**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policies, facility documentation, clinical records and staff interviews, it was determined that the facility failed to protect residents from neglect for one of eighteen residents reviewed (Resident 47). Resulting in actual harm of skin tear and bruising to Resident 47. Findings include: The facility's policy Preventing Resident abuse revised April 2019, indicated abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Additional review of same policy defines neglect as failure to provide goods and services as necessary to avoid physical harm, mental anguish, or mental illness. Review of Resident 47's clinical record indicated Resident 47 was admitted to the facility on [DATE]. Review of Resident 47's Minimum Data Set (MDS - periodic assessment of care needs) dated January 31, 2024, indicated Resident 26's diagnoses include but not limited to Alzheimer's disease (decline in memory, thinking, learning and organizing skills over time.), Peripheral Artery Disease (condition of narrowed arteries reducing blood flow to the arms or legs), Depression (persistent feeling of sadness and loss of interest), and Anxiety Further review of Resident 47's MDS dated [DATE] Section C; revealed a completed Brief Interview for Mental Status (BIMS -tool used to measure a person's cognition) with score of 3 (indicating severe impairment). Review of Resident 47's ADL (Activities of Daily Living) care plan dated December 27, 2023, revealed the following interventions for Resident 47: requires an assist for two for bed mobility (initiated on July 11, 2019), requires an assist of two for transfers (initiated on July 11, 2019), requires an assist of one for dressing (initiated July 11, 2019), and requires an assist of one with personal hygiene (initiated on July 11, 2019). Review of Resident 47's clinical record revealed Resident 47 was administered the following medications: Eliquis (blood thinner used to prevent blood clots), Remeron (used to treat depression), Ativan (used to treat anxiety). Review of information dated September 4, 2023 submitted by the facility submitted on September 4, 2023 revealed Resident 47 experienced neglect during afternoon care on September 4, 2023, at 11:30 a.m. from Certified Nursing Assistant (CNA) Employee E1. Further review of the information dated September 4, 2023 submitted on September 4, 2023 summarized; E1 entered Resident 47's room to get resident up and dressed, per E1 [he/she] told Resident 47 it was time to get ready for lunch, informing [resident] [he/she] was going to wash and dress [resident]. Resident 47 responded get the hell out of here. E1 went and gathered [his/her] supplies and reapproached the Resident 47, Resident 47 did not respond, so E1 initiated care, Resident 47 was calm until E1 began providing incontinence care when Resident 47 began to yell and tried to swing back and hit E1. E1 placed Resident 47 on [resident] back and calmly asked what is wrong, Resident 47 continued to yell Get the hell away from me. E1 waited a minute until Resident 47 calmed and explained once again, we have to get dressed. E1 then continued to wash Resident 47's bottom, Resident 47 pushed back and began to hit, at that time the E1 folded Resident 47's arms on her chest and tried to get a brief on her. E1 let [resident] arms go to roll Resident 47 back to the right side, as E1 did the Resident 47 started swinging [his/her] arms and trying to bite E1. When E1 sat Resident 47 on the side of the bed, E1 saw a skin tear. Resident 47 was calmed and assisted with transferring [resident] to the recliner with walker to chair, Resident 47 then began to yell get the hell out of here and E1 immediately reported skin tear. Review of Nurse Aide, Employee E2 witness statement dated September 4, 2023, indicated there was bruising on Resident 47's left arm and bruising and a skin tear on Resident 47's right arm. E2 also indicated, I went to check on Resident 47 at 2:15 p.m. and Resident 47 said she held both of my arms and there was nothing I could do. Review of Nurse Aide, Employee E1's witness statement revealed, Nurse Aide, Employee E1 folded Resident 47's arms against her chest which resulted in Resident 47 sustaining multiple bruises and skin tears. Review of facility investigative documentation including the PB-22 (form that is utilized to report instances of abuse, neglect, or exploitation of vulnerable adults) completed by the facility dated September 6, 2023, at 3:18 p.m. substantiated the information indicated above and concluded that Resident 47 experienced neglect from E1 resulting in bruising and skin tears to bilateral (right and left) lower arms. Additional review facility investigative document PB-22 revealed E1 was removed from the facility and placed on the do not return list, [Nursing Agency] employer notified via phone call of events and staff member status. Review of Resident 47's clinical record revealed a progress note by psychiatric-mental health nurse practitioner (PMHNP) dated September 