**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of clinical records, the facility's abuse prohibition policy, and select investigative reports, and interviews with staff, residents and resident representatives, it was determined that the facility failed to ensure that one resident was free from sexual abuse and resultant psychosocial harm (Resident 16) and that one resident (Resident 106) was free from physical abuse out of 11 residents sampled for abuse prohibition. Findings include: A review of a facility policy entitled Pennsylvania Resident Abuse: Abuse, Neglect, and Exploitation, dated August 30, 2023, revealed that it is the policy of the facility to not tolerate abuse, neglect, mistreatment, exploitation of residents, or misappropriation of resident property by anyone. The policy defines abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. It is the facility's policy to investigate all allegations, suspicions and incidents of abuse, neglect, involuntary seclusion, intimidation, exploitation of residents, misappropriation of resident property an injuries, of unknown source. The definition of sexual abuse incudes but is not limited to, non-consensual sexual contact of any type, sexual harassment. sexual coercion, or sexual assault. A review of Resident 16's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses, which included mild cognitive impairment of uncertain or unknown etiology. A review of the resident's admission Minimum Data Set Assessment (MDS - a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated April 24, 2024, revealed that the resident was severely cognitively impaired with a BIMS score of 7 (Brief Interview For Mental Status score of 7, a tool to assess the resident's attention, orientation and ability to register and recall new information, a score of 00-07 equates to severe cognitive impairment). A review of Resident 91's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses of hemiplegia (paralysis of one side of the body) affecting the left non dominant side due to history of a cerebral infarct (when a cluster of brain cells die due to lack of blood flow), depression and congestive heart failure (CHF occurs when the heart is unable to pump sufficiently to maintain blood flow to meet the body's needs A review of Resident 91's admission MDS assessment dated [DATE], revealed that the resident was cognitively intact with a BIMS score of 14 (scores of 13-15 equate to intact cognition). A review of a facility investigation report dated July 6, 2024, at 6:00 PM revealed that Employee 1, a nurse aide, walked into Resident 16's room and observed Resident 16 and Resident 91 naked in Resident 16's bed. A review of Employee 1's witness statement dated July 6, 2024 revealed that she entered Resident 16's room to give her a dinner tray and found both residents lying naked in the resident's bed. When Resident 16 saw Employee 1 she quickly sat up. The nurse aide immediately notified the nurse. The residents were quickly separated and were placed in their own rooms. Nursing documentation dated July 6, 2024, at 10:13 PM from Employee 2 the Registered Nurse indicated Resident 91 reported that Resident 16, called him over into her room and they engaged in a sexual act. A review of the facility investigation dated July 9, 2024, revealed statements from both residents. Employee 2, RN, obtained a statement from Resident 16, which indicated that this female resident did not remember a guy being in her room. She stated if a guy was in her room it would be her boyfriend. Resident 16 continued to state that all she did all was stay in her room and change her clothing twice. Employee 2 stated the resident had no recollection of the sexual encounter with Resident 91. A statement was obtained from Resident 91, whose primary language is not English, and may require a translator as requested, and was translated and written by Employee 3, Licensed Practical Nurse (LPN) on July 6, 2024. According to Resident 91's statement, he observed Resident 16 in her room across the hall. Resident 91 stated that Resident 16 was naked and gestured to him to come to her room. He walked over to Resident 16's room and he climbed on top of her and had sexual intercourse with Resident 16. He stated a girl walked in while he was still engaged in sexual intercourse with Resident 16. He then stopped the sexual act, pulled his pants up and left the room and went back to his room. Resident 91 also stated Resident 16 was provoking him the prior day by talking and conversing with him. A telephone interview conducted on July 9, 2024, at 1:26 AM with Employee 1. the nurse aide, revealed that she found both residents naked in bed in Resident 16's room on the evening of July 6, 2024, and immediately told a nurse. She stated she was very surprised because Resident 91 usually stays to himself in his room and he barely comes out. She stated he rings his call bell when he needs something. She stated she usually didn't see him conversing with Resident 16. Employee 1 stated that Resident 91 does speak to her because she is able to converse with him in his primary language. She stated on the evening of this sexual encounter Resident 91 was taken to the dayroom and staff watched him on a one-to-one basis until Resident 16 was moved to another room. Employee 1 stated Resident 16 is very social and was frequently observed walking up and down the hallway on a regular basis and often spoke to others about her boyfriend. An interview with Resident 91 was attempted on July 9, 2024 however the resident was not available as he was out at an appointment on the day of the survey. An interview with Resident 16 was conducted on July 9, 2024, but she was unable to recall the event and shared pictures of her boyfriend with the surveyor, that were on her dresser next to her bed in her new room. An interview with Employee 2, RN, at 12:52 PM on July 9, 2024, revealed that the residents were both separated