Health inspection·October 18, 2024

F 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, clinical records, facility documents, and staff interview, it was determined that the facility failed to identify and investigate an incident of possible abuse and/or neglect for three of five incidents reviewed (Resident R6, R25, and R49). Residents Affected - Few Findings include: A review of the facility policy Abuse, Neglect, Exploitation, Misappropriation or Resident Property and Prohibition Prevention reviewed 7/29/24, indicated the facility will do everything within its control to prevent and prohibit resident abuse, neglect, exploitation, or misappropriation of resident property. Staff will identify and observed or suspected occurrence, pattern, or here say, and report it to a supervisor for prompt investigation. The facility will investigate all allegations or occurrences of abuse, neglect, exploitation or misappropriation of resident property and will determine where the results are to be reported, if necessary. A review of the facility policy Incident and Accident Reports reviewed 7/29/24, indicated to document both incidents and accidents involving residents for use as an internal tool to investigate the event and to help prevent future similar events. Provide for the initiation of an investigation when there is an injury of undetermined origin. Witness statements are to be obtained by all parties involved at the time of the incident or accident. A review of the clinical record indicated Resident R6 was admitted to the facility on [DATE], with diagnoses that included Alzheimer's Disease (brain disorder that slowly destroys memory, thinking, and the ability to carry out the simplest tasks), depression, and reduced mobility. A review of the Minimum Data Set (MDS - a mandated assessment of a resident's abilities and care needs) dated 8/1/24, revealed the diagnoses remain current. Review of the care plan dated 9/2/22, indicated Resident R6 was at risk for falls and to ensure he was wearing appropriate footwear. Review of facility provided documents dated 5/9/24, revealed during a mechanical lift transfer, Resident R6's foot slipped off the lift and he received an abrasion to his left shin. There is no evidence the facility investigated the incident to confirm the lift was in working order, had any sharp points that could have injured the resident, if proper footwear was used, and failed to obtained witness statements regarding the incident. During an interview on 10/16/24, at 9:35 a.m. Licensed Practical Nurse (LPN) Employee E2 stated she Page 1 of 3 395873 395873 10/18/2024 LGAR Health and Rehabilitation 800 Elsie Street Turtle Creek, PA 15145

F 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few completed the incident report for Resident R6 on 5/9/24. She stated she was not involved in the incident and was not Resident R6's nurse on 5/9/24. She stated she did not know how to fully fill out the facility's incident report. Review of the clinical record indicated Resident R25 was re-admitted to the facility on [DATE], with diagnoses that included overactive bladder, depression, and diabetes. Review of the MDS dated [DATE], revealed the diagnoses remain current. Review of facility provided documents dated 9/24/24, indicated Resident R25 asked Nurse Aide (NA) Employee E 1 who was on her cell phone while providing care to Resident R25 and ignored her attempt get her attention, and when Resident R25 asked for her Kleenex box, NA Employee E1 threw the box towards Resident R25, turned and exited the resident's room. NA Employee E1 was terminated from the facility on 9/27/24, following this incident. The facility did not fully investigate the incident to ensure other residents were not affected and did not obtain witness statements from residents or staff on shift. Review of the clinical record indicated Resident R49 was re-admitted to the facility on [DATE], with diagnoses that included dementia (group of symptoms affecting memory, thinking and social abilities), Parkinsonism (term used to describe collection of movement symptoms like stiffness, balance issues, and tremor), and depression. Review of the MDS dated [DATE], indicated the diagnoses remain current. Review of facility provided documents dated 9/10/24, indicated it was reported to staff that NA Employee E1 was overheard speaking unkindly to Resident R49. Resident R49 was told I'm not taking that from you, put the pillow under your head. You have to stay in bed. The facility removed NA Employee E1 from that assignment, and she no longer provided care to Resident R49. The facility failed to fully investigate the incident to ensure other residents were not affected and did not obtain witness statements from residents or all staff on shift. During an interview on 10/17/24, at 9:00 a.m. the Director of Nursing confirmed the facility failed to identify and investigate an incident of possible abuse and/or neglect for Residents R6, R25, and R49. 28 Pa. Code: 201.14(a)(c)(e) Responsibility of licensee. 28 Pa. Code: 201.18(e)(1) Management. 395873 Page 2 of 3 395873 10/18/2024 LGAR Health and Rehabilitation 800 Elsie Street Turtle Creek, PA 15145

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, clinical records and staff interview, it was determined that the facility failed to provide adequate supervision to prevent falls for one of five residents (Resident R16). Findings include: A review of the clinical record indicated Resident R16 was admitted to the facility on [DATE], with diagnoses that included Alzheimer's disease with late onset (a progressive disease that destroys memory and other important mental functions), hyperlipidemia, abnormal posture, muscle weakness, and difficulty walking. A review of Resident R16's care plan initiated on 5/15/24, indicated for bed mobility: the Resident R16 requires extensive assistance by two staff to turn and reposition in bed and bilateral body pillows when in bed to assist with positioning. A review of Resident R16's quarterly Minimum Data Set (MDS- periodic assessment of resident care needs) dated 6/13/24, indicated that Resident R16 had a bed mobility (how resident moves to and from lying position, turns side to side, and positions body while in bed or alternate sleep furniture) of total dependence of staff with support of two plus persons. A written statement by Nurse Aide (NA) Employee E3 dated 9/3/24, states I was in the middle of changing resident in bed. She was rolled on her side. I was holding onto her putting brief under her. She started reaching over for something on the other side of the bed and rolled out of bed. A review of Resident R16's nurse practitioner note dated 9/5/24, indicated Resident R16 was seen for an acute fall that occurred on 9/3/24 at approximately 9:15 p.m. CNA E3 was providing care at bedside when Resident R16 rolled out of bed. During an interview on 10/17/24, at 2:23 p.m. the Director of Nursing confirmed the above findings and that the facility failed to provide adequate supervision for Resident R16. 28 Pa. Code: 211.12 (d)(1)(3)(5) Nursing Services. 395873 Page 3 of 3