Health inspection·May 30, 2024

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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 clinical records, select facility policy and investigative reports, and observation, and resident and staff interview, it was determined that the facility failed to ensure that two residents (Residents 2 and 5) out of seven sampled were free from physical abuse. Findings include: A review of facility policy titled Abuse Policy reviewed by the facility May 2024, revealed that residents have the right to be free from abuse, neglect, misappropriation of property, corporal punishment, and involuntary seclusion. Clinical record review reveled that Resident 1 was admitted to the facility on [DATE] with diagnoses of dementia, alcohol induced persisting dementia and anxiety. A review of a Quarterly Minimum Data Set Assessment (MDS - a federally mandated standardized assessment conducted periodically to plan resident care) dated March 29, 2024, revealed that the resident was severely cognitively impaired, with a BIMS score of 3 (the Brief Interview for Mental Status a tool to assess the resident's attention, orientation and ability to register and recall new information, a score of 0-7 equates to being severly impaired). Resident 1's current care plan, initiated December 15, 2023 for the problem of behaviors revealed that the resident makes accusatory statements, is resistive with care, displays verbal/physical agitation/aggression, yelling out at others, aggressive language,striking out at staff, striking out at other residents related to alcohol use history, Traumatic brain injury and dementia. The resident's goal was that the resident will be free of harming self or others during periods of combativeness. The planned interventions were noted as: Attempt to redirect resident when exhibiting behaviors; re-approach when resident has deescalated; Approach resident in a calm manner to avoid frustration and behavior escalation; If resident becomes agitated and shows signs of escalation, re-approach later; Attempt distraction during behavioral episodes by offering e-game, snack, talking about motorcycles or being in the outdoors putting Price is Right on TV; Keep resident safe during episodes of behaviors; attempt to redirect; Monitor and document episodes of inappropriate behaviors; notify physician/NP/PA when behaviors persist or won't deescalate; Provide a calm safe environment when the patient's frustrations escalate and allow time to voice feelings and the placement of a stop Sign to room entrance as deterrent and privacy. Page 1 of 4 395464 395464 05/30/2024 Forest Hills Rehabilitation & Healthcare Center 1000 Evergreen Avenue Weatherly, PA 18255

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some A review of Resident 2's clinical record revealed that the resident was admitted to the facility on [DATE], with diagnoses, which included Alzheimer's disease (chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning) and exhibited wandering behaviors. A quarterly Minimum Data Set assessment dated May, 2024, indicated that the resident was severely cognitively impaired with a BIMS score of 3. Nursing documentation revealed that Resident 1 had a history of aggressive behavior towards other residents in the facility, including on October 14, 2023, Resident 1 choked Resident 3 (roommates at that time) with a sock. Resident 3 had sat in Resident 1's chair, angering Resident 1. A review of nursing documentation and a facility investigation dated May 17, 2024 at 9:45 P.M. revealed that staff heard Resident 1 yelling get out of my room. Resident 2 entered Resident 1's room. Resident 1 grabbed and pulled Resident 2's hair and punched her several times in the face. Nursing staff entered the room, Resident 2 was holding her nose as it was bleeding. Resident 1's roommate told the nurse aide that Resident 1 pulled her hair and hit her in the face several times. Pressure and ice were applied to Resident 2's nose/face. The resident was not sent to the hospital nor were x-rays obtained to rule out any fractures or head injury. Both residents were placed on every 15 minute checks and a stop sign was placed across Resident 1's door as an interventions to prevent recurrence. A review of nursing documentation dated prior to this incident revealed multiple entries indicating Resident 1 was verbally and physically aggressive towards residents and staff. A nurses note dated May 23, 2024, at 6:17 A.M. revealed {Resident 1} up and at the nurses station every 30 minutes, did not sleep at all tonight, asking for food or pain medicine. At one point, just kept asking for a medication. He couldn't say what he wanted or what it was for, but kept arguing he wanted meds. He then said Ma'am, I've never hit a women, but I can today. An observation May 30, 2024 at 12:20 P.M., revealed Resident 1 seated on the side of his bed in his room. There was no stop sign banner on his door ( Stop Sign Door Banner is a mesh banner with bright red octagonal stop sign that easily attaches to a door frame, providing a visual reminder for wandering residents not to enter a room) as noted on the resident's care plan and as noted as an intervention following the incident on May 17, 2024. A review of a 30-minute observation sheet maintained by the facility dated May 30, 2024 at 12:20 PM revealed that Resident 1 was an every 30 minute watch by staff. The sheet , when reviewed, had been completed from 12 AM through 9:30 AM indicating that staff checked on Resident 1 at 30 minute intervals. The entry for the every 30 minute at 12:20 PM was blank. The facility failed to demonstrate consistent implementation of the measures planned to protect residents from Resident 1, with a known history of aggressive behaviors, and failed to prevent Resident 1 from physically assaulting Resident 2. Clinical record review revealed that Resident 4 was admitted to the facility on [DATE] with diagnoses to include, dementia and a history of wandering and the potential for elopement. A quarterly MDS dated [DATE] revealed Resident 4 was severely cognitively impaired with BIMS of 5 and required staff assistance for activities of daily living. 395464 Page 2 of 4 395464 05/30/2024 Forest Hills Rehabilitation & Healthcare Center 1000 Evergreen Avenue Weatherly, PA 18255

