Abington Manor

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.

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