Health inspection·December 3, 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 a review of facility policies, investigative reports, clinical records, and staff education records, as well as staff interviews, it was determined that the facility failed to ensure that residents were free from neglect for one of two residents reviewed (Resident 1), resulting in a dislocated shoulder. Findings include: The facility's policy regarding abuse and neglect, dated March 14, 2024, indicated that every resident has the right to be free from verbal, sexual, physical, and mental abuse; corporal punishment; and involuntary seclusion. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated September 17, 2024, revealed that the resident was cognitively impaired and was dependent on staff for all daily care needs. A nursing note for Resident 1, dated November 17, 2024, at 12:11 p.m., revealed that Resident 1 was exhibiting increased behaviors and requested something for pain. A nursing note for Resident 1, dated November 18, 2024, at 3:30 p.m., revealed that she had multiple scattered bruises on her upper arm measuring 15.0 centimeters (cm) x 8.5 cm and the arm was painful with touch. A nursing note for Resident 1, dated November 19, 2024, at 11:28 a.m., revealed that the bruise on the resident's upper arm was larger and the arm was more swollen. The resident was complaining of increased pain. New orders were received for an x-ray of the left upper arm. The x-ray report for Resident 1, dated November 19, 2024, at 12:22 p.m., revealed a dislocated left shoulder. Review of the facility's investigation for Resident 1, dated November 19, 2024, revealed that on November 14, 2024, Resident 1 was yelling and resisting care. A witness statement by Nurse Aide 1, dated November 20, 2024, revealed that she observed Nurse Aide 2 force Resident 1's left arm above her head, back against the bed, and then force the arm back to a normal position while putting on her deodorant. Nurse Aide 1 stated that she immediately observed a deformity in Resident 1's left shoulder and that the resident was complaining of pain, as well as tingling in her fingers. The investigation by the facility determined that Nurse Aide 2's forceful movement of Resident 1's arm caused the dislocated shoulder. (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 5 Event ID: 395387 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 395387 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/03/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fulton County Medical Center 214 Peach Orchard Road McConnellsburg, PA 17233 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)