Sayre Health Care Center

F 0627 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for

a safe transfer/discharge. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on closed clinical record review, review of facility documents, and staff interview, it was determined the facility failed to ensure the necessary resident information was documented by the physician to facilitate a facility-initiated transfer of a resident to another facility for one of one resident reviewed for a facility-initiated transfer (Resident CR1). Findings include: Closed clinical record review for Resident CR1 revealed the resident was admitted to the facility on [DATE REDACTED], with a diagnosis of dementia (memory loss), and was discharged to another skilled nursing facility on September 30, 2025, due to the facility documentation indicating the resident needs could not be met at the facility. Review of facility documents dated October 7, 2025, (after the resident was discharged ) completed by the Director of Nursing, noted that on September 23, 2025, the resident's responsible party was present for a care plan meeting with social services, and the resident care coordinator and the resident's behaviors such as attempting to elope (leave) the facility, pulling the facility fire alarms, threatening to let all the residents out of the building, inappropriate touching of other resident, entering resident rooms and taking items, and frequent falls after interventions implemented. It was discussed the facility is not able to meet the needs of the resident and it is in the best interest of the resident to be transferred to a facility that is able to provide the care and safety she desperately needs. It noted the responsible party was very angry regarding the information. A follow up meeting was requested by the responsible party and was scheduled for September 26, 2025, at 1:00 PM

on the same document. Review of Review of the same documents noted above dated October 7, 2025, revealed further documentation by the Director of Nursing that a meeting was held on September 26, 2025, with the inter-disciplinary team, nurse practitioner, and the resident's responsible party, son, and granddaughter to review the resident's behaviors and need to transfer the resident to another facility as the facility could not meet the resident needs and the other facility had a secured unit. Review of email communication between the Nursing Home Administrator and administration of the receiving facility dated September 26, 2025, indicated a transfer of the resident was planned for September 30, 2025. There was no evidence in Resident CR1s clinical record of physician documentation prior to discharge to indicate a transfer of the resident to another facility was necessary for the resident's welfare and the facility could not meet the resident's needs to include the following information as required: The basis for the transfer.The specific resident needs that could not be met in the facility.The facility's attempts to meet the resident's needs.The services available at the receiving facility to meet the needs of the resident. The above information was reviewed with the Nursing Home Administrator and Director of Nursing in a telephone

interview on October 9, 2025, at 10:30 AM. 28 Pa. Code 201.29 (a) Resident rights 28 Pa. Code 201.18 (3)(e)(1) Management

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date

these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

TITLE

(X6) DATE

FORM CMS-2567 (02/99) Previous Versions Obsolete

Facility ID:

If continuation sheet

Event ID:

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/08/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Sayre Health Care Center

151 Keefer Lane Sayre, PA 18840

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0628 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on closed clinical record review, review of facility documents, and staff interview, it was determined the facility failed to provide a written notice of transfer before discharge to a resident's responsible party for a facility-initiated discharge for one of one resident reviewed for a facility- initiated discharge (Resident CR1).

Findings include: Closed clinical record review for Resident CR1 revealed the resident was admitted to the facility on [DATE REDACTED], and was discharged to another skilled nursing facility on September 30, 2025. Review of facility documents dated October 7, 2025, (after the resident's discharge) revealed facility staff conducted meetings on September 23, 2025, and September 26, 2025, with Resident CR1's responsible party to

review resident behaviors in the facility including multiple elopement (leave the facility unattended) attempts, falls, wandering into other resident rooms, touching staff and other residents, removing clothing in common areas, and a sexual incident with another resident. It was noted in the documents that the facility could not meet the needs of the residents and a recommendation was made to transfer the resident to another facility. Review of email communication between the Nursing Home Administrator and administration of the receiving facility dated September 26, 2025, indicated a transfer of the resident was planned for September 30, 2025. There was no evidence Resident CR1's responsible party was provided a written notice of transfer as soon as practicable prior to a scheduled facility-initiated transfer that was known four days prior to discharge to include the following: the reason for the dischargethe effective date of dischargethe location to which the resident is to be discharged toa statement of the resident's appeal rights including the name, address (mailing and email), and telephone number of the entity which receives such requests; and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request.the name, address (mailing and email) and telephone number of the State Long-Term Care Ombudsman The above information was reviewed with the Nursing Home Administrator and Director of Nursing in a telephone interview on October 9, 2025, at 10:30 AM. 28 Pa.

Code 201.14(a) Responsibility of license28 Pa. Code 201.29(a) Resident rights

Event ID:

Facility ID:

If continuation sheet