Health inspection·August 20, 2025

F 0600 Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of clinical records, facility policy, investigative documentation provided by the facility, and resident and staff interviews, it was determined the facility displayed past non-compliance by failing to protect one of four sampled residents (Resident 3) from neglect by not implementing the individualized care plan intervention for transfers, resulting in actual harm in the form of a mid-humerus fracture. Findings Include: A review of the facility policy titled Identifying Types of Abuse, last reviewed by the facility on September 26, 2024, revealed that abuse of any kind against residents is strictly prohibited. The policy defines neglect as the failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Neglect includes cases where the facility's indifference or disregard for resident care, comfort, or safety results in physical harm, pain, mental anguish, or emotional distress. A clinical record review revealed Resident 3 was originally admitted to the facility on [DATE] , with diagnoses that included chronic respiratory failure with hypoxia (a condition where the respiratory system is unable to remove carbon dioxide from or provide oxygen to the body) and chronic obstructive pulmonary disease (COPD is a condition caused by damage to the airways or other parts of the lung that blocks airflow and makes it hard to breathe). A review of a significant change in status Minimum Data Set assessment (MDS a federally mandated standardized assessment process conducted periodically to plan resident care) dated August 7, 2025, revealed that Resident 3 was cognitively intact with a BIMS score of 13 (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 13-15 indicates cognition is intact).A review of the individualized care plan revealed Resident 3 had an activity of daily life self-care deficit related to decreased mobility initiated on October 25, 2023. Interventions developed to assist Resident 3 with this deficit included employees utilizing a mechanical lift with the assistance of two staff for transfers initiated on October 25, 2023.A review of the Kardex (a reference tool providing a concise, quick overview of a resident's essential information for nursing staff) dated July 29, 2025, revealed Resident 3 required a mechanical lift and the assistance of two staff members for all transfers.A review of facility provided investigative documentation revealed a written witness statement dated July 29, 2025, provided by Employee 1, Nurse Aide (NA), which indicated Employee 1, NA, was in the shower room getting ready to transfer Resident 3 from the shower chair to her wheelchair. Employee 1, NA, indicated that she put her arms around Resident 3, and when Resident 3 picked her arm up, they heard a cracking sound. Employee 1, NA, indicated she then went to get help. Employee 1, NA, reported Employee 2, Licensed Practical Nurse (LPN), was also present.A written witness statement dated July 29, 2025, provided by Employee 2, Licensed Practical Nurse (LPN), revealed she was asked by Employee 1, NA, to help with a transfer. She indicated Employee 1, Page 1 of 3 395701 395701 08/20/2025 Abington Manor 100 Edella Road Clarks Summit, PA 18411

