**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of clinical records and select facility documentation, and staff and resident interviews, it was determined that the facility failed to ensure that staff implemented a physician-ordered adaptive device (lidded cup) to mitigate the risk of injury from hot liquids for one of 21 sampled residents (Resident 60) resulting in actual harm, a burn injury to the upper thigh area and failed to ensure nurse aides demonstrated the necessary skills and competencies to safely perform mechanical lift transfers for one of 21 residents reviewed (Resident 195). These failures resulted in actual harm to both residents. Findings include: A review of Resident 60's clinical record revealed the resident was admitted to the facility February 1, 2024, with diagnoses to include dementia (the loss of cognitive functioning - thinking, remembering, and reasoning - to such an extent that it interferes with a person's daily life and activities). A quarterly Minimum Data Set assessment (MDS - a federally mandated standardized assessment process conducted at specific intervals to plan resident care) dated May 2, 2025, revealed that the resident was severely cognitively impaired with no BIMS score recorded (Brief Interview for Mental Status, a tool to assess the resident's attention, orientation, and ability to register and recall new information). The assessment noted that during eating, the resident had the ability to use suitable utensils to bring food and /or liquid to the mouth and required set up and clean up assistance Review of physician orders revealed that as of November 5, 2024, and active through May 20, 2025, the resident was to be provided with lidded cups for all liquids. An Occupational Therapy treatment encounter note dated May 13, 2025, identified the resident required set up/clean up assistance for all meals. A nurse's note dated May 19, 2025, at 2:16 PM, indicated that at approximately 11:45 AM that day, Resident 60 spilled hot coffee into her lap. The nurse noted pink, non-blanchable skin and four clear, fluid-filled blisters, each approximately 0.5 cm x 0.5 cm, located on the left anterior thigh. Silvadene was applied per protocol, and the practitioner and resident's family were notified. Resident denied pain and discomfort at that time. A Skin Evaluation completed by Employee 1 the RN Supervisor on May 20, 2025, at 9:15 AM, described six intact, clear fluid-filled blisters across multiple areas of the upper thigh. Left proximal 2 cm x1. 5 cm Left lateral 2 cm x1 cm Left lateral 1cm x 0.5cm Left distal 3. 5cm x 1. 5cm Left distal/ lateral 0.5cm x 0.5cm Left medial 3.5 cm x 1cm Silvadene was applied per physician order during the assessment. The resident denied having pain and was resting comfortably in bed with the call bell within reach. A Wound Care Physician evaluation dated May 20, 2025, at 1:53 PM, identified the burn as measuring 8 cm x 25 cm x 0 depth, with no exudate (discharge of moisture) or odor. The wound area was warm to the touch and the skin remained closed. The resident reported no pain. A review of facility's investigative report completed by the Director of Nursing (DON) dated May 19, 2025, at 11:45 AM, indicated the resident had been provided coffee without a lid, in violation of the physician's order, and subsequently spilled the beverage into her lap. A witness statement from Employee 5, Nurse Aide, dated May 19, 2025, revealed during the lunch meal, she placed the coffee in front of the resident without a lid and turned her back toward this resident to prepare another resident's beverage. When she turned back toward the resident she noticed Resident 60 had spilled the coffee into her lap. She reported to the Nursing Home Administrator (NHA) and Director of Nursing (DON) being unaware of the resident's requirement for a lidded cup. Employee 5 was suspended pending investigation and was unavailable to be reached by phone for an interview. On May 21, 2025, at approximately 10:00 AM, with the resident's permission, an observation of the resident's burn was conducted in the presence of the DON. The resident's burn was visible on her upper left thigh. The burn appeared pink, with scattered areas of white. Four blister like clusters remained, with no open areas seen, and no evidence of drainage or odor. Review of Resident 60's [NAME], which is used by staff to determine whether a resident required adaptive equipment for meals, prior to May 19, 2025, revealed the order for a lidded cup was not on the Resident's [NAME]. However, the resident did have a physician's order dated originally November 5, 2024, for lidded cups for all fluids. An interview with the NHA on May 21, 2025, at approximately 9:00 AM revealed there was an error in linking the active physician's order for lidded cups to the resident's [NAME]. Review of the food and beverage temperature logs maintained by the facility at resident meal service for May 19, 2025. The food/beverage temperatures for May 19, 2025, showed the coffee temperature for lunch tested at 139 degrees Fahrenheit. Interview with the NHA on May 21, 2025, at