Health inspection·October 23, 2025

F 0600 Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policies, facility documentation, and clinical records, and staff interviews, it was determined that the facility failed to ensure that two of three residents reviewed were free of neglect during care which resulted in actual harm of left femur fracture for one resident (Resident R1) and actual harm of a laceration of the right eyebrow and forehead for one resident (Resident R2).Findings include: Facility policy entitled Abuse Investigation and Reporting dated 1/22/25, revealed The Administrator or designee will monitor that any further potential abuse, neglect, exploitation, or mistreatment is prevented while the investigation is in progress. Facility policy entitled Abuse Prevention Program dated 1/22/25, revealed Our residents have the right to be free from abuse, neglect, misappropriation of residents properly and exploitation. Facility policy entitled Safe Resident Handling and Movement Policies' dated 1/22/25, revealed Subject to Care Plan team determinations regarding rehabilitation, restoration or maintenance of functional abilities, medical contraindications, emergencies, or other exceptional circumstances, staff is expected to follow the individual resident's plan of care as written. And Transfer assistance, mobility assistance and other resident handling and movement tasks are to be carried out in accordance with the individual resident's care plan. Facility investigation refers to the regulatory definition of Neglect as the failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Resident R1's physician's orders revealed an order dated 9/12/25, to transfer with staff assist of two with wheeled walker, stand up lift as needed. Resident R1's admission MDS dated [DATE], under Section GG 0170 Mobility for Sit to Stand. The ability to come to a standing position from sitting in a chair, wheelchair, or the side of the bed was coded as Dependent indicating Helper does ALL the effort. Resident does none of the effort to complete the activity OR, the assistance of 2 or more helpers is required for the resident to complete the activity. Resident R1's clinical record revealed a nursing note written by Registered Nurse (RN) Employee E13, dated 9/19/25, at 8:55 p.m. This writer called to [NAME] Wing shower room by Licensed Practical Nurse [LPN] due to Resident was on the floor. Upon entering room, note Resident lying supine [on back] on floor to left of the room with head toward the left side of room and legs stretched out with exception of left low extremity [LLE] which was slightly bent and externally rotated. Resident assessed. Skin pink, warm and dry. Respiration easy and regular with occasional dry cough noted. Skin assessed - Resident has old, scabbed abrasion to L knee noted. LLE noted to be slightly bent and externally rotated. Resident unable to participate in passive or active range of motion [ROM - how far you can move or stretch a part of your body such as a joint or muscle] in this leg. Resident indicated pain 9/10 across mid/posterior thigh. Denies hitting head. Note towels on the floor, Resident and Certified Nursing Assistant [CNA] explained that this was to keep him from slipping, however Resident stated that he stepped off of the towels and slipped. Page 1 of 5 395775 395775 10/23/2025 Sena Kean Nursing and Rehabilitation Center 17083 Route 6 Smethport, PA 16749

F 0600 Level of Harm - Actual harm Residents Affected - Few Resident was being assisted by CNA to wheelchair and was lowered to the ground. Certified Registered Nurse Practitioner [CRNP] was notified and resident sent to the ER. Resident R1's clinical record revealed a nurse's progress note dated 9/20/25, that identified the resident was sent from a local hospital ER to another medical center in another city due to Left hip/femur fracture due to this evening's fall. Daughter and CRNP notified. Documentation submitted by the facility dated 9/20/25, revealed that the facility initiated an investigation which revealed CNA Employee E9 provided a written statement with an incident date of 9/19/25, which revealed, When transferring from shower chair to wheelchair, towels were placed under feet to keep bottom of feet dry, he placed heel of foot at the top of towel and went to stand even with shower chair locked, he slid on towel and on the edge of shower chair. Employee E9, was able to catch his top half of body and carefully put him on the floor so that he didn't hit his head, but his bottom half had fallen onto the