Inspection·December 10, 2024

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interview, it was determined that the facility failed to protect a resident's right to be free from physical abuse for one of one resident reviewed for resident-to-resident interactions (Resident 1). Findings include: Clinical record review revealed the facility admitted Resident 1 on March 7, 2012, with diagnosis including unspecified dementia (a decline in mental ability that affects thinking, memory, and behavior, and interferes with daily life). Review of nursing documentation revealed a fall occurrence note dated November 30, 2024, at 4:37 PM indicating Resident 1 was noted to be on the floor next to her bed laying on her right side. Resident 1 was noted to be guarding her right arm and complaining of pain to her right arm. The fall was unwitnessed by staff. Resident 1's statement indicated Resident 1 reported her roommate (Resident 2) pushed me out of bed, and I'm scared. Nursing documentation dated December 1, 2024, at 1:22 PM revealed the facility received Resident 1's x-ray result, noting a mild fracture of the proximal humeral neck. Review of radiology results report dated December 1, 2024, confirmed a fracture of Resident 1's proximal right humeral neck. Clinical record review revealed the facility admitted Resident 2 on August 18, 2016, with diagnoses including bipolar disorder (a mental illness that causes extreme shifts in mood, energy, and activity levels). Review of Resident 2's most recent MDS (Minimum Data Set, an assessment completed at specific intervals to determine care needs) dated September 9, 2024, noted staff assessed Resident 2 with a BIMS (brief interview for mental status) summary score of 15 (a score of 13-15 indicates that a resident's cognition is intact). Review of Resident 2's clinical record revealed nursing documentation dated November 30, 2024, at 5:30 PM indicating Employee 1 (registered nurse) was called to Resident 2's room because Resident 1 was noted to be on the floor. Employee 1 noted when Resident 2 was seen by staff in the hallway, she turned around and walked away from the room. Resident 2 denied knowing what happened to her roommate (Resident 1). Nursing documentation revealed for safety reasons Resident 2 was moved to a room on a different floor. Documentation revealed the state police arrived at the facility at 5:04 PM and spoke with Resident 2. Employee 1 noted Resident 2 reported to the police that she pushed her roommate (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: 395683 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 395683 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/10/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highlands Rehabilitation and Healthcare 918 Main Street Laporte, PA 18626 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)