approximately 10:00 AM confirmed, the resident was not provided the ordered adaptive device (cup with lid). The administrator acknowledged the omission directly contributed to the hot liquid spill and subsequent injury. Following the incident on May 19, 2025, corrective actions were implemented by May 20, 2025, and included: Immediate clinical intervention following the incident, including removal of soiled clothing, application of cool compresses, wound treatment, and notification of the practitioner and family. Resident was evaluated by the Occupational Therapist for safety in consuming hot liquids. Occupational Therapist updated orders to include [NAME] Cup (spill proof cup that can be turned upside down without spilling) to further reduce spill risk. Residents with current adaptive equipment orders were prescreened by the Occupational Therapist to verify current orders and interventions are appropriate. Director of Nursing will review each order to verify the order is care planned and visible on the [NAME]. Regional Dietician re-educated the facility Dietician on appropriate steps to document orders, so they flow to the care plan and the [NAME]. The DON/designee provided in-service to facility staff on hot beverage policy. Staff not present during initial training were reeducated before their next shift. The DON/designee will review new resident orders for adaptive equipment to verify that they are documented correctly including link to [NAME]. Implementation of an audit system to review adaptive equipment use, ensure consistency between physician orders, care plans, and [NAME], and present findings to the facility's QAPI committee. A review of the clinical record revealed that Resident 195 was admitted to the facility on [DATE], with diagnoses to include, transient ischemic attach (TIA-a short period of symptoms similar to those of a stroke, caused by a brief blockage of blood flow to the brain), cerebral infarction (occurs when the blood supply to part of the brain is blocked or reduced and prevents brain tissue from getting oxygen and nutrients that results in brain cells beginning to die) without residual deficits (recovered without any effect), age related osteoporosis (a condition in which the bones become thinner, weaker, and more likely to break), and aphasia (a result of a stroke or brain injury that affects a person's ability to communicate). A Significant Change Minimum Data Set assessment (MDS- a federally mandated standardized assessment process conducted at specific intervals to plan a resident's care) dated January 14, 2025, revealed that Resident 195 had severe cognitive impairment with a BIMS score of 3 (Brief Interview for Mental Status - a tool to assess cognitive function - a score of 0 -7 indicates severe cognitive impairment), dependent (helper does all of the effort to complete the activity or the assistance of two or more helpers required to complete the activity) for bed mobility, transfers, toileting, and bathing. The resident was assessed to require a mechanical lift (a mechanical device used to assist with transfers and movement of individuals who require support for mobility beyond the manual support provided by caregivers alone) for all transfers. A review of Resident 195's physician's orders dated December 3, 2024, at 2:02 AM, specified mechanical lift use for all transfers. A review of a facility policy entitled Mechanical Lifting last reviewed February 18, 2025, indicated the facility utilizes floor-based full body sling lifts and overhead full body sling lifts with universal slings (intended as a general transfer sling, designed to be interchangeable between all manufacture's lifts and provides trunk and leg support for patients with limited upper body tone) and refer to the manufacturer's instructions for use of the universal slings. A review of facility provided investigative documentation completed by Employee 1, Registered Nurse (RN) Supervisor, dated January 30, 2025, revealed that at 8:00 AM, Resident 195 had a witnessed fall by Employee 2, an agency Nurse Aide (NA), and Employee 3, an agency Licensed Practical Nurse (LPN), the resident slid from the sling during a Hoyer lift transfer performed by Employee 2 (agency nurse aide) and Employee 3 (agency LPN), and struck her head on the floor. Employee 1 assessed Resident 195 and noted that the resident was moaning and not answering questions and 911 was called. The Resident's RP (Responsible Party), her son, was made aware and agreeable to send resident to the emergency department and the MD was made aware. A review of a witness statement completed by Employee 2, agency NA, dated January 30, 2025, no time indicated, Employee 2 reported: I was getting her {Resident 195} dressed and washed. I put the sling under her and strapped her up real good. The LPN was in with me when I lifted her up with the Hoyer. She slipped right out, landed on the bed and then on the floor. Wasn't a fall, she slipped onto the floor and hit her head. The LPN went to get the supervisor, and I tried to get her vitals, but she wouldn't let me. She was halfway on the bed when it