Inspection visit
Health inspection
1 citation recorded
Inspector’s narrative
What the inspector wrote
This survey cited 1 deficiency, 1 of them serious (actual harm or immediate jeopardy). The full statement and the facility’s plan of correction follow, verbatim from the federal record.
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 policies, investigative reports, and residents' clinical records, as well as staff
interviews, it was determined that the facility failed to ensure that residents were free from neglect caused
by the failure to transfer a resident properly, resulting in a fractured arm for one of three residents (Resident
2) reviewed. This deficiency was cited as past noncompliance.
Findings include:
The facility's policy on freedom from abuse, neglect, misappropriation of property, exploitation and other
suspicious crimes or events, dated January 11, 2024, indicated that each resident had the right to be free
from verbal, sexual, physical, and mental abuse; corporal punishment; misappropriation of property; and
involuntary seclusion. Every resident in the facility was to be treated with consideration, respect, and full
recognition of his/her dignity and individuality, and management and staff were jointly and individually
responsible to ensure each resident was free from abuse, neglect, and misappropriation of property.
A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident abilities and care
needs) for Resident 2, dated May 3, 2024, revealed that the resident was sometimes understood and could
sometimes understand, was cognitively impaired, required assistance for all care, and had diagnoses that
included dementia. A care plan for Resident 2, dated August 17, 2021, indicated that the resident required
assistance for all care.
A nursing note for Resident 2, dated June 12, 2024, at 5:04 p.m. revealed that staff reported the resident
had a bruise on her right arm. A registered nurse assessment was difficult because the resident was
guarding her arm. The family and physician were notified and an order was received for an x-ray.
A statement by Nurse Aide 4, dated June 12, 2024, at 5:00 p.m. revealed that her and Nurse Aide 5
transferred Resident 2 onto the toilet. Upon attempting to stand the resident to clean her behind, the
resident was unable. They used the sit-to-stand lift (a mechanical device designed to assist individuals in
moving from a sitting to standing position and vice versa) on the resident. She complained of pain in her
arm and could not use it for the sit-to-stand transfer to stand back up. Nurse Aide 4 went and got Licensed
Practical Nurse 6 and the three of them assisted the resident and sat her back down on the chair.
A statement by Nurse Aide 5, dated June 12, 2024, at 5:00 p.m. revealed that he and Nurse Aide 4 did a
two-arm assist on Resident 2 to help her hold the bar to sit on the toilet. Resident 2 was unable to stand so
they sat her on the toilet. Afterwards, they attempted to use the sit-to-stand lift to
(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:
395427
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
395427
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/25/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Lutheran Home at Hollidaysburg
916 Hickory Street
Hollidaysburg, PA 16648
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)
F 0600
help her off the toilet, but she complained of pain in her right arm. Nursing was notified.
Level of Harm - Actual harm
A statement by Licensed Practical Nurse 6, dated June 12, 2024, at 5:00 p.m. revealed that she was called
to Resident 2's room and the resident was on the toilet. Nurse Aides 4 and 5 were unable to get her off the
toilet. A sit-to-stand lift was used. The resident was noted to have a hematoma of her right upper arm and
complained of pain.
Residents Affected - Few
A statement by Registered Nurse 7, dated June 12, 2024, at 5:10 p.m. revealed that Licensed Practical
Nurse 6 brought Resident 2 to her to look at the her arm. The resident was complaining of pain, and there
was a bruise on her right upper arm. The resident was holding her arm and did not want Registered Nurse
7 to move it. Registered Nurse 7 assessed the area and found bruising and some swelling. The physician
was notified and an x-ray was ordered and scheduled for morning.
A nursing note for Resident 2, dated June 12, 2024, at 9:15 p.m., revealed that nursing staff reported the
resident's right arm was more swollen and more bruised. When Registered Nurse 7 attempted to assess
range of motion, she felt bone grind against bone and immediately stopped and started the notification
process. An order was received to transport the resident to the emergency room for evaluation and
treatment. Resident 2 left the facility at 9:45 p.m.
