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 Page 1 of 2 395685 395685 02/20/2024 Wallingford Skilled Nursing and Rehabilitation Cen 115 South Providence Road Wallingford, PA 19086

F 0600 slammed it on my table and told me I was not allowed to make calls at that time of the morning. Level of Harm - Minimal harm or potential for actual harm Review of witness statement from Resident CL2 from [DATE], revealed: Around 2am she (my roommate) tried to make a call and another .nurse .came in, snatched her phone and slammed it on the table and told her she wasn't allowed to call her sister. Residents Affected - Few Interview with the former Nursing Home Administrator (NHA), Employee E3, on February 20, 2024, at approximately 12:00 p.m. revealed licensed nurse Employee E4 was terminated on February 1, 2024, for not allowing Resident CL1 to call family and breaking the phone, and licensed nurse Employee E5 was terminated on February 1, 2024, for witnessing the interaction and not stopping it or reporting it. Interview with the current NHA and Director of Nursing on February 20, 2024, at approximately 3:30 p.m. confirmed the above findings. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1)(e)(1) Management. 28 Pa. Code 211.10(c)(d) Resident care policies. 28 Pa. Code 211.12(d)(1)(5) Nursing services. 395685 Page 2 of 2