Health inspection·December 8, 2022

F 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm Based on a review of the facility's policy, clinical record reviews, and staff interview, it was determined that the facility failed to investigate an injury of unknown origin for one of the 12 residents reviewed (Resident 8). Residents Affected - Few Findings include: Review of the facility's policy titled Abuse Prevention Program, revised in July 2021, revealed that if the cause of the injury is unknown, the person gathering facts will document the injury, the location and time it was observed, any treatment given and whether the physician, responsible party and/or the Department of Health were notified. The appointed investigator will, at a minimum, attempt to interview the person who reported the incident, anyone likely to have direct knowledge of the incident, and the resident if can be interviewed. Review of Resident 8's diagnosis list revealed Alzheimer's disease (irreversible, progressive degenerative disease of the brain, resulting in loss of reality contact and functioning ability), Dementia (term used to describe a group of symptoms affecting memory, thinking, and social abilities severely enough to interfere with daily life), Anxiety Disorder, Psychotic and Mood Disturbance. Review of Resident 8's Minimum Data Set (MDS- standardized assessment tool that measures health status in long-term care residents) dated July 6, 2022, revealed that the resident had severe cognitive impairment. The same MDS assessment revealed the resident required extensive bed mobility, transferring, personal hygiene, and grooming. Review of Resident 8's active care plan revealed resident had physical behaviors during hands-on care and was resistant to care. Both plans of care were developed on June 3, 2020. Review of Resident 8's clinical record including document titled Change in Condition, dated October 3, 2022 (6:57 p.m.), revealed the resident was observed with a bruise to the left forearm with a measurement of 6.5 x 4.0 cm. Interview with the Director of Nursing was conducted on December 7, 2022, at 1:00 p.m. The Director of Nursing reported the resident did not have documented falls or trauma. The DON confirmed the bruise observed on Resident 8's left forearm on October 3, 2022, was not investigated. An interview with the Nursing Home Administrator (NHA) was conducted on December 8, 2022, at 10:30 a.m. The NHA confirmed that the resident did not have falls/trauma before the discovery of the left forearm bruise. The NHA confirmed that Resident 8's left forearm bruise from an unknown source should have been investigated. (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 3 Event ID: 396062 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 396062 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/08/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Inn at Freedom Village,the 35 Freedom Boulevard West Brandywine, PA 19320 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)