Health inspection·March 8, 2024

F 0600 2023 revealed Resident 47 experienced neglect during afternoon care on September 4, 2023, at 11:30 a.m. from Certified Nursing Assistant (CNA) Employee E1. Level of Harm - Actual harm Residents Affected - Few Further review of the information dated September 4, 2023 submitted on September 4, 2023 summarized; E1 entered Resident 47's room to get resident up and dressed, per E1 [he/she] told Resident 47 it was time to get ready for lunch, informing [resident] [he/she] was going to wash and dress [resident]. Resident 47 responded get the hell out of here. E1 went and gathered [his/her] supplies and reapproached the Resident 47, Resident 47 did not respond, so E1 initiated care, Resident 47 was calm until E1 began providing incontinence care when Resident 47 began to yell and tried to swing back and hit E1. E1 placed Resident 47 on [resident] back and calmly asked what is wrong, Resident 47 continued to yell Get the hell away from me. E1 waited a minute until Resident 47 calmed and explained once again, we have to get dressed. E1 then continued to wash Resident 47's bottom, Resident 47 pushed back and began to hit, at that time the E1 folded Resident 47's arms on her chest and tried to get a brief on her. E1 let [resident] arms go to roll Resident 47 back to the right side, as E1 did the Resident 47 started swinging [his/her] arms and trying to bite E1. When E1 sat Resident 47 on the side of the bed, E1 saw a skin tear. Resident 47 was calmed and assisted with transferring [resident] to the recliner with walker to chair, Resident 47 then began to yell get the hell out of here and E1 immediately reported skin tear. Review of Nurse Aide, Employee E2 witness statement dated September 4, 2023, indicated there was bruising on Resident 47's left arm and bruising and a skin tear on Resident 47's right arm. E2 also indicated, I went to check on Resident 47 at 2:15 p.m. and Resident 47 said she held both of my arms and there was nothing I could do. Review of Nurse Aide, Employee E1's witness statement revealed, Nurse Aide, Employee E1 folded Resident 47's arms against her chest which resulted in Resident 47 sustaining multiple bruises and skin tears. Review of facility investigative documentation including the PB-22 (form that is utilized to report instances of abuse, neglect, or exploitation of vulnerable adults) completed by the facility dated September 6, 2023, at 3:18 p.m. substantiated the information indicated above and concluded that Resident 47 experienced neglect from E1 resulting in bruising and skin tears to bilateral (right and left) lower arms. Additional review facility investigative document PB-22 revealed E1 was removed from the facility and placed on the do not return list, [Nursing Agency] employer notified via phone call of events and staff member status. Review of Resident 47's clinical record revealed a progress note by psychiatric-mental health nurse practitioner (PMHNP) dated September 5, 2023, at 7:00 p.m. indicating, contacted by SW (social worker). Resident 47 with recent increase in aggression. Hit and bit staff. Aggressive with care. DVT (Deep vein thrombosis, a blood clot forms in one or more of the deep veins in the body) currently being treated. Increased pain. Probable increase in anxiety r/t (related to) care. Recommend Ativan .25 mg (milligrams) q (every) 12 hours for anxiety x 14 days. Hold of sedation. Resident 47 was unavailable for an interview due to being admitted to the hospital on [DATE]. Interview conducted with the Nursing Home Administrator (NHA) on March 8, 2024, at 10:30 a.m. confirmed that the facility failed to protect residents from abuse for one of eighteen residents reviewed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395326 If continuation sheet Page 2 of 3 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 395326 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Zerbe Sisters Nursing Center, 2499 Zerbe Road Narvon, PA 17555 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)

F 0600 resulting in actual harm to the resident (Resident 47). Level of Harm - Actual harm 28 Pa Code: 201.14 (a ) Responsibility of licensee Residents Affected - Few 28 Pa Code: 201.18 (b)(1)(3) Management 28 Pa Code: 211.10 (d) Resident care policies 28 Pa Code 211.12 (d)(3) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395326 If continuation sheet Page 3 of 3