§483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must:
§483.12(c)(2) Have evidence that all alleged violations are thoroughly investigated.
§483.12(c)(3) Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress.
§483.12(c)(4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken.
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Observations:
Based on review of policy, review of clinical records and review of facility provided documentation, it was determined that facility did not ensure to complete a thorough investigation for two of 18 residents reviewed regarding facility reported incidents (Resident R42, R2)
Review of facility policy 'Falls management program,' indicates that "when a resident sustains a fall, the assessment process will include an investigation using the Fall investigation analysis sheet. This is to help identify the root cause and whether or not the fall was avoidable or unavoidable."
Review of Resident R42 clinical record revealed medical diagnosis of Alzheimer's disease, pain in bilateral knees, osteoarthritis, long-term use of insulin.
Review of physical therapy discharge recommendations, completed on March 20, 2025, indicate that R42 is to "continue to walk and stand with supervision."
Review of R42's care plan, dated August 14, 2025, indicates that R42 is "at risk for falling related to confusion, history of falls, poor safety awareness," with following interventions, dated November 5, 2025: "resident prefers to sit down the floor occasionally. Encourage to sit on the chair or bed if she is in her room," and "walker within reach. Remind resident to use it unable to reeducate due to cognition."
Further review of R42's care plan, dated July 17, 2025, indicates "the resident requires 1 person assist with rolling walker for ambulation."
Review of R42's clinical record, revealed health status note, dated December 16, 2025 at 8:39 pm, stating R42 had a fall in her room at 7:15 in the morning. Fall was witnessed by nurse aide, employee E11.
Further review of R42's progress notes revealed that R42 "tripped over her own feet," resulting in head hematoma, closed non-displaced fracture of right middle finger, and right knee abrasion.
Review of 'interview/statement form for investigative purposes falls,' completed by nurse aide, E11 on December 16, 2025 at 7:15 am, indicates no evidence that R42 was supervised during ambulation with walker; and no indication of preventative measures in place during fall incident.
Interview with facility's physical therapist, employee E12 on Wednesday, February 4, 2025 at 12:00 pm, confirmed Resident R42 required supervision during ambulation with walker.
Review of Resident R2's clinical record revealed medical diagnosis of Alzheimer's disease, polyosteoarthritis, muscle weakness.
Review of physical therapy discharge recommendation notes for R2, completed on September 9, 2025, indicates R2 required "supervision or touching assistance" during ambulation.
Review of R2's care plan, dated July 21, 2025, indicates "the resident (R2) has an ADL self-care performance deficit related to Alzheimer's," with intervention to supervise/one person assist with walker for ambulation.
Review of facility provided investigation report related to R2's fall, completed on November 6, 2025, indicates that R2 was observed walking into the dining room with her walker and appeared to have tripped over her own feet while placing her walker to the side and lost her balance causing her to fall onto her left side. Staff had witnessed the fall and unable to get to her in time to intercept the fall." The fall resulted in left hip fracture.
Interview with facility's director of nursing and administrator on Thursday, February 5, 2025, at 12:30 pm, indicates the statement on investigative report related to R2's fall are inaccurate; further elaborating that R2 was actually on her way out of dining area.. further stating that an adequate amount of staff were present during incident.
However, further review of investigation report revealed no evidence that all fall preventative measures were in place, including supervision.
28 Pa Code 211.10(d) resident care policies
28 Pa Code 211.12(d)(5) nursing services
| | Plan of Correction - To be completed: 03/04/2026
R42 and R2 witnessed falls have been thoroughly investigated.
An initial audit of incident reports over the last 30 days involving falls has been completed to ensure a complete and thorough investigation has been conducted.
NHA and DON have been re educated by the Extended Care Manager and RN supervisors have been re educated by the DON to the Policy on Falls Management Program with emphasis on the process of including a complete and thorough investigation and the Abuse Policy.
NHA or designee will conduct weekly audits of fall incidents x 4 weeks and then monthly x 2 months to ensure a thorough investigation was completed.
Audits will be forwarded to the
Quality Assurance Process Improvement Committee for review and further recommendations if indicated.
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