that evening and placed on every 15 minute security checks. Resident 16 was moved to another room in a different building of the facility (facility comprised of two separate buildings on the same campus). A telephone interview was conducted with Resident 16's interested representative, a close friend, on July 9, 2024, at 11:46 PM. The resident's friend stated that Resident 16 is a long time friend, and she was not surprised of her actions with the male resident. The resident's friend stated that Resident 16 may have thought the male resident was her boyfriend. She stated that the resident may not want to remember what happened because she is very forgetful and may not want to accept what happened because of the loyalty she has to her boyfriend. The resident's friend stated that the resident can be very outgoing and that she wished had the opportunity to speak with facility staff to apprise them of the resident's resident's behavior and relationship with her boyfriend. The resident's representative stated that she believed that information would be necessary for the facility to explain the resident's behaviors. Resident 16's interested representative also relayed that she could never allow the resident's boyfriend to be aware of this sexual encounter because of the negative effects it would have on their relationship and also did not wish to notify the resident's daughter of the event due to the humiliation and embarrassment. A review of the resident's admission paperwork revealed that her daughter signed the documents upon admission and remained listed as a second emergency contact. The resident's friend was listed as the primary contact. A review of Resident 16's care plan, at the time of the survey, did not identify the significance of the resident's relationship with her boyfriend. Neither Resident 16's or Resident 91's care plans, identified any history of sexual behaviors. Resident 16 is cognitively impaired and did not possess the ability to consent to sex with Resident 91. A repeat BIMS score was obtained shortly after the encounter and her score was assessed at a 3 indicating severe cognitive impairment. Applying the reasonable person concept, in the case of Resident 16, who is unable to cognizantly speak for herself due to severe cognitive impairment, and the assessment of how most people would react to the situation of being sexually abused by Resident 91, Resident 16 would have been negatively affected by Resident 91's actions. A review of Resident 106's clinical record revealed admission to the facility on May 18, 2016, with diagnoses which include dementia (a chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning) and anxiety. A review of the resident's Quarterly Minimum Data Set assessment dated [DATE], indicated the resident was severely cognitively impaired with a BIMS score of 3. A review of Resident 12's clinical record revealed admission to the facility on August 7, 2023, with diagnoses which included intermittent explosive disorder and epilepsy. A review of the resident's annual Minimum Data Set assessment dated [DATE], indicated that the resident was severely cognitively impaired with a BIMS score of 3. A facility incident report dated June 21, 2024, at 2:30 PM indicated that Resident 109, a cognitively intact resident, reported observing Resident 12 hit Resident 106 in the stomach as Resident 106 was walking in the hallway. The residents were redirected and separated and placed on increased supervision. Assessment completed and no injuries were noted. Applying the reasonable person concept, in the case of Resident 106, who is severely cognitively impaired, and the assessment of how most people would react to the situation of being physically abused by Resident 12, Resident 106 would have suffered psychosocial harm and humiliation. An interview with the nursing home administrator on July 9, 2024, at approximately 1:00 PM confirmed that the facility failed to ensure that Residents 16 was free from sexual abuse perpetrated by Resident 91 and Resident 106 was free from physical abuse perpetrated by Resident 12. 28 Pa. Code 201.14 (a) Responsibility of licensee 28 Pa. Code 201.18 (e)(1) Management 28 Pa. Code 201.29 (a)(c) Resident Rights 28 Pa. Code 211.12(c)(d)(5) Nursing Services

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of clinical records, the facility's diet manual and select facility incident reports, and staff interviews, it was determined that the facility failed to ensure that a resident identified with swallowing difficulties was consistently served food in a form to meet the resident's individual needs, which caused a choking incident and aspiration (when food, drink, or foreign objects are breathed into the lungs) requiring hospitalization of one of 14 residents reviewed (Resident 196). Findings Include: Review of Resident 196's clinical record revealed that the resident was admitted to the facility on [DATE], with a diagnosis of dysphagia (difficulty swallowing). Review of resident's current care plan dated March 5, 2024, and in effect on April 21, 2024, revealed the resident required the assistance of one staff person with eating. Resident 196's admission Minimum Data Set assessment (MDS-a federally mandated standardized assessment process conducted at specific intervals to plan resident care) dated March 9, 2024, indicated that the resident was provided a mechanically altered diet (a diet that required a change in texture of food) daily. Resident 196 had a current physician order for a regular Pureed texture diet with nectar thickened consistency liquids (liquids thickened to the consistency similar to apricot nectar) initially dated March 27, 2024 (pureed diet is a type of diet that consists of foods with a smooth pudding-like consistency). A review of a facility incident report dated April 21, 2024, at 5:45 p.m. indicated that Employee 7 (RN) was called to the unit to assist Resident 196, because he was