floor. He stated he had throbbing pain in hip and Nurse and RN were notified. The facility investigation revealed that LPN Employee E7 provided a written statement with an incident date of 9/19/25, which revealed at the beginning of the shift between 1600 and 1700, CNA E9 and 2 other CNA's approached LPN E7 asking if Resident R1 was able to be put on the toilet. LPN E7 replied, yes, he/she can transfer with two assist and walker. Around 2000 that evening, CNA Employee E9 came and said, I have an emergency. He is on the floor. LPN employee E7 followed CNA Employee E9 to the shower room and saw Resident R1 laying on his back in the shower stall. His left leg was bent up with the knee going outward and towards the ground. He said they couldn't move his leg and had fallen directly on the left hip that he had previously repaired. During an interview on 10/22/25, at 12:00 p.m. the Director of Nursing (DON) confirmed that CNA Employee E9 had transferred Resident R1 on 9/19/25 without the assistance of a second staff member and did not follow orders which identified that Resident R1 required two staff for transfers. The facility failed to ensure that Resident R1 was free of an accident that resulted in actual harm of a left femur fracture from an improper transfer done with assistance of one staff and not with the required two-person assistance. Resident R2's clinical record revealed an admission date of 7/5/19, with diagnoses that included Alzheimer's (a brain disorder that destroys memory and thinking skills), Benign Prostatic Hyperplasia (BPH - a noncancerous enlargement of the prostate gland, which can result in frequent urination, difficulty starting or stopping urination and a weak urine stream) and Chronic Obstructive Pulmonary Disease (COPD - a condition that prevents airflow to the lungs resulting in difficulty breathing). Resident R2's quarterly Minimum Data Set (MDS - federally mandated standardized assessment conducted at specific intervals to plan resident care) dated 9/23/25, under Section C Cognitive Pattern Subsection C0100 Should Brief Interview for Mental Status Be Conducted was coded as No (resident is rarely/never understood) Resident R2's quarterly MDS dated [DATE], under Section GG 0170 Mobility for Roll left to right. The ability to roll from lying on back to left and right side and return to lying on back on the bed was coded as Dependent indicating Helper does ALL the effort. Resident does none of the effort to complete the activity OR, the assistance of 2 or more helpers is required for the resident to complete the activity. Resident R2's ADL (Activities of Daily Living) Self Care Performance Deficit care plan revealed an intervention effective 12/31/24, indicating that Resident R2 was Dependent on 2 staff for bed mobility. Resident R2's Kardex (a documentation system used to organize and reference key resident information) revealed under the section titled Bed Mobility, ADL - Bed Mobility (Assist of 2 staff) and Bed Mobility - Resident R2 is dependent on 2 staff for bed mobility. Resident R2's task (a program used by nursing staff to verify resident bed mobility assist orders) revealed ADL - Bed Mobility (assist of 2 staff). Resident R2's clinical record revealed a progress note written by Registered Nurse (RN) Employee E10 dated 10/16/25, at 6:41 395775 Page 2 of 5 395775 10/23/2025 Sena Kean Nursing and Rehabilitation Center 17083 Route 6 Smethport, PA 16749

F 0600 Level of Harm - Actual harm Residents Affected - Few a.m. Called to resident's room for a roll off the bed by the CNA [Certified Nursing Assistant]. Arrived to find the resident on the floor by his bed laying on his right-side bleeding from a laceration. The resident was moaning in pain and there was about 40 milliliters [ml] of blood on the phone. Apparently the CNA went to roll the resident on his side and rolled him onto the floor. The height of the bed was approximately 18 inches above the floor. The resident was transferred back to bed, the laceration was cleaned and dressing. Resident R2's clinical record revealed a progress note written by Certified Registered Nurse Practitioner (CRNP) Employee E11, dated 10/16/25, at 6:34 p.m. for earlier incident revealing Phone call from RN at this time. Resident was accidentally rolled out of bed while aide was performing a.m. care. He sustained a right eyebrow laceration. Upon assessment, laceration will require sutures and he should have a head CT also. Orders given to clean site, apply pressure dressing, and send to ED [Emergency Department] for eval