Health inspection·March 14, 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 review of policies, investigative reports, and residents' clinical records, as well as staff family interviews, it was determined that the facility failed to ensure that residents were free from neglect caused by a failure to follow a resident's care plan for preventing falls for one of four residents reviewed (Resident 1), resulting in a fall and fracture for the resident. This deficiency was cited as past noncompliance. Findings include: The facility's policy regarding resident abuse, dated January 10, 2024, revealed that neglect is defined as the failure of the facility, its employees, or services providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated January 5, 2024, revealed that the resident was cognitively intact and had diagnoses of seizure disorder. The resident's care plan, dated June 10, 2023, revealed that the resident was at risk for injury due to falls related to decreased mobility, muscle weakness, gait abnormality, lack of coordination, and history of falls. Staff was not to leave the resident alone with toileting, to walk the resident with use of gait belt (used to help nursing staff support a person who is unsteady or weak), and the resident was to be an assist two for the B (evening) and C (night) shifts. A Kardex report (a nursing worksheet that includes a summary of patient information, such as prescribed medications, clinical follow-ups, and daily care schedules) for Resident 1, dated March 7, 2024, revealed the following safety measures for staff to follow: Not to leave the resident alone with toileting, to walk the resident with use of gait belt, and the resident was to be an assist two for the B (evening) and C (night) shifts. A nursing note for Resident 1, dated March 7, 2024, revealed that at 12:10 a.m. the writer was called to the resident's room. The resident was lying on the floor in the bathroom. The resident had a large amount of blood coming out of her nose. The resident stated that she was dizzy and seeing double. When the writer asked the resident what she was doing, the resident stated she is dizzy and seeing double. A nursing note for Resident 1, dated March 7, 2024, revealed that the resident returned to the facility at 6:48 p.m. from the hospital after having a fall. She was diagnosed with a closed fracture of the nasal bone and a urinary tract infection (UTI). (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 7 Event ID: 396069 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 396069 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbutus Park Manor 207 Ottawa Street Johnstown, PA 15904 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)