Health inspection·December 5, 2024

F 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, resident observations, resident and staff interviews, and grievance review, it was determined that the facility failed to have sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for six of eight residents (Residents R2, R4, R5, R6, R7 and R8). Findings Include: Review of the facility policy Call Lights last reviewed 2/21/24, indicates all residents have a call light or alternative communication device within their reach at all times when unattended. Facility personnel will answer a call light as soon as possible. To ensure safety and communication between staff and residents in order to timely meet their needs. Respond to emergency call lights immediately. Respond to call lights and communication devices promptly and in person whenever possible. Review of the facility policy Resident Rights last reviewed 2/21/24, indicates a resident has the right to receive the services and items included in the resident's plan of care. A resident has the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences. A resident has the right to have grievances promptly resolved, in accordance with law. Review of the facility policy Nursing Service last reviewed 2/21/24, indicates nursing care includes the provision of all prescribed medications and treatments, personal care, hygiene, and nursing interventions in response to physical, emotional, or behavioral needs/problems. All nursing care is directed at attaining and maintaining optimal levels of health and functioning. To safely and effectively meet the nursing needs of the resident. Review of facility provided grievance dated 10/31/24, indicates received a phone call from Resident R2's son with concerns that Resident R2 called him the morning of 10/31/24, to report that no one is answering her call bell. Son stated that my mother previously fell in the bathroom and he is concerned that extended call bell responses times add to her potential for falls. Further review revealed that on 11/15/24, son again reported continued issues with call bell response via e- mail at approximately 9:55 p.m. yesterday evening my mother phoned me from her bed to say she needed to urinate, but no one was responding to her calls for assistance. Review of Resident R2's clinical record indicated she was admitted to the facility on [DATE], current room [ROOM NUMBER]. Page 1 of 13 395549 395549 12/05/2024 Sherwood Oaks 100 Norman Drive Cranberry Township, PA 16066

F 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of Resident R2's Minimum Data Set (MDS- a periodic assessment of care needs) dated 10/28/24, indicated the diagnoses of hypertension (high Blood pressure), hyperlipidemia (high fat in the blood) and hyperglycemia (high sugar in the blood). Section C0100 brief interview for mental status (BIMS- a structured evaluation aimed at evaluation aspects of cognition in the elderly a score 0-7 indicates severe cognitive impact, 8-12 moderate impairment, 13-15 intact cognitive response.) indicated a score of 12 moderate impairment. Review of the facility provided work order on 9/5/24, indicates round flat call bell isn't working room [ROOM NUMBER] please check. Response noted: tested call bell twice it is working. Review of the facility provided work order dated 11/15/24, indicates the call bells in room [ROOM NUMBER] and 426 are not working. Response: replaced batteries in call bell tested twice all is good. Observation and interview on 12/3/24, resident was sitting in her wheelchair next to bed, her over the bed tray table was next to her and had a flat call bell pressure pad as well as a silver bell that dings when tapped. Resident is dressed and well groomed. Upon asking resident about the call bell response time on the day she called her son, she replied it's been several years ago, I can't remember. Review of the facility provided device activity report indicated the following: Room Date Time alarmed Time cleared Total Time minutes (m) Seconds (s) 426 11/15/24, 1:38 p.m. 1:52 p.m. 13 m 8's Area: Bed 426 11/16/24, 1:08 p.m. 1:24 p. m. 15 m 53's Area: Bed 395549 Page 2 of 13 395549 12/05/2024 Sherwood Oaks 100 Norman Drive Cranberry Township, PA 16066

F 0725 426 Level of Harm - Minimal harm or potential for actual harm 11/16/24, 7:09 p.m. Residents Affected - Some 7:36 p.m. 27m 14's Area: Bed 426 11/17/24, 11:40 a.m. 11:50 a.m. 10m 4s Area: Bed 426 11/17/24, 9:53 p.m. 10:04 p.m. 10m 38s Area: Bed 426 11/18/24, 8:33 p.m. 9:01 p.m. 28m 53s Area: Bed 426 11/19/24, 9:30 p.m. 10:03 p.m. 33m 20s Area: Bed 395549 Page 3 of 13 395549 12/05/2024 Sherwood Oaks 100 Norman Drive Cranberry Township, PA 16066

F 0725 426 Level of Harm - Minimal harm or potential for actual harm 11/20/24, 10:38 p.m. Residents Affected - Some 10:57 p.m. 18m 54s Area: Bed 426 11/21/24, 2:51 a.m. 3:20 a.m. 29m 35s Area: Bed 426 11/22/24, 1:27 p.m. 1:55 p.m. 27m 34s Area: Bath 426 11/22/24, 8:26 p.m. 8:45 p.m. 19m 32s Area: Bed 426 11/23/24, 2:39 a.m. 3:01 a.m. 21m 34s Area: Bed 395549 Page 4 of 13 395549 12/05/2024 Sherwood Oaks 100 Norman Drive Cranberry Township, PA 16066

