Every finding on record at Rouse Warren County Home

Based on review of a facility policy, observations, and staff interview, it was determined that the facility failed to ensure that food was stored in accordance with standards for food safety in the main kitchen and two kitchenettes observed (kitchenettes 100 hall and 400 hall).Findings include: Review of facility policy entitled Date marking and Discarding of Food dated 1/5/26, revealed If there is a use by date on a product and the product is unopened this is the date you follow. If you open a food item., the use by date is 3 days from the date that it was open. Leftover food may be saved for 3 days after preparation. Review of the med pass supplement label revealed After open, consume product within 4 days if properly refrigerated. Observations during tour of the main kitchen on 8/4/26, at 11:50 a.m. revealed the following: in the dry storage room a bag of Oreo cookie crumbles with a best buy date of 5/11/26; in the first walk-in refrigerator revealed three metal pans the first pan contained prepared peas with a date of 7/30/26; the second pan contained prepared mixed vegetables with a date of 7/31/26; and the third pan contained prepared chicken with a date of 7/29/26; in the second walk-in refrigerator revealed three cartons of whip cream one opened, all with best buy dates of 7/31/26, an open package of corn beef lunch meat with an open date of 7/21/26, and an open container of horseradish with a best by date of 7/6/26. During an interview at the time of observation with the Dietary Manager, he/she confirmed that the Oreo cookie crumble, the peas, mixed vegetables, chicken, three containers of whip cream, package of corn beef lunch meat, and the container of horseradish were beyond their use by dates and should have been discarded. Observations on 8/5/26, at 9:43 a.m. of the 100-hall kitchenette refrigerator revealed and open container of med pass (a supplement given to residents during medication administration) with an open date of 7/18/26. During an interview on 8/5/26, at the time of observations Licensed Practical Nurse Employee E8 confirmed that the med pass was dated open on 7/18/26, which was beyond its use by date and should have been discarded. Observations on 8/5/26, at 9:50 a.m. of the 400-hall kitchenette refrigerator revealed an open half gallon of lactose free milk with a best buy date of 8/1/26, and a half gallon of regular milk with a best buy date of 8/4/26. During an interview on 8/5/26, at the time of observation Registered Nurse Employee E9 confirmed that the lactose free milk and the regular milk were beyond their use by dates and should have been discarded. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management

Based on review of facility policy, manufacturer's recommendations, observations, and staff interviews, it was determined that the facility failed to ensure that medications and stock supplements were properly dated when opened and discarded in a timely manner two of five medication carts reviewed (Unit 100 and Unit 700). Findings include: Review of a facility policy entitled Medication Administration General Guidelines dated 1/05/26, revealed it is the policy to administer medications as prescribed, in accordance with good nursing principles and practices and only by persons legally authorized to do so. Always check manufacturer's expiration date prior to administration and discard expired medications per policy. Review of a facility policy entitled House-Supplied (Floor Stock) Medications dated 1/05/26, revealed the facility will use the manufacturer's expiration date to determine when the medication is to be disposed of due to expired date. Manufacturer's recommendations for Insulin Lispro Kwikpen (a type of fast-acting insulin), revealed to throw away the Insulin Lispro pen you are using after 28 days, even if it still has insulin left in it. Manufacturer's recommendations for UTI-Stat (a supplement to prevent a urinary tract infection) 30 fl oz (fluid ounces) revealed discard three months after opening and record date opened on bottom of container. Observations of the 100 Unit's medication cart on 8/04/26, at 12:30 p.m. revealed an opened Kwikpen of Insulin Lispro without an open date, therefore the staff were unable to determine the discard date. Licensed Practical Nurse (LPN) Employee E5 confirmed at that time, that the opened Insulin Kwikpen lacked an open date, and staff were unable to determine the discard date for safety of use of the insulin. Observations of the 700 Unit's medication cart on 8/04/26, at 2:50 p.m. revealed an opened bottle of UTI-Stat with no open date, therefore the staff were unable to determine the discard date. The manufacturer instructions noted on the bottle revealed to discard 3 months after opening. LPN Employee E6 confirmed at that time, that there was no open date documented on the bottle, and staff were unable to determine the discard date for safety of use of the UTI-Stat supplement. Interview with the Director of Nursing on 8/05/26, at approximately 2 p.m. revealed it is the facility policy to always date insulin and supplements when opened to ensure safety when administering to a resident. 28 Pa. Code 211.9(a)(1) Pharmacy services 28 Pa. Code 211.10(c) Resident care policies 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on review of facility policy and clinical record, observations, and staff interview, it was determined that the facility failed to follow acceptable infection control practices regarding enhanced barrier precautions (EBP) for one of 27 residents reviewed (Resident R76) on the 400 unit (memory care unit.) Findings include: Review of a facility policy entitled, Isolation Precautions (Contact, Droplet, Airborne), dated 1/01/26, revealed it is the policy of this facility to prevent and limit the spread of infection within the facility through the use of isolation precautions while providing care to those that require isolation precautions. The policy further stated that An orange sign instructing visitors to report to the nursing station before entering should be placed at the doorway of the resident's room.Isolation precautions refer to the use of gown and gloves for certain residents during specific high-contact resident care activities that have been found to increase risk for transmission of multidrug-resistant organisms. Clear signage will be posted on the door or wall outside of the resident room indicating the type of precautions, required personal protective equipment (PPE), and the high-contact resident care activities that require the use of gown and gloves. An order for enhanced barrier precautions will be obtained for residents with any of the following: Wounds and/or indwelling medical devices (e.g., central line, urinary catheter [a tube inserted into the bladder to drain urine], feeding tube, tracheostomy/ventilator) regardless of MDRO colonization status. Resident R76's clinical record revealed an admission date of 1/12/26 with diagnoses of dysphagia (difficulty swallowing), difficulty in walking, abnormal posture and hypertension (high blood pressure). The clinical record also revealed an alert that the resident was on isolation precautions due to an eye inflammation which had been cultured with results pending. Observations on 8/04/26, 8/05/26, and 8/06/26, revealed no educational alert signage or PPE maintained for Resident R76 at the doorway of the resident room on the memory care unit, identified as being on contact precautions to alert nursing staff and visitors of potential infectious exposure. During an interview on 8/06/26, at 11:30 a.m. Licensed Practical Nurse Employee E4 confirmed the facility lacked signage for a resident with contact precautions who should have isolation precautions maintained. 