Health inspection·May 7, 2024

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility provided policies and documentation, clinical records, and staff interviews, it was determined that the facility failed to protect residents from staff-initiated physicial abuse. This failure resulted in a staff member physically assaulting a resident and which resulted in serious injuries and transfer to hospital which created an Immediate Jeopardy situation for one of 104 residents (Resident R1). Findings include: Review of the facility's policy Abuse and Neglect - Clinical Protocol reviewed 10/2/23, indicated the facility will provide protection for the health, welfare and rights of each resident by developing and implementing written policies that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Abuse is defined by willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Review of the Resident Assessment Instrument 3.0 User's Manual effective October 2019, indicated that a Brief Interview for Mental Status (BIMS) is a screening test that aides in detecting cognitive impairment. The BIMS total score suggests the following distributions: 13-15: cognitively intact 8-12: moderately impaired 0-7: severe impairment Review of the clinical record indicated that Resident R1 was admitted to the facility on [DATE], with diagnoses which included Alzheimer's disease, macular degeneration (difficulty with vision), difficulty walking, dementia without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety, adjustment disorder, and cognitive communication deficit. Review of a Minimum Data Set (MDS - periodic assessment of resident care needs) dated 2/8/24, indicated the diagnoses remained current. Review of Section C: Cognitive Patterns, Questions C0500 BIMS Summary Score revealed Resident R1's score to be 4. Review of Resident R1's physician orders active in April 2024, included: -Lexapro 5mg for depression Page 1 of 11 395028 395028 05/07/2024 Squirrel Hill Wellness and Rehabilitation Center 2025 Wightman Street Pittsburgh, PA 15217

F 0600 -Haldol 2.5 mg every 6 hours as needed for agitation, started on date of incident and was given. Level of Harm - Immediate jeopardy to resident health or safety -Psychiatry consult, last seen 3/29/24. Residents Affected - Few Review of a physician order originally dated 4/3/24, indicated that licensed nursing staff document on the Medication Administration Record (MAR) every shift related behaviors of hitting, pinching, scratching and attempt to use: one on one, activity, adjust room temperature, back rub, change positions, give fluids, give food, redirect, refer to progress notes, remove from environment, return to room, and/or toilet every shift. Review of documentation did not include any behaviors as indicated in the physician orders. Review of Resident R1's plan of care included: Alzheimer's and behaviors of exit seeking, use of wanderguard, behaviors of physical aggression towards other residents/staff, and to notify the Physician if any occurs. Plan of care also addressed Resident R1's having potential for urinary tract infections and to monitor for changes in behaviors, pain, etc. Plan of care also addressed Resident R1's impaired cognition. Review of a progress note dated 3/22/24, indicated Resident R1 was awake at 3:40 a.m., wandering the halls and getting out of bed and staff redirecting him. Review of a progress note dated 3/23/24, at 11:23 p.m., as waking up after sleeping most of the 3-11 shift wandering the halls, attempting to remove items from the medication cart, when being told to leave the items on the cart, he swung at the nurse and staff had to redirect him. Review of a progress note dated 3/24/24, at 3:30 p.m., indicated Resident R1 was standing over the medication cart, removing items, and when the nurse bent over to get trash bag, Resident R1 swung at her and it took three staff to redirect him. The documentation indicated Resident R1's behaviors had escalated and that Administration had been made aware. Review of a progress note dated 3/29/24, the Psychiatric Nurse Practitioner indicated an assessment of Resident R1 and continued monitoring of his behaviors due to staff indicating that Resident R1 is only aggressive if he is treated rudely and that if behaviors persisted, Seroquel may be used. Review of a progress note dated 4/21/24, 10:45 a.m., indicated that resident R1 had an altered level of cognition, slurred speech, complaints of back of neck pain, a bruise on his left shoulder, left elbow and a large bruise of his left hip and buttocks, and bruising of bilateral knees. He was unable to get out of bed. On call doctor called. The Assistant Director of Nursing (ADON) came into facility and called the Nurse Practitioner who ordered Resident R1 to go to the hospital for evaluation and treatment. Review of a facility provided document dated 4/21/24, indicated that Resident R1 had been assessed for the change in condition, indicated the bruising of Resident R1's scrotal and sphincter areas and that a female resident reported an altercation with Resident R1 and Licensed Practical Nurse (LPN) Employee E1 had struck Resident R1 in his genital area. Resident R1 was sent to the hospital for evaluation. The document indicated LPN Employee E1 was immediately removed from the facility after notfication of the incident and the investigation was being completed. Review of the statement obtained from Resident R2 dated 4/22/24, who observed the altercation, 395028 Page 2 of 11 395028 05/07/2024 Squirrel Hill Wellness and Rehabilitation Center 2025 Wightman Street Pittsburgh, PA 15217