happened. Employee 3's, agency LPN, witness statement dated January 30, 2025, no time indicated, noted I was called in by the nursing assistant to transfer the resident via Hoyer lift, with safety harness intact. The NA pulled the lift back and the resident slid out of the pad and bounced off the bed to the floor. Resident hit head on the floor. Supervisor was called and safety protocols initiated. A witness statement completed by Employee 4, former Director of Nursing (DON), dated January 30, 2025, documented the reenactment of the event that occurred at approximately 8:20 AM. The DON noted: Employee 2 stated she had retrieved a sling from the laundry, hooked the resident up appropriately, and sought assistance with the transfer. Unable to locate another aide, she was assisted by Employee 3. During the lift, the resident slid out from the bottom of the pad (sling) onto the bed and then onto the floor. When asked whether she crossed the leg straps of the sling, Employee 2 replied, no. Employee 3 described the lift transfer as follows: She was asked to come in and spot the resident transfer. She entered the room and stood by the bed while the lift was being performed. Upon elevation of the resident on the lift, the resident slid out of the bottom onto the bed and then the floor. A review of the emergency department after visit summary dated January 30, 2025, at 11:03 AM, revealed that she was being seen due after a fall off the Hoyer lift. Imaging results completed and CAT scan (computerized axial tomography - uses x-rays to take pictures of your blood vessels, tissues, bones, or organs) of the chest/abdomen/pelvis and CAT scan of her head, brain, and spine and determine that imaging was negative for intercranial bleed and fractures but positive for left posterior scalp hematoma (a condition characterized by the accumulation of blood beneath the scalp and occurs as a result of various factors, including trauma, head injuries, or medical conditions that affect blood clotting) with a planned discharge back to the facility for 11:30 AM. A review of Resident 195's clinical record revealed a nurses' progress notes dated February 4, 2025, at 10:28 PM, that indicated that the resident was complaining of increased pain to the left thigh area. Resident offered PRN (as needed) Tylenol and declined; resident was agitated and yelling at staff. Refusing all PRN medication but allowed the NA to reposition her in bed. Orders were obtained from the CRNP (Certified Nurse Practitioner) for left hip and femur x-rays and to increase Tramadol (opioid pain medication used to manage moderate to severe pain) to 25 mg po BID (twice per day) to TID (three times per day) and hold for sedation. Further review of the resident's clinical record revealed final x-ray results that indicated a left hip fracture, not present on prior study; clinical correlation and follow up radiographs suggested. CRNP made aware new orders received and noted to send the resident to the hospital emergency room (ER). A review of Resident 195's hospital discharge summary for admission February 5, 2025, through February 10, 2025, revealed the resident was admitted due to a left periprosthetic fracture (are considered fractures associated with an orthopedic implant, whether a replacement or internal fixation device) and multiple closed fractures of ribs (is a common injury that occurs when one of the bones in the rib cage breaks or cracks caused by hard impacts from falls, car accidents or contact sports) of the left side. A review of the manufacturer's instructions for the universal lift sling use during transfers from bed to chair indicated that for maximum security, gently raise the individual's legs, and pull the leg loops forward and under the thigh, cross the loops over the thighs, pull one strap through the other, and bring the lift over to the bed and roll the base as far underneath the bed as possible while positioning the cradle over the individual. When both sides of the sling are attached to their respective sides of the cradle, raise the individual slowly. Place the specific loop or chain the individual requires to ensure the proper fit to prevent from sliding out of the sling. The instructions for the universal sling confirmed that sling leg loops were to be crossed under the thighs and properly secured to prevent the resident from sliding. A review of a facility provided document entitled New Employee Orientation handbook provided by the Nurse Staffing Agency, reviewed and signed by Employee 2, Agency Nurse Aide (NA) on May 11, 2022 (date of hire with the nursing agency), acknowledged that Hoyer lift safety was completed on that date. Additionally, Employee 2 completed the facility's Nursing Agency Orientation on January 17, 2025, which included resident transfer safety. A review of the nursing agency's new hire documentation for Employee 3, Agency LPN, revealed that she was hired by the agency on August 17, 2023, however, no documentation was provided by the facility or staffing agency to demonstrate that Employee 3 had ever received training or competency validation on mechanical