5, 2023, at 7:00 p.m. indicating, contacted by SW (social worker). Resident 47 with recent increase in aggression. Hit and bit staff. Aggressive with care. DVT (Deep vein thrombosis, a blood clot forms in one or more of the deep veins in the body) currently being treated. Increased pain. Probable increase in anxiety r/t (related to) care. Recommend Ativan .25 mg (milligrams) q (every) 12 hours for anxiety x 14 days. Hold of sedation. Resident 47 was unavailable for an interview due to being admitted to the hospital on [DATE]. Interview conducted with the Nursing Home Administrator (NHA) on March 8, 2024, at 10:30 a.m. confirmed that the facility failed to protect residents from abuse for one of eighteen residents reviewed resulting in actual harm to the resident (Resident 47). 28 Pa Code: 201.14 (a ) Responsibility of licensee 28 Pa Code: 201.18 (b)(1)(3) Management 28 Pa Code: 211.10 (d) Resident care policies 28 Pa Code 211.12 (d)(3) Nursing services

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon review of facility policy and procedure, clinical records and documentation provided by the facility, it was determined that the facility failed to ensure residents were free from significant medication errors causing harm of hospitaization to one of eighteen residents reviewed (Resident 230). Findings include: Review of facility policy and procedure titled Medication Administration revealed The individual administering medications verifies the resident's identity before giving the resident his/her medications. Methods of identifying the resident include checking identification band; checking photograph attached to medical records and if necessary, verifying resident identification with other facility personnel. Additional review of the Medication Administration policy revealed The individual administering medication checks the label three (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication. Further review of the Medication Administration policy revealed the following information is checked/verified for each resident prior to administering medications: a) allergies to medications; and (b) vital signs if necessary. Review of Resident 230's diagnosis list revealed diagnoses including acute respiratory failure with hypoxia, Chronic Kidney Disease (failure of the kidneys to function properly), and Congestive Heart Failure (excessive body/lung fluid caused by a weakened heart muscle). Review of Resident 230's allergy list included allergies to Baclofen (muscle relaxant) and Gabapentin (anti-seizure and nerve pain medication). Review of Resident 230's clinical progress notes dated December 7, 2022, revealed [nurse practitioner] made aware of med error, patient was given another patient's medication. Gabapentin which causes patient to hallucinate and Baclofen which causes restless leg syndrome and insomnia in patient. New verbal order received and noted. RP [representative] needs to be made aware 12/8/2022. Neuro checks time 72 hours. Further review of Resident 230's clinical progress notes dated December 8, 2022, revealed This RN [Registered Nurse] and DON [Director Of Nursing] assessed [resident] this morning. [resident] was laying in her bed appeared to be sleeping, attempts made to arouse her via verbal and tactile stimuli. She was unresponsive, blood sugar 108, BP [blood pressure] 111/59, HR [heart rate] 68, pulse ox [oxygen saturation in blood] 94% with periods of apnea. [nurse practitioner] notified order to start oxygen at 2 liters and transport to ED [emergency department] for further evaluation. Review of hospital documentation dated December 8, 2022, revealed resident presented to the hospital with altered mental status after being administered Gabapentin 400 mg [milligram], Baclofen 20 mg and Melatonin 9 mg and found to be unresponsive this morning and had to be intubated for airway protection. Review of hospital history and physical documentation dated December 8, 2022, revealed given wrong medications at SNF [skilled nursing facility], became obtunded [reduced level of alertness or consciousness], intubated December 8, 2022, extubated December 9, 2022. Review of hospital admitting diagnosis dated December 8, 2022, revealed acute hypoxemic respiratory failure. Review of Resident 230's clinical record revealed that Resident 230 was readmitted to the facility on [DATE]. Review of facility documentation dated December 7, 2022, revealed [nurse] gave [resident] another resident's medication. [Resident] has allergy to baclofen and gabapentin. Interview with the Nursing Home Administrator and Director of Nursing on April 20, 2022, revealed that Resident 230 was administered another resident's medication on December 7, 2022, which resulted in Resident 230 becoming unresponsive and being transferred to an acute care facility. The facility failed to ensure residents were free from significant medication errors causing hospitalization, intubation and harm to Resident 230. 28 Pa. Code 211.12(c)(d)(1)(3) Nursing Services Previously cited 5/12/2022