Health inspection·February 16, 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 review of facility policy, clinical records, facility documents, and staff interview, it was determined that the facility failed to fully investigate alleged allegation of abuse/neglect for one of three residents (Resident R10). Residents Affected - Few Findings include: Review of the facility policy J-5-O Prohibition and Prevention of Resident Abuse, Neglect, Exploitation, Mistreatment, or Misappropriation of Resident Property dated [DATE], indicated to assure a timely, thorough, and objective investigation of all allegations of abuse, neglect exploitation, mistreatment, or misappropriation of resident property. The Investigation Statement form should include a graphic description if physical abuse is suspected. Be sure to include a description of the scene, positioning of resident and staff, time, nature of injury, etc. Review of the admission record indicated Resident R10 was admitted to the facility on [DATE]. Review of Resident R10's Minimum Data Set (MDS- a periodic assessment of care needs) dated [DATE], indicated the diagnoses of high blood pressure, heart failure (the heart doesn't pump blood as well as it should), and Parkinson's Disease (disorder of the nervous system that results in tremors). Review of Resident R10's incident report dated [DATE], at 8:00 p.m. indicated resident noted with a skin tear to right lower leg as he was being readied for bed. A trickle of bright red blood present, stopped with slight pressure. Review of facility provided Risk Management Report dated [DATE], indicated Nurse Aides (NA) Employee E3 and Employee E4 reported to Registered Nurse (RN) Employee E5 that they noticed a skin tear on Resident R10's right lower leg when getting him ready for bed. Review of NA Employee E3's Investigation Statement dated [DATE], indicated right lower leg skin tear was noted when getting client ready for bed. Review of NA Employee E4's Investigation Statement dated [DATE], indicated Pulled down pants, skin tear left lower leg. Review of Resident R10's second incident report dated [DATE], at 8:00 p.m. indicated during evening care the staff observed a horizontal skin tear to resident's right great toe at the bottom of the toe. (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 7 Event ID: 395605 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 395605 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/16/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Barnabas Nursing Home 5827 Meridian Road Gibsonia, PA 15044 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)