Health inspection·March 22, 2024

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Based on the review of the facility's abuse prohibition policy, clinical records, select facility investigations, and staff interviews, it was determined that the facility failed to timely report resident physical abuse to the State Survey Agency for one of the 20 residents reviewed (Resident 5). Findings include: A review of the facility's Prevention of Abuse/Neglect/Involuntary Seclusion/Exploitation: The Facility Procedures Policy, last reviewed by the facility in October 2023, revealed that the facility's policy is for staff to report any allegations of abuse, neglect, misappropriation of property, exploitation, or involuntary seclusion to their supervisor immediately. The facility administrator or designee will be responsible for the follow-up investigation and reporting to the required agencies within the required time frames. The policy indicated that the investigation results will be reported to the State Survey Agency and all other required agencies within five days of the allegation. Facility investigation documents dated February 29, 2024, indicated that a nurse aide observed Resident 4 use the back of her hand to hit Resident 5 in the mouth. A Resident Incident Investigation form dated February 29, 2024, revealed that Employee 2, a Nurse Aide, observed Resident 4 in the hallway telling Resident 5 to shut up and was holding her {Resident 5's} left wrist. {Resident 4} let go of Resident 5's wrist and slapped {Resident 5} with the backside of her hand across {Resident 5's} mouth. The residents were separated, and the incident was reported to supervisory staff. A progress note dated February 29, 2024, at 5:25 PM indicated that {Resident 4} hit her roommate with the back of her hand. Resident 4 stated that she wouldn't knock it off! I want her to shut up! A progress note dated February 29, 2024, at 5:25 PM indicated that Resident 5 was unable to describe details of the interaction but indicated to staff that I'm okay. Resident 5 was assessed with no skin impairments, open areas, bruising, swelling, or dental issues. During an interview on March 21, 2024, at approximately 1:00 PM, the Nursing Home Administrator (NHA) and Director of Nursing (DON) confirmed that the facility failed to report physical abuse of Resident 5 perpetrated by Resident 4 to State Survey Agency within the required time frames. 28 Pa Code 201.14 (c) Responsibility of licensee 28 Pa Code 201.18 (e)(1) Management 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 7 Event ID: 395480 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 395480 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mahoning Operating LLC 397 Hemlock Drive Lehighton, PA 18235 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)