The Inn at Freedom Village.

“A staff member spoke to a resident in a loud, demeaning voice, telling them they asked too many questions and repeatedly instructing them to be quiet, violating the requirement that residents be treated with dignity and respect.”

“A resident was physically abused by another resident. Staff witnessed resident 2 being pulled out of bed and hit with a lamp by resident 1, resulting in a large skin tear and bleeding on resident 2's head. Resident 2 was transported to the emergency room for evaluation.”

“The home's staff training plan does not include the name, position, and duties of each direct care staff member, nor does it include the times and locations of the scheduled training for each staff member for the upcoming year.”

“Purell high-performance liquid soap with a manufacturer's label indicating "Please keep out of reach of children; please contact poison control if swallowed" was unlocked, unattended, and accessible in the kitchen and all bedrooms to all residents in the Memory Care Unit. Not all residents have been assessed as capable of recognizing and using poisons safely.”

“On 7/02/2024, at 9:25 am, there was a strong urine odor in the bathroom of bedroom 1125, indicating unsanitary conditions.”

“On 7/02/2024, at 9:18 am, there was a trail of ants coming from outside the building through the window to bedroom 1125, indicating evidence of insect infestation.”

“The home's written emergency procedures do not include the contact information for each resident's designated person.”

“A resident was mistreated when staff person forcefully removed the resident's hands from a bookshelf and abruptly pulled the wheelchair backward, causing the resident to fall to the floor. The resident was agitated, not properly seated in the wheelchair, and the staff member failed to ensure the resident's safety.”

“Staff person B completed their 40th scheduled work hour on 6/21/22 without completing required orientation training in resident rights, emergency medical plan, mandatory reporting of abuse and neglect under the Older Adult Protective Services Act, and reporting of reportable incidents and conditions.”

“Staff person A failed to use positive interventions and safe management techniques when resident 1 was agitated and resisting. The resident's support plan indicated the need for repeated verbal prompts, multiple approach attempts, and moving the resident to a quieter environment to decrease anxiety. Instead, staff forcefully removed the resident's hands and abruptly pulled the wheelchair backward.”

“A resident was observed saturated in urine with peeling incontinence brief and saturated bed pad on 08/02/2023. Staff observed potential abuse but failed to report the allegation to the local area agency on aging as required.”

“Staff person C, assigned to provide overnight care for the resident, was not suspended or placed on a plan of supervision following the observed abuse incident and was allowed to continue working.”

“Resident #1, who requires total physical assistance with toileting and body repositioning per their assessment and support plan, did not receive this required assistance from approximately 8 p.m. on 08/02/2023 to approximately 6 a.m. on 08/03/2023.”

“Resident #1, requiring three-hour checks for incontinence and body repositioning, was not checked for incontinence during staff member D's shift. The resident was found saturated in urine with a peeling brief and saturated bed pad. The task sheet for the resident was not completed during the shift from 8 p.m. to 6 a.m.”

“Direct care staff person D does not have a high school diploma, GED, or active registry status on the Pennsylvania nurse aide registry, which are required qualifications for direct care staff.”

“Direct care staff person D, hired on 08/22/2022, began providing unsupervised ADL services on 08/22/2022 without completing and passing the Department-approved direct care training course and competency test.”