F 0600 Level of Harm - Immediate jeopardy to resident health or safety indicated that Resident R1 'was not bothering anyone', he leaned on [LPN Employee E1's] medication cart, LPN Employee E1 told him to get off of her cart and pushed his arm off of her cart, Resident R1 pushed her but she did not move then she began hitting him all over his body except his face, then she grabbed him and kneed him in his privates, she then kept punching him all over and she knocked him over and she fell on top of him continuing to it him she got up and left him on the floor. Resident R1 got up and walked to is room and you could tell he was in pain. Residents Affected - Few Review of an undated/untimed statement provided via telephone from LPN Employee E1, the alleged perpetrator, indicated that Resident R1 was hitting her and when he went to hit her he fell, and staff helped him up and that LPN Employee E2 was going upstairs to tell them about him (meaning Administration). Review of an udated statement from LPN Employee E2, who was identified as being present at the time of the altercation, indicated that Resident R1 was not violent. Review of a follow up statement dated 4/25/24, from LPN Employee E2 indicated hat she was not present during the altercation, although was identified by Resident R2 as having been present. Review of an undated statement obtained from LPN Employee E3, indicated that she overheard Resident R2 speaking about the incident identifying LPN Employee E1 as the alleged perpetrator who had punched Resident R1 and it was so bad he had to crawl to get up. Resident R2 then indicated that LPN Employee E2 and Nurse Aide(NA) Employee E4 were at the nurses station and did not intervene. The statement then stated, The next morning NA Employee E4 was talking at the desk about the incident, LPN Employee E2 then began to speak about it and stated she could not be responsible for his safety. Further review of the statement indicated that Friday, four days after the incident, LPN Employee E3 indicated she spoke with Nurse Aide Employee E5 who said she found bruising on Resident R1 scrotum and that LPN Employee E1 was the alleged perpetrator. The following day LPN Employee E3 found Resident R1's scrotum excoriated, red on front and back and it was dark purple towards his rectal area and it was only then that she contacted the Human Resources (HR) Director Employee E6 about the incident who then contacted Registered Nurse (RN) Unit Manager Employee E7. During a phone interview on 5/7/24, at 8:20 a.m., LPN Employee E3 stated that the staff on Thursday night or Friday morning, I can't remember which day, were in the kitchen doing their cold talk and NA Employee E5 was told by LPN Employee E1 to stop talking. and the she had counted medication carts with LPN Employee E1 and asked her what happened and she said I am not saying anything. LPN Employee E3 stated that once she put two and two together, she then contacted the HR Director Employee E6, that was on Sunday. During an interview on 5/6/24, at 12:20 p.m., the HR Director Employee E6 stated that she was not aware of the incident until Sunday when LPN Employee E6 texted her at 6:50 a.m., and then she called RN Employee E7 and told him what had occurred. She went on to ask LPN Employee E6 if the incident was it on the 24 hour report and did not get an answer. The 24 hour report has not been located. Further review of the facility documentation did not include any further investigation into the incident. On 5/6/24, at 2:54 p.m., the Nursing Home Administrator was made aware that an Immediate Jeopardy situation existed for one of 104 residents for staff initiated physical abuse and the Immediate Jeopardy template was provided to facility administration. 395028 Page 3 of 11 395028 05/07/2024 Squirrel Hill Wellness and Rehabilitation Center 2025 Wightman Street Pittsburgh, PA 15217

