Health inspection·March 27, 2025

F 0600 Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, clinical record review, review of facility documentation, and resident interview, it was determined that the facility failed to ensure that residents were free from mental and/or physical abuse for two residents (Residents 1 and 2), which resulted in psychosocial harm for one of seven residents reviewed. (Resident 1) Findings include: Review of the facility policy entitled, Abuse Prohibition, last reviewed February 21, 2025, revealed that instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain, or mental anguish. It included a resident's right to be free from verbal abuse, sexual abuse, physical abuse, and mental abuse. Clinical record review revealed that Resident 1 (R1) was admitted to the facility on [DATE], and had diagnoses that included hemiplegia and hemiparesis (paralysis on one side), anxiety, depression, and heart disease. Review of the Minimum Data Set (MDS) assessment (a periodic assessment of resident care needs) dated February 12, 2025, indicated that the resident was not cognitively impaired. Clinical record review revealed that Resident 2 (R2) was admitted to the facility on [DATE], and had diagnoses that included congestive heart failure, diabetes, borderline personality disorder (a mental disorder characterized by instability in mood, behavior, and functioning), major depressive disorder, and schizoaffective disorder (a mental health condition characterized by symptoms of schizophrenia, such as hallucinations and delusions, and mood disorder, such as mania and depression). Review of the MDS assessment dated [DATE], indicated that the resident was not cognitively impaired. Activities documentation dated March 13, 2025, revealed that an incident occurred on March 6, 2025, during a men's night pizza party involving R1 and R2. R1 was sitting with a peer and R2 entered the event and was not able to sit with R1. After a few minutes of R1 not paying attention to R2, R2 screamed at R1 and exited the activity. Additional facility documentation revealed that on March 14, 2025, R1 hit R2 with a walker following an argument. Review of a grievance form dated March 17, 2025, revealed that in the morning during the day shift (7:00 a.m. to 3:00 p.m.), R1 reported to staff that R2 had been harassing him if he didn't provide food and money and that R2 would enter his room during meals and take his food off his tray. R1 reported that R2 would harass and call him from his cellular phone and say, Bring me a drink, get me a blanket. He also reported that he would give R2 money to be left alone. R1 reported that R2 had threatened him with sexual acts, such as penetration, and he would always say no. R2 would then hit him on Page 1 of 3 395541 395541 03/27/2025 Sinking Spring Skilled Nursing and Rehabilitation 3000 Windmill Road Sinking Spring, PA 19608

F 0600 the arm and say, You have to take care of me. It was further noted on the grievance form that R1 reported R2 would go into R1's room with no pants on and request oral sex. Level of Harm - Actual harm Residents Affected - Few On March 17, 2025, R1 was seen by the psychologist who noted the resident appeared to be in emotional distress and was observed to have been tearful and upset. Documentation indicated that R1 reported R2 had been threatening to hurt him, asking him for money, wanting to penetrate him, and requesting oral sex. In addition, the psychologist noted that staff reported R1 had been complaining about R2 for a couple months and it had increased in the past few weeks. On March 21, 2025, R1 was seen by the psychologist for a follow-up visit for his emotional well-being. During the visit, R1 reported that R2 had threatened to perform sexual acts (oral sex, penetration) on him if R1 did not comply with R2's request for money and food. R1 stated that he had given R2 food and money to avoid being harassed and victimized and that the interactions with R2 had contributed to his depression and anxiety. During an interview with R1 on March 27, 2025, at 12:35 p.m., the resident stated that R2 had been sexually harassing him prior to March 14, 2025, by making threats to penetrate him and to perform oral sex if he didn't provide food or money and that he hit R2 with his walker because he was tired of it. Based on the findings, the facility failed to ensure that Resident 2 was free from physical abuse and that Resident 1 was free from physical abuse and mental abuse resulting in psychosocial harm, including increased anxiety and depression. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1) Management. 28 Pa. Code 201.29(a) Resident rights. 395541 Page 2 of 3 395541 03/27/2025 Sinking Spring Skilled Nursing and Rehabilitation 3000 Windmill Road Sinking Spring, PA 19608

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 facility policy review, clinical record review, and staff interview, it was determined that the facility failed to report an allegation of abuse to the State Survey Agency for one of seven sampled residents. (Resident 1) Findings include: Review of the facility policy entitled, Abuse Prohibition, last reviewed February 21, 2025, revealed that the Administrator or designee would report allegations of abuse to the appropriate state and local authority within two hours. Clinical record review revealed that Resident 1 (R1) had diagnoses that included hemiplegia and hemiparesis (paralysis on one side), anxiety, depression, and heart disease. Review of a grievance form dated March 17, 2025, revealed that in the morning during the day shift (7:00 a.m. to 3:00 p.m.), R1 reported to staff that Resident 2 (R2) had been sexually harassing him by making threats if he didn't provide food and money and would hit his arm. Additional documentation indicated that on the same day and shift, R1 reported to the psychologist that R2 had been threatening and sexually harassing him with inappropriate comments and gestures. In an interview on March 27, 2025, at 1:43 p.m., the Administrator confirmed that the facility did not report the incident to the State Survey Agency. 201.14(c) Responsibility of licensee. 28 Pa. Code 201.18(e)(1) Management. 395541 Page 3 of 3