Health inspection·December 20, 2024

F 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, review of clinical records, facility documentation, and interviews with staff, it was determined that the facility failed to conduct a thorough investigation related to an allegation of mental abuse for one of six residents reviewed (Resident R1) Residents Affected - Few Findings include: Review of facility policy Abuse Prohibition revised October 24, 2022, revealed mental abuse includes, but is not limited to humiliation, harassment, and threats of punishment or deprivation. Mental abuse may occur through verbal or nonverbal conduct which causes or has the potential to cause the patient to experience humiliation, intimidation, fear, shame, agitation, or degradation. Further review revealed the facility is to report allegation to the appropriate state and local authority involving neglect, exploitation, or mistreatment, suspected criminal activity, and misappropriation of patient property within 24 hours if the event does not result in serious bodily injury. Review of Resident R1's clinical record revealed Resident R1 was admitted to the facility on [DATE] with diagnoses of diabetes mellitus (insufficient production of insulin, causing high blood sugar), hypertension (high blood pressure), and bipolar disorder (mental disorder characterized by periods of depression and periods of abnormally elevated mood). Interview on December 11, 2024 at 9:50 a.m. with Resident R1 revealed Resident R1 requested his scheduled 12:00 p.m. medication on November 7, 2024 after his smoke break around 12:15 p.m. Resident R1 stated Employee E1, Registered Nurse, refused to give Resident R1's scheduled 12:00 p.m. medication when Resident R1 requested. Resident R1 stated he became upset and began to raise his voice at Employee E1, Registered Nurse. Resident R1 stated then Employee E1, Registered Nurse, began to yell at him and intimidate him. Resident R1 stated he reported the incident to management. Interview with Employee E2, Unit Manager, on December 11, 2024 at 10:30 a.m. revealed that on November 7, 2024 Resident R1 was scheduled for medication at 12:00 p.m. Employee E1, Registered Nurse, offered Resident R1 his scheduled 12:00 p.m. medication, but Resident R1 refused medication due to wanting to go outside to smoke. When Resident R1 came back to the unit after his smoke break, he requested his 12:00 p.m. medication. Employee E1 told Resident R1 that she was not able to give his 12:00 p.m. medication immediately. Resident R1 became angry, and a verbal altercation occurred between Resident R1 and Employee E1, Registered Nurse. Employee E2 stated that she heard Employee E1, Registered Nurse, talking loudly at Resident R1 and was loud enough to cause her to get up and intervene to de-escalate the situation. Page 1 of 2 395342 395342 12/20/2024 Hopkins Center 8100 Washington Lane Wyncote, PA 19095

F 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of facility documentation revealed a grievance/concern form dated November 20, 2024 that identified the perpetrator as Employee E1, Registered Nurse, and the victim, Resident R1. The grievance/concern form stated Resident R1 reports he is upset about getting to smoke time and getting his medication on time. Resident R1 stated the nurse asked him about his medication but he wanted to smoke and became angry with her. The facility's corrective action to the grievance/ concern was providing Employee E1, Registered Nurse, education on medication times and resident rights. Further review of facility documentation revealed three statements obtained November 7, 2024 in regards to the verbal altercation between Resident R1 and Employee E1, Registered Nurse. Resident R1's statement revealed Resident R1 does not want to wait for nursing to prepare his medication and gets frustrated and angry then leaves. Resident R1's statement did not include the verbal altercation that occurred with Employee E1, Registered Nurse. Employee E1's, Registered Nurse, written statement revealed Resident R1 would not calm down and Resident R1 and Employee E1 had to be separated due to the volume at the nurses station. Employee E2's, Unit Manager, written statement revealed charge nurse was trying to speak with Resident R1 and the two were separated by Employee E2 as the volume was loud for the unit. Review of facility documentation submitted to the State Survey Agency, dated November 18, 2024 revealed allegations of staff being rude and arguing with Resident R1. The facility submitted a follow up investigation on December 11, 2024 that stated a concern/grievance was created citing the exchange with a staff member, and an investigation was conducted. No perpetrator Identified; no PB22 (Report Form for Investigation of Alleged Abuse, Neglect, Misappropriation of Property) needed. According to three statements obtained on November 7, 2024, a perpetrator, Employee E1, was identified. Review of facility documentation revealed no thorough investigation related to the verbal altercation between Employee E1, Registered Nurse, and Resident R1, verbal altercation was not submitted to department of health timely, and no evidence whether the allegation was substantiated or unsubstantiated. During an interview on December 11, 2024, at 1:15 p.m. with Employee E3, Nursing Home Administrator, confirmed that Employee E1 engage in a verbal altercation with Resident R1. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.29(j) Resident rights 395342 Page 2 of 2