurse aide providing incontinence care to Resident 60. They indicated that Resident 60 only required one nurse aide for personal hygiene, according to his plan of care. The Surveyor reviewed the definition of personal hygiene (how a resident maintains personal hygiene, including combing hair, brushing teeth, shaving, applying makeup, washing/drying face, and hands) as defined by the minimum data set (MDS, and assessment completed by the facility at intervals, to determine care needs of the resident) assessment, with the DON and Employee 5. The Surveyor also revealed that to provide incontinence care on Resident 60, who was in bed, that he would need to be turned and repositioned (bed mobility), which requires (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 19 Event ID: 395350 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 395350 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Locust Grove Retirement Village 69 Cottage Road Mifflin, PA 17058 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)