Health inspection·July 8, 2025

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 a review of clinical records, information submitted to the State Survey Agency through the Electronic Reporting System, facility email communication, and staff interviews, it was determined the facility failed to ensure that all allegations of resident abuse and misappropriation were thoroughly investigated and that complete investigation results were submitted to the State Survey Agency within five working days of the incident, as evidenced by one of one allegation of misappropriation reviewed involving two residents of six residents sampled (Residents CR1 and CR2). Findings include: A review of the facility's policy titled Abuse Protection, last reviewed by the facility in February 2024, revealed that it is the policy of the facility to submit the required investigative documentation through the Electronic Event Reporting System within five working days of a reported allegation when an alleged perpetrator is identified. A review of incidents of alleged abuse, neglect, and misappropriation showed that the facility reported the following incident through the Electronic Reporting System but failed to submit a complete investigation report and documentation of corrective actions within the required timeframe: On May 25, 2025, the facility reported an incident involving an alleged misappropriation of property. According to the report, Resident CR1 had been discharged home from the facility on May 24, 2025, with a prescription for 28 tablets of Oxycodone 5 mg (narcotic medication) tablets. Upon arrival home, Resident CR1's responsible party (RP) discovered that 11 tablets were missing. The RP contacted the facility and spoke with Employee 1 (Licensed Practical Nurse), who had been assigned to Resident CR1 on the day of discharge. Employee 1 informed the RP that she had the remaining pills in a prescription bottle and offered to deliver them directly, however, the RP instead notified the facility administration. It was noted the facility's standard practice is to dispense prescription medications on a unit-dose card, not in a bottle. An internal review was initiated and further revealed that Resident CR2, who had recently been discharged to the hospital, was also missing 32 remaining Hydrocodone 10 mg tablets. In addition, the required controlled substance sign-out sheets for both residents' medications were missing. Although the facility initiated an investigation, the submitted investigative report was incomplete and did not include required supporting documentation such as witness statements or confirmation that the investigation contained all necessary components. The incomplete report was rejected by the State Survey Agency on June 5, 2025, due to insufficient detail, and the facility failed to submit a revised, complete investigation for review. (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 2 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 07/08/2025 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)