F 0600 On 5/6/24, at 4:49 p.m., an acceptable Corrective Action Plan was received which included the following interventions: Level of Harm - Immediate jeopardy to resident health or safety - LPN Employee E1's employment was suspended on 4/21/24, and terminated 4/24/24, due to abuse. Residents Affected - Few -LPN Employee E2's employment was suspended on 4/24/24, and terminated on 4/26/24, due to not reporting the abuse. -Resident R1 is no longer in the facility since 4/21/24. - Nurse Aide Employee E4's employment was suspended on 4/24/24, and terminated on 4/26/24, due to not reporting abuse. - Abuse training will be completed with all staff by 5/2/24, and then had been completed again with specific reviews of intervening and stopping abuse, how to identify abuse and reporting the abuse immediately with no retaliation and non intimidation and use of the 24 hour abuse hotline. which had been complete by 5/7/24, at 10:00 a.m. This specific education will be included for all new hires including agency. - Current employees who are not presently at work will be educated prior to the start of their next shift. All agency staff will be educated on the abuse policy prior to the start of their next scheduled shift. - Social Worker will audit all grievances for the past 6 months for unrecognized abuse. Any grievances identified for unrecognized abuse will be investigated and reported. - Resident interviews related to abuse were completed and if a non interviewable resident, a skin sweep was completed by 5/7/24. Skin sweeps will be completed weekly by the Director of Nursing or designee weekly for 4 weeks, then monthly for 3 months to ensure abuse prevention policy is followed. -The Social Worker will interview 25% of the residents moving forward to determine if any incidents or concerns for abuse are occuring weekly for 4 weeks, then monthly for three months. -Ongoing results will be submitted o the QA committee. During staff interviews conducted on 5/7/24, between 10:20 a.m. and 11:30 a.m., 34 staff members including the 3:00-11:00 p.m. and two 11:00 p.m.-7:00 a.m., staff confirmed they received education on abuse prevention. The Immediate Jeopardy was lifted on 5/7/24, at 2:06 p.m., when the action plan implementation was verified. During an interview on 5/7/24, at 2:10 p.m. the Nursing Home Administrator confirmed that facility failed to protect residents from staff-initiated physical abuse. This failure resulted in a staff member physically abusing a resident causing serious injury, and created an Immediate Jeopardy situation for one of 104 residents. 28 Pa. Code 201.18(e)(1) Management 395028 Page 4 of 11 395028 05/07/2024 Squirrel Hill Wellness and Rehabilitation Center 2025 Wightman Street Pittsburgh, PA 15217

F 0600 28 Pa. Code 201.20(a)(b) Staff development Level of Harm - Immediate jeopardy to resident health or safety 28 Pa. Code 201.29(a)(c)(d) Resident rights Residents Affected - Few 395028 Page 5 of 11 395028 05/07/2024 Squirrel Hill Wellness and Rehabilitation Center 2025 Wightman Street Pittsburgh, PA 15217

F 0609 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of state laws, facility policies, clinical records, and staff interviews, it was determined that the facility failed to implement policies and procedures for covered individuals to report the suspicion and/or observation of staff to resident abuse for one of 104 residents reviewed (Resident R1), which provided the opportunity of an additional eight days for abuse to possibly continue. This failure created an Immediate Jeopardy situation for one of 104 residents (Resident R1). Findings include: Review of the Older Adult Protective Services Act of 11/6/87, amended by Act 1997-13, Chapter 7, Section 701, requires any employee or administrator of a facility who suspects abuse is mandated to report the abuse. All reports of abuse should be reported to the local area agency on aging and licensing agencies. Review of the facility's policy Abuse Reporting and Investigation dated 10/2/23, indicated identification, correction and intervening in situations in which abuse, neglect, exploitation and/or misappropriation of resident property is more likely to occur with the deployment of trained and qualified, registered, licensed and certified staff on each shift in sufficient numbers to meet residents' needs and have the knowledge of the individual resident care needs and behavioral symptoms. Reporting of all alleged violations is immediate. Review of abuse education provided to facility staff defined abuse as willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish. the education further stated that an alleged violation whether observed or reported but not yet investigated if verified, can be indication of noncompliance with Federal requirements. Review of the Resident Assessment Instrument 3.0 User's Manual effective October 2019, indicated that a Brief Interview for Mental Status (BIMS) is a screening test that aides in detecting cognitive impairment. The BIMS total score suggests the following distributions: 13-15: cognitively intact 8-12: moderately impaired 0-7: severe impairment Review of the clinical record indicated that Resident R1 was admitted to the facility on [DATE], with diagnoses which included Alzheimer's disease, macular degeneration(difficulty with vision), difficulty walking, dementia without behavioral disturbance, psychotic disturbance,mood disturbance and anxiety, adjustment disorder, and cognitive communication deficit. A Minimum Data Set (MDS - periodic assessment of resident care needs) dated 2/8/24, indicated the diagnoses remained current. Review of Section C: Cognitive Patterns, Questions C0500 BIMS Summary Score revealed Resident R1's score to be 4. Review of Resident R1's physician orders active in April 2024, included: 395028 Page 6 of 11 395028 05/07/2024 Squirrel Hill Wellness and Rehabilitation Center 2025 Wightman Street Pittsburgh, PA 15217