28 Pa. Code 211.10(c) Resident care policies 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of facility policy, clinical records, and staff interview, it was determined that the facility failed to inform the resident and/or resident representative in advance of the risks and benefits of psychotropic medications (medications that affect the persons mental state, emotions and behavior) and the treatment alternatives prior to initiating the administration of the medication for one of five residents reviewed for unnecessary medications (Resident R11).Findings include: Facility policy entitled Psychotropic Medications dated 1/5/26, indicated that the facility will inform the resident's representative of the need for desired effects and potential side effects of medication. RN (Registered Nurse) will obtain consent either, verbally or in person, and complete Psychotropic Medication Consent form. Resident R11's clinical record revealed an admission date of 2/11/24, with diagnoses that included Diabetes (a health condition caused by the body's inability to produce enough insulin), Dementia (loss of cognitive functioning affecting a person's memory and behaviors), and Congestive Heart Failure (CHF - a long-term condition that happens when your heart can't pump blood well enough to give your body a normal supply causing blood and fluids collect in your lungs and legs over time). Resident R11's physician's orders revealed an order dated 4/21/26, for Diazepam (medication used to treat anxiety) 5 milligram (mg) by mouth twice daily for 90 days and a second order dated 6/17/26, for Diazepam 5 mg by mouth daily and 10 mg by mouth at bedtime. Resident R11's clinical record lacked evidence that he/she and/or his/her representative were informed in advance of the risks, benefits, and alternative treatments prior to the administration of Diazepam. During an interview on 8/7/26, at 9:53 a.m. the Director of Nursing confirmed that Resident R11's clinical record lacked evidence that he/she and/or his/her representative were informed in advance of the risk, benefits, and alternative treatment prior to the administration of Diazepam. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services 28 Pa. Code 201.18(b)(1) Management

Based on review of facility policies, clinical records, observations, and staff interviews, it was determined that the facility failed to provide housekeeping services necessary to maintain clean bed linens for one of 27 residents reviewed (Resident R59). Review of facility policy entitled Bed Linen Policy dated 1/5/26, indicated Bed linen will be changed: At least weekly. Whenever clinically indicated or requested by the resident. Review of Resident R59's clinical record revealed an admission date of 4/21/26, with diagnoses that included hypothyroidism (a condition when the thyroid produces low amounts of thyroid hormones), and chronic diastolic heart failure (a condition where the heart cannot supply the body with enough blood). Review of Resident R59's plan of care revealed a care plan dated 4/22/26 for impairment to skin with an intervention to keep bed linen clean. Observations on 8/4/26, at 1:47 p.m. and again on 8/5/26, at 9:27 a.m. revealed Resident R59's pillowcase had several dry areas of a dark brown/red substance. His/her bed sheets had a gray hue (a color or shade of color) and appeared to be unclean. During an interview on 8/4/26, at 1:47 p.m. with Resident R59, he/she said that they cannot remember the last time their sheets were changed. During an interview on 8/5/26, at 2:29 p.m. the Director of Nursing (DON) confirmed that Resident R59's pillowcase had several areas of a dark brown/red substance on it and the sheets appeared unclean. The DON also confirmed that Resident R59's bed linens should have been changed. 28 Pa. Code 201.14 (a) Responsibility of Licensee

Based on a review of clinical records and staff interviews, it was determined that the facility failed to refer residents with newly evident or possible serious mental disorders, intellectual disabilities, or related conditions for a Preadmission Screening and Resident Review (PASRR) level II resident review for one of 27 residents reviewed (Resident R10).Findings include: Preadmission Screening and Resident Review (PASRR) is a federal requirement to help ensure that individuals are not inappropriately placed in nursing facilities for long-term care. The PASRR process requires that all applicants to Medicaid-certified nursing facilities be given a preliminary assessment to determine whether they might have serious mental illness before admission. This is called a PASRR Level I screen. Those individuals who test positive for PASRR Level I are then evaluated in-depth; this is called PASRR Level II. The results of this evaluation result in a determination of need, a determination of an appropriate setting, and a set of recommendations for services for the individual's plan of care. A review of the Pennsylvania Department of Human Services Office of Long-Term Living Bulletin entitled Revised Pennsylvania Preadmission Screening Resident Review (PASRR) Level 1 Identification Form (MA 376), effective July 1, 2024, revealed if the individual has a change in condition that affects program office criteria as found on the PASRR Level I form, a PASRR Level II evaluation form will need to be completed. Nursing facilities will communicate the need to have a PASRR Level II form done by notifying the department's Office of Long-Term Living, Division of Nursing Facility Field Operations Team. Resident R10's clinical record revealed an admission date of 12/26/22 with diagnoses that included Multiple Sclerosis (MS is an autoimmune disease that affects the central nervous system resulting in a range of physical and cognitive symptoms), Dementia (loss of cognitive functioning affecting a person's memory and behaviors), and Depression (characterized by persistent feeling of sadness loss of interest in activities once enjoyed). Resident R10's PASRR completed 12/21/22, under Section III Mental Health indicated that a Serious Mental Illness diagnosis may include Schizophrenia, Schizoaffective Disorder, Delusional Disorder, Psychotic Disorder, Personality Disorder, Panic or Other Severe Anxiety Disorder, Somatic Symptom Disorder, Bipolar Disorder, Depressive Disorder, or another mental disorder that may lead to chronic disability. Section III A for Diagnosis was checked as No with notation dated 12/27/22, that depression was managed with medication. The 12/21/22, PASRR was reviewed and signed off by Pennsylvania Department of Human Services Office Of Long Term Living on 4/11/23. Resident R10's Minimum Data Set (MDS - federally mandated standardized assessment conducted at specific intervals to plan resident care) with an Assessment Reference Date (ARD) of 11/26/24, Section I5900 Bipolar Disorder was checked Yes. Bipolar is defined as a mental health condition where you experience extreme mood swings that include emotional highs and lows. It causes significant shifts in mood, energy, activity levels, and concentration, affecting a person's overall functioning. Resident R10's clinical record lacked evidence that the facility referred him/her for a PASRR level II through the state mental health authority following the new diagnosis of Bipolar on 11/26/25. During an interview on 8/6/26, at 2:28 p.m. Registered Nurse Assessment Coordinator Office Manager Employee E7 confirmed that the facility did not refer to the state mental health authority following the new diagnosis of Bipolar as required. 28 Pa. Code 201.14(a) Responsibility of licensee

Based on review of facility policy, clinical records, observation, and staff interview, it was determined that the facility failed to maintain proper care of respiratory equipment according to physician's orders for two of five residents reviewed for respiratory care (Residents R18 and R20). Findings include: Review of facility policy entitled Medication Administration General Guidelines dated 1/5/26, indicated Medications are administered in accordance with written orders of the attending physician. Review of Resident R18's clinical record revealed an admission date of 2/21/25, with diagnoses that included chronic respiratory failure (a condition where your lungs don't exchange air properly), chronic obstructive pulmonary disease (when your lungs do not have adequate air flow), and hypertension (high blood pressure). Review of Resident R18's physician's orders dated 10/20/25, revealed an order to change O2 (oxygen) tubing (a thin tube with two prongs that fit into the resident's nostrils to deliver oxygen), water bottle (used to humidify the oxygen being delivered to prevent drying of the nares), and tubing bag (a zip lock type bag to store the oxygen tubing when not in use) weekly every night shift every Sunday. Observation on 8/4/26, at 2:00 p.m. revealed an oxygen concentrator sitting next to Resident R18's bed and attached to the concentrator was a water bottle and O2 tubing with a date of 7/27/26, written on