Pennswood Village

In the surveyor’s words

From the most serious findings on record at Pennswood Village, in the surveyor’s own words.

• Immediate jeopardy, isolatedF684Dec 5, 2024

  Based on review of clinical records, hospital records, facility documentation, facility policies, FDA (Food and Drug Administration) guidelines, and interviews with staff, it was determined the facility failed to provide care and services that meet the professional standards of quality and as outlined in resident's plan of care for one of 13 residents reviewed (Resident R17). The facility failed to accurately and timely notify the physician after Resident R17 who was on blood thinner medication, sustained a fall in the bathroom. The facility failed to conduct comprehensive assesment of Resident R17 in a timely manner after the resident showed abnormal blood pressure levels following the fall and after the administration of a routine anti-coagulant medication. […]

• Actual harm, isolatedF600Apr 3, 2025

  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. […]

• Actual harm, isolatedF689Apr 23, 2021

  Based on review of clinical records, review of facility policy, review of facility documentation and interviews with staff, it was determined that the facility failed to provide adequate supervision to one resident who had a history of falls with injuries, resulting in actual harm to the resident (Resident R3), who sustained a fractured wrist and a [CONDITION(S)] requiring five staples following two subsequent falls. Additionally, the facility failed to provide a safe shower chair to one resident (Resident CL188) resulting in a fall. […]

• No harm, potential for more than minimal, patternF585Apr 23, 2021

  Based on a Resident Council meeting, review of facility policy and procedures, and staff interview, it was determined that the facility failed to ensure that the Grievance process was posted in a place that was visible for residents to read, understand, follow and complete, for three of three residents (Residents R4, R7 and R22). Findings include: Review of the facility policy and procedure titled, Resident Rights, under grievances section; indicated The facility must make information on how to file a grievance or complaint available to the resident further it states notifying resident individually or through postings in prominent locations throughout the facility of the right to file grievance anonymously. […]

• No harm, potential for more than minimal, isolatedF684Dec 3, 2025

  Based on staff interviews, review of facility policy and clinical record review, it was determined that the facility failed clinically assess and notify the resident's physician after a change in condition for 1 out of 16 residents reviewed (Residents R12). Findings include: Review of Resident R12's September 2025 physician orders included the following diagnoses obesity, hypertension (high blood pressure); chronic pain; depression (a mood disorder that causes a persistent feeling of sadness and loss of interest); anxiety (intense, excessive and persistent worry and fear about everyday situations); muscle weakness, and osteoarthritis (the most common form of arthritis, characterized by joint pain and stiffness). […]