F 0609 -Lexapro 5 mg for depression Level of Harm - Immediate jeopardy to resident health or safety -Haldol 2.5 mg every 6 hours as needed for agitation, started on date of incident and was given. Residents Affected - Few Review of a physician order originally dated 4/3/24, indicated that licensed nursing staff document on the Medication Administration Record (MAR) every shift related behaviors of hitting, pinching, scratching and attempt to use: one on one, activity, adjust room temperature, back rub, change positions, give fluids, give food, redirect, refer to progress notes, remove from environment, return to room, and/or toilet every shift. -Psych consult, last seen 3/29/24. Review of documentation did not include any behaviors as indicated in the physician orders. Review of Resident R1's plan of care included plan of care for Alzheimer's and behaviors of exit seeking, use of wanderguard, behaviors of physical aggression towards other residents/ staff, and to notify the Physician if any occurs. Plan of care also addressed Resident R1's having potential for urinary tract infections and to monitor for changes in behaviors, pain, etc. Plan of care also addressed Resident R1's impaired cognition. Review of a progress noted dated 3/22/24, indicated Resident R1 was awake at 3:40 a.m., wandering the halls and getting out of bed and staff redirecting him. Review of a progress note dated 3/23/24, at 11:23 p.m., indicated, waking up after sleeping most of the 3-11 shift wandering the halls, attempting to remove items from the medication cart, when being told to leave the items on the cart, he swung at the nurse and staff had to redirect him. Review of a progress note dated 3/24/24, at 3:30 p.m., indicated Resident R1 was standing over the medication cart, removing items, and when the nurse bent over to get trash bag, Resident R1 swung at her and it took three staff to redirect him. The documentation indicated Resident R1's behaviors had escalated and that Administration had been made aware. Review of a progress note dated 3/29/24, from the Psychiatric Nurse Practitioner indicated an assessment of Resident R1 and continued monitoring of his behaviors due to staff indicating that Resident R1 is only aggressive if he is treated rudely and that if behaviors persisted, Seroquel may be used. Review of a progress note dated 4/21/24, 10:45 a.m., indicated that resident R1 had an altered level of cognition, slurred speech, complaints of back of neck pain, a bruise on his left shoulder, left elbow and a large bruise of his left hip and buttocks, and bruising of bilateral knees. He was unable to get out of bed. On call doctor called. The Assistant Director of Nursing (ADON) came into facility and called the Nurse Practitioner who ordered Resident R1 to go to the hospital for evaluation and treatment. Review of a facility provided document dated 4/21/24, indicated that Resident R1 had been assessed for the change in condition, indicated the bruising of Resident R1's scrotal and sphincter areas and that a female resident reported an altercation with Resident R1 and Licensed Practical Nurse (LPN) Employee E1 who had struck Resident R1 in his genital area. Resident R1 was sent to the hospital for evaluation. The document indicated the LPN was immediately removed from the facility and the 395028 Page 7 of 11 395028 05/07/2024 Squirrel Hill Wellness and Rehabilitation Center 2025 Wightman Street Pittsburgh, PA 15217

