Health inspection·May 21, 2025

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, clinical records, and investigation documents, as well as staff interviews, it was determined that the facility failed to ensure that residents were free from abuse for one of eights residents reviewed (Resident 2). Findings include: The facility's policy for abuse, dated October 10, 2024, indicated that the facility forbids and prohibits the mistreatment, neglect, verbal, mental, physical or sexual abuse of residents. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated February 19, 2025, revealed that the resident was understood, could understand, was cognitively intact, and had diagnoses that included Parkinson's Disease (a medical condition that affects movement). A nursing note for Resident 2, dated May 8, 2025, at 7:04 p.m., revealed that the resident had a coughing episode after medication administration. His lungs were decreased in all lobes and vital signs taken were temperature of 97.6, pulse of 97 beats per minute, respirations at 18 breaths per minute, blood pressure of 122/64 mmHg, and an oxygen level of 93 percent on room air. The physician was notified and no new orders were received. A facility report, dated May 8, 2025, at 12:03 p.m. indicated that Licensed Practical Nurse (LPN) 1 was administering medication to Resident 2, and the resident made the statement that he takes his pills one at a time on a spoon. LPN 1 stated that she put all of his pills into his mouth at one time. LPN 1 was subsequently fired after the investigation was completed. A witness statement from Nurse Aide 2, dated May 8, 2025 revealed that she went in to retrieve Resident 2's meal tray and found the resident with watery eyes and running nose and he was visibly upset. Resident 2 informed her that he choked when LPN 1 administered all his pills at one time. Nurse Aide 2 informed LPN 1 about Resident 2's distress, and LPN 1 refused to see Resident 1, stating, Oh my God, it was three little pills, he's ok. Nurse Aide 2 had to inform LPN 3 who got the Registered Nurse (RN) to assess the resident. A nursing note, dated May 9, 2025, at 11:25 a.m., revealed that Resident 2's daughter was informed that the resident's diet was downgraded to mechanical soft and will be seen by speech therapy for evaluation and treatment. Interview with Resident 2 on May 21, 2025, at 11:02 a.m. revealed that LPN 1 administered all his Page 1 of 2 395539 395539 05/21/2025 Saint Anne Home 685 Angela Drive Greensburg, PA 15601

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few pills at one time after he informed her that he takes them one at a time on a spoon. He stated that he began to cough on the pills and tried to get LPN 1 to stay, but she walked away from him. He was able to clear the pills, but continued to cough and developed watery eyes, and runny nose. It was not until Nurse Aide 2 came in to take his tray that the registered nurse was in to assess him. He stated, She almost killed me. Interview with the Director of Therapy on May 21, 2025, at 11:48 a.m. revealed that Resident 2 stated that after the incident he was assessed and he was to have his pills crushed in applesauce, and diet was downgraded to mechanically soft. Interview with LPN 4 on May 21, 2025, at 12:04 p.m., revealed that how a resident takes their pills was in their clinical records, and Resident 2 can tell the nurse how he prefers to take his pills. He used to take them one at a time on a spoon without issue. Interview with the Director of Nursing on May 21, 2025, at 1:03 p.m. confirmed that LPN 1 administered all Resident 2's pills at one time causing physical and emotional distress to the resident and that she should have administered them per the resident's preference, and she should have reported to the registered nurse to assess Resident 2 after he coughed during medication administration and was visibly distressed. 28 Pa. Code 201.14(a) Responsibility of Licensee. 28 Pa. Code 201.18(b)(1)(e)(1) Management. 28 Pa. Code 201.29(j) Resident Rights. 395539 Page 2 of 2