F 0725 426 Level of Harm - Minimal harm or potential for actual harm 11/23/24, 9:05 p.m. Residents Affected - Some 9:31 p.m. 26m 7s Area: Bed 426 11/23/24, 9:38 p.m. 9:52 p.m. 13m 36s Area: Bed 426 11/24/24, 8;33 p.m. 8:57 p.m. 24m 0s Area: Bed 426 11/26/24, 9:11 p.m. 9:31 p.m. 20m 28s Area: Bed 426 11/27/24, 11:00 a.m. 11:30 a.m. 29m 59s Area: Bath 426 395549 Page 5 of 13 395549 12/05/2024 Sherwood Oaks 100 Norman Drive Cranberry Township, PA 16066

F 0725 11/29/24, Level of Harm - Minimal harm or potential for actual harm 9:14 a.m. 9:34 a.m. Residents Affected - Some 19m 52s Area: Bed 426 12/1/24, 8:03 p.m. 8:37 p.m. 33m 56s Area: Bed Review of Resident R4's clinical record indicated she was admitted to the facility on [DATE], current room [ROOM NUMBER]. Review of Resident R4's Minimum Data Set (MDS- a periodic assessment of care needs) dated 10/10/24, indicated the diagnoses of hypertension (high Blood pressure), hyponatremia (low sodium levels), and hyperlipidemia (high fat in the blood). Section C0100 BIMS- indicated a score of 12 moderate impairment. During an interview completed on 12/3/24, at 10:26 a.m. Resident R4, was resting in her bed, upon asking if staff was answering her call bell timely Resident R4 stated It takes a long time for them to answer my bell, sometimes I will pee in my bed. Review of the facility provided device activity report indicated the following: Room Date Time alarmed Time cleared Total Time minutes (m) Seconds (s) 431 11/15/24, 7:17 p.m. 7:43 p.m. 395549 Page 6 of 13 395549 12/05/2024 Sherwood Oaks 100 Norman Drive Cranberry Township, PA 16066

F 0725 25m 33s Area: Bed Level of Harm - Minimal harm or potential for actual harm 431 11/16/24, Residents Affected - Some 5:12 p.m. 5:24 p.m. 12m 18s Area: Bath 431 11/17/24, 7:06 p.m. 7:25 p.m. 18m 58s Area: Bed 431 11/19/24, 7:10 p.m. 8:44 p.m. 94m 4s Area: Bed 431 11/20/24, 5:24 p.m. 5:49 p.m. 25m 1s Area: Bed 431 11/21/24, 7:01 p.m. 7:52 p.m. 395549 Page 7 of 13 395549 12/05/2024 Sherwood Oaks 100 Norman Drive Cranberry Township, PA 16066

F 0725 50m 57s Area: Bed Level of Harm - Minimal harm or potential for actual harm 431 11/22/24, Residents Affected - Some 8:32 p.m. 9:04 p.m. 31m 51s Area: Bed 431 11/23/24, 7:14 a.m. 7:27 a.m. 12m 37s Area: Bed 431 11/24/24, 9:06 p.m. 9:40 p.m. 33m 36s Area: Bed 431 11/25/24, 7:15 a.m. 7:45 a.m. 29m 14s Area: Bed 431 11/27/24, 8:49 p.m. 9:28 p.m. 395549 Page 8 of 13 395549 12/05/2024 Sherwood Oaks 100 Norman Drive Cranberry Township, PA 16066

F 0725 39m 35s Area: Bed Level of Harm - Minimal harm or potential for actual harm 431 11/28/24, 12:52 p.m. Residents Affected - Some 1:29 p.m. 37m 23s Area: Bed 431 11/29/24, 10:26 p.m. 11:05 p.m. 39m 16s Area: Bed 431 12/1/24, 6:38 p.m. 7:02 p.m. 24m 26s Area: Bed Review of Resident R5's clinical record indicated she was admitted to the facility on [DATE], current room [ROOM NUMBER]. Review of Resident R5's Minimum Data Set (MDS- a periodic assessment of care needs) dated 10/7/24, indicated the diagnoses of skin cancer, anemia (low iron in the blood), and hypertension. Section C0100 BIMS- indicated a score of 15 intact cognitive response. During an interview on 12/3/24, at 10:08 a.m. Resident R5, room [ROOM NUMBER], indicated it can take staff a while to answer her light and stated oh my God at least 20 minutes. I have had accidents it's not my fault, I ring the bell, I keep hearing we are short of help. It's even during the day, I can't walk, I use the bed pan. Just once a couple of weeks ago they left me on it, it hurt, it was more than half an hour. Review of the facility provided device activity report indicated the following: Room Date Time alarmed Time cleared Total Time minutes (m) Seconds (s) 395549 Page 9 of 13 395549 12/05/2024 Sherwood Oaks 100 Norman Drive Cranberry Township, PA 16066