coughing. Employee 7 arrived to find resident coughing mucous out, and eventually spits out a small piece of shrimp. Further stating that only a small amount of food was eaten from the top of the resident's meal plate. Review of employee witness statements for this incident revealed none of the nurse aide employees interviewed as witnesses indicated that they had provided feeding assistance to the resident during the dinner meal on April 24, 2024. Review of nurse aide tasks dated April 21, 2024, revealed Employee 6 (NA) provided resident 196's ADL (activities of daily living) care of toileting and other tasks associated with activities of daily living. Employee 6's witness statement indicated that she was not in the room with Resident 196 when he was eating his dinner meal on April 21, 2024. There was no documented evidence that any staff member was present when Resident 196 began eating his dinner meal on April 21, 2024. A review of facility planned menu for the evening meal on April 21, 2024, revealed that Shrimp Scampi over angel hair pasta was the dinner for residents receiving pureed diets. A review of the recipe for pureed shrimp scampi indicated that the shrimp and pasta servings should be separately put into the food processor, should be blended until smooth, served scoop of blended pureed shrimp over blended pureed pasta. Further review of resident's clinical record revealed that a stat chest x-ray was ordered by the physician at 5:45 p.m., on April 21, 2024. At approximately 10:00 p.m., the mobile x-ray company responded that they would not be able to make it to the facility until the next morning. Resident 196 was sent to the emergency room at approximately 10:19 p.m., on April 21, 2024, due to potential aspiration and drop in Spo2 (what percentage of your blood is saturated) registering in the 60's (normal range is 95-100%) requiring 2 liters of oxygen. Hospital documentation dated April 22, 2024, indicated that Resident 196 had acute respiratory failure requiring 4 liters of oxygen to maintain oxygen levels above 89%, had scattered rhonchi, moist respirations and an elevated temperature. The resident was started on Rocephin and Flagyl for likely aspiration pneumonia. Interviews with the director of nursing (DON) and nursing home administrator (NHA) on May 31, 2024, at approximately 3:00 p.m. the DON and NHA confirmed that the facility failed to serve food to Resident 196 that met the resident's individual needs for safe swallowing and consistent with the current prescribed pureed diet with nectar thick liquids resulting in a choking episode and aspiration pneumonia. Refer 677 28 Pa. Code 211.6 (a) Dietary Services 28 Pa. Code 211.12 (d)(3)(5) Nursing services

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of clinical records, the facility's abuse prohibition policy, and select investigative reports, and staff interviews, it was determined that the facility failed to ensure that six residents (Residents 212, 93, 203, 178, 487, and 152) were free from physical abuse perpetrated by other residents (Residents 3, 188, 225, 212, 221, 213, and 56) out of 41 residents sampled for abuse prevention, which resulted in serious harm and injury to one resident, a fractured leg and hip (Resident 203). Findings include: A review of a facility policy entitled Pennsylvania Resident Abuse: Abuse, Neglect, and Exploitation, dated August 30, 2023, revealed that it is the policy of the facility to not tolerate abuse, neglect, mistreatment, exploitation of residents, or misappropriation of resident property by anyone. The policy defines abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. A review of Resident 212's clinical record revealed that the resident was admitted to the facility on [DATE], with diagnoses, which included dementia with behavioral disturbances (a chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning. A review of the resident's Quarterly Minimum Data Set Assessment (MDS - a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated December 18, 2023, revealed that the resident was severely cognitively impaired. A review of Resident 3's clinical record revealed that the resident was admitted to the facility on [DATE], with diagnoses, which included dementia and unspecified psychosis. The resident's Quarterly Minimum Data Set assessment dated [DATE], revealed that the resident was severely cognitively impaired. A facility investigation report dated January 3, 2024, revealed that at 8:40 PM Resident 212 was outside Resident 3's room. The residents appeared to be arguing. At that time Resident 3 hit Resident 212 in the left side of her face. A review of a witness statement from Employee 6, NA (nurse aide), dated January 3, 2024, revealed that the employee was walking through the hallway when she heard Resident 212 and Resident 3 arguing. Employee 6 indicated she walked over to see what was going on and saw Resident 3 hit Resident 212 on the cheek. A review of a witness statement from Employee 7, NA, dated January 3, 2024, indicated that she was in front of Resident 3's room and heard the residents arguing. The employee indicated that she and Employee 6 were telling the residents to calm down and Resident 3 hit Resident 212. Applying the reasonable person concept, in the case of Resident 212, who is unable to speak for herself, and the assessment of how most people would react to the situation of being physically abused by Resident 3, Resident 212 would have suffered psychosocial harm and humiliation. An interview with the Nursing Home Administrator and Director of Nursing on April 19, 2024, at approximately 1:45 PM confirmed the facility failed to ensure that Resident 212 was free from physical abuse perpetrated by Resident 3. A review of Resident 212's clinical record revealed admission to the facility on June 17, 2023, with diagnoses to include dementia with other behavioral disturbances (a condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change), anxiety, and