them. Observation on 8/5/26, at 9:30 a.m. of the water bottle and O2 tubing attached to the oxygen concentrator remained with a date of 7/27/26 (Monday). Review of Resident R20's clinical record revealed an admission date of 8/21/23, with diagnoses that included chronic obstructive pulmonary disease, gastro esophageal reflux disease (a condition when stomach acid repeatedly flows back up into your throat), and hypothyroidism (a condition when the thyroid produces low amounts of thyroid hormones). Review of Resident R20's physician orders revealed an order dated 10/20/25, to change O2 tubing, water bottle, and tubing bag weekly every night shift every Sunday. Observation on 8/4/26, at 2:00 p.m. revealed an oxygen concentrator sitting next to Resident R20's bed and attached to the concentrator was a water bottle and O2 tubing with a date of 7/27/26, written on them. Observation on 8/5/26, at 9:30 a.m. of the water bottle and O2 tubing attached to the oxygen concentrator remained with a date of 7/27/26 (Monday). During an interview on 8/5/26, at 2:29 p.m. the Director of Nursing (DON) confirmed that Resident's R18 and R20's water bottle and oxygen tubing were dated 7/27/26. He/she also confirmed that Resident's R18 and R20's water bottles and oxygen tubing should have been changed per physician orders. 28 Pa. Code 211.12(d)(1)(5) Nursing services 28 Pa. Code 211.10(c) Resident care policies

Based on review of facility policy, review of facility documentation and clinical records, observations, and staff interviews, it was determined that the facility failed to provide necessary precautionary measures to maintain resident safety and prevent injury during transport in a wheelchair and/or Broda chair (a specialized chair used for residents who require pressure relief, advanced postural support, and long-term sitting) resulting in actual harm of an acute non-displaced fracture of the lateral malleolus and medial malleolus ( a recent break located on the outer side of the ankle at the end of the fibula and the inner side of the ankle at the end of the tibia with the bone fragments not shifting out of their normal position) for one of four residents reviewed (Resident R1). Findings include: Facility policy entitled Wheelchair Footrest Assessment, dated 1/5/26, states, No Resident is to be transported by staff or family members unless the wheelchair footrest are properly attached during transport. Resident R1's clinical record revealed an admission date of 11/1/25, with diagnoses that included dementia (a decline in mental abilities severe enough to interfere with daily life), depression, and weakness. Resident R1's Functional Self Performance Deficit care plan, date initiated 4/14/26, revealed, Broda chair with pommel cushion (cushion with a raised center section) with footrest and footbuddy (a cushioned wheelchair accessory used to support the lower legs and feet) on at all times. Resident R1's clinical record revealed a nursing note written by Licensed Practical Nurse (LPN) Employee E1, dated 5/25/26, at 1:25 p.m. Resident was being pushed up the hallway to lunch when her right foot dropped and got caught under her Broda chair. Resident c/o (complained of) 8/10 pain (pain scale ranging from 0-10, with 10 being the worst pain ever experienced). Right ankle swollen. Pain medication administered, right ankle elevated, ice pack applied, RN (Registered Nurse) and family notified. VS (Vital Signs) baseline. X-ray ordered. Staff teaching done on the importance of using footrests. Will continue to monitor Resident R1's clinical record revealed a nursing note written by RN Employee E2, dated 5/25/26, at 1:32 p.m. LPN reported resident's right leg buckled under wheelchair, c/o pain, ibuprofen administered. Writer assessed resident. Resident assisted into bed by two nursing staff, very heavy assist as resident will not bear weight on right leg. FOB (foot of bed) elevated. Writer observed right with significant swelling, bruising. Resident with c/o pain. Resident R1's clinical record revealed a nursing note written by RN Employee E2, dated 5/25/26, at 2:34 p.m. Transfer resident to ER (Emergency Room) to be evaluated and treated for right ankle trauma. Writer called diagnostics x-ray to inquire if x-ray could be performed in house today. After one-hour diagnostics had not returned phone call. Resident R1's clinical record revealed a nursing note written by RN Employee E2, dated 5/25/26, at 3:15 p.m. Resident R1 has left the facility. The resident was transferred to the hospital .Reason for Transfer/Condition: trauma to right ankle with c/o pain, will not bear on right extremity, significant swelling with bruising to right ankle . Resident R1's clinical record revealed x-ray scan results dated 5/25/26, at 5:58 p.m. indicating an acute non-displaced fracture of the lateral malleolus and medial malleolus. Resident R1's clinical record revealed a nursing note written by RN Employee E3, dated 5/25/26, at 11:11 p.m. Patient returned from ER at 10:30 p.m. Doctor made aware. Patient to be non-weight bearing to right lower extremity. Ice and elevate right extremity. Keep splint on at all times. Follow up with Ortho (specialize in treating bone fractures) in morning. Resident R1's clinical record revealed a nursing note written by RN Employee E4, dated 5/26/26, at 8:20 a.m. OT (Occupational Therapy) eval for positioning in new chair support of LE (Lower Extremity) r/t (related to) acute ankle fracture. The facility investigation revealed that CNA (Certified Nursing Assistant) Employee E5 provided a written statement with an incident date of 5/25/26, which revealed, [He/she] helped another aide get [Resident R1] to the restroom, once they got [him/her] off and into [his/her] chair and the aide told [him/her] to take [him/her] to the dining room. When wheeling [him/her] to the dining room [his/her] right leg dropped and got caught under [his/her] wheelchair. [He/she] immediately informed the nurse of what happened.Was missing footrests. The facility investigation revealed that LPN Employee E6 provided a written statement with an incident date of 5/25/26, which revealed, Heard [Resident R1] crying out and aide apologizing. Resident was grasping [his/her] leg and grimacing. Aide was comforting resident. After a few minutes noticed residents, right ankle was very swollen and was discolored and resident was expressing that it was painful .foot pedals were missing. The facility investigation revealed that CNA Employee E7 provided a written statement with an incident date of 5/25/26, which revealed, [He/she] was walking back on the hall from taking a resident to the dining room for lunch to get another resident when [he/she] saw CNA Employee E5 pushing Resident R1 to the dining room and [he/she] put [his/her] foot down and it got caught under the Broda chair .footrests were not on chair. Review of facility orientation documents dated 11/8/25, upon hire for CNA Employee E5 revealed he/she received training related to safe transports related to a Broda chair and reviewed the facility's Foot Rest Policy. Observations made on 6/18/26, between approximately 2:00 p.m. and 2:30 p.m. revealed that Resident's R2, R3, and R4 were being pushed by staff down the hallways in wheelchairs and/or Broda chairs without footrests in place. Interview with the Assistant Director of Nursing (ADON) and Nursing Home Administrator (NHA) on 6/18/26, at approximately 4:45 p.m. confirmed that during Resident R1's transport on 5/25/26, leg rest were not in place, and the resident sustained actual harm of an acute non-displaced fracture of the lateral malleolus and medial malleolus. ADON and NHA confirmed the leg rests should always be in place during transport and were not in place for Residents R2, R3, and R4. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(e)(1) Management 28 Pa. Code 211.12(c) Nursing services 28 Pa. Code 211.12(d)(3) Nursing services 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of facility policy, review of facility documentation and clinical records, and staff interviews, it was determined that the facility failed to ensure that one resident was free of neglect during care which resulted in actual harm of an acute non-displaced fracture of the lateral malleolus and medial malleolus ( a recent break located on the outer side of the ankle at the end of the fibula and the inner side of the ankle at the end of the tibia with the bone fragments not shifting out of their normal position) for one of four residents reviewed (Resident R1).Findings include: The Abuse, Neglect, and Exploitation policy, dated 1/5/26, revealed It is the policy of the Rouse Home to prevent, report, and investigate all allegations of abuse, neglect, or misappropriation of property relative to all residents in our care. Resident R1's clinical record revealed an admission date of 11/1/25, with diagnoses that included dementia (a decline in mental abilities severe enough to interfere with daily life), depression, and weakness. Resident R1's Functional Self Performance Deficit care plan, date initiated 4/14/26, revealed, Broda chair (a specialized chair used for residents who require pressure relief, advanced postural support, and long-term sitting) with pommel cushion (cushion with a raised center section) with footrest and footbuddy (a cushioned wheelchair accessory used to support the lower legs and feet) on at all times. Resident R1's clinical record revealed a nursing note written by Licensed Practical Nurse (LPN) Employee E1, dated 5/25/26, at 1:25 p.m. Resident was being pushed up the hallway to lunch when her right foot dropped and got caught under her Broda chair. Resident c/o (complained of) 8/10 pain (pain scale ranging from 0-10, with 10 being the worst pain ever experienced). Right ankle swollen. Pain medication administered, right ankle elevated, ice pack applied, RN (Registered Nurse) and family notified. VS (Vital Signs) baseline. X-ray ordered. Staff teaching done on the importance of using footrests. Will continue to monitor. Resident R1's clinical record revealed a nursing note written by RN Employee E2, dated 5/25/26, at 1:32 p.m. LPN reported resident's right leg buckled under wheelchair, c/o pain, ibuprofen administered. Writer assessed resident. Resident assisted into bed by two nursing staff, very heavy assist as resident will not bear weight on right leg. FOB (foot of bed) elevated. Writer observed right with significant swelling, bruising. Resident with c/o pain. Resident R1's clinical record revealed a nursing note written by RN Employee E2, dated 5/25/26, at 2:34 p.m. Transfer resident to ER (Emergency Room) to be evaluated and treated for right ankle trauma. Writer called diagnostics x-ray to inquire if x-ray could be performed in house today. After one-hour diagnostics had not returned phone call. Resident R1's clinical record revealed a nursing note written by RN Employee E2, dated 5/25/26, at 3:15 p.m. Resident R1 has left the facility. The resident was transferred to the hospital .Reason for Transfer/Condition: trauma to right ankle with c/o pain, will not bear on right extremity, significant swelling with bruising to right ankle . Resident R1's clinical record revealed x-ray scan results dated 5/25/26, at 5:58 p.m. indicating an acute non-displaced fracture of the lateral malleolus and medial malleolus. Resident R1's clinical record revealed a nursing note written by RN Employee E3, dated 5/25/26, at 11:11 p.m. Patient returned from ER at 10:30 p.m. Doctor made aware. Patient to be non-weight bearing to right lower extremity. Ice and elevate right extremity. Keep splint on at all times. Follow up with Ortho (specialize in treating bone fractures) in morning. Resident R1's clinical record revealed a nursing note written by RN Employee E4, dated 5/26/26, at 8:20 a.m. OT (Occupational Therapy) eval for positioning in new chair support of LE (Lower Extremity) r/t (related to) acute ankle fracture. The facility investigation revealed that CNA (Certified Nursing Assistant) Employee E5 provided a written statement with an incident date of 5/25/26, which revealed, [He/she ]helped another aide get [Resident R1] to the restroom, once they got [him/her] off and into [his/her] chair the aide told [him/her] to take [him/her] to the dining room. When wheeling [him/her] to the dining room [his/her] right leg dropped and got caught under [his/her] wheelchair. [He/she] immediately informed the nurse of what happened.Was missing footrests. The facility investigation revealed that LPN Employee E6 provided a written statement with an incident date of 5/25/26, which revealed, Heard [Resident R1] crying out and aide apologizing. Resident was grasping [his/her] leg and grimacing. Aide was comforting resident. After a few minutes noticed resident's, right ankle was very swollen and was discolored and resident was expressing that it was painful .foot pedals were missing. The facility investigation revealed that CNA Employee E7 provided a written statement with an incident date of 5/25/26, which revealed, [He/she] was walking back on the hall from taking a resident to the dining room for lunch to get another resident when [he/she] saw CNA Employee E5 pushing Resident R1 to the dining room and [he/she] put [his/her] foot down and it got caught under the Broda chair .footrests were not on chair. Review of facility orientation documents dated 10/22/25, for CNA Employee E5 revealed he/she received training related to Resident Abuse Policy and Procedure, indicating he/she understood the policy is to prevent neglect relative to all residents. Review of facility orientation documents dated 11/8/25, for CNA Employee E5 revealed he/she received training related to safe transports related to a Broda chair and reviewed the facility's Foot Rest Policy. Interview with the Assistant Director of Nursing and the Nursing Home Administrator on 6/18/26, at approximately 4:45 p.m. confirmed CNA Employee E5 failed to place the leg rests on Resident R1's Broda chair per his/her care plan and facility policy during transport on 5/25/26, causing harm to Resident R1. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(e)(1) Management 28 Pa. Code 211.12(c) Nursing services 28 Pa. Code 211.12(d)(3) Nursing services 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of clinical records and facility policy, observations, and staff interview, it was determined that the facility failed to appropriately maintain respiratory care equipment and promote cleanliness and help prevent the spread of infection regarding respiratory care equipment according to physician's orders for three of 25 residents reviewed (Resident R22, R55, and R120).Findings include: A facility policy entitled Oxygen dated 1/08/25, indicated that the humidifier (bottle of distilled water that adds moisture to the dry oxygen flow, preventing irritation and promoting comfort during inhalation) and tubing (tubing that connects the oxygen source (like a concentrator or tank), which then delivers the oxygen to the patient) will be changed and the concentrator (medical device that draws in room air, filters out nitrogen, and provides a concentrated stream of oxygen) filter will be cleaned every two weeks and as needed, and would be labeled with the date every time the humidifier/tubing is changed. Review of Resident R22's clinical record revealed an admission date of 2/19/24, with diagnoses that included respiratory failure, stroke with left-sided weakness, and metabolic encephalopathy (form of brain dysfunction caused by systemic illnesses, infections, toxins, or imbalances in the body's chemicals that affect brain function). Further review of Resident R22's clinical record revealed a physician's order dated 7/18/25, to administer ipratropium-albuteral solution (medication that relaxes and opens the air passages to the lungs to make breathing easier) through a nebulizer (small machine that turns liquid medicine into a mist that can be easily inhaled) by mouth three times a day for cough was discontinued on 7/20/25. Observation on 8/19/25, at 10:27 a.m. revealed a nebulizer machine on Resident R22's bedside stand and a nebulizer mask dated 7/26/25, lying on the floor between the bed and bedside stand. During an interview at that time, the Director of Nursing confirmed that the nebulizer mask and machine should have been removed from Resident R22's room upon the nebulizer order being discontinued. Resident R55's clinical record revealed an admission date of 6/12/23, with diagnoses that included heart failure, long-term kidney disease, and Type 2 Diabetes (condition where the body cannot use insulin correctly and sugar builds up in the blood). Further review of Resident R55's clinical record revealed a physician's order dated 12/30/23, to administer oxygen through a nasal cannula (thin, flexible tube that goes around your