Health inspection·February 19, 2025

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. Based on clinical record review, facility documentation review, and staff interview, it was determined that the facility failed to protect one of eight sampled residents (Resident 2) from sexual abuse by another resident (Resident 1). Findings include: Clinical record review revealed that Resident 2 had diagnoses that included dementia and depression. According to her Minimum Data Set (MDS) assessment, dated February 3, 2025, she was cognitively impaired, had difficulty communicating, and was dependent on staff for mobility. Clinical record review revealed that Resident 1 had diagnoses that included cancer and dementia. According to the MDS assessment, dated August 12, 2024, the resident had periods of depressed mood and was able to move about the facility independently. In an interview on February 19, 2025, at 11:53 a.m., the nurse practitioner (NP 1) stated that Resident 1's room was changed on June 7, 2023, due to sexually inappropriate behavior with a cognitively impaired female resident, and as a result he was monitored by the psychiatrist for concerns including sexually inappropriate behavior. On July 10, 2024, the psychiatrist noted that the resident had begun to have behaviors towards a specific female peer (not identified in the note). Further review of progress notes dated August 4 and October 2, 2024, revealed that the resident was wandering into a specific female resident's room without consent and would become aggressive towards staff who discovered him unsupervised with the female without their consent. On December 4, 2024, the psychiatrist noted that Resident 1's room was again changed again due to interactions with a female resident of a sexual nature. There was no documentation in the clinical record that the facility took any action to protect residents from abuse. There was no evidence that the resident's sexually inappropriate behavior was included in the plan of care. On January 6, 2025, at 10:35 a.m., a nurse noted that a nurse aide observed that the resident exposed himself to another resident. There was no documentation in the clinical record that the facility took any action to protect residents from abuse despite Resident 1's continued sexually inappropriate behavior towards female peers. On February 9, 2025, at 10:34 p.m., a nurse noted that Resident 1 was discovered groping a female peer (Resident 2) while unsupervised in her room. Review of the facility investigation into the Page 1 of 3 395477 395477 02/19/2025 Laureldale Skilled Nursing and Rehabilitation Cent 2125 Elizabeth Avenue Laureldale, PA 19605

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some incident revealed that staff observed him in the resident room fondling both of her breasts outside her gown. In an interview on February 19, 2025, the Administrator confirmed that the facility did not increase supervision or include sexually inappropriate behavior on the resident's care plan despite a previous pattern of this behavior. CFR 483.12 Freedom from Abuse, Neglect, and Exploitation Previously cited 8/16/24 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1) Management. 28 Pa. Code 211.12(d)(1)(5) Nursing Services. 395477 Page 2 of 3 395477 02/19/2025 Laureldale Skilled Nursing and Rehabilitation Cent 2125 Elizabeth Avenue Laureldale, PA 19605

F 0622 Level of Harm - Minimal harm or potential for actual harm Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. Based on clinical record review and staff interview, it was determined that the facility failed to readmit a resident after a transfer to the hospital for one of eight sampled residents. (Resident 1) Residents Affected - Few Findings include: Clinical record review revealed that Resident 1 had diagnoses that included cancer and dementia. On February 9, 2025, at 10:34 p.m., a nurse noted that the resident was observed groping another resident and that he became combative with staff. On February 10, 2025, at 2:37 p.m., a nurse noted that the resident was sent to the hospital for an evaluation from a psychiatrist. In an interview on February 19, 2025, at 1:22 p.m., SW 1 (the hospital social worker) stated that the resident received the psychiatric evaluation and was deemed safe to return to the facility. She further stated that the resident remained in the facility and that the facility instructed the hospital that they would not be accepting the resident back. In an interview on February 19, 2025, at 9:30 a.m., the Administrator confirmed that the resident was discharged to the hospital and was not permitted to return. 28 Pa. Code 201.14(a) Responsibility of licensee. 395477 Page 3 of 3