major depressive disorder (persistent depressed mood or loss of interest in activities). A quarterly Minimum Data Set assessment dated [DATE], indicated that the resident was severely cognitively impaired with a BIMS (Brief Interview for Mental Status - a tool to assess cognition) score of 3 (0-7 represents severe cognitive impairment). The resident's initial care plan dated June 19, 2023, indicated that Resident 212 exhibited the following behaviors due to anxiety and depression: verbal aggression directed at others, non-nonsensical and rambled speech, exit-seeking, verbal outbursts, talking to self, removes clothes, wanders, yells at peers, propels self into other resident's rooms under stop sign, and holds/pushes other residents wheelchairs. The planned interventions were to administer medications as ordered, provide opportunity for positive interaction, encourage activity distraction, and reorient as needed. A review of Resident 178's clinical record revealed admission to the facility on April 5, 2023, with diagnoses to include vascular dementia with behavioral disturbances, anxiety, and major depressive disorder with severe psychotic symptoms. A quarterly Minimum Data Set assessment dated [DATE], indicated that the resident was severely cognitively impaired with a BIMS score of 3. A nursing note dated February 9, 2024, at 9:45 PM indicated Resident 212 had increased confusion and behaviors, and was wandering into other residents' rooms. Nursing noted on February 12, 2024, at 1:00 AM indicated that Resident 212 exhibited increased agitation and restlessness and was wandering into residents' rooms looking for her purse and cigarettes. On February 12, 2024, at 10:28 AM nursing indicated that resident displayed agitation, increased anxiety and verbal outbursts. A nursing note dated February 12, 2024, at 12:55 PM indicated that Resident 212 had increased behaviors of yelling outbursts and cursing at staff. Nursing documentation dated February 14, 2024, at 7:34 PM indicated that Resident 212 had increased behaviors, yelling at staff and peers, wandering, and refusing assistance. A nursing note dated February 16, 2024, at 10:58 AM revealed Resident 212 was an aggressor of physical aggression with a peer. The note indicated that Resident 212 was observed wheeling herself into the dining room for activities. The Activities Assistant observed Resident 212 speaking loudly with a peer. The activities aide came and tried to separate the residents but was unable to do so prior to the physical incident occurring. Review of the facility investigation report dated February 16, 2024, at 10:20 AM, revealed that Resident 212 stood up from her wheelchair and punched another resident (Resident 178) on the left side of her face after a verbal aggression, causing Resident 178 to sustain a small abrasion. Review of the ACT-13 Mandatory Abuse Report dated February 16, 2024, at 12:15 PM, revealed the facility identified Resident 178 as the victim and Resident 212 as the perpetrator. The facility reported that Resident 178 was seated in the dining room participating in activities at 10:20 AM. At that time, Resident 212 was observed rolling in her wheelchair into the room, where the activities program was occurring. The activities aide could see Resident 212 and Resident 178 talking to one another and, as she walked over, Resident 212 stood up from her wheelchair and struck the left side of Resident 178's face. The actions taken by facility included immediately separating the resident and placing both on increased supervision. New orders for lab work obtained for Resident 212. A review of Employee 5 (Activities Assistant) witness statement dated February 16, 2024, (no time indicated) revealed that she was getting the morning snack ready for the residents around 10:15-10:20 AM when she heard Resident 212 arguing with Resident 178. She walked over to separate the residents but Resident 212 stood up from her wheelchair and punched Resident 178 in the left cheek. Resident 212 was removed from the dining room and two nurses' aides came in to assist. Afterwards, Resident 178 told Employee 5 that she called Resident 212 a whore in response to her repeatedly accusing Resident 178 of stealing her purse, clothes, etc. Applying the reasonable person concept, in the case of Resident 178, who is unable to speak for herself, and the assessment of how most people would react to the situation of being physically abused by Resident 212, Resident 178 would have suffered psychosocial harm and humiliation. The facility was aware of the physically aggressive behavior of Resident 212 but failed to demonstrate sufficient supervisory measures of this resident to monitor her whereabouts to prevent the physical abuse of another resident. During an interview with the Nursing Home Administrator on April 19, 2024, at approximately 9:45 AM, it was confirmed that the facility failed to protect Resident 178 from physical abuse and failed to effectively monitor and supervise a resident with known episodes of aggressive behaviors to prevent resident-to-resident alterations. Clinical record review revealed that Resident 93 had diagnoses, which included dementia (a chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning. Resident 93's quarterly Minimum Data Set assessment dated [DATE], indicated that the resident had severe cognitive impairment, had no behaviors, and required staff assistance for eating. Clinical record review revealed that Resident 188 was admitted to the facility on [DATE], and had diagnoses which included bipolar disorder (mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration) and Lewy body dementia (a type of progressive dementia that leads to a decline in thinking, reasoning, and independent function). Resident 188's admission MDS assessment dated [DATE], indicated that the resident had severe cognitive impairment, inattention, disorganized thinking, verbal