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some The resident's current care plan dated June 29, 2023 revealed that the resident was at risk for elopement related to dementia. Resident verbalizes he wants to leave the facilit, Refuses use of Wanderguard device and will self remove the device. The planned interventions were noted as: Calmly redirect and divert resident's attention; Distract resident when wandering/insistent on leaving facility by offering pleasant diversions, structured activities, food, conversation, television, books, etc; Promptly check when alarm system goes off to ensure resident is safe and remains in facility. The resident had a history of wandering the facility and voicing his need to leave the facility. In response to these behaviors, Resident 4 was relocated to the locked dementia unit in the facility. The resident's care plan continued, noting that the resident has impaired cognitive function related to dementia, short term memory impairment. He will display appropriate response to inappropriate situations. Interventions planned were to Approach/speak in a calm, positive/reassuring manner; Attempt to provide consistent routines/caregivers; and redirect as needed. A review of nursing documentation and a facility investigation dated May 21, 2024, at 4 PM revealed that staff heard Resident 5, a cognitively intact resident with a BIMS of 15, yelling and her call bell was activated. Resident 4 was in Resident 5's room and was physically aggressive towards towards her. Resident 5 stated that Resident 4 walked into her room. She asked him to leave, but he kept coming into the room. Resident 5 then raised her voice and asked him loudly to leave the room. She put the tray table between them. He attempted to take her belongings off the table (a phone and rosary). Resident 5 then put on her call bell. Resident 4 then swung his tote bag, containing towels and a t-shirt, and hit Resident 5 in the head. Nursing responded and separated the 2 residents, removing Resident 4 from the room. Resident 5 sustained a 1 cm x 1 cm hematoma on the top of her head as a result of the altercation. A witness statement dated May 21, 2024, (no time indicated), from Resident 5 revealed that the resident stated that {Resident 4} came into my room and walked in with out knocking. I told him to leave nicely at first. He didn't leave. He started coming towards me, then I yelled at him to get out of my room. I grabbed my rosary and phone. He then picked up his shopping bag and hit me over the head. I called for someone to come get him out of my room. The nurse came in and took him away. I told her that if he comes at me again, I will defend myself. The facility failed to ensure that Resident 5 was free from physical abuse perpetrated by Resident 4. An interview with the DON (director of nursing) and NHA (nursing home administrator) on May 30, 2024, at approximately 1 PM confirmed the facility substantiated Resident 1's physical abuse of Resident 2. The DON stated that because Resident 4 was an elopement risk he could not be moved off the locked dementia unit. She stated that staff should redirect Resident 4's aggressive behavior, however in this case did not, failing to protect Resident 5 from physical abuse. The facility failed to ensure that Resident 5 was free from physical abuse perpetrated by Resident 4. 28 Pa. Code 211.12(d)(5) Nursing Services 395464 Page 3 of 4 395464 05/30/2024 Forest Hills Rehabilitation & Healthcare Center 1000 Evergreen Avenue Weatherly, PA 18255

F 0600 28 Pa. Code 201.14 (a) Responsibility of licensee Level of Harm - Minimal harm or potential for actual harm 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 201.29(a) Resident Rights Residents Affected - Some 395464 Page 4 of 4