Health inspection·December 4, 2025

F 0600 Level of Harm - Minimal harm or potential for actual harm 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 policy, facility provided documents, clinical record review, and staff interviews it was determined that the facility failed to protect residents from neglect for one of three residents (Residents R1). This was identified for past non-compliance for Resident R1.Findings include: Review of the facility policy Abuse, Neglect and Exploitation last reviewed 10/13/25, indicated the facility is to provide protection for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, and exploitation and misappropriation of resident property. Review of the admission record indicated Resident R1 was admitted to the facility on [DATE]. Review of Resident R1's Minimum Data Set (MDS - a periodic assessment of care needs) dated 10/11/25, indicated diagnoses of high blood pressure, dementia (a group of symptoms that affect memory, thinking and interfere with daily life), and impulse disorder. Review of Resident R1's progress note dated 10/24/25, at 10:24 a.m. revealed that Resident R1 was complaining of increased hip pain. Hospice was consulted for further orders. New order was obtained for an X-ray. Family updated. Review of Resident R1's progress note dated 10/25/25, at 10:24 a.m. revealed X-ray results received. Acute displaced fracture of left proximal femur noted. Hospice notified and will call physician. At 2:46 p.m. Resident R1 was sent to Acute care hospital for evaluation and treatment.During an interview on 12/3/25, at 11:59 a.m. the Director of Nursing (DON) stated that she was made aware of the fracture and arrived at facility after receiving notification of event to start an investigation. DON stated that witness statements were gathered, and staff interviews were conducted. We didn't know he had a previous fall on 10/23/25, or that the Alleged Perpetrator Licensed Practical Nurse (LPN) Employee E1 threw him back to bed after he fell out of bed. While gathering statements and conducting an investigation, Activity Aide Employee E2 came up to me and described an incident that happened concerning Resident R1. Review of a written statement indicated that Activity Aide Employee E2 stated the following: I was in the room with another resident. I turned around and Resident R1 fell out of bed. I ran to get a nurse. LPN Employee E1 was who I got. I told her that Resident R1 had just fallen. LPN Employee E1 said Again, He's always falling. I don't know where his aide was and sat there. I asked her if she wanted me to help. LPN Employee E1 said I suppose. We went to the room. I took him under his right arm to lift him, and she grabbed the back of his pants and threw him on to the bed. LPN Employee E1 just walked out of the room. I stayed there to see if he was alright. I asked him if he was ok. He just shook his head yes. During a review of Resident R1's clinical record failed to include a fall from bed or any notification or documentation of incident. Review of documentation provided by the facility indicated that LPN Employee E1 was suspended pending investigation and was terminated on 11/4/25. The facility implemented a plan of correction that included the following: - Facility initiated whole house audits on 10/25/25, of all incidents/risk for any indications of abuse.- Facility initiated whole house audits on Page 1 of 2 395471 395471 12/04/2025 Armstrong Rehabilitation and Nursing Center 265 South McKean Street Kittanning, PA 16201

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 10/25/25, of all residents for concerns of abuse/neglect.- Facility initiated whole house education on 10/25/25, on abuse/neglect, and reporting requirements.- Education initiated on 10/25/25, and provided to all nursing staff on assessing residents' post fall, proper notification, and monitoring.- Facility will audit 15 residents weekly for signs and symptoms of abuse by examination or interview, to be completed weekly for three weeks and then monthly for two months.- QAPI (Quality Assurance Performance Improvement) was conducted on 10/25/25. During an interview on 12/4/25, at 10:35 a.m. LPN Employee E3 stated she was educated on abuse, neglect, falls and reporting. We call for the Registered Nurse (RN) so they can assess the resident before getting them off the floor. I would not pick them up and not report a fall. During an interview on 12/4/25, at 10:47 a.m. LPN Employee E4 stated, I would get the RN supervisor. Don't move the residents unless they are in a position of getting hurt. I don't know if they had a break or injury so I would not move them. The facility has demonstrated compliance with the above since 10/25/25. Information was verified via review of Plan of Correction binder. During an interview on 12/4/25, at 12:15 p.m. with the Nursing Home Administrator (NHA) and review of the facility's immediate actions, education, and review of the QAPI monitoring process, it was verified that the facility had implemented a plan of correction and achieved compliance ensuring residents are protected from abuse or neglect and fall protocols. During an interview on 12/4/25, at 12:20 p.m. the Nursing Home Administrator, and Director of Nursing confirmed the facility failed to protect residents from neglect for one of three residents (Residents R1). 28 Pa. Code 201.14(b) Responsibility of licensee.28 Pa. Code 201.18(b)(1)(2)(3) Management.28 Pa. Code 211.10(a)(c.)(d) Resident care policies.28 Pa. Code 211.12(d)(1)(3)(5) Nursing services. 395471 Page 2 of 2