Health inspection·July 27, 2023

F 0744 Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. Level of Harm - Actual harm Based on review of facility policy, clinical records, and investigation reports, as well as staff interviews, it was determined that the facility failed to provide the necessary services and failed to make certain appropriate treatment, and services for dementia were provided to one resident (Resident 3) to ensure safety for eight of nine residents reviewed (1, 2, 4, 5, 6, 7, 8, 9), resulting in an incident in which one of nine residents reviewed suffered a fracture (Resident 1). Residents Affected - Few Findings include: The facility's behavior management policy, dated April 24, 2023, revealed that staff were to develop, implement, and maintain behavior management plans. Staff would consult with the attending physician, facility psychiatrist, and other behavior management specialists as a available to develop and individualized behavior management plan. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 3, dated June 19, 2023, revealed that the resident was cognitively impaired; had physical behaviors directed towards others; verbal behaviors towards others; other behaviors not directed towards others; rejection of care; wandering behaviors; ambulated (walked) with supervision; was receiving anti-psychotic, anti-anxiety, and anti-depressant medications; and had diagnoses that included dementia, traumatic brain injury, anxiety, and depression. The behavior care plan for Resident 3, dated November 11, 2022, and revised on March 5 and June 6, 2023, revealed that staff were to offer diversional activities when the resident was having behaviors which included: listening to music such as the oldies or country music, watching NCIS when available as this was her favorite television show, provide newspapers or magazines to look at, provide word search books, provide the task of folding laundry to occupy her attention, and encourage her to walk in the hallway to divert her attention; staff were to stop giving care if the resident becomes upset and attempt at a later time; approach her calmly and slowly; speak with her calmly and spend time with her to attempt to calm her when she is agitated; when she was agitated or tearful attempt to get her to stay in a supervised area; if agitated offer a snack; if over-stimulated, redirect her to a private/quiet area; maintain consistent and routine care givers; when agitated staff were to call the resident's son so that he could speak with her to calm her down; educate her that physical abuse with others is not acceptable; minimize contact with Resident 1 as much as possible; and discourage her from wandering into other resident's rooms. There was no evidence of routine preventative interventions in order to protect all other residents on a daily basis. A nursing note, dated March 8, 2023, at 7:16 p.m. revealed that Resident 3 was observed grabbing a book out of the hands of Resident 7 and when Resident 7 went to reach for her book, Resident 3 Page 1 of 4 395830 395830 07/27/2023 Meadow View Nursing Center 1404 Hay Street Berlin, PA 15530

F 0744 Level of Harm - Actual harm reached out and struck Resident 7 on the left side of her face. Resident 3 was re-directed away from Resident 7 and placed on 15-minute checks and was administered one dose of 1 milligram (mg) of Haldol (anti-psychotic). The resident was seen by psychiatric services due to worsening behaviors, and orders were received to start 0.5 mg of Ativan twice day. Residents Affected - Few A nursing note, dated March 9, 2023, at 2:08 p.m. and 2:15 p.m. revealed that Resident 9 was sitting at a table in the solarium and Resident 3 wandered toward the resident and slapped her on the right cheek. Resident 9 was tearful and her cheek was reddened. The residents were separated and diversional activities were provided. The residents were to be monitored with 15-minute checks. Resident 3 was unable to be re-directed and several diversional activites were offered, but the resident does not have the attention span lasting longer than one minute with activities. The physician was notified, and the resident was ordered a laxative and an antibiotic for a urinary tract infection. A nursing note, dated March 19, 2023, at 2:16 p.m. revealed that Resident 4 was ambulating in the hallway going back up to the solarium when Resident 3 was ambulating from the solarium and stopped, turned around, and with a closed fist struck Resident 4's right cheek. Resident 3 was redirected and monitored closely for approximately two hours by staff. The physician was notified and orders were received to increase the resident's Ativan (anti-anxiety) to three times day. A nursing note, dated April 24, 2023, at 9:17 p.m. revealed that Resident 3 was in another resident's room visiting