Health inspection·November 16, 2023

F 0744 Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of clinical records and staff interview, it was determined that the facility failed to develop and implement an individualized person-centered plan to address a resident's dementia-related behavioral symptoms for one out of six residents reviewed (Resident 1) Residents Affected - Few Findings include: A review of the clinical record revealed that Resident 1 was admitted to the facility on [DATE], with diagnoses that included Dementia with behavioral disturbance. A quarterly Minimum Data Set assessment (a federally mandated standardized assessment completed periodically to plan resident care) dated October 27, 2023, indicated that the resident was severely cognitively impaired with a BIMS (brief interview for mental status - a tool to assess cognitive status) score of 03. Review of Resident 1's nursing progress notes during the months of September 26, 2023 through the time of the survey ending November 16, 2023, revealed that the resident displayed increasing behaviors of aggressiveness with staff and physically assaulting staff. Resident 1 was the aggressor in all the resident to staff incidents between September 26, 2023 and November 16, 2023. The facility was monitoring and tracking the resident's behavioral symptoms during the months of September 2023, and November 2023, however, there was no documented evidence of the behavioral management or behavior modification interventions developed for use by staff to respond to the resident's dementia related behavioral symptoms. The facility's evaluation was noted as {Resident 1} is non compliant with care. Unable to console even with the assistance of additional staff. Resident physically abusive towards staff. Shoving/pushing staff out of the room. Slamming the door on 1 to 1 staff feet. Refusing staff from sitting in room. When staff left room resident calmed down. A behavior note dated October 15, 2023 at 9:45 PM revealed that Resident 1 had an increase in agitation and physical aggression with staff. The noted intervention was a physical intervention by other staff. The resident had stood up, when her 1 to 1 sitter when to intervene for the resident's safety, Resident 1 grabbed the sitter by the throat and began squeezing while holding her against the bathroom door. The sitter yelled for assistance. The other aide and supervisor intervened and was able to verbally deescalate the situation removing the 1 to 1 sitter from harm and calming down the resident. Resident 1 was then brought back to the restroom with 2 staff and 1 to 1 sitter after the incident. A behavior note dated October 10, 2023 at 00:48 A.M., {Resident 1} was aggressive with staff. The noted intervention was 1 to 1 sitter, supervision and redirection. The resident remained on 1 to 1. Resident 1 without understanding or ability to redirect toward understanding of safety precautions. Resident continues to attempt to climb out of low bed of own accord. verbally and physically aggressive with staff during redirection for safety and care. Resident continues to attempt to remove leg immobilizer despite continuous redirections.(resident had sustained a fracture during September 2023). A behavior note dated November 16, 2023 at 06:21 A.M. revealed that the resident displayed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395936 If continuation sheet Page 2 of 3 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395936 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wayne Woodlands Manor 37 Woodlands Drive Waymart, PA 18472 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0744 Level of Harm - Minimal harm or potential for actual harm aggression towards staff. Pushing staff out of the room. The noted staff intervention was to redirect aggression, deescalate situation, and justify staff presence. Resident 1 was verbally and physically aggressive towards staff related to staff presence. Physically escorted staff out of the room and slammed the door. Residents Affected - Few A review of a Behavior Note dated November 16, 2023 at 07:17 AM revealed that Resident 1 was combative with staff, ignoring safety cues, refusing 1 to 1 Refusing immobilizer, Attempted to deescalate, Requested assistance from additional staff; Attempted to encourage resident to use walker and immobilizer. Staff educated Resident 1 on purpose of 1 to 1 being in room. Resident 1 was non-compliant with care. Unable to console even with the assistance of additional staff. Resident physically abusive towards staff. Hitting staff in face. Slamming the door on 1 to 1 staff feet. Refusing staff from sitting in room. When staff left room resident calmed down. A Behavior Note dated November 16, 2023 at 08:17 AM revealed that Resident 1 was combative with staff and ignoring safety cues, refusing 1:1, refusing immobilizer ( a brace on the leg to keep from bending the leg). The intervention at the time was an attempt to deescalate the situation and to again reeducate Resident 1 on the purpose of 1 to 1 observation and being in her room, despite the resident's severe cognitive impairment. The resident's current care plan, in effect at the time of the survey of November 16, 2023, did not identify the specific dementia related behaviors the resident exhibits and individualized person-centered interventions to address each of these behaviors. The facility failed to develop and implement an individualized person-centered plan to address, modify and manage the residents' dementia-related behaviors. The resident's care plan for behavioral symptoms failed to include individualized interventions based on an assessment of the resident's preferences, social/past life history, customary routines, and interests in an effort to manage the resident's dementia-related behavioral symptoms. Interview with Director of Nursing and the Nursing Home Administrator on November 16, 2023, at approximately 2 p.m., confirmed that the facility was unable to provide evidence of the development and implementation of an individualized person-centered plan to address dementia-related behaviors and consistent and accurate monitoring of the resident's dementia related behaviors and any approaches used to manage or modify those behaviors. 28 Pa Code 211.12 (d)(3)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395936 If continuation sheet Page 3 of 3