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F0600
G

Failure to Protect Resident from Mental Abuse and Intimidation During Public Debt Collection

Saxonburg, Pennsylvania Survey Completed on 11-13-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A deficiency occurred when a resident with moderate cognitive impairment and a diagnosis of dementia and anxiety was subjected to mental abuse and intimidation by facility staff in a public hallway. The resident, who had a Power of Attorney (POA) assigned to handle financial matters, was confronted by the Nursing Home Administrator (NHA) and a sheriff's deputy regarding an outstanding facility bill of $26,827. The confrontation took place in a public area, with other residents and staff present, and involved repeated verbal statements about the resident owing money and threats of issuing 30-day notices. The resident became visibly distraught, tearful, and expressed confusion about the situation, stating they did not understand why they were being held or what the debt referred to. Multiple staff members witnessed the incident and expressed concern about the appropriateness of discussing private financial matters in a public space, especially given the resident's cognitive status. Written statements from staff described the resident as confused and tearful during and after the incident. Some staff members reported feeling pressured not to report the event as abuse, and there was a lack of a formal investigation into the incident. The facility's own policies required that such matters be handled privately and with the appropriate responsible party, in this case, the POA, rather than the resident. Interviews with staff and a representative from the sheriff's office confirmed that the resident's POA should have been the party served with legal or financial documents, not the resident with dementia. The NHA acknowledged that the situation was not handled appropriately and that the resident was not protected from mental/emotional abuse. The incident resulted in psychosocial harm and mental anguish to the resident, as evidenced by the resident's emotional response and the application of the reasonable person concept.

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