Health inspection·September 11, 2024

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 policies, documents and clinical records and staff interviews, it was determined that the facility failed to make certain residents were free from neglect for one of ten residents reviewed (Resident R1). Findings include: A review of the facility policy Abuse, Neglect, Mistreatment, Exploitation, and Misappropriation of Resident Property reviewed 1/2/24, defines abuse as the willful infliction of injury, and includes verbal, sexual, physical, and mental abuse. Willful is defined as the individual must have acted deliberately. Physical abuse includes hitting, slapping, pinching, kicking, etc. The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides instructions and guidelines for completing required Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2019, indicated that a BIMS (Brief Interview of Mental Status) is a brief screener that aids in detecting cognitive impairment. Scores from a BIMS assessment suggests the following distributions: 13 - 15: cognitively intact 8 - 12: moderately impaired 0 - 7: severe impairment The admission record indicated that Resident R1 was re-admitted to the facility on [DATE], with diagnoses that included dementia (dementia (group of symptoms affecting memory, thinking and social abilities), high blood pressure, and diabetes. A review of the admission Minimum Data Set (MDS - standardized assessment tool for all residents of long-term care facilities) dated 8/6/24 indicated the diagnoses remain current. Further review of the MDS Section C: Cognitive Patterns, Question C0500 BIMS Summary Score indicated Resident R1 scored 04 out of a possible 15 on the BIMS assessment indicating she had severe impairment. Review of facility provided information dated 8/22/24, at approximately 4:20 p.m. Nurse Aide (NA) Employee E2 witnessed NA Employee E1 strike Resident R1 in the face multiple times. NA Employee E1 was also witnessed restraining Resident R1 by holding her arms down. Resident R1 was able to get one of her arms free and attempted to strike NA Employee E1 unsuccessfully. NA Employee E1 then began to Page 1 of 2 395692 395692 09/11/2024 Transitions Healthcare Washington PA 90 Humbert Lane Washington, PA 15301

F 0600 slap the resident in her face several times very hard then walked away. Level of Harm - Minimal harm or potential for actual harm During an interview on 9/11/24, at 9:20 a.m. the Director of Nursing stated NA Employee E2 came to the front office upset and shaking, stating she just witnessed Resident R1 being physically abused by NA Employee E1. NA Employee E1 was immediately switched assignments and monitored by the Assistant Director of Nursing until the cops arrived. The police were immediately notified, and NA Employee E1 was arrested at the facility and taken to jail. Residents Affected - Few Review of a progress note dated 8/23/24, at 2:44 p.m. revealed Resident R1 had a visible abrasion to the left nose measuring 1.5 centimeters (cm). An interview was attempted on 9/11/24, at 10:30 a.m. Resident R1 was unable to answer questions appropriately. Review of the care plan dated 1/14/20, indicated to allow Resident R1 to de-escalate when agitated, prior to further care. Further review of the care plan dated 3/2/20 indicated when resident becomes agitated: Intervene before agitation escalates. Guide away from source of distress, staff to walk calmly away and approach later. On 1/9/24, indicated the following interventions should be attempted as non-pharm (no medication) approached when attempting to redirect combative behaviors: Staff leave room when resident gets agitated and attempt care at a later time. Review of the Behavior Symptoms charting dated 8/20/24 through 8/22/24, revealed Resident R1 did not have behavioral symptoms (yelling/screaming, kicking/hitting, pushing, grabbing, pinching/scratching/spitting, siting, threatening behavior, etc.) during that time. A telephone interview was attempted on 9/11/24, at 10:51 a.m. with NA Employee E2. A voicemail was left, no return telephone call was received. A telephone interview was attempted on 9/11/24, at 10:53 a.m. with NA Employee E1. A voicemail was unable to be left, Mailbox is full message received. Facility provided re-education was conducted on 8/23/24, on Abuse and Neglect for all facility staff. Review of NA Employee E1 ' s personal file revealed Abuse training was completed on 7/23/24. During an interview on 9/11/24, at 1:00 p.m. the Nursing Home Administrator confirmed that the facility failed to make certain a resident was free from physical abuse for one resident (Resident R1). 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1)(3)(e)(1) Management. 28 Pa. Code 211.10(d) Resident care policies. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services. 395692 Page 2 of 2