and physical behaviors, puts others at significant risk of physical injury, intrudes on the privacy or activity of others, and wandering behavior. A review of Resident 188's care plan, dated March 11, 2024, revealed that the resident was identified to exhibit behaviors due to cognitive status which include agitation, verbal outbursts, physical aggression, combativeness, stands unassisted, attempts to transfer, and attempting to hit, choke, and punch staff. Interventions planned were to allow resident to vent thoughts and feelings, always approach in a calm, relaxed manner, encourage to express feelings, listen with empathy and non-judgmental acceptance, compassion, and ensure residents feels safe in environment. A nurses note dated March 15, 2024 at 6:58 PM indicated that Resident 188 was observed hitting Resident 93 on top of the head while staff were feeding Resident 93. Employee 1, a nurse aide, witnessed the abuse, and attempted to redirect Resident 188, the aggressor. Resident 188 then struck Employee 1 (nurse aide) in the stomach and arms. Resident 188 was immediately redirected out of the area and brought to the resident's room. Physician and resident representative notified. Increased supervision per protocol. Plan to Redirect Resident 188 to high visibility areas to maintain watchful eye. Review of the facility investigation dated March 15, 2024, at 5:30 PM indicated that no injuries were observed to Resident 93 at the time of the incident. Review of Employee 1 (nurse aide)'s witness statement revealed that after Resident 188 hit Resident 93, Employee 1 made sure Resident 93 had no red marks on top of her head and Resident 93 seemed fine. Employee 1 was standing behind Resident 188's chair trying to redirect him to sit back down in his chair. As Employee 1 tried to redirect Resident 188, Resident 188 hit Employee 1 in the stomach and arm. Resident 188 became agitated while Employee 1 was assisting him back into his chair. Interview with employee 1 (nurse aide) on April 18, 2024, at 1:05 PM revealed that on the date of the incident she was feeding Resident 93 in the unit 5 (blue building third floor) dining room. At the same time, Resident 188 was also in the dining room at a table with other residents. Resident 188 was repeatedly attempting to stand from his wheelchair. Employee 1 stated that she was the only employee in the dining room at this time as other staff were passing meal trays in the hall for residents who eat in their rooms. Employee 1 stated that Resident 188 started hanging on the table with his hands while attempting to stand and seemed to be getting aggressive. Employee 1 brought Resident 188 closer to where she was feeding Resident 93 so she could supervise Resident 188. Resident 188 stood up again and when she asked him to sit down he grabbed the back of Resident 93's wheelchair and hit her on the top of the head. Employee 1 stated that Resident 93 did not seem to realize she was hit on the head. Employee 1 stated that Resident 188 then punched her twice. Employee 1 stated that after the incident she was able to get to the nurses station for assistance. The facility failed to protect Resident 93 from physical abuse and failed to effectively monitor and supervise a resident with known episodes of aggressive behaviors to prevent a physical abuse of another resident. Applying the reasonable person concept, in the case of Resident 93, who is unable to speak for herself, and the assessment of how most people would react to the situation of being physically abused by Resident 188, Resident 93 would have suffered psychosocial harm and potential injury. During an interview with the administrator on April 18, 2024, at 2:00 PM, it was confirmed that the facility failed to protect Resident 93 from physical abuse and failed to effectively monitor and supervise a resident with known episodes of aggressive behaviors to prevent a resident-to-resident altercation. A review of Resident 225's clinical record revealed admission to the facility on February 3, 2024, with diagnoses to include dementia with other behavioral disturbances (a condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change), and paranoid schizophrenia (a severe mental health disorder in which a person interprets reality abnormally, experiencing hallucinations, delusions, and extremely disordered thinking and behaviors). An admission Minimum Data Set assessment dated [DATE], indicated that the resident was severely cognitively impaired with a BIMS score of 0. The resident's initial care plan dated February 5, 2024, and revised March 25, 2024, indicated that she was an independent ambulator on the unit and was impaired in her ability to make herself understood and to understand others related to Spanish-speaking only. According to the resident's care plan, she exhibited behaviors of repetitiveness, anxiousness, looking for her checks, refused activity programs and showers, and accusatory regarding her clothing. The planned interventions were to approach the resident in a calm manner, be reassuring, allow resident to vent thoughts and feelings, and ensure resident feels safe in environment. A review of Resident 203's clinical record revealed admission to the facility on June 15, 2023, with diagnoses to include dementia, anxiety, and hypertension (a condition in which the force of the blood against the artery walls is too high) A quarterly Minimum Data Set assessment dated [DATE], indicated that the resident was severely cognitively impaired with a BIMS score of 0. A review of the resident's care plan, initially dated June 20, 2023, indicated that Resident 203 was bilingual, communicating in Hindi and English. A review of a nursing note dated March 22, 2204, at 7:35 PM revealed that Resident 203 was observed in the doorway of the lounge on the east wing of Blue 3. She was speaking in loud voice to Resident 225. According to the witness, the aggressor, Resident 225, pushed Resident 