lift use. During on-site survey, telephone calls were placed to both Employee 2 and Employee 3, but the employees did not return the calls. During an interview with the Nursing Home Administrator (NHA) on May 20, 2025, at 10:45 AM, he acknowledged that Employee 2 failed to properly apply the universal sling and failed to cross the leg straps, resulting in the resident sliding from the sling onto the bed and then the floor. He further confirmed the facility was unable to produce documented evidence that Employee 3 had ever received mechanical lift training prior to assisting with the transfer. Further interview with the NHA confirmed that Employee 2 failed to ensure Resident 195's safety when applying the universal sling when performing a Hoyer/mechanical lift transfer that resulted in Resident 195 sliding out of the bottom of the sling onto the bed and then onto the floor hitting her head. Subsequently, Resident 195 sustained a left posterior scalp hematoma, left periprosthetic fracture, and multiple closed fractures of ribs on the left side. The facility failed to ensure that all nursing staff had the necessary clinical competency validation skills when operating mechanical lifts with universal slings for resident transfers to prevent injuries sustained from unsafe transfer practices by staff. Following the incident with Resident 195 on January 30, 2025, the facility provided evidence that corrective actions were completed by January 31, 2025. Resident was assessed for injury (no injury apparent) and was sent to the hospital for an evaluation. The current residents who utilize a Hoyer lift for care were audited to determine the following a-proper sling fitment b-care plan updated The maintenance director/designee re-audited all lifts to ensure proper functioning. Lifts are on a monthly preventative maintenance schedule. The DON/designee will in-service the nursing staff on proper sling use, colors, sizes and location. The ESD audited all slings in the building to ensure they are functional. The NHA/designee will randomly audit nursing staff 2x/week for 4 weeks to ensure the slings/lifts are being used in accordance with manufacturer recommendation and facility policy. 28 Pa Code 201.18(b)(1) Management. 28 Pa Code 211.10 (d) Resident care policies. 28 Pa Code 211.12 (d)(3)(5) Nursing services.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of clinical records, select facility reports and the facility's abuse prohibition policy, and resident and staff interviews, it was determined that the facility failed to ensure that one resident was free from sexual abuse (Resident 48) and the facility neglected to provide the necessary care and services to prevent psychosocial and/or physical harm and physical discomfort for two residents out of 21 sampled (Residents 21 and 80). Findings include: A review of the current facility policy titled Abuse Policy, last reviewed by the facility on May 10, 2024, indicated that each resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in the regulation. Residents must not be subjected to abuse by anyone, including but not limited to, facility staff, other residents, consultants or volunteers, staff or other agencies serving the resident, family members or legal guardians, friends, or other individuals. Each resident has the right to be free from mistreatment, neglect, and misappropriation of property. This includes the facility's identification of residents whose personal histories render them at risk for abusing residents, the development of intervention strategies to prevent occurrences, monitoring for changes that would trigger abusive behavior, and reassessment of the interventions on a regular basis. Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Sexual abuse is non-consensual sexual contact of any type with a resident, including sexual harassment, sexual coercion, or sexual assault. Sexual contact or assault that results from threats, force, or the inability of the person to give consent and involving a range of activities. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. A review of Resident 48's clinical record revealed admission to the facility on May 16, 2022, with diagnoses that included Alzheimer's disease (a type of brain disorder that causes problems with memory, thinking, and behavior and is a gradually progressive condition), cognitive communication deficit (occurs when someone has trouble with one or more cognitive processes involved in communication), and anxiety disorder (a group of mental illnesses that cause constant fear and worry and are characterized by sudden feelings of worry, fear, and restlessness). Resident 48's care plan, initiated on May 17, 2022, and revised on November 24, 2023, identified that the resident had impaired/declined cognitive function or impaired thought processes related to diagnosis of Alzheimer's dementia without behavioral disturbance diagnosis. A review of the resident's annual Minimum Data Set (MDS), a federally mandated standardized assessment conducted at specific intervals to plan resident care] assessment dated [DATE], indicated that the resident