§483.12(b) The facility must develop and implement written policies and procedures that:
§483.12(b)(1) Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property,
§483.12(b)(2) Establish policies and procedures to investigate any such allegations, and
§483.12(b)(3) Include training as required at paragraph §483.95,
§483.12(b)(4) Establish coordination with the QAPI program required under §483.75.
§483.12(b)(5) Ensure reporting of crimes occurring in federally-funded long-term care facilities in accordance with section 1150B of the Act. The policies and procedures must include but are not limited to the following elements.
§483.12(b)(5)(ii) Posting a conspicuous notice of employee rights, as defined at section 1150B(d)(3) of the Act.
§483.12(b)(5)(iii) Prohibiting and preventing retaliation, as defined at section 1150B(d)(1) and (2) of the Act.
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Observations:
Based on review of facility documents, facility policy, clinical records, and staff interviews, it was determined that the facility failed to develop written policies and procedures that include training new and existing nursing home staff on abuse, neglect, misappropriation of resident property, and exploitation. This failure resulted in the actual harm of staff members being unaware that unauthorized physical restraints can be a form of physical abuse and restraining a resident to a bed with a bed sheet which caused abdominal bruising for one of eight residents (Resident R1).
Findings include:
Review of the United Stated Code of Federal Regulations indicated that the facility must have written policies and procedures that include training new and existing nursing home staff in the following topics which include:
Prohibiting and preventing all forms of abuse, neglect, misappropriation of resident property, and exploitation.Identifying what constitutes abuse, neglect, exploitation, and misappropriation of resident property.Recognizing signs of abuse, neglect, exploitation and misappropriation of resident property, such as physical or psychosocial indicators.Reporting abuse, neglect, exploitation, and misappropriation of resident property, including injuries of unknown sources, and to whom and when staff and others must report their knowledge related to any alleged violation without fear of reprisal; andUnderstanding behavioral symptoms of residents that may increase the risk of abuse and neglect and how to respond.
Review of facility policy "Identifying Involuntary Seclusion and Unauthorized Restraint" dated 1/20/26, previously reviewed 1/21/25, defined a physical restraint as any manual method, physical or mechanical device, equipment, or material that meets all of the following criteria:
Is attached or adjacent to the resident's body;Cannot be removed easily by the resident (in the same manner it was applied by staff); andRestricts the resident's freedom of movement or normal access to his/her body.
The policy further indicated that "Sometimes the use of restraints in not intentional, but this does not absolve the staff of the responsibility to recognize and report the unauthorized use of restraints. Examples of physical restraints (intentional or unintentional) include: (Provided in the list of examples was) "tucking in a sheet tightly so that the resident cannot get out of bed or fastening fabric or clothing so that a resident's freedom of movement is restricted."
Review of the clinical record indicated Resident R1 was admitted to the facility on 7/23/25.
Review of the Minimum Data Set (MDS - federally mandated assessment of a resident's abilities and care needs) dated 1/16/26, included diagnoses of heart failure (a progressive heart disease that affects pumping action of the heart muscles), anxiety, depression, and dementia (a group of symptoms that affects memory, thinking and interferes with daily life). Review of Section C: Cognitive Patterns, Questions C0500 "BIMS Summary Score" revealed Resident R1's score to be "9".
Review of Resident R1's plan of care for risk of falls related to gait/balance problems initiated 10/13/25, indicated staff should follow the facility fall protocol.
Review of Resident R1's clinical record dated 1/8/26, at 10:26 a.m. stated "Head to toe assessment completed on resident. Noted scattered fading discolorations to bilateral upper extremities and scabbed areas, 0.5x 4cm left lower abdomen/pelvis linear purple discoloration. Scattered bruising to bilateral lower extremities with scabbed areas."
Review of documentation submitted by the facility on 1/8/26, revealed "It was reported to this DON (Director of Nursing) that resident [Resident R1] was found to be in bed with a sheet over her tied to the bed to hold her down at the beginning of 6a-2pm shift. Staff interviews being completed at this time." "Alleged perpetrators noted as Nurse Aide (NA) Employee E1, NA Employee E2, and NA Employee E3, who all three worked the 10p-6a shift. No other residents were affected."
Review of an employee statement written by NA Employee E1 dated 1/8/26, indicated, "I was caring for the resident whenever I noticed the sheet was tied to the bed frame e on the right and left side, at two points. As I was trying to look for the RN Supervisor and the LPN (licensed practical nurse) on shift, I was answering call lights. I noticed they were not around, and the LPN was in another resident's room providing care. I finished the last round and was charting whenever dayshift CNA (nurse aide) came in. As I was giving report, I got to the resident's name, and I pulled the dayshift CNA to look at the resident. I showed her the way it was tied and asked if she wanted to help me undo it. She told me to leave it. Apparently while I was off the floor, the other CNAs were making sure she didn't fall out of the bed. I did not witness anyone tie the sheet, and I did not tie the sheet in any way to the bed frame and/or the resident."
Review of a second employee statement written by NA Employee E1 dated 1/8/26, indicated, "When I saw NA Employee E3, the CNA, she told me NA Employee E2 came and got her to help while I was off the floor. NA Employee E3 told me they tied the sheet to the frame to make sure the resident didn't fall out of the bed."