head with two prongs that go inside your nostrils that deliver the oxygen) to maintain blood oxygen saturations between 88-92%; a physician's order dated 3/18/24, to change oxygen tubing, water (humidifier) bottle, and clean the filter every two weeks. Review of Resident R55's treatment administration record (TAR) revealed that he/she received supplemental oxygen routinely. Observation on 8/19/25, at 10:50 a.m. revealed Resident R55's tubing bag was dated 8/05/25, the humidifier bottle was dated 8/11, there was no date on the oxygen tubing, and the external concentrator filter was covered with a copious amount of white fluffy substance. During an interview at that time, Licensed Practical Nurse (LPN) Employee E5 confirmed that the tubing bag and humidifier bottle should have been changed, the tubing should have been dated; and that the filter was dirty and needed cleaned/replaced. Resident R120's clinical record revealed an admission date of 2/17/23, with diagnoses that included emphysema (lung disease leading to difficulty breathing), heart failure, and chronic obstructive pulmonary disease (COPD- a progressive group of lung diseases causing airflow obstruction and breathing problems). Further review of Resident R120's clinical record revealed a physician's order dated 5/13/25, to administer oxygen through a nasal cannula to maintain blood oxygen saturations between 88-92%; a physician's order dated 3/18/24, to change oxygen tubing, water bottle, and clean the filter every two weeks. Review of Resident R120's TAR revealed he/she received supplemental oxygen routinely. Observation on 8/19/25, at 10:40 a.m. revealed Resident R120's oxygen concentrator external concentrator filter was covered with a copious amount of white fluffy substance. During an interview at that time LPN Employee E6 confirmed that the filter was dirty and needed to be cleaned. 28 Pa. Code 201.18(b)(1) Management28 Pa. Code 201.14(a) Responsibility of licensee28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of a facility policy, observations and staff interviews, it was determined that the facility failed to safely store food containers in the main kitchen and ensure that food was stored in accordance with standards for food safety in pantry refrigerators on two of three nursing units observed (100 Unit and 700 Unit).Findings include: A facility policy entitled Cleaning-Dishes with Dish Machine dated 1/08/25, indicated that staff are to allow dishes to dry on racks, do not dry with towels, and do not put any dishes away wet. A facility policy entitled Handling and Storage of Food brought in by Family or Friends dated 1/08/25, indicated that food should se stored with the name of the resident and date brought in, a refrigerator is available on B-side of the building for storage of Family/Friend delivered perishable food, perishable food or beverages brought in to residents from outside are not co-mingled with main facility refrigerators, and food handled safely will be held for 72 hours. Observation in the main kitchen on 8/18/25, at 11:05 a.m. revealed a moderate amount of clear liquid and a small amount of moist food particles between metal stacked steam table trays. Interview at that time with Dietary Manager Employee E2 confirmed that the metal trays were stacked wet and that they would have to be rewashed and dried properly. Observation in the main kitchen on 8/19/25, at 10:20 a.m. revealed a moderate amount of clear liquid between metal stacked steam table trays. During an interview at that time Dietary Aide Employee E1 confirmed the wet stacking between metal steam table trays. Observation on 8/18/25, at 12:36 p.m. of the 700 Unit pantry refrigerator revealed unknown food item wrapped in foil lacked name and/or date, facility side salad lacked a date, and a white foam cup containing ham salad that lacked name/date. During interview at that time, Dietary Employee E3 confirmed that the above listed items were in the facility unit pantry and lacked labels for names and dates. Observation on 8/18/25, at 12:49 p.m. of the 100 Unit pantry refrigerator revealed the following: 1/2 of a bologna and cheese sandwich in an open baggie and lacked a date; three 1/2 cup clear containers with red lids (2 containing gray tinted sauerkraut, one containing unidentifiable food item) and the containers were labeled with an unknown name and lacked a date; and one white oblong container with clear lid containing two pieces of blueberry cake/muffins and lacked a name and date. Interview at that time Dietary Employee E4 confirmed that food items need to be dated and labeled with resident names. During an interview on 8/19/25, at approximately 12:45 p.m. the Director of Nursing confirmed that there is a specific refrigerator for families to use when they bring items into the facility and that the refrigerators in the unit pantries are only for dietary staff to use during mealtimes. 28 Pa. Code 201.14(a) Responsibility of licensee28 Pa. Code 201.18(b)(1)(3) Management28 Pa. Code 211.6(f) Dietary services

Based on review of facility policy, observations and staff interviews, it was determined that the facility failed to appropriately discard outdated medications for one of three medication carts reviewed (700 cart). Findings include: Review of facility policy entitled Medication Cart, Cleaning of dated [DATE], indicated the Registered Nurse (RN) and/or Licensed Practical Nurse (LPN) is to check expiration date and dispose of medications that are expired. Insulin expiration is 28 days after opening and is to be dated accordantly; this supersedes the manufacturer expiration date. Review of manufacturer's guidelines revealed that an open NovoLog (type of Insulin) FlexPen (pre-filled syringe) must be used within 28 days after opening or be discarded, even if the vial still contains insulin. Observation of drug storage on [DATE], at 1:46 p.m. of Unit 700 medication cart revealed an open NovoLog FlexPen with an open date of [DATE], which was beyond the 28 days after opening. During an interview at the time of observation, LPN Employee E7 confirmed that the open date on the NovoLog FlexPen was beyond the 28 days and it should have been discarded. 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.9(a)(1) Pharmacy services 28 Pa. Code 211.12(d)(1) Nursing services

Based on review of facility policies and grievances, observations, and staff interviews, it was determined that the facility failed to maintain a clean and sanitary environment on two of seven units observed (100 and 200 units). Findings include: A facility policy entitled, Daily Room Cleaning dated 1/8/25, revealed To maintain a clean environment that is odor free . Pull the garbage and replace the bag .Sweep the floor and clean up .Mop the floor . A facility policy entitled, Room Completes dated 1/8/25, revealed Room completes are to be done on each hall daily .Pull Trash clean trash can replace liner .Sweep floor from corner to corner .Mop entire room from corner to corner . Review of Grievances from June 2025 revealed concerns with the cleanliness of a resident room and bathroom on the 200 unit. Observations made at approximately 11:30 a.m. on 7/2/25, revealed resident room [ROOM NUMBER] and the 200-unit break/storage area behind the nurse's station had thick dry spots from what appeared to be a spilled liquid, there was debris, straw wrappers, and napkins on the floors, fuzzy dust and food crumbs on the floor, and trash that needed to be emptied. Staff interviews conducted on all units throughout the visit on 7/2/25, revealed Employees E1, E2, E3, E4, E5, E6, E7, E8, E9, E10, and E11 all had concerns related to housekeeping, especially on the 100-unit, 200-unit, and 300-unit. During an interview and tour with the Nursing Home Administrator at approximately 12:30 p.m. on 7/2/25, he/she confirmed the dirty conditions in Resident room [ROOM NUMBER] and in the 200-unit break/storage area behind the nurse's station. 28 Pa. Code 201.18 (b)(1)(3) Management

