Health inspection·February 8, 2024

F 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm Based on review of facility policy and clinical records, and staff interviews, it was determined that the facility failed to fully investigate an injury of unknown origin in a timely manner for one of one residents reviewed (Resident R1). Residents Affected - Few Findings include: Review of facility policy entitled Incidents and Accident Reports, Resident dated 9/2023, revealed An incident report is completed whenever there is an occurrence ., The following is a list of the types of occurrences for which an incident report is prepared . Injury of unknown origin and Those incidents requiring investigation . will be reported to the Administrator and Director of Nursing . Review of Resident R1's clinical record revealed an admission date of 11/16/23, with diagnoses that included hypothyroidism (a condition when the thyroid produces low amounts of thyroid hormones), hypertension (high blood pressure), and anxiety (a condition that causes a person to be nervous, uneasy, or worried about something or someone). Review of Resident R1's nursing documentation revealed a progress note dated 12/12/23, that identified he/she was seen by his/her physician and a new order was given from his/her physician for x-rays of left shoulder, left humerus, and left foot and deformity. Further review of Resident R1's nursing documentation revealed a progress note dated 12/13/23, that indicated x-ray results were received by the facility. Physician was updated on Resident R1's acute fracture of the fifth metatarsal (foot bone between the ankle and toe) and gave an order to have Resident R1 seen by an orthopedic physician (a physician that specializes in bone care). Review of Resident R1's care plan revealed a care plan dated 12/14/23, for left foot fracture related to previous fall. Review of a Minimum Data Set (MDS-a periodic assessment of resident care needs) dated 12/15/23, section J 1800 indicated Resident R1 had not had any falls since admission/reentry. Review of facility incident report for December 2023, revealed no evidence that Resident R1 had any type of incident. Review of Resident R1's clinical record lacked evidence that an investigation was started or completed, regarding the identified of the fracture of the fifth metatarsal. Further review of clinical record lacked evidence of interviews from staff present at the time of the incident or handwritten statements from staff. (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: 395959 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 395959 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Caring Place, The 103 N. Thirteenth Street Franklin, PA 16323 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)