Review of an employee statement written by NA Employee E2 dated 1/8/26, indicated, "I was working 10p-6a. Resident R1 had fell out of bed twice onto her fall mat around 10:20 p.m. The RN Supervisor did not want to do a incident report and we were afraid Resident R1 would get hurt. Myself and NA Employee E3 put a bed sheet across her hips and just lightly looped it through the bed so she couldn't fall. There was no intent to hurt this resident we just didn't want her to fall, get hurt and it not get reported. We didn't know what else to do to keep her safe. We then told NA Employee E1 it was there and if she wanted to remove it she could. I did not know that the bed sheet could be considered a restraint."
Review of an employee statement written by NA Employee E3 dated 1/9/26, indicated, "NA Employee E2 came back to (nursing unit) because she needed help getting Resident R1 up off the floor. When I got in the room Resident R1 was laying on the fall mat. We got her back in bed. NA Employee E2 handed me a sheet and we looped it around the bed to try to keep Resident R1 safe. I didn't realize this is a restraint."
Review of a facility submitted "Report Form for Investigation of Alleged Abuse, Neglect, Misappropriation of Property" dated 1/12/26, indicated, "Staff did not think that placing a sheet over her was a restraint. They felt they were doing it to keep resident safe due to falls."
On 2/18/26, the facility was asked to provide what literature was used to educate staff on abuse and neglect prevention, and evidence that NAs Employee E1, E2, and E3 received that education.
On 2/18/26, the facility provided sign-in sheets that indicated that NA Employee E1 received education on abuse and neglect prevention on 10/29/25, and NA Employees E2 and E3 received education on abuse and neglect prevention on 10/28/25.
Review of the facility provided literature used during the above education, the facility provided a copy of the facility policy "Abuse, Neglect, Exploitation and Misappropriation Prevention Program." Review of the policy stated the facility will "Provide staff orientation and training/orientation programs that include topics such as abuse prevention, identification and reporting of abuse, stress management, and handling verbally or physically aggressive resident behavior."
During an interview on 2/18/26, at approximately 2:30 p.m. the Nursing Home Administrator and the Director of Nursing confirmed that the policy utilized for abuse and neglect prevention education stated the topics that staff will have training on, but the policy did not in itself include that information, and education on those topics was not provided.
During an interview on 2/18/26, at approximately 2:30 p.m. the Nursing Home Administrator and the Director of Nursing confirmed that the facility failed to develop written policies and procedures that include training new and existing nursing home staff on abuse, neglect, misappropriation of resident property, and exploitation. This failure resulted in the actual harm of staff members being unaware that unauthorized physical restraints can be a form of physical abuse and restraining a resident to a bed with a bed sheet which caused abdominal bruising for one of eight residents.
28 Pa. Code 201.14(a): Responsibility of licensee.
28 Pa. Code 201.18(b)(1)(e)(1): Management.
28 Pa Code: 201.20 (b): Staff development.
| | Plan of Correction - To be completed: 03/12/2026
Resident R1 was immediately assessed by the RN Supervisor following the incident. The unauthorized restraint (bed sheet used to secure the resident to the bed) was immediately removed. The resident received a full nursing assessment including evaluation of abdominal bruising. The physician and responsible party were notified.
The staff members involved were immediately removed from resident care duties pending investigation and were re-educated on Identifying Involuntary Seclusion and unauthorized restraint. Resident Rights and Abuse, Neglect, Exploitation and Misappropriation Prevention Programs and Mandatory Abuse reporting. The resident's care plan was reviewed and updated to reflect individualized interventions to prevent recurrence. The Director of Nursing and interdisciplinary team conducted an audit of all residents residing on the same unit to ensure no unauthorized restraints were in use. Residents on Zones 1, 2 and 4 with a BIMs of less than 13 were assessed for any new skin integrity areas of concern. Resident interviews were conducted for those with BIMs scores of 13 or above to determine if they felt they had been restricted in any way. No additional residents were identified as being restricted. No additional residents were identified as being subjected to unauthorized restraints. The facility developed and implemented revised written Abuse Prevention policies and procedures in accordance with 42 CFR §483.12 to ensure staff understand that unauthorized physical restraints constitute abuse. Systemic actions include revision of facility policy to clearly define physical abuse, including the use of unauthorized physical restraints such as tying a resident to a bed or chair using linens or other devices. A state approved directed in-service entitled Abuse Prohibition & Unauthorized Restraint will be provided beginning 3/7/26 - 3/12/26 or until all staff have received education by Masters Crafted in Healthcare, 129 Parker Avenue, Ligonier, PA 15678 and development of a mandatory training module for all new and existing staff covering abuse, neglect, misappropriation, and exploitation, recognition of physical restraints and prohibited practices, resident rights and alternatives to restraints, mandatory reporting procedures with 100% re-education of all facility staff, including nursing, therapy, housekeeping, dietary, maintenance, and administration. Orientation procedures will be revised to include abuse prevention training prior to direct resident contact.
To ensure ongoing compliance the Director of Nursing or designee will conduct weekly audits of 5 residents for restraint practices and resident observations for 8 weeks, then monthly for 4 additional months. Audits will include direct observation of residents and review of incident reports. Results will be reviewed by the facility Quality Assurance and Performance Improvement Committee (QAPI). The QAPI Committee will evaluate audit results, identify trends, and implement additional corrective actions if needed.
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