§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 review of facility policy, resident clinical records, facility documents, reports submitted to the State, and staff interview, it was determined that the facility failed to report allegations of verbal abuse for one of three sampled resident records (Resident R1).
Findings include:
Review of the facility provided policy titled "Abuse- Resident and Reasonable Suspicion of a Crime"" dated 5/28/26, indicated that the facility will treat every resident with consideration, respect and full recognition of his/her dignity and individuality. Verbal abuse is identified as any use of oral, written or gestured language that includes disparaging and derogatory terms to the resident or their families, or within their hearing distance, regardless of their age, ability to comprehend or disability. Alleged violations, whether or not confirmed, must be reported to the Administrator, Dof health, the Area Agency on Aging, Compliance Officer, and to the Executive Director, and a full investigation conducted.
Review of Resident R1's admission record indicated she was admitted on 4/3/20.
Review of Resident R1's MDS assessment (Minimum Data Set: MDS - a periodic assessment of care needs) dated 5/27/26, indicated she had diagnoses that include diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time), dysphagia (difficulty swallowing), and muscle weakness.
Review of facility "Concern Form" dated 6/2/26, stated that Resident R1 reported that a staff member on evening shift has been mean to her and will tell her to "shut up".
Review of alleged abuse allegations submitted to the State field office did not include the verbal abuse incident involving Resident R1 reported on 6/2/26.
During an interview on 6/15/26, at 3:58 p.m. the Director of Nursing confirmed that the facility failed to report allegations of verbal abuse for Resident R1 as required.
28 Pa. Code: 201.14(a) Responsibility of licensee.
28 Pa. Code: 211.10(d) Resident care policies.
28 Pa. Code: 201.18 (b) (1) (e) (1) Management.
28 Pa. Code: 211.12 (d) (1) (2) (5) Nursing services.
| | Plan of Correction - To be completed: 06/30/2026
Report for resident R1 was submitted on June 16, 2026
Prior 30 days of concern forms were audited by NHA to ensure that all reportable concerns were submitted to the State.
Director of Nursing, Administrator, and Grievance Officer were educated by the Deputy Executive Director on Abuse Reporting Requirements.
The Nursing Home Administrator, or designee, will audit all concern forms for the next 30 days during the business week for reportable events and ensure that such events are reported to the State within a timely manner.
This plan of correction will be monitored at the monthly Quality Assurance meeting until such time consistent substantial compliance has been met.
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