F 0725 409 Level of Harm - Minimal harm or potential for actual harm 11/15/24, 10:31 a.m. Residents Affected - Some 10:43 p.m. 11m 32s Area: Bed 409 11/16/24, 8:06 a.m. 8:53 a.m. 47m 11s Area: Bed 409 11/19/24, 9:31 a.m. 9:58 a.m. 26m 45s Area: Bed 409 11/19/24, 1:31 p.m. 1:49 p.m. 18m 39s Area: Bed 409 11/21/24, 748 a.m. 8:06 a.m. 18m 5s Area: Bed 395549 Page 10 of 13 395549 12/05/2024 Sherwood Oaks 100 Norman Drive Cranberry Township, PA 16066

F 0725 409 Level of Harm - Minimal harm or potential for actual harm 11/22/24, 7:33 a.m. Residents Affected - Some 7:47 a.m. 14m 3s Area: Bed 409 11/23/24, 6:06 p.m. 6:24 p.m. 18m 28s Area: Bed 409 11/23/24, 8:19 p.m. 8:50 p.m. 31m 17s Area: Bed 409 11/24/24, 4:39 p.m. 4:50 p.m. 11m 6s Area: Bed 409 11/25/24, 2:18 p.m. 2:57 p.m. 39m 17s Area: Bed 395549 Page 11 of 13 395549 12/05/2024 Sherwood Oaks 100 Norman Drive Cranberry Township, PA 16066

F 0725 409 Level of Harm - Minimal harm or potential for actual harm 11/27/24, 6:43 p.m. Residents Affected - Some 8:15 p.m. 92m 21s Area: Bed 409 11/27/24, 9:02 p.m. 9:31 p.m. 28m 58s Area: Bed 409 11/28/24, 8:14p.m. 8:28 p.m. 14m 19s Area: Bed 409 11/30/24, 9:29 a.m. 9:40 a.m. 11m 41s Area: Bed 409 12/1/24, 9:57 a.m. 10:15 a.m. 18m 34s Area: Bed 395549 Page 12 of 13 395549 12/05/2024 Sherwood Oaks 100 Norman Drive Cranberry Township, PA 16066

F 0725 Level of Harm - Minimal harm or potential for actual harm During an interview completed on 12/3/24, at 11:00 a.m. Resident R6 stated he has on occasion had to wait for his call bell to be answered and stated we were short staffed over the holiday weekend. During an interview completed 12/3/24, at 11:05 a.m. Resident R7 stated I just go on my own, I don't have to wait. Residents Affected - Some During an interview completed on 12/3/24, at 10:38 a.m. Resident R8 stated at night sometimes they run short. Review of facility provided matrix dated 12/3/24, indicated current in-house census at 31. Review of facility provided Care Plan/Task listing report dated 12/4/24, indicated eleven residents require an assist of two for transfers. Seven residents requires an assist of two for bed mobility. During an interview completed on 12/3/24, at 2:50 p.m. upon asking the Director of Nursing (DON) what the expectation time frame is for staff is to answer call bells the DON stated, a reasonable time frame less than twenty minutes. During an interview completed on 12/4/24, at 8:55 a.m. upon asking the Nursing Home Administrator (NHA) what is the expectation for answering call bells stated, based upon what is going on at that time, that is I would expect it to be answered. Upon asking for clarification concerning the extended call bell answer times on the facility provided device activity report the NHA responded You are looking at data that few places could provide, strapping it out. The majority are answered prompt, more than you would see anywhere else. The expectation is prompt call bell response, upon asking what he would consider as prompt, the NHA sated prompt would be a wide variety, I don ' t know how to answer that question. During an interview completed on 12/4/24, at 12:20 p.m. the DON stated after 7:00 p.m. it's the busy time for getting the residents to bed. I think they try to get in as soon as possible. Upon asking about Resident R2's son call bell response concerns the DON stated I'm in constant communication with the staff addressing his concerns (referring to Resident R 2's son) about call bells. I would expect that there is a lot of competing factors with the activities of daily living (ADLs) and nighttime care. We are transparent about concerns being recorded. The floor Resident R2 is on has a high number of resident's that require an assist of two. We are addressing our call bell times in general and in our quality assurance performance improvement (QAPI) plan, confirming that the facility failed to have sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of six of eight residents (Residents R2, R4, R5, R6, R7 and R8). 28 Pa. Code: 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(e)(6) Management. 28 Pa. Code: 201.20(a) Staff development. 28 Pa. Code: 211.12(a)(c)(d)(1)(2)(3)(4) Nursing services. 395549 Page 13 of 13