had severe cognitive impairment with a BIMS (brief interview for mental status - a tool to assess cognitive status) of 3. A review of Resident 8's clinical record revealed admission to the facility on June 26, 2023, with diagnoses that included unspecified dementia and adjustment disorder (difficulty in managing stressful life changes such as coping with work-related problems, loss of loved ones, or relationship issues that leads to significant impairment in functioning) with mixed disturbance of emotions and conduct. The resident had severe cognitive impairment. A review of Resident 8's plan of care initiated June 25, 2023, and revised on March 26, 2024, indicated that the resident had the potential to demonstrate verbally abusive and sexually inappropriate behaviors related to dementia and poor impulse control, with the noted goal that the resident would verbalize understanding of the need to control verbally abusive behavior. Planned interventions were to conduct every fifteen-minute checks related to behaviors, analyze of key times, places, circumstances, triggers, and what de-escalates behavior and document, monitor and document observed behavior and attempted interventions in behavior log, and intervene before agitation escalates; guide away from source of distress; engage calmly in conversation; if response is aggressive, staff to walk calmly away, and approach later. Additionally, encourage seating next to males and/or leader during activities and meals or otherwise provide arm's length space or supervision and reminders of expected behavior. A progress note in Resident 8's clinical record completed by Employee 4, Social Services, dated October 16, 2023, at 5:13 p.m., indicated that it was called to this social workers attention that Resident 8 may become a little too handsy with some female residents and likes to hold and sometimes kiss female residents hands and was known as a ladies' man. According to the entry, it was explained to him the best way possible by myself {Employee 4} and his daughter. However, his BIMS score was 9 (moderate cognitive impairment) with his short-term memory impaired and resident needs reminders. The Activity Department was also made aware and will intentionally seat Resident 8 closer to men and all staff will continue to provide reminders. The progress note written by Employee 4 did not document details regarding the resident's behavior towards female residents and if the resident becoming too handsy was sexual abuse, sexual harassment, sexual coercion, or sexual assault and if abuse reporting and investigation was required, including identifying Resident 8's female resident victims. A progress note written by Employee 5, a licensed practical nurse (LPN), dated January 7, 2024, at 12:09 p.m., revealed that Resident 8 was observed multiple times the shift being sexually inappropriate with the female residents, rubbing their thighs up to their crotch. This was witnessed by this nurse {Employee 5} and by one of the CNAs. Resident 8 was placed in his room and told that he needs to be appropriate and to keep his hands to himself. This nurse {Employee 5} also called resident's daughter and explained the situation to her. Daughter seemed to be embarrassed and apologized. Daughter also stated that if it happened again, to give her a call and put him on the phone with her. A nurse progress note completed by Employee 6, RN Supervisor, dated January 7, 2024, at 12:31 p.m., revealed that related to inappropriate sexual behavior, Resident 8 was redirected and placed on every 15-minute checks for behavioral observation. Resident made aware behaviors was inappropriate. Resident stated, I don't remember doing it. Daughter was in to visit and made aware of behavior and behavioral monitoring checks and was okay with same. Employee 6 failed to initiate an investigation into the sexual abuse perpetrated by Resident 8 and failed to identify the female resident victims. At the time of the survey ending June 28, 2024, the facility was unable to provide documented evidence that they attempted to identify and protect the female resident victims from sexual abuse perpetrated by Resident 8. The facility failed to prevent, report, investigate and protect female residents from sexual abuse by Resident 8 as indicated in the facility's abuse prohibition policy. Resident 8's clinical record revealed a progress note completed by Employee 7, RN/former DON, dated February 29, 2024, at 5:55 p.m., revealed that the resident's representative was made aware on February 28, 2024, that a female resident reported that on February 27, 2024, Resident 8 approached her in the lobby and rubbed her leg over her clothes and stated oh you like this, and when she responded that she did not like this, he proceeded to grab her left breast over her clothes. The female resident removed herself from the lobby. Resident's RP, daughter, was very apologetic and has spoken with her father regarding these behaviors. RP reported that Resident 8 had no recollection of these behaviors when they happened, and he was remorseful and tearful when they discuss his