Health inspection·May 22, 2024

F 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm Based on review of clinical records, facility policies and procedures, interviews with staff, it was determined that the facility failed to conduct a complete and thorough investigation of one alleged violation of unknown source of injury for one of 16 residents reviewed. (Resident R165). Residents Affected - Few Findings include: Review of the facility policy titled, Abuse, Neglect & Exploitation - Prevention, Reporting and Investigation dated, May 4, 2016, revealed, The SNA/designee manages and directs the investigation of all abuse, neglect and/or exploitation. Review of facility investigation dated August 21, 2023, revealed that while providing care, a nurse aide transferred Resident R165, and her head hit the guard rail. This resulted in a hematoma on the right side of her forehead. Resident was sent to the hospital for further assessment. Further review of the investigation revealed a statement by Employee E13, nurse aide revealed that she provided care to resident including transfer with the help of other staff. She also provided care to resident in bed. Employee E13 indicated that there was no incident happened during her care or the resident did not complain of any pain or incident. Employee E13 indicated that the incident did not happen on her shift. Further review of the investigation revealed a hospital record dated August 21, 2023, which indicated that the resident stated she sustained the injury during a transfer by nurse aide. Continued review of the investigation revealed that facility did not obtain statements or conducted interviews with other staff who provided care to the resident prior to the injury. Interview with the Administrator on May 22, 2024, at 11:30 a.m. stated resident alleged that the injury was sustained during a transfer from previous shift. She stated the injury was reported by the employees of 7am-3pm shift. Administrator confirmed that the facility investigation was focused on Nurse aide, Employee E13 who allegedly transferred the resident. However, it was determined that there was no transfer occurred during the care. Administrator also confirmed that there was no other staff interviewed or obtained statements from staff who provided care to Resident R165. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(e)(1) Management. (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 11 Event ID: 395801 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 395801 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Quadrangle 3300 Darby Road Haverford, PA 19041 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)