Health inspection·September 16, 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 Based on review of clinical records, the facility's abuse prohibition policy, facility investigative documentation, and interviews with staff and residents, it was determined that the facility failed to ensure that a resident was free from neglect by not providing care with the required assistance of two staff members as planned to ensure safety and prevent major injuries. As a result, one resident (Resident 1) sustained multiple subdural hematomas and a scalp laceration requiring hospitalization, representing actual harm for one resident out of one sampled for abuse prohibition.Findings include: Review of the facility's policy entitled Abuse, Neglect, and Exploitation last revised by the facility March 2025, defined 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. It is the policy of the facility to protect the residents from abuse, misappropriation of property, corporal punishment and involuntary seclusion. Resident 1's clinical record revealed admission to the facility on August 1, 2025, with diagnoses including atrial fibrillation (an irregular and often rapid heart rhythm that can lead to blood clots or stroke), a history of cerebral infarction (stroke), and hypertension (high blood pressure). Review of Resident 1's admission MDS assessment (Minimum Data Set a federally mandated standardized assessment process conducted periodically to plan resident care) dated August 6, 2025, revealed the resident had a BIMS score of 00 (Brief Interview for Mental Status, a tool used to evaluate cognitive impairment and assist with dementia diagnosis. A score of 0-7 equates to severe cognitive impairment) and required assistance of staff for activities of daily living (ADL's). Review of Resident 1's current comprehensive person-centered care plan, initiated on August 5, 2025, indicated the resident had an ADL (activities of daily living) self-care performance deficit related to confusion, musculoskeletal impairment and a history of stroke. Planned resident centered interventions revealed the resident required two-staff assistance with transfers to move between surfaces, required two-staff participation for bathing/showering and required assistance of one staff for bedpan use and brief changes, personal hygiene and oral care and eating. A review of a fall care plan for at risk for falls initiated August 5, 2025, revealed interventions to include, ensure that the resident is wearing appropriate footwear when ambulating and mobilizing in the wheelchair. Additionally, the resident's impaired cognitive function care plan indicated the resident had impaired cognition. A physician's order dated August 12, 2025, indicated Eliquis 2.5 mg twice daily for atrial fibrillation. Review of the August 2025 medication administration record showed the resident received Eliquis as prescribed through August 17, 2025. (Eliquis is an anticoagulant medication that increases bleeding risk.) A nurse's note written by Employee 1 (Registered Nurse), dated August 18, 2025, at 5:15 AM, documented that Employee 2 (nurse aide) exited Resident 1's room and stated, I need a nurse, Resident 1 is on the floor. Employee 2 reported transferring the resident from bed to wheelchair alone, despite the care plan requirement for two-staff assistance. She stated the bed alarm activated, and Page 1 of 4 396151 396151 09/16/2025 Tunkhannock Rehabilitation & Health Care Center 27 West Street Tunkhannock, PA 18657

F 0600 Level of Harm - Actual harm Residents Affected - Few while she turned her back to silence it, Resident 1 fell forward out of the wheelchair, the nurse aide was unable to prevent the resident from falling. The RN found Resident 1 lying face-down on the floor, on the door side of her bed on her stomach with her head facing her bed, barefoot, and no nonskid socks in place, with the wheelchair near her feet. The resident had a large hematoma (collection of blood between layers of tissue) and a moderately bleeding forehead laceration (wound). A pressure dressing was applied Emergency services were contacted, and the resident was transported to the hospital for evaluation and treatment. Hospital records dated August 18, 2025, at 6:08 AM, documented that Resident 1 presented as a Level II trauma (requiring urgent trauma care) with head and knee pain. A CT scan (computed tomography imaging test that uses X-rays and a computer to get detailed images of an injury) of the head revealed multiple subdural hematomas (collections of blood between the brain and its protective covering), a