Health inspection·January 6, 2026

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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, clinical records and incident reports and staff interviews, it was determined that the facility failed to ensure that residents were free from neglect by not providing adequate supervision for one of three resident reviewed (Resident R1), which resulted in actual harm of a resident, resulting in a head laceration requiring transfer to the hospital. Findings include: A review of the facility policy, Resident Protection from abuse, neglect or exploitation, dated 4/17/25, indicated that the residents will be treated with kindness, respect and in a manner that is at all times free from any form of abuse, neglect, misappropriation of property, exploitation or mistreatment. A review of the clinical record revealed that Resident R1 was admitted to the facility on [DATE], with diagnoses that included cerebral infarction (condition when blood flow to a part of the brain is obstructed leading to death of brain cells), encephalopathy (condition that disrupts the normal functioning of the brain) and urinary tract infection. A review of physician orders dated 12/3/25 indicated Resident R1 was an assist of two staff members for transfers. A review of the care plan dated 5/31/25, indicated Resident R1 was at moderate risk for falls related to deconditioning, gait/balance problems. A review of a nurse progress note dated 12/16/25, indicated the resident had been placed in shower chair, showered, returned to room and left unattended while NA went for lift. In that time resident fell from shower chair resulting in laceration. A review of an investigative report of alleged neglect submitted by the facility, dated 12/16/25, indicated that facility nurse aide (NA) Employee E1 reports assisted resident with a shower. Resident was assisted back to room, NA Employee E1 left to secure hoyer to transfer resident back to bed. NA was asked by another NA to use hoyer, he said she could have it. Employee E1 left the room, Resident R1 sustained the fall from shower chair when left in the room unsupervised. A review of a facility witness statement dated 12/17/25, indicated the following: Review of Registered Nurse (RN) Employee E2's witness statement signed and dated 12/17/25, indicated Employee E1 acknowledged that he shouldn't have left him alone. Employee E1 stated that he didn't ask anyone to sit with Resident R1 while he got the hoyer. Review of Licensed Practical Nurse (LPN) Employee E3's witness statement signed and dated 12/16/25, indicated Employee E1 stated Resident R1 was on the floor. LPN Employee E3 asked if someone was with resident while Employee E1 went to get the lift, he said no, he just went to get the lift and went right back to the room. Review of Nurse Aide (NA) Employee E1's witness statement sign and dated 12/17/25, indicated he left Resident R1 in the shower chair and went to get the hoyer. I was only out of the room for roughly 30 seconds. Employee E1 stated he knew that you can't leave a resident unattended in the shower chair, there is no excuse. Interview 1/6/26 at 10:15 a.m. with Nurse Aide Employee E4 indicated she knows not to leave a resident alone in a shower chair and to either look on the kardex or on their orders for care instructions. Attempts to call and interview NA Employee E1 were unsuccessful. Interview 1/6/26 at 10:20 a.m. with Nurse Aide Employee E5 indicated she would look on Page 1 of 2 395371 395371 01/06/2026 Quality Life Services - Apollo 151 Goodview Drive Apollo, PA 15613

F 0600 Level of Harm - Actual harm the kardex on how to care for a resident or ask the nurse. During an interview on 1/6/26, at 1:30 p.m., the Director of Nursing confirmed that the facility neglected to provide proper supervision for Resident R1, resulting in a fall with injury. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1) Management. 28 Pa. Code 211.12(d)(1) Nursing services. Residents Affected - Few 395371 Page 2 of 2