F 0609 investigation was being completed. Level of Harm - Immediate jeopardy to resident health or safety Review of the statement obtained from Resident R2 dated 4/22/24, who observed the altercation, indicated that Resident R1 'was not bothering anyone', he leaned on [LPN Employee E1's] medication cart, LPN Employee E1 told him to get off of her cart and pushed his arm off of her cart, Resident R1 pushed her but she did not move then she began hitting him all over his body except his face, [NAME] she grabbed him and kneed him in his privates, she then kept punching him all over and she knocked him over and she fell on top of him continuing to it him she got up and left him on the floor. Resident R1 a got up and walked to is room and you could tell he was in pain. Residents Affected - Few Review of an undated/untimed statement provided via telephone from LPN Employee E1, the alleged perpetrator, indicated that Resident R1 was hitting her and when he went to hit her he fell and staff helped him up and that LPN Employee E2 was going upstairs to tell them about him (meaning Administration). Review of LPN Employee E2's statement undated who was identified as being present at the time of the altercation indicated that Resident R1 was not violent. Review of a follow-up statement dated 4/25/24, from LPN Employee E2 indicated hat she was not present during the altercation, although identified by Resident R2 as having been present. Review of an undated statement obtained from LPN Employee E3, indicated that she overheard Resident R2 speaking about the incident identifying LPN Employee E1 as the alleged perpetrator who had punched Resident R1 and it was so bad he had to crawl to get up. During the conversation Resident R2 indicated that LPN Employee E2 and Nurse Aide(NA) Employee E4 were at the nurses station and did not intervene. The next morning NA Employee E4 was talking at the desk about the incident, LPN Employee E2 then began to speak about it and stated she could not be responsible for his safety. Further review of the statement indicated that Friday, four days after the incident, LPN Employee E3 indicated Nurse Aide Employee E5 was talking about finding bruising on Resident R1 scrotum and spoke of LPN Employee E1 being the alleged perpetrator. The following day LPN Employee E3 found Resident R1's scrotum excoriated, red on front and back and it was dark purple towards his rectal area and she then contacted the Human Resources (HR) Director Employee E6 about the incident who then contacted Registered Nurse (RN) Unit Manager Employee E7. During a phone interview on 5/7/24, at 8:20 a.m., LPN Employee E3 stated that the staff on Thursday night or Friday morning, I can't remember which day, in the kitchen doing their cold talk and NA Employee E5 was told by LPN Employee E1 to stop talking. and the she had counted medication carts wit LPN Employee E1 and asked her what happened and she said I am not saying anything. LPN Employee E3 stated that once she put two and two together, she then contacted the HR Director Employee E6, that was on Sunday. During the interview, LPN Employee E3 stated that she was aware of the situation that she is required to report but failed to do so before Sunday. The failure to report this instance at the time of occurrence caused the abuse to possibly continue from the date of occurrence of 4/16/24 through the initial report of 4/21/24 or eight days. During an interview on 5/6/24, at 12:20 p.m., the HR Director Employee E6 stated that she was not aware of the incident until Sunday 4/21/24, when LPN Employee E6 text her at 6:50 a.m., and then she called RN Employee E7 and told him what had occurred. She went on to ask LPN Employee E6 if the incident was it on the 24 hour report and did not get an answer. The 24 hour report cannot be found. 395028 Page 8 of 11 395028 05/07/2024 Squirrel Hill Wellness and Rehabilitation Center 2025 Wightman Street Pittsburgh, PA 15217