actions. The facility failed to report this sexual abuse of the female resident perpetrated by Resident 8 and failed to promptly implement their abuse prohibition policy. An interview with the DON on June 26, 2024, at 11:25 a.m., confirmed that the facility was unable to provide documented evidence that the facility had implemented their abuse prohibition policy for identifying, reporting, investigating and protecting residents from sexual abuse perpetrated by Resident 8. The facility failed to identify the female resident victim. A review of Resident 48's clinical record revealed that the resident was admitted to the facility on [DATE], with diagnoses that included Alzheimer's disease (a type of brain disorder that causes problems with memory, thinking, and behavior and is a gradually progressive condition), cognitive communication deficit (occurs when someone has trouble with one or more cognitive processes involved in communication), and anxiety disorder (a group of mental illnesses that cause constant fear and worry and are characterized by sudden feelings of worry, fear, and restlessness). Resident 48's care plan, initiated on May 17, 2022, and revised on November 24, 2023, identified that the resident had impaired/declined in cognitive function or impaired thought processes related to diagnosis of Alzheimer's dementia without behavioral disturbance diagnosis. A review of the resident's annual Minimum Data Set assessment dated [DATE], indicated that the resident had severe cognitive impairment with a BIMS of 3. An incident report, completed by Employee 1, a Registered Nurse (RN), dated June 6, 2024, at approximately 5:30 p.m., revealed that Employee 2, a nurse aide (NA), reported that while by nurses' station talking with the scheduler, she looked down the hall (300's hallway) and saw another resident {Resident 8} close to Resident 48. Employee 2 went to Resident 48 and observed that her right breast was exposed and a male resident {Resident 8} had his hand on the resident's bare breast. Residents were separated immediately and taken to their rooms. Resident 48 was assessed by this writer {Employee 1} and no signs or symptoms of distress and offered no complaints and was acting per usual, pleasantly confused. Vital signs were obtained, and skin check completed with no abnormalities or injuries noted. Voice message left for Resident 48's attending physician and responsible party (RP), son, were informed of incident. A review of a witness statement written by Employee 2, no date or time noted, described that at approximately 3:30 p.m., I was at the nurses' station talking to [scheduler] about staying tonight. I happened to look down the hall and saw Resident 8 feeling Resident 48's right exposed breast. I ran down the hall, separated them and I put her {Resident 48} in her room and Resident 8 in his room. Further review of the incident report indicated that Resident 8's attending physician and RP were notified of the incident and the facility immediately initiated one-to-one direct observation of Resident 8. A review of a physician's order dated June 6, 2024, at 8:28 p.m., revealed an order for one-to-one direct observation by staff at all times. There was no documented evidence that the facility consistently provided sufficient supervision of Resident 8 and monitored the resident every fifteen-minute checks as care planned as of March 26, 2024, to ensure the safety of other residents due to Resident 8's sexual behaviors towards female residents. A review of Resident 8's clinical record revealed a nurses' progress note Health Status Note completed by Employee 3, a licensed practical nurse (LPN), dated June 6, 2024, at 10:26 p.m., revealed this writer last saw resident at approximately 5:00 p.m., seated in his wheelchair by nurses' station sleeping intermittently. One-to-one supervision and one-to-one supervision followed post incident and continued with no further incident this shift. An interview with the Director of Nursing (DON) on June 26, 2024, at 2:05 p.m., revealed that that Resident 8 was known to have sexually inappropriate encounters/behaviors with female residents as noted in his clinical record by staff. The DON was unable to provide documented evidence that the incidents noted on October 16, 2023, January 7, 2024, and on February 29, 2024, were thoroughly investigated. The facility did not report these incidents to the State Survey Agency, there were no incident reports or PB-22s (state agency standardized format for completion of abuse investigations) completed. The DON was unable to state why the facility did not implement their abuse policy for reporting, investigating and protecting residents because this DON was not employed at the facility during the times of the noted incidents. The only incident reported and investigated was the abuse of Resident 48 on June 6, 2024. The DON confirmed that the facility could not provide documented evidence that every fifteen-minute checks were conducted to provide supervision of Resident 8 with known sexually inappropriate behaviors to prevent him from further sexually abusing other female