203 causing her to fall on the floor. The nurse, who witnessed the event, separated them immediately. Resident 203 was assessed for injuries and noted the resident with left leg in abduction. The resident was tearful and guarding her leg with her hands. A review of ACT-13 Mandatory Abuse Report dated March 22, 2024, at 7:15 PM identified Resident 203 as the victim and Resident 225 as the perpetrator. The report indicated that Resident 225 was observed to push Resident 203. Actions taken by the facility included immediate separation, increased supervision for the perpetrator and to send the victim to the ER to be evaluated for left hip abduction and pain. The report also indicated that both residents have a diagnosis of dementia. A review of an Employee 4's (licensed practical nurse) witness statement dated March 22, 2024, (no time indicated) revealed the date of the incident was March 22, 2024. According to the employee's witness statement she reported that Resident 203 was standing in the doorway of the South dining room. Resident 225 was standing in front of her, and they were speaking loudly to each other in their native languages. Resident 225 pushed Resident 203, and Resident 203, fell backwards. Resident 203's left leg was rotated out and she had pain with movement. The supervisor came to the floor to assess the resident. A nursing note on March 22, 2024, at 8:15 PM, revealed Resident 203 was sent to the hospital, where she was diagnosed with a left leg and hip fracture. Review of the x-ray report dated March 22, 2024, at 10:33 PM revealed that Resident 203 sustained an acute fracture of the left proximal femur (upper leg) and an acute nondisplaced fracture of the left hip as a result of the fall. A nursing note dated April 1, 2024, at 5:14 PM revealed Resident 203 was readmitted to the facility from the hospital on April 2, 2024, at 5:00 PM status post a left hip fracture. A review of Resident 203's Physical Therapy Evaluation upon return to the facility from the hospital dated April 2, 2024, revealed that the resident sustained a left hip fracture as a result of being pushed by another resident. The resident underwent a left hip ORIF (open reduction internal fixation- surgical procedure to stabilize and heal a broken bone using hardware to hold the bone together). Prior to the incident and fall, the resident was independent to transfer and ambulate on the unit. Since suffering the fall, fracture, and surgery, the resident was totally dependent on staff to stand and perform transfers. The resident was no longer able to ambulate. The facility failed to prevent the physical abuse of Resident 203 perpetrated by Resident 225, which resulted in Resident 203 being pushed to the ground, sustaining a left hip fracture which required surgical repair. As a result of the fall, Resident 203 experienced a significant decline in her functional abilities, transfers and ambulation and was now dependent on staff for her mobility needs. During an interview with the Nursing Home Administrator on April 19, 2024, at approximately 9:30 AM, it was confirmed that the facility failed to ensure that Resident 203 was free from physical abuse perpetrated by Resident 225. A review of Resident 221's clinical record revealed that the resident was admitted to the facility on [DATE], with diagnoses to have dementia with other behavioral disturbance. A quarterly MDS assessment dated [DATE], revealed that the resident was severely cognitively impaired. A review of Resident 487's clinical record revealed that the resident was admitted to the facility on [DATE], with diagnoses that included mild neurocognitive disorder due to known physiological condition without behavioral disturbances and reduced mobility. An admission MDS dated [DATE], indicated the resident was cognitively intact. A progress note dated April 11, 2024, at 10:11 AM revealed that Resident 221 was noted to have verbal behaviors including yelling/screaming and verbal aggression towards staff and her roommate, Resident 487. She was encouraged to be respectful to roommate, no mood concerns at present time and staff will continue to monitor. A facility investigation dated April 12, 2024, at 1:24 AM revealed that staff heard yelling from Resident 221's and Resident 487's room. Upon entering the room staff observed Resident 221 attempting to remove a shirt from Resident 487, who was sitting on her bed. Resident 221 was stating that it was her shirt. While Resident 221 was attempting to remove the shirt from Resident 487, Resident 221 pulled Resident 487's hair. No injuries were noted. Staff separated the residents. Resident 221 stated she is going through my stuff; she is going to end up eating everything. Resident 221 was assessed to have a superficial scratch on her chest measuring approximately 4.5 centimeters (cm) long. Resident 221 was placed on increased supervision. The local police department and Area on Aging Agency (AAA) was notified of the altercation between the residents involved. Resident 487 had a room change to a different unit in the building. A review of a witness statement from Employee 4, Licensed Practical Nurse (LPN), dated April 12, 2024, revealed that the employee was working at the desk and heard yelling coming from the East wing, went down the hall and found Resident 221 trying to take a shirt off Resident 487's body and immediately separated the residents. Resident 487 was sitting on Resident 221's bed and holding Resident 221's necklace. A review of a witness statement from Resident 487 on April 12, 2024, revealed that I put the blue shirt on because it was cold and then {Resident 221} came in and thought I was stealing it, she tried pulling it off me until she took it off completely. I did not get hurt; I would have offered her money for it. Further review of progress notes dated April 12, 2024, at 1:36 AM revealed that during the altercation when Resident 221 forcefully attempted to remove a shirt