§483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must:
§483.12(c)(1) Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures.
§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 facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to ensure that staff report allegations of possible neglect to the administrator and/or director of nursing for one of five residents reviewed (Resident 2).
Findings Include:
Review of facility policy, titled "Abuse, Neglect, Mistreatment, Exploitation, and Misappropriation of Resident Property", revised June 14, 2023, revealed "This facility's policy is to immediately report and investigate all allegations of mistreatment, neglect, abuse, misappropriation of a resident's property or any injury of unknown origin. ... Neglect occurs when the facility is aware of, or should have been aware of, goods or services that a resident(s) requires but the facility fails to provide them to the resident(s), that has resulted in or may result in physical harm, pain, mental anguish, or emotional distress. ... The charge nurse/supervisor who receives the initial report of the alleged or suspected abuse, neglect, or misappropriation of property will initiate the investigation immediately and report the incident also to the Administrator and Director of Nursing and/or Social Worker immediately."
Review of Resident 2's clinical record revealed diagnoses that included dementia (a general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life) and severe intellectual disabilities (when limitations in a person's mental abilities affect intelligence, learning and everyday life skills).
Review of Resident 2's current care plan revealed that he required assistance with toileting tasks, with an intervention, revised July 7, 2022, to offer the toilet every two hours and as required for incontinence.
Review of Resident 2's intervention/task list revealed a task for toileting every two hours.
Review of Resident 2's nurse aide task documentation, dated June 21, 2026, revealed no documentation that Resident 2 was toileted at 2:00 PM, 4:00 PM, 6:00 PM, or 8:30 PM.
On August 13, 2026, at 8:51 AM, the Nursing Home Administrator (NHA) stated that he spoke to Employee 1 (Registered Nurse [RN]), who confirmed that she spoke with Employee 2 (Nurse Aide) after being made aware that Resident 2 was found to be "saturated" on June 21, 2026. The NHA stated that according to Employee 1, Employee 2's resident care assignment changed for the evening shift and Employee 2 told Employee 1 that she did not realize that Resident 2 was assigned to her on the evening shift. Employee 1 stated that she was going to give Employee 2 a write-up initially, but "upon talking with another nurse, they felt it was an honest mistake and not a situation of neglect and did not feel it needed to be escalated."
There was no evidence that an investigation was completed for the allegation of possible neglect when Resident 2 was found to be incontinent. There was no documentation that Resident 2 was provided incontinence care, and Employee 2 confirmed in an interview that she did not provide any care to Resident 2 because she didn't know the resident was on her assignment. There was no further investigation to include resident record reviews and interviews with other residents assigned to Employee 2 during that shift, to ensure care was not missed being provided to them also.
During an interview with the NHA on August 13, 2026, at 10:47 AM, the surveyor asked the NHA what prompted Employee 1 to call Employee 2 and question her about Resident 2's care. He stated that the LPN (licensed practical nurse) reported that Resident 2 came walking out into the hallway and his pants were "saturated." Employee 1 called Employee 2, who left early, at 8:03 PM, and Employee 2 stated she was unaware that Resident 2 was on her assignment. The NHA stated that neither he nor the Director of Nursing were made aware of the allegation or an investigation would have been done.
28 Pa. Code 201.14(a) Responsibility of licensee
28 Pa. Code 201.18(b)(1) Management
28 Pa. Code 211.12(d)(1)(2)(5) Nursing services
| | Plan of Correction - To be completed: 09/08/2026
Preparation and or evaluation of the following plan of correction set forth in this document does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and executed solely because it is required by the provisions of federal and state law.
The facility cannot go back in time for Resident 2 when resident was missed due to an assignment change on June 21, 2026. The facility will complete an investigation for the allegation of possible neglect and submit results via the Department of Health event reporting system.
No other resident has been identified as being missed due to change in assignment on June 21, 2026.
The Director of Nursing/designee will conduct training with the RN Supervisors on completion of assignments and reassignments when staff changes. Training includes notifying the working C.N.As of the reassignment to ensure all residents are assigned staff and receive care per their care plan. Education also includes reporting to the Director of Nursing on any concerns with assignments and care.
The Regional Clinical Nurse will provide education on reportable incidents to the Director of Nursing and Administrator. Education includes investigating potential allegations of neglect.
The Director of Nursing/designee will conduct training with the C.N.A.s on completion of documentation for care provided. This includes documentation on toileting programs.
The Director of Nursing/designee will audit C.N.A. assignment sheets and task documentation for completion of five residents a day, five days a week for four weeks. Audit also includes ensuring that any identification of missed care has been investigated for allegation of neglect.
Audits will be taken to QAPI for review/discussion.
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