Health inspection·February 20, 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy and facility documentation, and staff interview, it was determined that the facility failed to ensure one of three residents reviewed was free from abuse (Resident CL1). Findings include: Review of facility policy, Abuse Prohibition, last reviewed [DATE], revealed that Centers prohibit abuse, mistreatment, neglect, misappropriation of resident/patient property, and exploitation for all patients. Review of Resident CL1's clinical record revealed the resident was admitted to the facility on [DATE], with a diagnosis of lung cancer with metastasis to the brain and expired on [DATE]. Review of Resident CL1's comprehensive Minimum Data Set (MDS - periodic assessment of resident care needs) dated [DATE], revealed the resident's Brief Interview for Mental Status (BIMS) score was 13, indicating the resident was cognitively intact. Review of Resident CL1's roommate's clinical record, Resident CL2, revealed a comprehensive MDS dated [DATE], with a BIMS score of 15, indicating that the resident was cognitively intact. Further review of Resident CL2's clinical record revealed the resident was discharged home on [DATE]. Review of information submitted by the facility revealed that on [DATE], at approximately 2:00 a.m., Resident CL1 was attempting to call a family member. Licensed Nurses Employees E4 and E5 entered the room at the time. Employee E4 grabbed the phone from the resident and threw it against the nightstand, breaking it. Resident CL2 was awake at the time and witnessed the interaction. Interview with Employee E6 on February 20, 2024, at approximately 1:00 p.m. revealed the employee was the Manager on Duty on [DATE]. Employee E6 revealed that Resident CL1's family member reported the incident to her after visiting the resident. Employee E6 and Licensed Nurse Employee E7 went to the residents' room and interviewed Residents CL1 and CL2 and noted that the resident's phone was broken. Employee E6 stated that Employees E4 and E5 were suspended on [DATE], following the abuse allegations. Further review of facility investigation revealed the phone was later fixed by Employee E8. Review of witness statement from Resident CL1 from [DATE], revealed: Around 2:30 in the morning I was trying to make a phone call and a different nurse came in .who grabbed by house phone from me (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 395685 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395685 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/20/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wallingford Skilled Nursing and Rehabilitation Cen 115 South Providence Road Wallingford, PA 19086 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)