from Resident 487. Resident 487 stated that she got me real good with those knuckle punches and pointed to her head. An interview with the NHA and DON on April 19, 2024, at approximately 1:45 PM confirmed the facility failed to ensure that Resident 487 was free from physical abuse perpetrated by Resident 221. Review of clinical record of Resident 213 revealed that the resident was admitted to the facility on [DATE], with diagnoses including dementia. A 5-Day/admission Minimum Data Set assessment dated [DATE], indicated that Resident 213 was severely cognitively impaired with a BIMS score of 1. A review of Resident 152's clinical record revealed that the resident was admitted to the facility on [DATE], with diagnoses, which included schizoaffective disorder. A review of the resident's Quarterly Minimum Data Set assessment dated [DATE], revealed that the resident was moderately impaired with a BIMS score of 12. A review of Resident 213's clinical record revealed the resident had been intrusively wandering into other resident rooms since his admission on [DATE], which occurred almost daily while in the facility. A review of a facility investigation dated February 21, 2024, revealed Resident 213 wandered into Resident 152's room and would not leave. Resident 152 punched Resident 213 in the face. Resident 152 went to the nurses' station and informed Employee 8 LPN that he had punched Resident 213 in the face. A review of a witness statement from Employee 8 LPN (Licensed Practical Nurse) dated February 21, 2024, revealed the employee was at the nurses' station when Resident 152 walked up to the desk and told her that Resident 213 came in his room and would not leave so he punched him in his face. Employee 8 noted that Resident 152 had blood on his hand. Employee 8 went to Resident 152's room and saw Resident 213 was still in Resident 152's room and he was on the floor and bleeding. Resident 213 was assisted back to his room and an ice pack was applied. Resident 213's clinical record revealed that the resident had a 3 cm by 3 cm laceration on his forehead. An x-ray was completed and there was no fracture to his nose noted. The facility failed to protect Resident 152 from physical abuse and failed to effectively monitor and supervise this resident with known episodes of intrusive wandering behaviors to prevent physical abuse. An interview with the NHA and DON on April 19, 2024, at approximately 1:45 PM confirmed the facility failed to ensure that Resident 152 was free from physical abuse perpetrated by Resident 213. A review of Resident 203's clinical record revealed admission to the facility on June 15, 2023, with diagnoses to include dementia, anxiety, and hypertension (high blood pressure). A quarterly Minimum Data Set assessment dated [DATE], indicated that the resident was severely cognitively impaired with a BIMS score of 0. A review of Resident 56's clinical record revealed that the resident was admitted to the facility on [DATE], with diagnoses, which included schizophrenia. A review of the resident's Quarterly Minimum Data Set assessment dated [DATE], revealed that the resident was severely cognitively impaired. A review of a facility investigation dated January 29, 2024, revealed Resident 203 was outside Resident 56's room. Employee 10, NA (Nurse Aide), was taking Resident 56 out of her room and Resident 56 punched Resident 203 in the chest. A review of a witness statement from Employee 10 NA (nurse aide) dated January 29, 2024, revealed the Resident 56 was leaving her room and saw Resident 203 and started calling her derogatory names and then struck out and punched Resident 203 before Employee 10 could stop her. Applying the reasonable person concept, in the case of Resident 203, who is unable to speak for herself, and the assessment of how most people would react to the situation of being physically abused by Resident 56, Resident 203 would have suffered psychosocial harm and humiliation. An interview with the Nursing Home Administrator and Director of Nursing on April 19, 2024, at approximately 1:45 PM confirmed that the facility failed to ensure that Resident 203 was free from physical abuse perpetrated by Resident 56. 28 Pa. Code 201.14 (a) Responsibility of licensee 28 Pa. Code 201.18 (e)(1) Management 28 Pa. Code 201.29 (a)(c) Resident Rights 28 Pa. Code 211.12(c)(d)(5) Nursing Services

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of clinical records, select facility policy and investigative reports, and resident and staff interview, it was determined that the facility failed to ensure that one resident out of 25 sampled residents out was free from physical abuse resulting in serious injury, a fractured hip. (Resident 201). Findings including Review of a facility policy entitled Abuse Policy and Procedure with a policy review date of January 17, 2023, revealed It is the policy of the facility to protect our residents from abuse, neglect, misappropriation of property, corporal punishment, and involuntary seclusion. Abuse as used in this policy will refer to the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical pain or mental anguish and to misappropriation of resident property. Willful means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Physical abuse includes hitting slapping, pinching, and kicking. Our facility is committed to protecting our residents from abuse. Prevention of abuse is to include monitoring residents with needs and behaviors. Review of Resident 201's clinical record revealed that the resident was admitted to the facility on [DATE], with diagnoses to have included dementia without behaviors disturbance [a group of symptoms affecting memory, thinking and social abilities], anxiety, unspecified lack of coordination, and depression. Review of Resident 201's annual Minimum Data Set Assessment (MDS - a federally mandated standardized assessment conducted at specific intervals to plan resident care) assessment dated [DATE], revealed that the resident had severe cognitive impairment and ambulated without an assistive device. Review of Resident 201's comprehensive care plan initiated on October 26, 2018, identified that the resident had self-care deficits with a noted intervention to supervise the resident when ambulating without an assistive device. Review of Resident 185's clinical record revealed that she was most recently admitted to the facility on [DATE], with diagnoses of paranoid schizophrenia [involves a range of problems with thinking (cognition), behavior and emotions. Signs and symptoms may vary, but usually involve delusions, hallucinations, or disorganized speech, and reflect an impaired ability to function], major depressive disorder, anxiety, and unspecified psychosis [is the term for a collection of symptoms that happen when a person has trouble telling the difference between what's real and what's not and a disconnection from reality can happen for several reasons, including many different mental and physical conditions]. A review of Resident 185's annual MDS dated [DATE], revealed that the resident had Brief Interview for Mental Status [(BIMS) section of the MDS which assesses cognition, a tool to assess the resident's attention, orientation, and ability to register and recall new information], revealed that the resident had scored 13 and indicated that she was cognitively intact. Resident 185's care plan dated as initiated on April 23, 2019, identified that Resident 185 had an altered or at risk for altered behaviors and/or mood due to diagnosis of depression with a noted goal that the resident would be free of behavioral outbursts and/or unusual behaviors daily thru next review. Intervention planned were to to remove the resident from negative stimuli and model calm behaviors. The resident's care plan, initiated April 23, 2019, identified that Resident 185 exhibited behaviors such as verbal aggression toward staff and peers at times, curses at staff, dumps water pitcher, accusatory statements directed at others, enters other resident's rooms, and goes through their clothing, noted with a history of bumping into other residents, self-propels and ambulates, crawls and scoots on floor, undresses in hallway, puts toothpaste on self, grabs at staff's hair, states she is not going to eat at times, states that she is leaving at times, wandering behaviors at times, attempts to enter the elevator noted with exhibiting paranoid behaviors, noted with verbal and vocal outbursts, noted with repetitive questions and vocalizations. Review of an incident reported dated June 6, 2023, at 4:00 PM, revealed that Resident 201 was attending an activity when she was approached by Resident 185. Resident 185 then pushed Resident 201, causing Resident 201 to fall to the floor. Resident 201 was observed lying on the floor in the dining room with staff around her. Resident 201 had pain and was grabbing her left leg and crying. Resident 201's left leg was externally rotated. According to the incident report, the incident was unprovoked. As a result of the fall, Resident 201 was admitted to an acute care facility and treated for subtrochanteric fracture of the left hip [a fracture in the upper part of the femur, the upper bone of the thigh that extends from hip to knee] as a result of being pushed by Resident 185. A fall witness statement completed by Employee 1, an activities aide, dated June 6, 2023, at 4:04 PM, revealed that Resident 201 was just ambulating when she was deliberately pushed by another resident {Resident 185}, and she fell to the floor onto her left side. The facility failed to protect residents from physical abuse and failed to effectively monitor and supervise a resident with known episodes of aggressive behaviors to prevent a resident-to-resident altercation and serious injury to Resident 201. The facility incident revealed that the facility interviewed all like residents that were capable of being interviewed to identify concerns regarding abuse and/or neglect. Residents that were not capable of participating in an interview were assessed by licensed nurse staff and body audits were completed to rule out or confirm abuse and/or neglect. The facility did not identify any negative findings related to abuse and/or neglect. During interview with the Director of Nursing (DON) on June 21, 2023, at 12:00 PM, confirmed that the facility failed to consistently monitor residents with known physical aggressive behaviors to prevent resident to resident abuse that resulted in Resident 201 sustaining a major injury, a fractured hip. This deficiency is cited as past non-compliance. To identify other resident that had the potential to have the potential to be affected, on June 7, 2023, the interdisciplinary team (IDT) reviewed all residents with a BIMs of 12 or higher located on unit Blue 3 to ensure that residents were appropriate for that unit and any issues were corrected, as needed. To prevent a reoccurrence, the Nursing Home Administrator (NHA)/designee provided education to all residents regarding abuse, types of abuse, examples of abuse, how to report abuse, and what to do and what not to do. Education was completed on June 7, 2023. To monitor and maintain on-going compliance the NHA/designee will interview five residents weekly for four weeks, and then monthly for two months on abuse. Additionally, to monitor and maintain on-going compliance the Director or Nursing (DON)/designee will complete body checks on five residents weekly, then monthly for two months to rule out abuse. Any negative findings will be corrected as needed. Results of audits will be brought to QAPI for review and revision as indicated. The facility's immediate corrective action plan was completed June 8, 2023. 483.13 - Resident Behavior and Facility Practices, 10-1-1998 edition 28 Pa. Code 201.29(a)(c)(d) Resident rights 28 Pa. Code 201.14(a) Responsibility of Licensee 28 Pa. Code 201.18(e)(1) Management