and treat. Resident R2's clinical record revealed a progress note written by RN Employee E12 dated 10/16/25, at 10:20 a.m. that indicated an RN from local hospital called report to this writer on resident s/p (status post) fall this AM. Resident has 10 stitches to laceration above R (right) eye, stitches are absorbable but can be removed after 10 days if provider prefers. Bacitracin ointment and kerlix over stitched area. VSS (vital signs stable). Resident's family at bedside, leaving ER estimated 1040. Unit RN Supervisor notified via telephone. Review of Resident R2's incident investigation revealed that CNA Employee E2 revealed he/she was performing morning care on Resident R2 and when he rolled Resident R2 over he started to roll too far and then rolled out of bed onto the floor. The facility failed to ensure that Resident R2 was free from neglect resulting in actual harm of a laceration of the right eyebrow and forehead. During an interview on 10/22/25, at approximately 3:10 p.m. the Nursing Home Administrator and DON confirmed that CNA Employee E2 did not follow the task orders, Kardex information, or the care plan, which identified that Resident R2 required two staff for bed mobility / rolling side to side and attempted to roll Resident R2 independently that caused harm to Resident R2. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(e)(1) Management 28 Pa. Code 211.12(c) Nursing services 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services 395775 Page 3 of 5 395775 10/23/2025 Sena Kean Nursing and Rehabilitation Center 17083 Route 6 Smethport, PA 16749

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, facility documentation and clinical record, and staff interviews, it was determined that the facility failed to appropriately transfer a resident in accordance to facility policy which resulted in actual harm of a left hip and femur (upper leg) fracture for one of three residents reviewed (Resident R1). This deficiency is cited as past non-compliance.Findings include: Facility policy entitled Safe Resident Handling and Movement Policies, dated 1/22/25, revealed, staff is expected to follow the individual resident's plan of care as written. Residents identified using the Minimum Data Set Assessment as Totally Dependent or requiring Extensive Assistance for Transfer and/or Mobility will be handled by means of mechanical lift equipment and/or other resident assist devices; A total dependent transfer requiring a mechanical lift will require two staff for bed mobility; transfer assistance, mobility assistance and other resident handling and movement tasks are to be carried out in accordance with the individual resident's care plan; and individual employees shall not deviate from the individual resident's care plan. Resident R1's clinical record revealed an admission date of 8/8/25, with diagnoses that included fracture of left femur (upper leg), difficulty in walking, Atrial Fibrillation (A-Fib - irregular and often rapid heartbeat that can lead to stroke, heart failure, and other complications), and asthma. Resident R1's physician's orders revealed an order dated 9/12/25, to transfer with staff assist of two with wheeled walker, stand up lift as needed. Resident R1's admission MDS dated [DATE], under Section GG 0170 Mobility for Sit to Stand. The ability to come to a standing position from sitting in a chair, wheelchair, or the side of the bed was coded as Dependent indicating Helper does ALL the effort. Resident does none of the effort to complete the activity OR, the assistance of 2 or more helpers is required for the resident to complete the activity. Resident R1's clinical record revealed a nursing note written by Registered Nurse (RN) Employee E13, dated 9/19/25, at 8:55 p.m. This writer called to [NAME] Wing shower room by Licensed Practical Nurse [LPN] due to Resident was on the floor. Upon entering room, note Resident lying supine [on back] on floor to left of the room with head toward the left side of room and legs stretched out with exception of left low extremity [LLE] which was slightly bent and externally rotated. Resident assessed. Skin pink, warm and dry. Respiration easy and regular with occasional dry cough noted. Skin assessed - Resident has old, scabbed abrasion to L knee noted. LLE noted to be slightly bent and externally rotated. Resident unable to participate in passive or active range of motion [ROM - how far you can move or stretch a part of your body such as a joint or muscle] in this leg. Resident indicated pain 9/10 across mid/posterior