small subarachnoid hemorrhage (bleeding between the brain and protective membranes), and a 3 cm forehead laceration. The resident was admitted to the Progressive Care Unit (unit in a hospital unit that provides a level of care between the general medical-surgical units and the Intensive Care Unit) for treatment and remained hospitalized until August 23, 2025. The CT results were as follows: The resident was diagnosed with a right superior tentorium hyperdense subdural hematoma. A subdural hematoma is bleeding that becomes trapped between the brain's surface and its tough outer covering, called the dura. The tentorium is a thick membrane inside the skull that separates the upper and lower parts of the brain. The term hyperdense means the bleeding is new or fresh and appears brighter on the CT scan, indicating recent injury. The scan further showed left anterior and right mid parafalcine hyperdense subdural hematomas, each measuring 4 millimeters. The falx is another protective fold of tissue that separates the left and right halves of the brain. Parafalcine means the bleeding is located next to this divider. The small size (4 millimeters each) indicates small but significant fresh blood collections near the brain's central dividing structure. Additionally, the CT scan identified bilateral parafalcine hypodense subdural hematomas measuring 7 millimeters. Bilateral means on both sides of the brain. Hypodense means the blood appears darker on the scan, suggesting it is older or less recent. This finding reflects older blood collections on both sides of the brain near the dividing fold (falx), and their size (7 millimeters) indicates a larger volume than the acute bleeds. Finally, the CT scan revealed a small hypodense subarachnoid hemorrhage located beneath the left frontal lobe. A subarachnoid hemorrhage is bleeding in the space between the brain and the arachnoid membrane (one of the thin protective coverings of the brain). The term hypodense again suggests this bleed was either resolving or less acute. The left frontal lobe is the front part of the brain, just behind the forehead, which plays a role in thinking and movement. The scan showed both new and older areas of bleeding inside the skull, including fresh blood along internal brain membranes, older blood collections on both sides of the brain, and a small bleed beneath the left frontal brain region. These findings represented significant head trauma. A review of the facility's investigative documentation completed by Employee 1 (RN Supervisor) on August 18, 2025, at 5:01 AM, revealed that Employee 2 (nurse aide) walked out of Resident 1's room and approached Employee 1 (RN), stating, I need a nurse, Resident 1 is on the floor. Employee 2 (nurse aide) reported that she had transferred Resident 1 from the bed to the wheelchair, which caused the bed alarm to start ringing. She stated that she turned her back to the resident to turn the alarm off and, when she turned back around, the resident was falling forward out of the wheelchair. Employee 2 stated she was unable to stop the fall. Employee 1 (RN) documented that upon entering Resident 1's room, the resident was found lying on her stomach on the floor near the door side of the bed, with her head facing the bed. The resident was barefoot with no footwear or non-skid socks in place. The 396151 Page 2 of 4 396151 09/16/2025 Tunkhannock Rehabilitation & Health Care Center 27 West Street Tunkhannock, PA 18657

F 0600 Level of Harm - Actual harm Residents Affected - Few wheelchair was noted to be near the resident's feet. Blood was observed under the left side of the resident's forehead. The resident was rolled onto her back and found to have a laceration with a large hematoma and moderate bleeding above her left eye. A pressure dressing was applied, the physician was contacted, and the resident was transferred to the hospital for evaluation. Human resources documentation revealed that Employee 2 (nurse aide) was suspended from employment on August 18, 2025, and terminated on August 19, 2025. A written witness statement completed by Employee 1 (RN Supervisor) on August 18, 2025 (no time indicated) revealed that Employee 2 (nurse aide) reported, Resident 1 was on the floor. Employee 2 further stated that the resident had fallen out of her wheelchair after she transferred her from bed to the chair. She stated she had turned her back to shut off the bed alarm, and the resident was found face down on the floor, barefoot, with the wheelchair near her feet. Employee 1 documented that a forehead laceration and hematoma were observed. A