§483.12 Freedom from Abuse, Neglect, and Exploitation
The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms.
§483.12(a) The facility must-
§483.12(a)(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion;
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Observations:
Based on review of facility policies, clinical record, facility documentation and interviews with staff, it was determined the facility failed to ensure a resident remained free from neglect, which resulted in actual harm to Resident R5 who sustained a left leg periprosthetic femur fracture for one of five residents reviewed (Resident R5).
Findings include:
Review of facility policy "Resident Abuse Prevention and Reporting" dated July 22, 2009, with a last revision date of November 28, 2016, and November 29, 2016, defines Neglect as "the failure of the facility, it's employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress."
Review of Resident R5's MDS (Minimum Data Set - mandatory periodic assessment) dated May 8, 2026, revealed Resident R5 was readmitted to the facility on April 20, 2026, with the diagnoses of unspecified fall, repeated falls, other abnormalities of gait and mobility, cognitive communication deficit, and need for assistance with personal care. Additional review revealed Resident R5's toilet transfer status is Substantial/maximal assistance (Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort). Continued review revealed the resident was severely cognitively impaired with a Brief Interview of Mental Status of a 7 out of 15.
Review of Resident R5's care plan, date-initiated April 20, 2026, revealed the resident ambulation status is "non-ambulatory."
Further review of Resident R5's care plan revealed the resident was designated by the facility to be "at risk for falls." Interventions included "anticipate and meet the resident's needs."
Review of documentation submitted on June 17, 2026, to the State Survey Agency revealed on June 14, 2026, Resident R5 experienced a witnessed fall while Certified Nursing Assistant, Employee E3 was assisting Resident R5 from the bathroom ambulating without a walker or gait belt when resident's left knee buckled, causing her to lower herself to the floor. Nursing staff assessed Resident R5 following the fall, documented left knee discomfort and inability to straighten her leg, notified the physician and Power of Attorney (POA), obtained an X-ray, and implemented pain management interventions (ice pack). The X-ray results documented a knee prosthesis in place without loosening, with an effusion and no fracture identified at that time. On June 16, 2026, Resident R5 was transferred to a nearby hospital and admitted with a diagnosis of a left periprosthetic femur fracture (fracture occurring around or near a hip replacement implant).
Review of the facility-submitted PB-22 (Report of Investigation of Alleged Abuse, Neglect, or Misappropriation of Property), initiated June 16, 2026, revealed Resident R5's ambulation status was noted to be "non-ambulatory" and Resident R5, "should not have been ambulated by Certified Nurse Aide, Employee E3."
Further review of the PB-22 revealed the facility substantiated the allegation of neglect and concluded Resident R5 experienced neglect as a result of Certified Employee E3's actions.
Review of facilities fall investigation revealed the following transcript between the Nursing Home Administrator (NHA) and Certified Employee E3, dated June 17, 2026, at approximately 2:35 p.m.
Certified Employee E3: We (E3 and Resident R5) went into the bathroom and when we were walking back we right by resident's bed. I turned my head to turn the light off and he/she went down on his/her behind. He/she went down so fast I didn't have time to grab him/her. I was trying to make sure he/she didn't hit his/her head on the footboard.
NHA: Do you know what his/her ambulation status is on his/her Kardex?
Certified Employee E3: One assist with walker.
NHA: Do you remember the last time you looked at resident's Kardex?
Certified Employee E3: No I don't I'm not sure, I just know I was told he/she is a 1 assist with walker.
NHA: Who told you he/she is a 1 assist with a walker?
Certified Employee E3: I don't know someone when he/she was admitted.
NHA: Do you know her transfer status on her Kardex?
Certified Employee E3: A one assist I'm always there with him/her.
NHA: Does a one assist require hands on assistance?
Certified Employee E3: Is she needs assistance I am there to assist. But I am always standing right there.
NHA: Were you using a gait belt?
Certified Employee E3: NO I was not using a gait belt.
Certified Employee E3: So, we are supposed to check the Kardex every shift!?
NHA: Yes, that was the expectation- actually, the Kardex should be checked multiple times a shift as things can change.
Certified Employee E3: We don't have time for that.
Further review of the investigation transcript revealed Certified Nurse Aide, Employee E3 was suspended pending the outcome of the facility's investigation. Documentation further revealed Employee E3 subsequently resigned effective immediately.
Interview conducted with Resident R5 on June 29, 2026, at approximately 12:50 p.m. revealed Resident R5 recalled walking back from the bathroom when his/her knee gave out, causing him/her to fall to the floor. Resident R5 stated Certified Nurse Aide, Employee E3 did not prevent the fall.
The above findings were discussed with the Nursing Home Administrator and Director of Nursing on June 29, 2026, at approximately 2:23 p.m.
The facility failed to ensure Resident R5 was free from neglect. As a result, Resident R5 sustained a fall resulting in actual harm, including transfer to the hospital via emergency medical services and a diagnosis of a left periprosthetic femur fracture.
28 Pa. Code 201.14(a) Responsibility of licensee
28 Pa. Code 201.18(b)(1)(e)(1)(3) Management
28 Pa. Code 201.29(c) Resident rights
28 Pa. Code 211.5(f) Clinical records
28 Pa. Code 211.10(d) Resident care policies
28 Pa. Code 211.11(d) Resident care plan
28 Pa. Code 211.12(c)(d)(1)(5) Nursing services
| | Plan of Correction - To be completed: 08/10/2026
The statements made on this plan of correction are not an admission to and do not constitute an agreement with the alleged deficiencies herein. To remain in compliance with all federal and state regulations the facility has taken and will take actions set forth in the plan of correction. The plan of correction constitutes the facility's allegation of compliance such that the deficiencies cited have been corrected by the date certain.
1.R5 received immediate medical treatment and followed up with Orthopedics as ordered.
MD and POA notified at time of event.
Employee is no longer employed by this organization.
Care plan reviewed post incident.
Investigation initiated and completed on 6/17/26 and PB-22 submitted on 6/22/2026.
2.Facility wide audit will be completed by NHA/Nursing Leadership to ensure Kardex accuracy for all residents.
3.NHA/Nursing Leadership will provide education to direct care staff on the proper use of the Kardex to determine resident care needs prior to delivering care, the use of gait belts, reporting discrepancies between the Kardex and resident status, and abuse/neglect prevention expectations.
DOH approved Directed In-Service Provider Sophie Campbell from PADONA will complete education with facility wide staff on F0600.
Executive Leadership, NHA and Nursing Leadership will review facility policy on Safe Handling of Residents to ensure it clearly defines staff responsibilities regarding verification of resident transfer status, required assist level, gait belt use, and use of the Kardex prior to resident transfers. Policy revisions will be made as needed.
4.NHA/Nursing Leadership will conduct random facility wide Kardex Use Observation Audits across all shifts and all days of the week daily x30 days then weekly x4 weeks then every other week for 8 weeks then 5 per month.
Staff will demonstrate competency in locating and interpreting Kardex information and identifying resident transfer status including required transfer equipment before providing resident care.
Findings will be reported to QAPI for review/recommendations.
Immediate corrective action will be taken by facility Administration in the event of staff non-compliance.
All corrective actions will be completed by 8/10/2026.
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