F0600

J

Verbal Abuse and Threats by Administrator and LPN Toward Resident Requesting Pain Medication

Saxonburg, Pennsylvania Survey Completed on 03-14-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to protect a resident from verbal and mental abuse by facility leadership and nursing staff, resulting in severe psychosocial harm in the form of embarrassment and humiliation. The facility’s own abuse policy, reviewed with a date of 1/21/26, states that the facility will not tolerate abuse, neglect, or exploitation and defines abuse as the willful infliction of injury, intimidation, or punishment resulting in physical harm, pain, or mental anguish, including verbal and mental abuse. Despite this policy, a cognitively intact resident with bilateral above-knee amputations and opioid dependence, who had a physician’s order for oxycodone 10 mg every four hours, reported that when he requested his pain medication, an LPN refused to assist and told him she would not come into his room while he was screaming. The resident stated that this led him to yell and scream for help.

The resident reported that the Nursing Home Administrator (NHA) then came to his room and verbally abused and threatened him. According to the resident, the NHA told him he sounded like an idiot and stated that if the resident had legs, he would beat his “a**,” and also yelled out the resident’s medical history, including calling him an addict, in a manner that could be heard by others. The resident stated that the Director of Maintenance had to pull the NHA out of his room twice. Another cognitively intact resident confirmed witnessing the altercation, stating that the NHA physically threatened the resident, referenced his medical information, and called him an addict, and that the Director of Maintenance had to carry the NHA away twice. Two additional residents reported hearing yelling and commotion lasting approximately 20 minutes, describing it as sounding like people fighting and exchanging words.

The LPN involved acknowledged that the resident was screaming for his medications and that she told him his pain medication was scheduled every four hours and that she did not have to come into the room if he continued screaming, stating she would not enter until he calmed down. She reported going outside to cool down and smoke a cigarette while the resident continued to scream, and she admitted that she may have given the resident the middle finger. The resident reported that the LPN gave him the middle finger behind the curtain and then directly to his face when confronted, and he documented these events in a written letter given to an RN supervisor, stating he felt verbally and physically threatened by the NHA, unsafe with the NHA around, and that his personal information was being yelled in the hall. The RN supervisor confirmed receiving the written concern and hearing from several employees that the incident was “pretty bad.” The DON acknowledged that the NHA was asked to see the resident and confirmed that the facility failed to protect the resident from verbal abuse, which caused severe psychosocial harm. Surveyors determined that this failure created an Immediate Jeopardy situation for one of six residents reviewed.