F 0609 Further review of the facility documentation did not include any further investigation into the incident. Level of Harm - Immediate jeopardy to resident health or safety On 5/6/24, at 2:54 p.m., the Nursing Home Administrator was made aware that an Immediate Jeopardy situation existed for one of 104 residents for failure to report the suspicion and/or observation of staff to resident physical abuse and the Immediate Jeopardy template was provided to facility administration. Residents Affected - Few On 5/6/24, at 4:49 p.m., acceptable Corrective Action Plan was received which included the following interventions: - LPN Employee E1's employment was suspended on 4/21/24, and terminated 4/24/24, due to abuse. -LPN Employee E2's employment was suspended on 4/24/24, and terminated on 4/26/24, due to not reporting the abuse. -Resident R1 is no longer in the facility since 4/21/2. - Nurse Aide Employee E4's employment was suspended on 4/24/24, and terminated on 4/26/24, due to not reporting abuse. - Abuse training will be completed with all staff by 5/2/24, and then had been completed again with specific reviews of intervening and stopping abuse, how to identify abuse and reporting the abuse immediately with no retaliation and non intimidation and use of the 24 hour abuse hotline. which had been complete by 5/7/24, at 10:00 a.m. This specific education will be included for all new hires including agency. - Current employees who are not presently at work will be educated prior to the start of their next shift. All agency staff will be educated on the abuse policy prior to the start of their next scheduled shift. - Social Worker will audit all grievances for the past 6 months for unrecognized abuse. Any grievances identified for unrecognized abuse will be investigated and reported. - Resident interviews related to abuse were completed and if a non interviewable resident, a skin sweep was completed by 5/7/24. Skin sweeps will be completed weekly by the Director of Nursing or designee weekly for 4 weeks, then monthly for 3 months to ensure abuse prevention policy is followed. -The Social Worker will interview 25% of the residents moving forward to determine if any incidents or concerns for abuse are occuring weekly for 4 weeks, then monthly for three months. -Ongoing results will be submitted o the QA committee. During staff interviews conducted on 5/7/24, between 10:20 - 11:30 a.m., 34 staff members including the 3:00 - 11:00 p.m. and two 11:00 p.m.- 7:00 a.m., staff confirmed they received education on abuse prevention. The Immediate Jeopardy was lifted on 5/7/24, at 2:06 p.m., when the action plan implementation was verified. 395028 Page 9 of 11 395028 05/07/2024 Squirrel Hill Wellness and Rehabilitation Center 2025 Wightman Street Pittsburgh, PA 15217

F 0609 Level of Harm - Immediate jeopardy to resident health or safety During an interview on 5/7/24, at 2:10 p.m. the Nursing Home Administrator confirmed that facility failed to implement policies and procedures for covered individuals to report the suspicion and/or observation of staff to resident physical abuse for one of 104 residents, which provided and opportunity of an additional eight days for abuse to possibly continue, and that this failure created an Immediate Jeopardy situation for one of 104 residents. Residents Affected - Few 28 Pa. Code 201.14(a)(c)(e) Responsibility of licensee. 28 Pa. Code 201.18(b)(1)(e)1) Management. 395028 Page 10 of 11 395028 05/07/2024 Squirrel Hill Wellness and Rehabilitation Center 2025 Wightman Street Pittsburgh, PA 15217

F 0865 Have a plan that describes the process for conducting QAPI and QAA activities. Level of Harm - Minimal harm or potential for actual harm Based on review of facility documentation, review of cited deficiencies from the facility's annual survey of 4/16/21, and staff interview, it was determined that the facility's Quality assurance and performance improvement (QAPI) program failed to correct previous cited deficiencies. This has the potential to effect all 104 residents of the facility. Residents Affected - Few The findings include: Health) survey ending April 18,2024, revealed that the facility developed plans of corrections that included quality assurance systems to ensure that the facility maintained compliance with cited nursing home regulations. The results of the current survey, ending May 7, 2024, identified a repeated deficiency related to not providing protection of abuse, resident rights and implementation of the policies and procedures to prohibit abuse for one of 104 residents resulting in physical harm. The facility QAPI Committee is responsible for the review and approval of facility policies, procedures and guidelines on an annual basis. The following schedule should be followed to assure review and adoption of key policies, procedures and guidelines. Additional requirements may be specified in other company programs. The facility policy Quality Assurance Process Improvement Plan, last reviewed 10/2/23, indicated that the purpose is to establish and maintain an organized program that is data driven and utilizes a proactive approach to improving quality of care and services throughout the facility. This is a living document that will continue to be revised and revisited. Objectives of the QAPI plan include a facility wide process to identify opportunities for improvement, address gaps in systems and processes, ensure adequate provisions for staffing, etc. continually improve the quality of care and services for our residents. During an interview on 7/8/22, at 1:30 p.m. the Nursing Home Administrator confirmed the facility failed to maintain their plan of correction for the deficient practices. Federal and state deficiencies cited in this report demonstrated that the facility failed to maintain an effective Quality Assurance Committee to ensure that the concerns related to abuse and safety needs of the residents were identified. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(a)(b)(3)(e)(1)(3)(4) Management 28 Pa. Code 211.12(c) Nursing services 395028 Page 11 of 11