Health inspection·May 28, 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. Based on review of policies, clinical records, and investigation documents, as well as staff interviews, it was determined that the facility failed to ensure that residents were free from abuse for one of eight residents reviewed (Resident 6). Findings include: The facility's abuse policy, dated September 26, 2024, indicated that the facility would not tolerate abuse, neglect, mistreatment, exploitation of residents and misappropriation of resident property by anyone. Facility staff must immediately report all such allegations to the administrator/abuse coordinator. An investigation would begin immediately and all applicable local and state agencies would be notified in accordance with the procedures in this policy. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 6, dated December 12, 2024, revealed that the resident was understood and could usually understand others, was dependent on staff for transfers, had no behaviors, and had a diagnosis of dementia. A nursing note for Resident 6, dated March 12, 2025, at 12:22 p.m., revealed that the Director of Nursing was notified of an allegation of neglect/abuse. A nurse aide moved the call bell from a resident's reach over the weekend and refused to get her out of bed. The facility's investigation, dated March 12, 2025, revealed that Nurse Aide 1 removed Resident 6's call bell and refused to get the resident out of bed. A witness statement by Licensed Practical Nurse (LPN) 2, signed and undated, regarding the incident of March 9, 2025, revealed that Nurse Aide 1 reported to her that Resident 6 was not getting out of bed because she had played in her bowel movement after Nurse Aide 1 washed her. Resident 6 rang the call light multiple times asking to get out of bed. During the dinner tray pass, Resident 6 was hitting her remote off the table and LPN 2 heard Nurse Aide 1 say stop hitting your remote off the table or I will move your table too. Resident 6's call light was noted to be draped over the night stand. Resident 6 said, I don't have my call bell, they moved it. A witness statement by Nurse Aide 3, dated March 11, 2025, revealed that she was not aware that Resident 6's call bell was out of reach and denied involvement with it being moved. A witness statement by Nurse Aide 1, dated March 13, 2025, revealed that she had worked the past Saturday and Sunday. Resident 6 started yelling that she wanted up in the middle of an emergency. She revealed that Nurse Aide 3 removed Resident 6's call bell on Saturday and when Resident 6 wanted to Page 1 of 3 395604 395604 05/28/2025 Greene Health & Rehab Center 119 Industrial Park Road Greensburg, PA 15601

F 0600 get out of bed on Sunday Nurse Aide 3 said the resident was not getting out of bed. Level of Harm - Minimal harm or potential for actual harm A witness statement from Registered Nurse 4, dated March 14, 2025, revealed that Nurse Aides 1 and 3 informed her that they moved the call bell away from Resident 6 so she could not reach it and bother them because they were too busy to deal with her that day. Residents Affected - Few Interview with the Nursing Home Administrator on May 18, 2025, at 4:30 p.m. confirmed that Nurse Aides 1 and 3 were both assigned to Resident 6's hall and accused each other of removing the call bell. Resident 6's call bell was removed and she was not allowed out of bed. The investigation determined that Nurse Aide 1 removed the call bell, but Nurse Aide 3 was aware and Registered Nurse 4 was aware of the incident but did not report it timely per the abuse policy. 28 Pa. Code 201.14(a) Responsibility of Licensee. 28 Pa. Code 201.18(b)(1)(e)(1) Management. 28 Pa. Code 201.29(j) Resident Rights. 28 Pa. Code 211.12 (d)(5) Nursing Services. 395604 Page 2 of 3 395604 05/28/2025 Greene Health & Rehab Center 119 Industrial Park Road Greensburg, PA 15601

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm Based on clinical record reviews, as well as staff interviews, it was determined that the facility failed to follow physician's orders for one of eight residents reviewed (Resident 2). Residents Affected - Few Findings include: An admission Minimum Data Set (MDS) assessment (a mandatory assessment of a resident's abilities and care needs) for Resident 2, dated April 11, 2025, revealed that the resident was cognitively intact, needed assistance from staff for daily care needs, and had diagnoses that included paraplegia (no feeling below the abdomen), wound infection, and a Stage 4 pressure ulcer (wound that exposes bone, tendon or muscle). Physician's orders for Resident 2, dated April 5, 2025, included an order for the resident to receive 4.5 grams of Piperacillin-tazobactam (antibiotic) intravenously (IV-administered through the vein) every eight hours. A review of Resident 2's Medication Administration Record for April 2025 revealed no documented evidence that the resident received the Piperacillin-tazobactam per physician's orders on April 6, 2025, at 12:00 a.m., 8:00 a.m., and 4:00 p.m. A nursing note for Resident 2, dated April 6, 2025, at 2:28 a.m., revealed that the resident requested bed rails and an air mattress for repositioning and pressure ulcers. A wound consult for Resident 2, dated April 7, 2025, at 10:45 a.m. revealed that the Certified Registered Nurse Practitioner (CRNP - an advanced practice nurse who can diagnose and treat medical conditions, prescribe medications, and provide comprehensive patient care) recommended an air mattress for the resident's pressure ulcers; however, a review of Resident 2's clinical record revealed no documented evidence that the resident received an air mattress per the wound consultant's recommendation and resident's request. Interview with the Director of Nursing on May 28, 2025, at 2:36 p.m. confirmed that Resident 2 did not receive IV Piperacillin per physician's orders. She also confirmed that there was no documented evidence that the resident received an air mattress per the wound consultant CRNP's recommendation and resident's request. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services. 395604 Page 3 of 3