Health inspection·August 5, 2024

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 Based on a policy review, clinical record review, select document and investigation review, and resident and staff interviews, it was determined that the facility failed to protect residents from sexual abuse, resulting in psychosocial harm for one of four residents reviewed (Resident 1). Findings included: Review of current facility policy, titled Abuse, neglect, mistreatment, misappropriation of resident property and exploitation prevention, revised March 26, 2024, revealed that it is the policy that abuse, neglect, misappropriation of resident property, and exploitation of residents will not be tolerated in any manner. All staff will be provided education related to abuse and components to prevent potential abuse. A review of Resident 1's clinical record revealed an admission date of May 31, 2015, with diagnoses that included atherosclerotic heart disease (condition where a sticky substance made of cholesterol, fat, calcium, and other materials builds up inside the walls of the arteries) and diabetes (condition that affects blood sugar levels). A quarterly Minimum Data Set assessment (Minimum Data Set - a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated May 23, 2024, indicated that the Resident was moderately cognitively impaired, with a BIMS (Brief Interview for Mental Status - a tool to assess cognitive status) score of 7. Review of a facility investigation report dated August 2, 2024, at 7:15 AM, revealed that on that date and time Resident 1 was about to receive morning care when she disclosed to Employee 1 (Nurse Aide [NA]) that during the night (the prior 11 PM to 7 AM shift) a man came into her room, pinned her down and fucked her, and that she was sore down there. Per Employee 1, the Resident was in bed, her brief was in place, and her pajama bottoms at her knees. Employee 1 reported this to Employee 2 (Licensed Practical Nurse [LPN]), and both then reported it to the Director of Nursing (DON). The DON attempted to do a physical assessment; however, when staff attempted, the Resident refused to have her bra removed. When staff attempted to help the Resident undress her lower body, she became guarded and started crying, stating I cannot do this. It hurts and I am frightened. The examination immediately ceased. The Resident's brief had been changed related to being soaked with urine. In an attempt to maintain evidence, the Resident's brief was kept in the bathroom, the sheets were left untouched, and her clothing was kept on Resident 1. The State Police, Physician, responsible party, and Department of Aging were notified. Resident 1 was taken to the hospital for evaluation. Review of Resident 1's facility transfer to the hospital form dated August 2, 2024, at 7:48 AM, (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 9 Event ID: 395936 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395936 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wayne Woodlands Manor 37 Woodlands Drive Waymart, PA 18472 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)