Based on review of facility policy and clinical records, and staff interview it was determined that the facility failed to provide the resident and/or resident representative with a written notice of the facility bed-hold policy (explanation of how long a bed can be held during a leave of absence and the cost per day) upon transfer for three of 24 residents reviewed (Residents R30, R88 and R114). Findings include: Review of the facility policy entitled Bed Hold Policy dated 1/06/24, indicated At the time of transfer, the Admissions office will send out the Notice of Involuntary Discharge, Transfer and Bed Hold letter. Review of Resident R30's clinical record revealed an admitted [DATE], with diagnoses that included chronic obstructive pulmonary disease (condition when your lungs do not have adequate air flow), vascular dementia (a disease that affects short term memory and the ability to think logically), and hypotension (low blood pressure). Review of Resident R30's progress note dated 5/31/24, revealed the resident was transferred to the hospital. The clinical record lacked documentation that Resident R30 and/or their representative was provided with a copy of the facility bed-hold policy. Review of Resident R88's clinical record revealed an initial admitted [DATE], with diagnoses that included dementia (memory loss that interferes with daily living), anxiety, hyperlipidemia (high cholesterol), and feeding difficulties. Review of Resident R88's progress note dated 8/16/24, revealed the resident was transferred to the hospital. The clinical record lacked documentation that Resident R88 and/or their representative was provided with a copy of the facility bed-hold policy. Review of Resident R114's clinical record revealed an initial admitted [DATE], with diagnoses that included dementia, difficulty walking, hyperlipidemia, and anxiety. Review of Resident R114's progress note dated 9/02/24, revealed the resident was transferred to the hospital. The clinical record lacked documentation that Resident R114 and/or their representative was provided with a copy of the facility bed-hold policy. During an interview on 9/27/24, at 10:00 a.m. the Nursing Home Administrator confirmed that there was no evidence that the residents listed above and/or their representatives were provided with a copy of the facility bed-hold policy and also confirmed that the bed-hold policy should have been provided upon transfer. 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 201.29(c.3) (2) Resident rights

Based on review of clinical records, the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, and staff interview, it was determined that the facility failed to ensure that the Minimum Data Set (MDS - a federally mandated standardized assessment conducted at specific intervals to plan resident care) accurately reflected the status of three of 24 residents reviewed (Residents R78, R72, and R99). Findings include: Review of Section O0110 of the RAI User's Manual entitled Special Treatments, Procedures, and Programs directs staff to Check all of the following treatments, procedures, and programs that were performed (a) on admission- days one through three, (b) while a resident- within the last 14 days, (c) at discharge- last three days of the resident's stay. Review of Section I of the RAI User's Manual entitled Active Diagnoses in the Last 7 days directs staff to Check the following information sources in the medical record for the last 7 days to identify active diagnoses: transfer documents, physician progress notes, recent history and physical, recent discharge summaries, nursing assessments, nursing care plans, medication sheets, doctor's orders, consults and official diagnostic reports, and other sources as available. Resident R78's clinical record revealed an admitted [DATE], with diagnoses that included arthritis, neuropathy (nerve damage outside the brain and spinal cord that causes pain or numbness), depression, anxiety, hearing loss, difficulty swallowing, and injury of the facial nerve. Review of R78's Quarterly MDS with an Assessment Reference date (ARD) of 6/10/24, revealed Section O0110E1 (tracheostomy care- a surgical procedure that creates an opening in the neck into the windpipe (trachea) to allow air to flow into the lungs) was coded b (while a resident) therefore indicating Resident R78 had a tracheostomy. Observation on 9/25/24, at 9:58 a.m. revealed Resident R78 lacked visual evidence of a tracheostomy, and during an interview at that time Resident R78 confirmed that he/she never had a tracheostomy. Resident R72's clinical record revealed an admitted [DATE], with diagnoses that included muscle weakness, anxiety, dementia (memory loss that interferes with daily living), and difficulty walking. Review of R72's Comprehensive MDS with an ARD of 7/01/24, revealed that Section I5950 Psychotic Disorder (other than schizophrenia) was incorrectly marked as an active diagnosis for Resident R72. Resident R99's clinical record revealed an admitted [DATE], with diagnoses that included weakness, dementia, and hyperlipidemia (high cholesterol). Review of R99's Quarterly MDS with an ARD of 7/29/24, revealed Section I5950 Psychotic Disorder (other than schizophrenia) was incorrectly marked as an active diagnosis for Resident R99. During an interview on 9/26/24, at 10:02 a.m. the Registered Nurse Assessment Coordinator (RNAC) confirmed that Resident R78's 6/10/24, quarterly MDS Section O0110E1 was coded incorrectly and during an interview on 9/27/24, at 10:36 a.m. the RNAC confirmed that Resident R72's comprehensive MDS section I5950 and R99's quarterly MDS section I5950 were also coded incorrectly. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of facility policy and clinical record, and staff interview, it was determined that the facility failed to provide a written summary of the baseline care plan and order summary to the resident and/or representative for one of 24 residents reviewed (Resident R55). Findings include: A facility policy entitled, 48-Hour Care Plan dated 1/06/24, revealed It is the policy of Rouse [NAME] County Home to provide the resident and family with baseline care plan that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. Procedure: RNAC (Registered Nurse Assessment Coordinator) 6. Reviews 48-hour care plan for completion and provides copy to resident/family in resident room. Document in record that resident was given copy. Review of Resident R55's clinical record revealed an admitted [DATE], with diagnoses that included dementia (a disease that affects short term memory and the ability to think logically), hypertension (high blood pressure), and hypothyroidism (a condition when the thyroid produces low amounts of thyroid hormones). Review of R55's clinical record lacked evidence that a written summary of the baseline care plan and order summary was provided to Resident R55 and/or his/her representative. During an interview on 9/26/24, at 2:00 p.m. the Director of Nursing (DON) confirmed that the clinical record for Resident R55 lacked evidence that a written summary of the baseline care plan and order summary was provided to the resident and/or his/her representative upon admission to the facility. 28 Pa. Code 211.10(c) Resident care policies

Based on review of facility policyand manufacturer's guidelines, observations, and staff interview, it was determined that the facility failed to ensure that medications were properly dated when opened and discarded in a timely manner in one of four medication rooms reviewed (central medication storage room). Findings include: Review of a facility policy entitled Medication Administration General Guidelines dated 1/06/24, revealed, When opening a new multi-dose bottle, the bottle must be dated and initialed. Manufacturer's guidelines for Tubersol PPD (solution used for tuberculosis testing upon admission and for employment), indicated that vials which are entered and in use for 30 days should be discarded. Observations of drug storage on 9/25/24, at approximately 9:26 a.m. in the central medication storage room refrigerator revealed two opened vials of Tubersol without an open date, therefore the staff were unable to determine the discard date. During an interview at that time Licensed Practical Nurse Employee E1 confirmed that the two opened Tubersol vials lacked an open date and staff were unable to determine the discard date. 28 Pa. Code 211.9(a)(1) Pharmacy services 28 Pa. Code 211.10(c) Resident care policies 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Based on review of facility policy and clinical records, and staff interview, it was determined that the facility failed to maintain accurate clinical records for two of 24 residents reviewed (Residents R48 and R116). Findings include: A facility policy entitled, Admission Policy dated 1/06/24, revealed that