residents. The facility failed to protect and ensure that Resident 48 {victim} was free from sexual abuse perpetrated by Resident 8 who had a known documented history of sexual inappropriate behaviors. According to the Centers for Medicare and Medicaid Services psychosocial outcome guide, application of reasonable person concept, Resident 48 would have the expectation that she was safe in her home and treated with respect and dignity. When applying the reasonable person concept, Resident 48 would have suffered psychosocial harm and humiliation due to being sexually abused by Resident 8. An interview with the Nursing Home Administrator (NHA) on June 27, 2024, at 2:30 p.m., confirmed that the facility failed to protect Resident 48 from a resident {Resident 8} with known sexually inappropriate behaviors from sexual abuse. The NHA confirmed that the facility failed to ensure that each incident of sexual abuse towards other female residents was identified, by implementing their abuse policy in response and timely initiate an investigation to identify resident victims of sexual abuse perpetrated by Resident 8 and the protection of other female residents. A review of the facility's policy titled Bladder and Bowel Screening and Assessment, dated reviewed by the facility on May 10, 2024, revealed that incontinent management (check and change) is a technique for use with residents who are mostly incontinent, and staff will perform incontinent care on a check and change schedule. A clinical record review revealed that Resident 80 was admitted to the facility on [DATE], with diagnoses that included transient ischemic attack (a temporary blockage of blood flow to the brain) and cerebral infarction (brain damage that results from a lack of blood). The resident's care plan indicated that Resident 80 was at risk for decreased ability to perform activities of daily living in bathing, grooming, personal hygiene, dressing, eating, bed mobility, transfer, locomotion, and toileting, initiated on May 16, 2024. An MDS assessment dated [DATE] revealed that Resident 80 was cognitively intact with a BIMS score of 14 (a score of 13-15 indicates cognition is intact), dependent on staff for toileting hygiene (the ability to maintain perineal hygiene and adjust clothes before and after voiding having a bowel movement) and required substantial or maximal assistance for lower body dressing, showering, bathing, and moving from a sitting position to a standing position or transferring to the toilet. Resident 80 was always incontinent of bowel and bladder according to this assessment. A facility investigation dated June 6, 2024, revealed that Employee 12, Nurse Aide (NA), checked Resident 80 for incontinence and changed her at 11:20 AM on June 5, 2024 . Employee 12, NA, indicated that the resident is incontinent of urine, every two hours, and {communicates to staff when she} needs to be changed. Employee 12, NA, explained that she recalls seeing Resident 80 at 1:30 PM or 2:00 PM {on that date}but stated that she did not check if Resident 80 was incontinent because she was multi-tasking and helping two other residents with moving rooms. A facility investigation, dated June 6, 2024, revealed that Employee 13, NA, indicated that she changed Resident 80 before therapy {on June 5, 2024} and responded to her call bell later in the day. Employee 13, NA, indicated that Resident 80 is normally incontinent, and it is frequent. Employee 13, NA, indicated that she last checked and changed Resident 80 prior to the resident's therapy session {at 11:30 AM} A witness statement, undated, revealed that Employee 14, Certified Occupational Therapy Aide, indicated that Resident 80 received therapy services and was returned to her room at approximately 12:00 PM {on June 5, 2024}. A facility investigation, dated June 6, 2024, revealed that Employee 15, NA, checked Resident 80 during her first set of rounds on the 3:00 PM to 11:00 PM shift on June 5, 2024. Employee 15, NA, explained that the resident was soiled through her clothes and had dried bowel movement on her at the time. Employee 15, NA, indicated that Resident 80 was upset because she asked to be changed after lunch, but no one changed her when requested. A witness statement provided by Resident 80 dated June 6, 2024, revealed that on June 5, 2024, Resident 80 indicated she rang her call bell between 1:00 PM and 2:00 PM on June 5, 2024, to be changed. Resident 80 explained that the nurse aide told her she would change her, then told her the next shift staff would provide her care and left without providing her care. A witness statement provided by Employee 11, Registered Nurse, dated June 6, 2024, revealed that she entered Resident 80 ' s room {on June 5, 2024,} at 5:20 PM and saw urine dripping to the floor from the resident's lift pad. Employee 11, RN, explained that Resident 80 looked at her with tear-filled eyes and said they {staff} said they would be back, but they didn't come. Employee 11, RN, promised the resident that she would take care of this, changed the resident's clothes and hoyer pad, then assisted the resident to bed. A progress