with the family's dog. She returned later to the room and was rambling incoherently and screaming, and when they attempted to re-direct her, Resident 6 stood up and Resident 3 punched him in the chest. Staff were called and they immediately removed Resident 3 from his room. The physician was notified and the Resident 3 was given 1 mg of Haldol, close supervision so that the resident did not go after anyone else, and snacks and drinks were offered to redirect the resident. A psychiatric service note, dated April 26, 2023, revealed the resident's anti-anxiety medication was changed. A nursing note, dated May 26, 2023, 7:09 p.m. revealed that Resident 5 was arguing with Resident 3 when Resident 3 punched Resident 5 in the face. The nurse aide stepped in between them and Resident 3 reached around the staff member and hit Resident 5 again. The residents were separated and no new orders were received. There was no documented evidence that any changes were made to Resident 3's behavior management plan. A nursing note, dated June 4, 2023, at 6:38 p.m. revealed that Resident 3 was tearful and wandering on the unit, then walked up to Resident 1 while he was seated eating his dinner in the lounge and screamed f*** y**, and slapped Resident 1 across the left side of the face. Both residents were immediately separated and Resident 3's behavior care plan was updated to minimize contact with Resident 1 as much as possible. A psychiatric service note, dated June 7, revealed that Resident 3's current antipsychotic was to be discontinued and 0.5 mg of Rexulti (anti-psychotic) daily be added. A nursing note, dated June 14, 2023, at 7:14 p.m. revealed that Resident 1 was sitting in a chair in the middle of the solarium and had a bedside table set up in front of him so he could have a FaceTime (electronic face-to-face visit) visit with his daughter. Resident 3 tipped the table over onto Resident 1, bumping his feet. Resident 1 was very angry and began to yell out loudly. Resident 3 was re-directed away from Resident 1. There was no documented evidence that any interventions were in place to prevent Resident 3 from coming into close contact with Resident 1. A nursing note, dated June 16, 2023, at 8:16 a.m. revealed that Resident 8 was sitting at a table 395830 Page 2 of 4 395830 07/27/2023 Meadow View Nursing Center 1404 Hay Street Berlin, PA 15530

F 0744 Level of Harm - Actual harm Residents Affected - Few in the common area eating her breakfast when Resident 3 reached over the resident for her breakfast. Resident 8 shooed Resident 3 away and then Resident 3 hit Resident 8 in the back with an open hand. Resident 3 was redirected, given a baby doll, and toileted. A nursing note, dated June 19, 2023, at 7:01 p.m. revealed that all day Resident 3 was randomly swearing at residents and staff and attempting to strike out at residents and staff to hit them. After staff redirected the resident she would start to cry and kept stating I'm sorry, I'm sorry. The resident would sit down in a chair, get up swiftly, and target another resident or a staff member. A social service note, dated June 20, 2023, at 4:35 p.m. revealed that Resident 3 was noted daily for numerous behaviors and was easily agitated with others often with little to no provocation. Her agitation often occurred with no warning or indication and appeared to be impulsive. She appeared to respond to certain staff with redirection at times. A nursing note, dated June 21, 2023, at 11:49 a.m. revealed that Resident 4 was walking around the solarium when Resident 3 turned around and punched Resident 4 on the right cheek, while yelling This is my pillow! Staff re-directed both residents away from each other. Resident 3 was to be a one-to-one observation and staff were instructed to keep the residents away from each other. A psychiatric service note, dated June 21, 2023, indicated that Resident 3's Rexulti was to be increased to 1 mg daily due to several aggressive incidents over the past week. A nursing note, dated June 26, 2023, at 11:09 a.m. revealed that staff reported that Resident 1 was reading a magazine and Resident 3 threw fluids onto his lap. Resident 1 stood up and staff redirected him to avoid a resident-to-resident confrontation. A psychiatric service note, dated June 28, 2023, indicated that Resident 3's Rexulti would be increased to 2 mg daily for further aggression. A nursing note, dated July 3, 2023, at 5:07 p.m. revealed that Resident 4 was witnessed walking in the hallway by staff when Resident 3 was walking in the opposite direction and yelled out Why are you following me, then smacked Resident 4 on the left side of her face. Both residents were separated and Resident 3 was assigned to a nurse aide for one-to-one observation to prevent recurrence. A psychiatric service note, dated July 12, 2023, revealed that