Health inspection·December 19, 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 a review of select facility policy, clinical records, information submitted by the facility, select investigative reports, and staff interviews, it was determined the facility failed to conduct a thorough investigation into an injury of unknown origin (a fractured humeral neck) for one resident out of 24 sampled (Resident 23). Residents Affected - Few Findings include: A review of facility policy titled Abuse Prevention Policy and Procedure, last reviewed by the facility on January 2, 2024, revealed it is the facility policy that an incident or suspected incident of resident abuse, mistreatment, neglect, or injury of unknown source is reported, then the administrator will assign the investigation to an appropriate individual. The policy indicates the information to be collected includes a review of all events leading up to the incident, a review of the resident's medical record to determine events leading up to the incident, and interviews with staff members on all shifts who have had contact with the resident at the time of the incident. The policy defines an injury of unknown source as the injury was not observed by any person or the source of the injury could not be explained by the resident, and the injury is suspicious because of the extent of the injury, location of the injury, number of injuries, or the pattern of injuries over time. A clinical record review revealed that Resident 23 was admitted to the facility on [DATE], with diagnoses that included peripheral vascular disease (a circulatory condition that occurs when blood vessels outside the brain and heart narrow, spasm, or become blocked). A review of a quarterly Minimum Data Set assessment (MDS-a federally mandated standardized assessment process conducted periodically to plan resident care) dated April 2, 2024, revealed that Resident 23 is severely cognitively impaired with a BIMS score of 00 (Brief Interview for Mental Status- a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 00-07 indicates severe cognitive impairment). A progress note dated June 13, 2024, at 9:59 AM revealed Resident 23 rolled out of bed during care. During care, Employee 6, Nurse Aide (NA), reported the resident was rolled to her side to complete care and proceeded to fall out of bed. The resident landed on her knees on a fall mat with her torso remaining on the bed. New orders for X-rays to right femur and bilateral knees was obtained. The certified registered nurse practitioner was in to assess the resident and identified bruising to her lateral right femur. Resident 23 grimaced when bilateral knees were palpated. (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 10 Event ID: 395566 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 395566 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highland Manor Rehabilitation and Nursing Center 750 Schooley Avenue Exeter, PA 18643 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)