note dated June 5, 2024, at 11:34 PM indicated that a skin check assessment was performed and no new skin injuries or wounds were identified. During an interview on June 27, 2024, at 10:30 AM, Resident 80 stated that she sometimes waits over 30 minutes or more for care from staff when she needs to be changed. The resident explained that she needs staff assistance because she is not able to care for herself. Resident 80 recalled that on June 5, 2024, staff came into her room and told her that they couldn't change her because they were assisting others and too busy to provide her care. She explained that they told her the next shift would have to take care of her. She stated that she waited in a soiled brief for hours that day. Resident 80 stated that she is upset, frustrated, and cries when she needs to wait for care after soiling her brief. Resident 80 stated that staff continue to check on her, turn her call bell light off, but leave her without providing care. During an interview on June 28, 2024, at approximately 10:30 AM, the Nursing Home Administrator (NHA) and Director of Nursing (DON) confirmed that that facility neglected to provide the care and services necessary to avoid psychosocial upset and physical discomfort for Resident 80 failing to assure the resident's physical, mental, and psychosocial well-being. The NHA and DON confirmed that the facility investigation identified that Resident 80 was left in a soiled brief from approximately 1:30 PM on June 5, 2024, until 5:20 PM. The NHA and DON stated that Employee 12, NA, was terminated for neglecting Resident 80's needs. A clinical record review revealed that Resident 21 was admitted to the facility on [DATE], with diagnoses that include cerebral infarction (brain damage that results from a lack of blood) and hemiplegia (paralysis on one side of the body). A review of a quarterly MDS assessment dated [DATE] revealed that Resident 21 is cognitively intact with a BIMS score of 15 (a score of 13-15 indicates cognition is intact), and required substantial or maximal assistance for lower body dressing, showering, bathing, and moving from a sitting position to a standing position or transferring to the toilet. Resident 21's care plan indicated that the resident was at risk for urinary incontinence related to impaired mobility, physical limitations, and a history of hemiplegia initiated January 14, 2024, with a planned intervention to check the resident every two hours and as needed for incontinence also implemented on January 14, 2024. A facility investigation, dated May 23, 2024, revealed that Resident 21 reported that at night sometimes the {staff} comes in and tells me I'm not wet and leave my room. Resident 21 explained that in the middle of the night last {May 22, 2024}, she rang her call bell because she was wet. Resident 21 relayed that staff came in and told her she wasn't wet and would be back later but did not return to provide her care for about two hours. A statement dated May 24, 2024, at 11:00 AM, revealed that Employee 16, NA, stated that she changed Resident 21 at 3:00 AM on May 22, 2024. Employee 16 indicated that she responded to Resident 21's call bell for assistance at 4:30 AM. Employee 16, NA, stated that she did not check to see if Resident 21 was wet or provide Resident 21 with incontinence care because she assumed she was dry, despite the resident indicating she needed to be changed. Employee 16, NA, stated that she was trying to get caught up on documentation that night and went back to change the resident at 4:55 AM. Employee 16, NA, stated that her action in making the resident wait to be changed was wrong. A progress note dated May 24, 2024, at 9:01 PM indicated that Resident 21's skin was assessed and no new skin injuries or wounds were identified. During an interview on June 27, 2024, at 10:00 AM, Resident 21 stated that sometimes she waits a long time for care. She stated that she waits 20 minutes for staff to provide her care and longer when the facility is short on staff. Resident 21 stated that a few weeks ago, there was an incident where she rang her call bell for assistance to be changed, but staff told her she had to wait to be changed. Resident 21 stated that she felt disappointed because she was treated in that manner by staff. During an interview on June 28, 2024, at approximately 10:30 AM, the Nursing Home Administrator (NHA) and Director of Nursing (DON) confirmed that that facility neglected to provide the care and services necessary to avoid harm and to attain or maintain Resident 21's physical, mental, and psychosocial well-being. The NHA and DON confirmed that the facility investigation identified that Resident 21 rang her call bell because she soiled her brief but was not provided care timely because Employee 16, NA, was completing documentation. The NHA and DON stated that Employee 16, NA, was suspended, received a final level of discipline, and returned to work after completing abuse, neglect, and resident rights training. 28 Pa. Code 201.18 (e)(1) Management 28 Pa. Code 201.29 (a) Resident Rights 28 Pa. Code 211.12 (d)(5) Nursing Services