Health inspection·April 9, 2025

F 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of clinical records and select facility policy. facility investigative reports, and staff interviews, it was determined the facility failed to thoroughly investigate an incident of unknown origin to rule out abuse, neglect or mistreatment as the potential cause, for one out of 5 sampled residents (Resident 1). Residents Affected - Few Findings include: A review of the facility's Abuse Policy, last reviewed by the facility in January 2025, indicated that incidents of unknown origin will be investigated as abuse until root cause can be identified. Written procedures for investigation include: identifying staff responsible for the investigation; exercising caution in handling evidence that could be used in a criminal investigation; investigating different types of alleged violations; identifying and interviewing all involved persons, including alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations; focusing the investigation on determining if abuse, neglect, exploitation, and/or mistreatment has occurred, the extent, and cause; and providing complete and thorough documentation of the investigation. A review of clinical record revealed Resident 1 was admitted to the facility on [DATE], with diagnoses which included diabetes and severe protein/calorie malnutrition. A review of an admission Minimum Data Set assessment (MDS - a federally mandated standardized assessment process completed periodically to plan resident care) dated January 21, 2025, revealed the resident was cognitively intact with a BIMS score of 13 (brief interview for mental status, a tool to assess the residents attention, orientation and ability to register and recall new information, a score of 13-15 equates to being cognitively intact) and requires staff assistance with activities of daily living (ADLs). A review of physician orders dated February 21, 2025, revealed an order for potassium chloride extended release, 10 MEQ tablets, four tablets by mouth, three times daily. A review of a February 2025 Medication Administration Record (MAR) revealed that nursing staff documented administration of all prescribed medications, including the potassium chloride, from February 21 through February 28, 2025 when he was transferred out to the hospital. Nursing documentation dated February 28, 2025, at 11:52 AM indicated the resident's son requested hospital evaluation due to the resident feeling unwell, with symptoms of nausea and loose stools. The resident was noted to be incontinent of a small, pasty, tarry stool. He refused breakfast and morning medications. The abdomen was soft, non-tender, with positive bowel sounds. The physician (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: 395357 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 395357 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/09/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ellen Memorial Rehabilitation and Healthcare Cente 23 Ellen Memorial Lane Honesdale, PA 18431 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)