Health inspection·January 23, 2024

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 Based on observation, clinical record review, review of facility documents, and staff interview, it was determined that the facility failed to protect the rights of a resident to be free from neglect by not providing the services necessary to avoid physical harm resulting in fractures for one of two residents reviewed (Resident 1). Findings include: An observation of Resident 1 on January 23, 2024, at 11:35 AM revealed she was in an activity with her head down. An alarm box was noted on her wheelchair. Clinical record review for Resident 1 revealed that the facility admitted her on September 8, 2023. A progress note date December 29, 2023, at 9:15 PM revealed that the nurse aide (NA) notified the registered nurse (RN) that Resident 1 fell and hit the back of her head. Resident 1was observed by the RN sitting in the hallway on the carpeted floor near the parlor. Resident 1 was bleeding from the back of her head and was noted to have a laceration on the right side of the back of her head. The RN notified the certified registered nurse practitioner and received orders to send Resident 1 to the emergency room. Further clinical record review revealed that Resident 1 returned from the emergency room on December 30, 2023, at 11:03 AM. She was wearing a cervical soft collar. Review of the emergency room report revealed that she had a displaced fracture (bone breaks in two or more places and moves out of alignment) of the left sixth cervical vertebrae (near the base of the neck) and a transverse process remote deformity (a break or crack in one of the wing-like sides at the back of a vertebrae) of the thoracic vertebrae T3 (middle section of your spine, third segment of the 12 thoracic vertebrae). She also had 9 sutures intact to the right posterior (back) scalp laceration. Review of the facility's investigation into Resident 1's fall revealed that Employee 1 forgot to move the alarm box from the resident's chair to her bed on December 29, 2023, at approximately 8:30 PM. A witness statement from Employee 1, NA, indicating that she neglected to move the alarm box from Resident 1's chair onto her bed. Review of Resident 1's care plan entitled Potential for Falls initiated on September 8, 2023, revealed an intervention for Resident 1 to have a silent bed and chair alarm for resident safety. Further clinical record review for Resident 1 revealed a care plan for activities of daily living self-care performance deficit with an intervention that was initiated on September 22, 2023, indicating Resident 1 required the assistance of one to ambulate and transfer in her room and in the hallway (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 2 Event ID: 395838 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 395838 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/23/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Foxdale Village 500 E. Marylyn Avenue State College, PA 16801 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)