Health inspection·November 21, 2024

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Based on review of facility policies, investigation reports, and clinical records, as well as staff and resident interviews, it was determined that the facility failed to ensure that residents were free from abuse for one of 8 residents reviewed (Resident 1) Findings include: The facility's policy regarding abuse and neglect, last revised November 2019, define abuse as infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. 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. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse . A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated October 31, 2024, revealed Resident 1's brief interview for mental status (BIMS, used to identify cognitive impairment) of 15 out of 15 (cognition is intact). Review of Event number: 1045802, revealed Resident 1 was verbally abused by Employee 3 (E3) when Resident 1 attempted to enter the kitchen to offer help, due to believing the kitchen was short staffed. Review of facility investigation, dated October 26, 2024, revealed that E3 verbally abused Resident 1 at approximately 12:30 p.m. on October 26, 2024, when Resident 1 attempted to enter the Kitchen. Review of investigation statement 1 from Employee 4 (E4) stated The [E3] came out of the kitchen complaining at a [Resident 1] in the kitchen. [Resident 1] and [E3] are yelling back and forth. [E3] threatens, yells at the [Resident 1], that she will slap the shit out of her . She told the [Resident 1] she will get scraps. Told resident she will not receive a meal . Review of investigation statement 2, dated October 26, 2024, states While cleaning the service hallway [Resident 1] had walked back to volunteer to help the cooks, one of the cooks snapped and told [Resident 1] to leave, as she followed [Resident 1], [E3] argued with [Resident 1] and said You dirty whore, I'll slap the shit out of you . Review of investigation statement 3, dated October 26, 2024, at 1:34 p.m. states At approximately 12:30 p.m., [E3] opened the door to the hall and stated to me come get your resident, I don't need them back in the kitchen . I came out through the doors and observed [Resident 1] yelling and [E3] Page 1 of 2 395284 395284 11/21/2024 Phoenix Center for Rehabilitation and Nursing,the 833 South Main Street Phoenixville, PA 19460

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few stated back I will come over there and slap the shit out of you and then proceeded to call her a dirty hoe . [Resident 1] stated I was only trying to help but you are probably eating it all for yourself . [E3] then stated, I don ' t eat this food, I save the scraps for you . Then stated, keep talking and you won't get a meal at all . I then told [Resident 1] to go upstairs, and the elevator was shutting and [E3] called her a dirty smelly bitch . Review of facility completed PB-22 (mandated report that is submitted when a resident is suspected of being a victim of abuse) dated October 28. 2024, substantiated Resident 1 was a victim of verbal abuse at the hands of E3. Additional review of the PB-22 revealed E3 was terminated and placed on the do not hire list. Thorough review of employee files for all 11 staff members in the Dietary Department confirmed that each individual had completed mandatory abuse training prior to their employment start date. An additional interview was conducted with R1 at 11:05 a.m., during which she confirmed that the incident described was the only instance of verbal abuse she experienced while residing at the Phoenix Center. An interview conducted with Resident 1 on November 21, 2024, at 10:23 a.m. reported E3 did verbally abuse her when she offered to staff in the kitchen. Resident 1 reports that she feels safe in the facility and did not suffer any harm form the incident. Resident 1 also reported that she turned down therapy services because the whole thing wasn't that big of a deal . Interview conducted with the Nursing Home Administrator (NHA) and Director of Nursing (DON) on November 21, 2024, at 11:45 a.m. confirmed the above. 28 Pa. Code 211.10(d) Resident Care Policies. 28 Pa. Code 211.12(d)(1)(5) Nursing Services. 395284 Page 2 of 2