telephone interview conducted with Employee 1 (RN Supervisor) on September 16, 2025, at 2:00 PM revealed that at approximately 5:00 AM on August 18, 2025, she was walking down the hallway toward Resident 1's room when Employee 2 (nurse aide) exited the room and stated, Resident 1 is on the floor. Employee 1 confirmed the bed alarm was sounding. Both entered the room and observed Resident 1 lying face down on the floor. Employee 2 (nurse aide) stated, She [Resident 1] fell out of the wheelchair. Employees 3 (nurse aide) and 4 (nurse aide), who were also on duty, were called to assist. Using a mechanical lift, the staff returned Resident 1 to bed. The physician and family were notified, and Resident 1 was transferred to the hospital. Employee 1 stated she obtained witness statements from all three nurse aides on duty, including confirmation from Employees 3 and 4 that Employee 2 had transferred Resident 1 by herself and, when turning her back to shut off the alarm, Resident 1 fell forward from the chair. A written statement from Employee 2 (nurse aide), dated August 18, 2025 (no time indicated), documented: Resident 1 was in a locked wheelchair. I turned to shut off the bed alarm and as I began to turn back towards her, she fell forward and hit the left part of her forehead on the floor. During the on-site survey on September 16, 2025, a call was placed to Employee 2 at 1:30 PM to gather additional details regarding the incident of August 18, 2025; however, Employee 2 did not return the call. A written witness statement from Employee 3 (nurse aide), dated August 18, 2025 (no time indicated), documented: Myself and Employee 4 were getting a mechanical lift weight on Resident 2 in the resident's room when Employee 2 came to the room and stated, ‘Resident 1 is on the floor.' When we had Resident 2 back in bed, we went to Resident 1's room where the resident was laying on the floor. A phone call was placed to Employee 3 at 1:35 PM on September 16, 2025, for further details; however, Employee 3 did not return the call. A written witness statement from Employee 4 (nurse aide), dated August 18, 2025 (no time indicated), documented: While using a mechanical lift on Resident 2, Employee 2 came to the room stating, ‘I need one of you to come down and help me with Resident 1.' When Employee 3 and I asked what was wrong, Employee 2 stated ‘She [Resident 1] is on the floor, and I need someone to help. I dropped her.' A telephone interview conducted on September 16, 2025, at 1:45 PM with Employee 4 (nurse aide) revealed: Employee 2 came into the room and stated, ‘I need one of you to come with me right now.' I asked her, ‘Why, what's wrong?' Employee 2 stated that Resident 1 was on the floor and that she dropped her. Employee 4 further stated that he and Employee 3 had to safely return Resident 2 to bed before going to Resident 1's room, where they observed Employee 1 (RN) and Employee 2 (nurse aide) attending to Resident 1 on the floor. Review of human resources documentation revealed Employee 2 was hired March 14, 2025, and completed initial in-service training on that date, including abuse prevention education. Mandatory annual in-service documentation, completed March 14, 2025, indicated Employee 2 was deemed competent to perform her duties.There was no documented 396151 Page 3 of 4 396151 09/16/2025 Tunkhannock Rehabilitation & Health Care Center 27 West Street Tunkhannock, PA 18657

F 0600 Level of Harm - Actual harm Residents Affected - Few evidence that Employee 2 followed the resident's care plan, which required two staff members for safe transfers. Instead, Employee 2 transferred Resident 1 by herself at approximately 5:00 AM on August 18, 2025, turned her back to silence the alarm, and left the resident unattended, resulting in Resident 1 falling forward from the wheelchair, sustaining a forehead laceration and hematoma. Employee 2 then left the resident on the floor while she went to seek help from two other nurse aides in the building. During an interview on September 16, 2025, the facility's Nursing Home Administrator and Director of Nursing confirmed that the facility's investigative findings substantiated that Employee 2 neglected Resident 1 by failing to follow the planned two-person transfer intervention. The neglect resulted in Resident 1 sustaining multiple subdural hematomas, a scalp laceration, and hospitalization for five days. 28 Pa. Code 201.18 (b)(1) Management 28 Pa. Code 201.29 (a) Resident Rights 28 Pa. Code 211.10 (c)(d) Resident care policies, 28 Pa. Code 211.12 (d)(5) Nursing Services. 396151 Page 4 of 4