Health inspection·April 3, 2025

F 0600 Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of clinical record, facility documentation, facility policy and interviews with staff, it was determined the facility failed to protect the resident's right to be free from physical abuse by Employee E1 which resulted in actual harm to Resident R1 who sustained a bruise and hematoma (collection of blood outside of a blood vessel) to right hand and wrist for one of three residents reviewed (Resident R1). Findings include: Review of facility policy titled Abuse Policy, revised 2023, revealed abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Physical abuse includes, but is not limited to, hitting, slapping, pinching, and kicking. Review of Resident R1's clinical record revealed Resident R1 was admitted to the facility on [DATE] with a diagnosis of Alzheimer's Disease (brain disease that causes memory loss and other cognitive impairment), Hypothyroidism (thyroid gland does not produces enough hormones), and Anxiety disorder. Review of Resident R1's quaterly Minimum Data Set (MDS) assessment (mandated assessment of a resident's abilities and care needs), dated January 20, 2025, revealed Resident R1 had a Brief Interview for Mental Status (BIMS) score of 4 indicating severe cognitive impairment. Review of Resident R1's care plan, initiated on March 03, 2023, revealed Resident R1 can be resistive to care as evident by refusing care and refusing to get dressed related to Alzheimer's disease and Dementia mild with psychotic disturbance. One intervention included if Resident R1 resists ADL's (activities of daily living), reassure resident, leave and return 5-10 minutes later and try again. Review of Resident R1's nursing note, dated March 21, 2025, at 11:41 a.m, indicated Resident R1 was in the lounge and staff observed a hematoma measuring 4.7 centimeters (cm) x 3.8 cm to right dorsal (back) hand. Area is tender to touch and purple in color. Resident frequently attempts to self transfer from bed and from wheel chair. Resident at times can be combative with staff during care, (she/he) will attempt to swat away and refuse care. Provider notified of new finding. Review of Resident R1's physician note, dated March 21, 2025, at 2:13 p.m., revealed physician assessed Resident R1's hematoma on right hand and wrist. Hematoma measured 7 to 8 cm in diameter, raised, and slightly tender to touch. Continued review of physician note dated March 21, 2025, revealed it was reported Resident R1 was Page 1 of 2 395473 395473 04/03/2025 Pennswood Village Route 413 Newtown, PA 18940

F 0600 punched in the stomach by one of the aides during care. Physician returned to reassess Resident R1and noted no injuries on abdomen or chest. Level of Harm - Actual harm Residents Affected - Few Review of facility investigation dated, March 21, 2025 at 1:30 p.m., revealed Nurse Aide, Employee E2, reported to Director of Nursing, Employee E3, of an abuse incident that occurred on March 21, 2025 during morning care. Nurse Aide, Employee E2, stated she was providing Resident R1 morning care with assistance from Nurse Aide, Employee E1. Resident R1 began kicking and punching the staff. Nurse Aide, Employee E2, then observed Nurse Aide, Employee E1, punch Resident R1 on the right side of her abdomen and grabbed Resident R1's wrist / hands and twisted aggressively. Further review of facility investigation revealed Nurse Aide, Employee E1, was immediately removed from the nursing unit at 1:35 p.m. Police was immediately notified at 1:44 p.m., county area agency on aging at 1:49 p.m., Ombudsman notified at 2:15 p.m. Power of Attorney notified. Verbal statement taken. Skin assessment completed on [Resident R1], findings were new bruise/hematoma to right dorsal hand/wrist. Physician assessed [Resident R1] at 2:20 p.m., no findings noted to abdomen, no complaints of pain and or discomfort expressed by [Resident R1] at this time, [Resident R1] does not recall situation related to cognitive impairment. Police substantiated abuse incident. Additional review of facility documenation revealed the allegation of abuse was substantiated by the facility. Interview conducted on April 02, 2025 at 11:00 a.m. with Administrator, Employee E3, and Director of Health Services, Employee E4, confirmed the above incident was substantiated. The facility failed to ensure that Resident R1 was free from physical abuse by Employee E1. This failure resulted in actual harm to Resident R1 who sustained a bruise and hematoma to right hand and wrist. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(e)(1) Management. 28 Pa. Code 211.12(d)(1)(5) Nursing services 395473 Page 2 of 2