Health inspection·May 31, 2024

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 facility policy and procedure review, clinical record review, and staff interviews, it was determined the facility failed to thoroughly investigate incidents for three of 32 residents reviewed. (Residents 2, 95, and 155) Residents Affected - Some Findings include: Review of facility policy and procedure titled Protection of Residents: Reducing the Threat of Abuse & Neglect, reviewed May 15, 2020, revealed when an incident of or suspected incident of resident abuse and/or neglect of unknown source, exploitation or misappropriation of resident property is reported the administrator/designee will investigate the occurrence. The administrator/designee will complete an Incident Report and will utilize the Incident Investigation Questionnaire Form to document the investigation. The written summary of the investigation should include, but is not limited to: a review of the incident report, an interview with the person reporting the incident, interviews of any witnesses to the incident, an interview with the resident if appropriate, a review of the residents medical record, an interview with employees as needed, a review of the employees file as needed, Interviews with staff members on all shifts having contact with the resident at the time of the incident. Interview with the resident's roommate, family, and or visitors which may have information regarding the incident, interview other resident who received care and services from the alleged perpetrator, a review of all circumstances surrounding the incident. Review of Resident 2's clinical record revealed the following diagnosis: Unspecified Dementia (the loss of cognitive functioning - thinking, remembering, and reasoning - to such an extent that it interferes with a person's daily life and activities), Cognitive communication deficit (difficulty with communication that is caused by a problem with thinking), Anxiety disorder (intense, excessive and persistent worry and fear about everyday situations.), Major Depressive disorder (a persistent feeling of sadness and loss of interest). Additional review of Resident 2's clinical record revealed Resident 2 was actively prescribed Eliquis (blood thinner, blocks the activity of certain clotting substances in the blood). Review of Resident 2's progress notes revealed a progress note dated April 23, 2024, which states the following On this night the CAN (Certified nursing assistant) informed me that this resident had blood on his hand, wrist and on many tissues in the trash can. When assessing the situation, there was a band aide soaked with blood on his left wrist. When the band aide was removed the area was still bleeding. There was approximately a straight line cut approximately 1 centimeter long with no depth nor width on his left wrist. The area kept bleeding. The edges were approximated with 2 steri strips (strong adhesive bandages. They're often used to hold together the edges of a cut or wound, (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 9 Event ID: 395436 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 395436 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/31/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hickory House Nursing Home 3120 Horseshoe Pike Honey Brook, PA 19344 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)