395378
01/29/2026
Quincy Retirement Community
6596 Orphanage Road Waynesboro, PA 17268
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, review of select facility documentation, and staff interviews, it was determined that the facility failed to ensure alleged violations involving abuse were investigated thoroughly and reported in a timely manner for one resident reviewed for abuse allegation (Residents 1).Findings include: Review of facility policy, titled Abuse, Neglect, Exploitation last reviewed December 25, 2025, revealed Under the Elder Justice Act, an individual must report any reasonable suspicion of a crime against a resident or participant within 2 hours of the reasonable suspicion if the incident involves serious bodily injury and within 24 hours if the incident does not involve serious bodily injury. The facility policy added a section, titled Identification of Abuse, that stated:All bruises, skin tears and other found injuries are investigated for potential abuse.Event and Response Reports are reviewed by physician, Director of Nursing, MedicalDirector, and Administrator for further action.Review of the facility incident dated December 24, 2025, at 9:00 PM, stated NA (Nursing Assistant) reported [Resident 1] had a bruise on left forearm. Upon assessment resident was found to have a 10 cm (centimeter) x 6 cm red/purple colored bruise on left forearm near the elbow. Some swelling noted. The writer of the incident also added that the Resident was asked if she knew how it happened, and the Resident stated, him. The Resident did not elaborate how it happened, but did say she doesn't want him to ever touch her again. The only person notified based on the incident report was the daughter of Resident 1. The daughter was notified on December 24, 2025, at 10:20 PM. A review of the form titled, Interview/Statement Form for Investigative Purposes, was completed by Employee 3 (NA) who was providing care to Resident 1 on December 24, 2025. This statement was obtained on December 24, 2025, at 10:00 PM. Employee 3 (NA) documented that he noticed a mark on Resident 1 while getting her ready for bed. While getting resident ready for bed halfway through she started tossing and turning and when I sat her back into chair I noticed the mark. There was not further investigation into the abuse allegation. Review of facility's interview dated December 26, 2025, two days after the allegation, a statement obtained from Employee 3 regarding the events of December 24, 2025, during care of Resident 1. On last rounds on 3-11 shift I saw resident becoming anxious and normally that means she needs changed. So I got her in bed and started to change her and I had removed her brief and after that she became restless and agitated and started tossing and turning not allowing me to change her. After a few moments I got her changed and put back into her chair when I noticed the bruise on her arm and reported it to the nurse. Prior to changing her she had been wheeling herself all around the unit as well as exit seeking. While she was roaming she was pulling herself by the wall. Review of facility's interview on December 26, 2025, with Employee 1 (NA) provided a statement while providing care to [Resident 1] this morning I noticed a large dark bruise. Unaware of it on 12/25 she had long sleeves on and went LOA (leave of absence) with family at noon. Review of facility's interview on December 26, 2025, with Employee 4 (Licensed Practical Nurse) stated, I worked 12/24/25 7-3 PM. I did not notice bruise to [Resident 1's] left forearm. No
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395378
395378
01/29/2026
Quincy Retirement Community
6596 Orphanage Road Waynesboro, PA 17268
F 0609
Level of Harm - Minimal harm or potential for actual harm
Residents Affected - Few
incident reported to this writer on 12/24/2025. I did not work 12/25/25. Incident not reported to this writer. [Resident 1] informed this writer and NA on 12/26/2025, at 10 AM that the 'Big fat white guy was rough with her yesterday and mean to her.' On December 26, 2025, the Nursing Home Administrator (NHA) filed a Community Grievance Form documenting that Resident 1 was upset with a male caregiver from 12/24/2026. During an interview with the NHA on January 28, 2026, at 3:00 PM, the NHA said that a grievance form was completed December 26, 2025, Administration decided the incident should not be reported as abuse. The NHA added that no other residents complained about Employee 3's care when questioned on December 26, 2025. When asked about Employee 3's working status, the NHA stated that he worked 3:00 PM until 3:00 AM on December 24, 2025, and has no longer been utilized by the facility. When asked if the provider was notified on December 24, 2025, the NHA was unable to determine if he was notified. 28 Pa. Code 201.14(a) Responsibility of licensee28 Pa. Code 201.18(b)(1) Management28 Pa. Code 211.12(d)(1)(2)(5) Nursing services
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