A nursing note for Resident 2, dated June 13, 2024, at 2:57 a.m., revealed that a call was received from the
hospital to inform them that the resident was being admitted with a displaced fracture of the midshaft of the
right humerus. The Director of Nursing was notified and arrived at the facility at 4:45 a.m.
Investigation documents for Resident 2, dated June 13, 2024, at 10:15 a.m. revealed that the Director of
Nursing made contact with Nurse Aide 4 for further questioning of what happened. Nurse Aide 4 refused to
speak over the phone and wanted to come to the building. Nurse Aide 4 came to the building and provided
new verbal and written statements revealing that she did not use a gait belt when transferring Resident 2 to
the toilet with Nurse Aide 5. She stated that he transferred her by bear hugging her (when someone wraps
their arms all the way around a person and squeezes tightly).
The second written statement by Nurse Aide 4, dated June 13, 2024, revealed that on June 12, 2024, she
brought Resident 2 into the bathroom to be toileted. She and Nurse Aide 5 planned on cleaning the
resident because she could smell a bowel movement. Nurse Aide 5 bear hugged the resident so that Nurse
Aide 4 could pull down her pants and her incontinent brief prior to sitting on the resident on the toilet. They
cleaned and changed the resident's clothing as much as they could while she was on the toilet. Upon
standing her up they noticed she was not able to do it. Nurse Aide 4 decided to get the sit-to-stand lift. After
hooking her up and trying to put her arm up on the bar to lift her up, she complained of pain and could not
move it. Nurse Aide 4 went and found Licensed Practical Nurse 6, and she came back and assisted them
with a three-person transfer. Nurse Aide 5 supported her left side, Nurse Aide 4 supported her waist and
lower back to help her stand better, and Licensed Practical Nurse 6 assisted with perineal, bowel and urine
cleaning. They sat the resident down on her wheelchair. A couple hours later a coworker noticed more
bruising and brought it to the attention of the Registered Nurse Supervisor, who assessed her arm and
stated the resident needed to be sent out.
Investigative documents for Resident 2, dated June 13, 2024, at 11:10 a.m. revealed that the Director of
Nursing made contact with Nurse Aide 5. His statement remained consistent with statement given the night
of injury. He confirmed that he did not use a gait belt.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395427
If continuation sheet
Page 2 of 3
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
395427
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/25/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Lutheran Home at Hollidaysburg
916 Hickory Street
Hollidaysburg, PA 16648
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)
F 0600
The facility's investigation concluded on June 13, 2024, at 6:00 p.m. and determined the cause of Resident
2's injury to be from neglect.
Level of Harm - Actual harm
Residents Affected - Few
Review of Nurse Aide 5's personnel file revealed that he had completed training regarding preventing,
recognizing, and reporting abuse on March 18, 2024.
Following the investigation on June 13, 2024, the facility's corrective actions included:
Nurse Aide 5 was terminated from employment at the facility.
Staff education on abuse was completed.
Audits to identify any issues with abuse were started.
The results of these audits will be brought to Quality Assurance Performance Improvement committee for
further analysis and corrective actions if necessary.
Review of the facility's corrective actions and interviews completed with staff regarding their re-education
revealed that they were in compliance with F600 on June 24, 2024.
28 Pa. Code 201.14(a) Responsibility of Licensee.
28 Pa. Code 201.18(b)(1)(e)(1) Management.
28 Pa. Code 211.10(c)(d) Resident Care Policies.
28 Pa. Code 211.12(d)(1)(5) Nursing Services.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395427
If continuation sheet
Page 3 of 3
Reading this as a family member? Your long-term care ombudsman is a free advocate for residents and families.
Back to topCitations
1 citation recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F600 - Freedom from Abuse, Neglect, and Exploitation
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
FAQ · About this visit
Common questions about this visit
What happened during the June 25, 2024 survey of LUTHERAN HOME AT HOLLIDAYSBURG?
This was a inspection survey of LUTHERAN HOME AT HOLLIDAYSBURG on June 25, 2024. The surveyor cited 1 deficiency, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at LUTHERAN HOME AT HOLLIDAYSBURG on June 25, 2024?
Yes, 1 deficiency was cited, each with a CMS Scope and Severity grade. The first was: "Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect b..."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.