Health inspection·May 15, 2024

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Based on review of policies, clinical records, and investigation documents, as well as staff interviews, it was determined that the facility failed to ensure that staff reported an allegation of verbal abuse in a timely manner for one of six residents reviewed (Resident 2). Findings include: The facility's policy regarding abuse, dated May 8, 2024, indicated that each resident had the right to be free from mistreatment, neglect, and misappropriation of property. No one may subject residents to abuse including, but not limited to facility staff, other residents, consultants, volunteers, staff or other agencies serving the residents, family members or legal guardians, friends and other individuals. Observances, complaints or evidence of alleged abuse, neglect and/or mistreatment are thoroughly investigated and reported to the appropriate parties. The definition of verbal abuse meant the use of oral, written or gestured language that willfully included disparaging and derogatory terms to residents or their families or within hearing distance regardless of their age, ability to comprehend, or disability. Language that can be interpreted as threatening, malicious, inappropriate language, name calling, angry or hostile tone. Verbal abuse was considered inappropriate and detrimental to the resident's emotional health and well being. An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated April 3, 2024, indicated that the resident could make herself understood and understood others and was cognitively impaired. A care plan, dated April 4, 2024, revealed that the resident's daughter was permitted to visit but was not permitted to take the resident out of the facility. A nursing note for Resident 2, dated April 26, 2024, at 12:40 p.m., revealed that the Director of Nursing received concerns from the Area Agency on Aging that the resident had stated that Family Member 1 has been mean to her lately, called her a bitch, and was mad at her because she didn't get the farm. An attempt was made to reach Family Member 1 and a voicemail was left. A nursing note, dated April 29, 2024, at 7:20 p.m. and 9:00 p.m., revealed that Resident 2 was tearful, requesting that Family Member 1 leave, and stated I'm afraid of Family Member 1. The Director of Nursing was notified of Family Member 1 upsetting the resident and refusing to leave. The resident was in the dining hall and did not want to be in the room with Family Member 1. Two police officers arrived at the facility and removed Family Member 1. A witness statement from Licensed Practical Nurse 1, dated April 29, 2024, revealed that the nurse Page 1 of 2 395514 395514 05/15/2024 Maybrook Hills Rehabilitation and Healthcare Cente 301 Valley View Boulevard Altoona, PA 16602

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few aide reported that Resident 2 was visibly upset and shaking, stating that Family Member 1, who was in visiting, was being very mean to her, trying to take her farm. The resident stated that she did not want to be in the room with Family Member 1 and was taken to the dining room. The facility's investigation, dated April 30, 2024, revealed that Resident 2 was asked if she had concerns for her safety while Family Member 1 was visiting, and she stated that Family Member 1 has never hit her since she has been there; however, Family Member 1 will frequently call her names and get mad at her about the farm. A nursing note, dated April 30, 2024, at 10:46 a.m. revealed that Family Member 1 was informed that she was no longer permitted to visit. If Family Member 1 arrived at the facility, she would be asked to leave, and if she did not leave, the police would be contacted to have her escorted from the building. As of May 15, 2024, there was no documented evidence that the facility reported the allegation of verbal abuse to the Department of Health. Interview with the Director of Nursing on May 15, 2024, at 11:10 a.m. confirmed that the facility did not report the allegation of verbal abuse regarding Resident 2 and Family Member 1 to the Department of Health. He indicated that they did not have much to go on since they did not witness any verbal abuse to Resident 2 from Family Member 1, and that Resident 2 was cognitively impaired. 28 Pa. Code 201.18(e)(1) Management. 28 Pa. Code 211.12(d)(5) Nursing Services. 395514 Page 2 of 2