F 0600 Level of Harm - Actual harm Residents Affected - Few NA, wanted her to clean Resident 3 and pull up her brief as Employee 1, NA, assisted her to a standing position. Employee 2, LPN, indicated she heard a pop as Employee 1, NA, lifted Resident 3. Resident 3 was assisted back down and began stating she could not move her arm. Employee 1, NA, left to get assistance. Employee 2, LPN, described specifically that Employee 1, NA, put her arms under Resident 3's arms so that they were chest to chest. As Employee 1, NA, began to stand with Resident 3, they heard the pop.An investigation document provided by the facility dated July 29, 2025, at 10:33 AM revealed Employee 1, NA, attempted to manually lift Resident 3 after completing a shower. Employee 1, NA, heard a crack, lowered Resident 3 back to her chair, and alerted additional staff for further assessment. The certified registered nurse practitioner assessed Resident 3's left arm to have notable swelling and bruising. Resident 3 was guarding her arm and complained of severe pain. The document indicated Employee 1, NA, was suspended pending an investigation.A progress note dated July 29, 2025, at 10:23 AM revealed a call was placed for a stat (immediate) x-ray of Resident 3's left arm.A progress note dated July 29, 2025, at 11:25 AM revealed Resident 3 was transferred to the community hospital by way of ambulance for left arm pain. The resident representative and physician were made aware.A review of x-ray results titled XR Humerus 2 or More Views, dated July 29, 2025, at 12:59 PM revealed three views of the left shoulder and three views of the left humerus (the large arm bone between the shoulder and the elbow). Shoulder views revealed Resident 3 sustained a fracture in the mid-diaphysis humerus (the long, cylindrical shaft or body that forms the middle section of the bone). No dislocation noted. Probable old, healed fracture of the proximal humerus. Views of the left humerus revealed a spiral oblique displaced fracture (a bone broken into at least two pieces by a twisting force, with the break curving around the bone at an angle) mid-diaphysis (long straight shaft of upper arm bone). Other bones were intact, and no dislocation noted. The impression from the x-rays indicated Resident 3 sustained a humerus fracture.A review of community hospital discharge instructions dated August 1, 2025, revealed Resident 3 presented at the community hospital on July 29, 2025, with complaints of left arm pain. Resident 3 was found to have a spiral fracture of the left humerus. Resident 3 was admitted for pain management, orthopedic and vascular consultation, and rehabilitation therapy, and the fracture was treated non-operatively with immobilization and pain control before the resident was discharged back to the facility on August 1, 2025, at 5:37 PM. During a telephone interview on August 20, 2025, at 10:10 AM Employee 1, a nurse aide (NA), confirmed she attempted to lift Resident 3 manually and heard a crack as she lifted the resident from the chair. Employee 1, NA, confirmed that she was aware of Resident 3's need to be transferred by way of mechanical lift with the assistance of two staff, but she explained that she was lifting her enough to slide a lift pad under the resident. Employee 1, NA, explained she no longer works at the facility.During an interview on August 20, 2025, at 10:25 AM, Resident 3 recalled her arm injury but could not describe the incident. She remembered experiencing terrible pain. Resident 3 indicated that her arm remains sore, but the pain has greatly improved.During a telephone interview on August 20, 2025, at approximately 11:00 AM, Employee 2, Licensed Practical Nurse (LPN), explained that Employee 1, NA, asked her to help provide care for Resident 3 in the shower room on July 29, 2025. Employee 2, LPN, explained that she was new to the facility and not familiar with Resident 3 or Resident 3's plan of care. Employee 2, LPN, indicated that she recalled Employee 1, NA, wrapping her arms around Resident 3, beginning to lift the resident, hearing a crack, putting the resident back in the chair, and then going to get assistance. Employee 2, LPN, explained that she no longer works at the facility. During an interview on August 20, 2025, at approximately 12:00 PM, the Nursing Home Administrator (NHA) and the Director of Nursing (DON) stated the facility's investigation determined that Employee 1 failed to follow 395701 Page 2 of 3 395701 08/20/2025 Abington Manor 100 Edella Road Clarks Summit, PA 18411

F 0600 Level of Harm - Actual harm Residents Affected - Few Resident 3's plan of care, which required transfers to be performed using a mechanical lift with the assistance of two staff. They confirmed that the failure to follow the plan of care resulted in a serious physical injury in the form of a mid-humerus fracture. The NHA and DON stated that Employee 1 was terminated as a result of the investigation findings. This deficiency was cited as past non-compliance and verified as implemented.The facility's corrective action plan included the following:The facility cannot retroactively correct the deficient practice. Employee 1, Nurse Aide, was terminated.A full house audit was completed on July 29, 2025, on resident transfer status to ensure the care plan and Kardex are up to date and correct.Education was provided to nursing staff regarding the use of the correct sling while operating the mechanical lift, review of the resident Kardex protocol, and the facility's policy for abuse and neglect.Education was initiated on July 29, 2025, and continued on July 30, 2025, and July 31, 2025, with current employees. Nurses not educated by 11:00 PM on July 31, 2025, will not be able to work until education is completed. Education is ongoing with new hires and agency staff.Transfer observations were conducted with staff on each unit. Transfer audits will be completed on every shift daily for one week, with weekly random audits to continue. Results of the audits were reviewed at the AD HOC Quality Assurance Performance Improvement Committee Meeting. The facility's compliance date was July 31, 2025. 28 Pa. Code 201.14 (a) Responsibility of licensee. 28 Pa. Code 201.18 (e)(1) Management. 28 Pa. Code 201.29 (a) Resident rights. 28 Pa. Code 211.10 (c) Resident care policies. 28 Pa. Code 211.12 (d)(5) Nursing services. 395701 Page 3 of 3