medical records from the referring agencies and discharge orders are given to the Medical Records office at the Rouse Home and uploaded to the resident chart. Review of Resident R48's clinical record revealed an admitted [DATE], with diagnoses that included heart failure, diabetes, dysphagia (difficulty swallowing), depression and anxiety. Review of Resident R48's clinical record diagnoses list revealed that on 3/06/24, a diagnosis of Post Traumatic Stress Disorder (PTSD-a psychiatric disorder that may occur in people who have experienced or witnessed a traumatic event, series of events or set of circumstances) was added Further review of Resident R48's clinical record revealed psychiatric consult notes from 3/06/24, 5/22/24 and 8/22/24, all which lacked evidence of a diagnosis of PTSD. During interview on 9/27/24, at 10:30 a.m. the Director of Nursing confirmed that Resident R48's clinical record had no evidence of a diagnosis of PTSD from a licensed practitioner. Resident R116's clinical record revealed an admitted [DATE], with diagnoses that included diverticulosis (condition where small pouches, or diverticuli, form in the walls of the gastrointestinal tract) of the large intestine, urinary tract infection, heart disease, dementia, and PTSD. Further review revealed that Resident R116's clinical record erroneously contained pre-admission information from a referring agency for another potential resident. During an interview on 9/27/24, at 9:29 a.m. the Director of Social Services confirmed that Resident R116's clinical record contained information for another potential resident and should not have been uploaded into Resident R116's clinical record. 28 Pa. Code 211.12(d)(1) Nursing Services 28 Pa. Code 211.5(f)(v) Medical records

Based on review of facility policy and clinical record, and staff interview, it was determined that the facility failed to include reconciliation of all pre-discharge medications with the resident's post-discharge medications in the resident's discharge summary, for one of two closed records reviewed (Closed Record Resident CR122). Findings include: Review of a facility policy entitled, Discharge of Resident dated 1/06/24, revealed that discharge medications will be listed in the Discharge Planning & Instructions assessment section medications. This will include the name of medication, dose, directions for use and quantity. Review of Resident CR122's clinical record revealed an admitted [DATE], with diagnoses that included, dementia (a disease that affects short term memory and the ability to think logically), high blood pressure, depression, anxiety, and weakness. Resident CR122's clinical record also revealed a discharge date of [DATE]. Review of the discharge summary lacked evidence of reconciliation of discharge medications on discharge. Review of nursing documentation lacked evidence of the type or number of medications sent home with Resident CR122 on discharge. During an interview on 9/27/24, at 11:30 a.m. the Director of Nursing (DON) confirmed there was no documentation of what medications or number of medications that were sent home with Resident CR122. The DON also confirmed that discharge medications should have a reconciliation of type of medication and amount of medications on the discharge summary. 28 Pa. Code 211.9(j.4) Pharmacy services 28 Pa. Code 211.5(f)(x) Medical records

Based on review of facility policies, clinical records, and facility documentation, and staff interviews, it was determined that the facility failed to provide a safe environment by not providing adequate supervision to protect residents from injury during a resident to resident altercation between two of 17 residents (Residents R25 and R94), that resulted in actual harm of a laceration to the thumb and transport to the emergency room for treatment of sutures (stitches) for one resident (Resident R94). Findings include: Review of the facility policy entitled, Staffing - [NAME] Lane dated 1/6/23, indicated that there will always be a minimum of two nursing staff on the hall when at least one resident is there. Review of facility policy entitled Resident Abuse, Neglect and Misappropriation of Property dated 1/6/23, indicated that it is the facility policy to prevent, report and investigate any and all allegations of abuse and neglect relative to all residents in the facility's care. The policy also revealed, that the definition of abuse will be defined per the CFR 488.301, 488.355 and the HCFA State Operations Manual Appendix P which defines abuse means the willful infliction of injury, .with resulting physical harm, pain, or mental anguish. Willful as used in the definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Review of Resident R25's clinical record revealed an admitted [DATE], with diagnoses that included dementia (condition of impaired ability to remember, think, or make decisions that interferes with everyday activities), with behavioral disturbance, anxiety, depression and alcohol, cannabis and inhalant dependence, in remission. Review of Resident R25's Annual Minimum Data Set (MDS-a periodic assessment of resident care needs), dated 8/9/23, revealed under Section C: cognitive patterns, questions from C0500 BIMS Summary Score: Resident R25 scored a 9, indicating cognitive impairment. Review of a nursing note, dated 3/10/23, at 4:07 p.m. documented that Resident R25 had hands on another resident ripping the resident's shirt. Review of a nursing note, dated 7/23/23, at 8:20 p.m. revealed Resident R25 grabbed ahold of another resident's sweatshirt. Review of a nursing note, dated 8/16/23, at 7:00 p.m. revealed Resident R25 was noted holding a closed fist and yelling at roommate in hallway. Review of a nursing note, dated 8/19/23, revealed that Nurse Aide (NA) Employee E3 had come out of a resident room to find Resident R25 engaged in an altercation with Resident R94. Resident R25 was seated in the wheelchair and Resident R94 standing in front of Resident R25, both residents had grabbed each other's shirt's with Resident R25's one hand held back as if preparing to punch Resident R94. NA Employee E3 was unable to separate the residents and called for assistance. Resident R25 had swelling and bleeding to inner right lower lip. Review of Resident R94's clinical record revealed an admitted [DATE], with diagnoses that included dementia (condition of impaired ability to remember, think, or make decisions that interferes with everyday activities), with behavioral disturbance, depression, cognitive impairment and high blood pressure. Review of Resident R94's Quarterly MDS, dated [DATE], revealed under Section C: cognitive patterns, questions from C0500 BIMS Summary Score: Resident R94 scored a 6, indicating severe cognitive impairment. Review of a nursing note, dated 7/7/23, at 5:04 p.m. revealed a NA observed Resident R94 strike another resident while ambulating beside the resident, punched with a closed fist to the other residents left upper arm. Review of a nursing note, dated 7/26/23 at 4:02 a.m. revealed that Resident R94 was having increased agitation tonight with another resident and staff. Resident refusing care yelling at staff and being confrontational with other residents in hallway. Review of Resident R94's clinical record revealed a nursing note, dated 8/19/23 at 10:58 p.m. that NA Employee E3 had come out of a resident room to find Resident R25 engaged in an altercation with Resident R94. Resident R25 was seated in the wheelchair and Resident R94 standing in front of Resident R25, both residents had grabbed each other's shirt's with Resident R25's one hand held back as if preparing to punch Resident R94, NA Employee E3 was unable to separate the residents and called for assistance. When assistance arrived they were able to separate the residents and Resident R94 stepped backward and fell on to his/ her buttocks. Review of information submitted by facility dated 8/20/23, revealed that on 8/19/23, Resident R25 had a physical altercation with Resident R94. When staff intervened to separate the residents, Resident R94 fell backwards onto their buttocks. Resident R25 had a split lip with bleeding and swelling to right lower lip. Resident R94 was taken to the emergency room for evaluation after the altercation with Resident R25. Review of a facility incident report, dated 8/19/23, revealed that Resident R94 was sent to the emergency room at 9:30 p.m. due to complaints of a two centimeter laceration to the right thumb, and received three sutures for the laceration, right side of face was red with superficial abrasions to bridge of nose, right temple and right upper eyelid. Resident R94's right eye was reddened and complained of pain to the right eye. Review of the facility investigation notes revealed that it was determined that staff left the hall and went to an adjoining unit for approximatley three and a half to four minutes, leaving the residents unattended. Upon return to the hall, this staff member intervened in the altercation. The staff member provided a witness statement with false information resulting in termination. During an interview on 10/19/23, at 11:00 a.m. the Nursing Home Administrator and Director of Nursing confirmed that NA Employee E3 left the 300 hall (Willow Lane) unsupervised without any staff on 8/19/23, for approximatley three and a half to four minutes when Resident R25 and Resident R94 were engaged in an altercation. The facility failed to implement adequate supervision to protect cognitively impaired residents from a physical altercation in a locked dementia care unit resulting in actual harm of a laceration requiring sutures to Resident R94. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(3) Management 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 211.12(d)(3)(4)(5)Nursing services 28 Pa. Code 211.12(f.1)(1) Nursing services

Based on review of facility policies, clinical records, and facility investigation, and staff interviews, it was determined that the facility failed to implement adequate safeguards in the locked dementia care unit to protect residents from abuse and physical altercation for two of 17 residents (Residents R25 and R94) resulting in actual harm of a laceration to the thumb and transport to the emergency room for treatment of sutures (stitches) for one Resident R94. Findings include: Review of the facility policy entitled, Staffing - [NAME] Lane dated 1/6/23, indicated that there will always be a minimum of two nursing staff on the hall when at least one resident is there. Review of facility policy entitled Resident Abuse, Neglect and Misappropriation of Property dated 1/6/23, indicated that it is the facility policy to prevent, report and investigate any and all allegations of abuse and neglect relative to all residents in the facility's care. The policy also revealed, that the definition of abuse will be defined per the CFR 488.301, 488.355 and the HCFA State Operations Manual Appendix P which defines abuse means the willful infliction of injury, .with resulting physical harm, pain, or mental anguish. Willful as used in the definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Review of CMS Guidelines 483.12 (a)(1) Freedom from Abuse, Neglect and Exploitation defines abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish.Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes .physical abuse . Also under the guidance under Abuse: Sections 1819 and 1919 of the Social Security Act provide that each resident has the right to be free from, among other things, physical or mental abuse and corporal punishment. The facility must provide a safe resident environment and protect residents from abuse. Review of Resident R25's clinical record revealed an admitted [DATE], with diagnoses that included dementia (condition of impaired ability to remember, think, or make decisions that interferes with everyday activities), with behavioral disturbance, anxiety, depression and alcohol, cannabis and inhalant dependence, in remission. Review of Resident R25's Annual Minimum Data Set (MDS-a periodic assessment of resident care needs), dated 8/9/23, revealed under Section C: cognitive patterns, questions from C0500 BIMS Summary Score: Resident R25 scored a 9, indicating cognitive impairment. Review of a nursing note, dated 3/10/23, at 4:07 p.m. documented that Resident R25 had hands on another resident ripping the resident's shirt. Review of a nursing note, dated 7/23/23, at 8:20 p.m., revealed Resident R25 grabbed ahold of another resident's sweatshirt. Review of a nursing note, dated 8/16/23, at 7:00 p.m., revealed Resident R25 was noted holding a closed fist and yelling at roommate in hallway. Review of Resident R25's clinical record revealed a nursing note, dated 8/19/23, revealed that Nurse Aide (NA) Employee E3 had come out of a resident room to find Resident R25 engaged in an altercation with Resident R94. Resident R25 was seated in the wheelchair and Resident R94 standing in front of Resident R25, both residents had grabbed each other's shirts with Resident R25's one hand held back as if preparing to punch Resident R94. NA Employee E3 was unable to separate the residents and called for assistance. Resident R25 had swelling and bleeding to inner right lower lip. Review of Resident R94's clinical record revealed an admitted [DATE], with diagnoses that included dementia (condition of impaired ability to remember, think, or make decisions that interferes with everyday activities), with behavioral disturbance, depression, cognitive impairment and high blood pressure. Review of Resident R94's Quarterly MDS, dated [DATE], revealed under Section C: cognitive patterns, questions from C0500 BIMS Summary Score: Resident R94 scored a 6, indicating severe cognitive impairment. Review of a nursing note, dated 7/7/23, at 5:04 p.m. revealed a NA observed Resident R94 strike another resident while ambulating beside the resident, punched with a closed fist to the other residents left upper arm. Review of a nursing note, dated 7/26/23, at 4:02 a.m. revealed that Resident R94 was having increased agitation tonight with another resident and staff. Resident refusing care yelling at staff and being confrontational with other residents in hallway. Review of Resident R94's clinical record revealed a nursing note, dated 8/19/23 at 10:58 p.m. that NA Employee E3 had come out of a resident room to find Resident R25 engaged in an altercation with Resident R94. Resident R25 was seated in the wheelchair and Resident R94 standing in front of Resident R25, both residents had grabbed each other's shirt's with Resident R25's one hand held back as if preparing to punch Resident R94, NA Employee E3 was unable to separate the residents and called for assistance. When assistance arrived they were able to separate the residents and Resident R94 stepped backward and fell on to his/ her buttocks. Review of information submitted by facility dated 8/20/23, revealed that on 8/19/23, Resident R25 had a physical altercation with Resident R94. When staff intervened to separate the residents, Resident R94 fell backwards onto their buttocks. Resident R25 had a split lip with bleeding and swelling to right lower lip. Resident R94 was taken to the emergency room for evaluation after the altercation with Resident R25. Review of a facility incident report, dated 8/19/23, revealed that Resident R94 was sent to the emergency room at 9:30 p.m. due to complaints of a two centimeter laceration to the right thumb, and received three sutures for the laceration, right side of face was red with superficial abrasions to bridge of nose, right temple and right upper eyelid. Resident R94's right eye was reddened and complained of pain to the right eye. Review of the facility investigation notes revealed that it was determined that staff left the hall and went to an adjoining unit for approximatley three and a half to four minutes, leaving the residents unattended. Upon return to the hall, this staff member intervened in the altercation. The staff member provided a witness statement with false information resulting in termination. During an interview on 10/19/23, at 11:00 a.m. the Nursing Home Administrator and Director of Nursing confirmed that NA Employee E3 willfully left the 300 hall (Willow Lane) without any staff on 8/19/23, for approximatley three and a half to four minutes when Resident R25 and Resident R94 were engaged in a physical altercation. The facility failed to implement adequate safeguards to ensure residents are free from abuse for cognitively impaired residents in a locked dementia care unit resulting in actual harm of a laceration with sutures to Resident R94. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(3) Management 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 211.12(d)(3)(4)(5)Nursing services 28 Pa. Code 211.12(f.1)(1) Nursing services