Health inspection·August 6, 2024

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, clinical records, incident reports, resident and staff interviews it was determined that failed to report a resident-to-resident abuse altercation for two of three sampled residents (Resident R1 and Closed Resident Record CR2). Findings include: The facility Abuse, neglect, and exploitation policy dated 7/11/24, indicated that the facility will not tolerate abuse, neglect, mistreatment, and exploitation of residents. Facility staff must immediately report all such allegation to the Administrator. The Administrator will notify the applicable local and state agencies. Review of Resident R1's admission record indicated he was originally admitted on [DATE] and readmitted [DATE]. Review of Resident R1's MDS assessment (MDS-Minimum Data Set assessment: periodic assessment of resident care needs) dated 4/9/24, indicated he had diagnoses that included dementia with behavioral disturbance (neuro-cognitive disorder impacting reasoning, judgment, and memory), anxiety disorder (a medical condition creating a sense of acute fear, restlessness, and worry), and chronic obstructive pulmonary disease (COPD-a disease characterized by persistent respiratory symptoms involving breathlessness, coughing, and obstructed airflow to the lungs). These diagnoses were the most recent upon review. Review of Resident R1's clinical nurse progress note dated 7/15/24, indicated that staff was notified by another resident that Resident R1 was on the smoking patio and was arguing with another resident, Closed Resident Record CR2, over a lighter. Per other resident's that witnessed the altercation, Resident R1 had grabbed Closed Resident Record CR2 lighter and wouldn't give it back. Closed Resident Record CR2 got the lighter back and Resident R1 grabbed her arm and caused a skin tear with his fingernails to Closed Resident Record CR2's right forearm. Review of Closed Resident Record CR2's admission record indicate she was admitted on [DATE]. Review of Closed Resident Record CR2's MDS assessment dated [DATE], indicated she had diagnoses that included a fall history, COPD, and history of a left femur fracture. These diagnoses were the most recent upon review. Review of Closed Resident Record CR2's clinical nurse progress notes dated 7/15/24, indicated that Page 1 of 2 395603 395603 08/06/2024 Caring Heights Community Care & Rehab Ctr 234 Coraopolis Road Coraopolis, PA 15108

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Resident R1 tried to grab Closed Resident Record CR2's lighter from her. She took it back from him and Resident R1 grabbed her right forearm, causing a skin tear. Resident R1 was immediately removed from the smoking patio. Closed Resident Record CR2 stated that she was ok and just a little shaken up. Closed Resident Record CR2 was taken back to the nurses' station; the skin tear was cleansed and steri strips were applied. Emotional support provded; Closed Resident Record CR2 again stated that she was fine. Resident's husband was notified in person of the incident. Incident/investigation documents dated 7/15/24, indicated that Registered Nurse (RN) Supervisor Employee E1 provided a statement. She stated Closed Resident Record CR2 reported that another resident tried to take her lighter, grabber her arm and caused a skin tear. Review of reports submitted and provided by the facility dated July 2024 did not include a report for the resident-to-resident altercation between Resident R1 and Closed Resident Record CR2. During an interview on 8/4/24, at 9:39 a.m. Resident R3 stated: I did witness a resident scratch another resident during smoke break. Resident was Resident R1. He scratched Closed Resident Record CR2 and she was bleeding. During an interview on 8/4/24, at 12:21 p.m. Registered Nurse (RN) Supervisor Employee E1 stated: one resident, Resident R3, opened the smoking patio door and yelled. She said that Resident R1 had grabbed Closed Resident Record CR2 and gave her a skin tear to her right arm. I observed two skin tears, maybe 3 c.m. x 0.5c.m. x 0.1c.m. It was open. There was a bit of a skin flap area. It was on the right arm. Seems liked Resident R1 grabbed and pulled. I took Closed Resident Record CR2 back to the unit, I put 2 steri strips on her arm. There was no active bleeding. And she said she was fine. During an interview on 8/4/24, at 11:18 a.m. the Director of Nursing (DON) confirmed that the facility failed to report a resident-to-resident abuse altercation involving Resident R1 and Closed Resident Record CR2 as required. 28 Pa Code: 201.14 (a ) Responsibility of Management 28 Pa Code: 201.18 (e)(1) Management 395603 Page 2 of 2