the resident was having daily agitation on the day and evening shift and the current antipsychotics that she was receiving were not managing her distress. A nursing note, dated July 14, 2023, at 8:46 a.m. revealed that Resident 3 had a violent outburst when staff attempted to re-direct her and she scratched the licensed practical nurse on the face and hand. She threw a cup of water onto the licensed practical nurse and raised closed fists to all of the staff that attempted to re-direct her to an activity. She punched two nurse aides and picked up a resident's walker and threw it at a nurse aide. The resident was sent to the hospital and received medications and returned to the facility. A nursing note, dated July 15, 2023, at 7:15 a.m. revealed that Resident 1 was seen by a staff member being pushed down by Resident 3. Resident 3 pushed Resident 1 with both of her hands and Resident 1 fell backwards hitting the back of his head off the floor and injuring his right hip. Resident 3's hip was hurting when touched and his right leg and foot were rotated to the right and he was sent to the hospital. A nursing note, dated July 16, 2023, at 2:14 a.m. revealed that Resident 1 had a fractured right hip and was to have surgery. There was no documented evidence that any interventions were in place to prevent Resident 3 from coming into close contact with Resident 1. 395830 Page 3 of 4 395830 07/27/2023 Meadow View Nursing Center 1404 Hay Street Berlin, PA 15530

F 0744 Level of Harm - Actual harm Residents Affected - Few A behavior note, dated July 15, 2023, at 8:15 a.m. revealed that Resident 3 was walking down the hall towards the common area when she saw Resident 2 standing in front of the nurse's station door. Resident 3 punched and shoved this resident into the medication cart, which was seen by staff, and Resident 3 was re-directed and staff attended to the resident that was punched and shoved. The nurse aide that came out of the shower room witnessed Resident 3 push Resident 1 backwards with both of her hands causing him to fall backwards sustaining an injury. Resident 3 was sent to the hospital and admitted to the behavioral health unit. A nursing note, dated July 15, 2023, at 12:39 p.m. revealed that Resident 2 was punched in the chest and pushed into the nurse's med cart by Resident 3. Staff re-directed Resident 3 away from Resident 2. Staff ensured Resident 2's safety by keeping Resident 3 within view Following the above incidents, there was no documented evidence that Resident 3's care-planned behavior interventions were revised when they were not effective, and no evidence that an individualized behavior management plan was developed in an attempt to prevent Resident R3's behaviors from affecting the safety of all other residents. Interview with Registered Nurse 1 on July 27, 2023, at 2:30 p.m. revealed that Resident 3 had behaviors of pacing quickly, being combative at times, screaming obscenities, pinching, hitting her, and being combative with other residents. She indicated that Resident 3 was scary to be around because she was volatile and could be really sweet one minute and then could switch on you at the drop of a hat. She revealed that Resident 3 did not have the attention span for activities and would wander, and that sometimes there were staff to do one-to-one supervision and sometimes not. Interview with Nurse Aide 2 on July 27, 2023, at 2:47 p.m. revealed that Resident 3 would wake up in the morning and cry, throw food and drinks during breakfast, beat up and shove staff, hit other residents for no reason, and hit the same resident again. She indicated that staff would keep an eye on her but one-to-one observation was usually added after she hit someone. She did not think any of the medication changes made helped Resident 3's behaviors and that nothing really helped her behaviors. She felt that the other residents were not safe around Resident 3 and now that Resident 3 is no longer there everyone is safe. Interview with the Director of Nursing on July 27, 2023, at 3:30 p.m. revealed that Resident 3 had a very short fuse, and her behaviors came and went. Most of her behavior was crying and at times she would become aggressive and start yelling and swearing with no warning sign. When she was in the common area staff would re-direct her and if Resident 3 was escalating, you could not be beside her. She had hospitality aides on the unit for observation and used them for one-to-one observations. She indicated that when Resident 3 punched and shoved Resident 2, staff attended to Resident 2 and did not stop Resident 3 from approaching Resident 1 and pushing him down. She agreed that the unit was not the safest environment at times for the residents with Resident 3's aggressive behaviors. 28 Pa. Code 211.12 (d)(5) Nursing services. 395830 Page 4 of 4