thigh. Denies hitting head. Note towels on the floor, Resident and Certified Nursing Assistant [CNA] explained that this was to keep him from slipping, however Resident stated that he stepped off of the towels and slipped. Resident was being assisted by CNA to wheelchair and was lowered to the ground. Certified Registered Nurse Practitioner [CRNP] was notified and resident sent to the ER. Resident R1's clinical record revealed a nurse's progress note dated 9/20/25, that identified the resident was sent from a local hospital ER to another medical center in another city due to Left hip/femur fracture due to this evening's fall. Daughter and CRNP notified. Documentation submitted by the facility dated 9/20/25, revealed that the facility initiated an investigation which revealed CNA Employee E9 provided a written statement with an incident date of 9/19/25, which revealed, When transferring from shower chair to wheelchair, towels were placed under feet to keep bottom of feet dry, he placed heel of foot at the top of towel and went to stand even with shower chair locked, he slid on towel and on the edge of shower chair. Employee E9, was able to catch his top half of body and carefully put him on the floor so that he didn't hit his head, but 395775 Page 4 of 5 395775 10/23/2025 Sena Kean Nursing and Rehabilitation Center 17083 Route 6 Smethport, PA 16749

F 0689 Level of Harm - Actual harm Residents Affected - Few his bottom half had fallen onto the floor. He stated he had throbbing pain in hip and Nurse and RN were notified. The facility investigation revealed that LPN Employee E7 provided a written statement with an incident date of 9/19/25, which revealed at the beginning of the shift between 1600 and 1700, CNA E9 and 2 other CNA's approached LPN E7 asking if Resident R1 was able to be put on the toilet. LPN E7 replied, yes, he/she can transfer with two assist and walker. Around 2000 that evening, CNA Employee E9 came and said, I have an emergency. He is on the floor. LPN employee E7 followed CNA Employee E9 to the shower room and saw Resident R1 laying on his back in the shower stall. His left leg was bent up with the knee going outward and towards the ground. He said they couldn't move his leg and had fallen directly on the left hip that he had previously repaired. During an interview on 10/22/25, at 12:00 p.m. the Director of Nursing confirmed that CNA Employee E9 had transferred Resident R1 on 9/19/25 without the assistance of a second staff member and did not follow orders which identified that Resident R1 required two staff for transfers. The facility failed to ensure that Resident R1 was free of an accident that resulted in actual harm of a left femur fracture from an improper transfer done with assistance of one staff and not with the required two-person assistance. This deficiency is cited as past non-compliance. On 9/20/25, the facility concluded the investigation of Resident R1's fall and initiated the following actions: Facility immediately suspended agency CNA Employee E9 and at conclusion of investigation made CNA Employee E9 a Do Not Return. Review of all resident transfer orders, Kardex (a nursing tool for resident information) transfer status and care plan transfer status were completed and updated by the DON on 9/20/25. All nursing staff were re-educated by the Assistant Director of Nursing (ADON) regarding how to locate resident's transfer status, two person assists and definition of neglect. Interviews with NA Employees E1, E2, E3, E4, E6, and LPN Employee E5 on 10/22/25, confirmed that they were re-educated a few weeks ago on where to find information regarding a resident's transfer status, two person assists, and the definition of neglect. Audits were conducted to ensure residents are transferred per their care plans, Kardex, and orders, which occurred from 9/24/25, through 10/21/25 with all transfers performed appropriately. The facility has demonstrated compliance with using correct transfer status for residents since 10/21/25. During an interview with the NHA and the DON on 10/22/25, at approximately 3:10 p.m. and review of the facility's immediate actions, education, competencies, and audits, it was verified that the facility had implemented a plan of correction to ensure residents are free from harm/injury regarding transfer status and had achieved substantial compliance. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(e)(1) Management 28 Pa. Code 211.12(c) Nursing services 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services 395775 Page 5 of 5