§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 a review of select facility policies and procedures, clinical record review, personnel record review, and staff interview, it was determined that the facility failed to protect a resident's right to be free from physical abuse by staff that resulted in actual harm with a serious injury of a rib fracture for one of seven residents reviewed (Resident 1).
Findings include:
The facility policy entitled, "Abuse Prevention and Prohibition Program, Operational Manual, Abuse and Neglect," last reviewed February 3, 2026, noted that the purpose of the program is to ensure that the facility establishes, operationalizes, and maintains an Abuse Prevention and Prohibition Program designed to screen and train employees, protect residents, and to ensure a standardized methodology for the prevention, identification, investigation, and reporting of abuse, neglect, mistreatment, misappropriation of property, and crime in accordance with federal and state requirements. The procedure for Screening referred to the policy, "Staff Screening" training procedures included that covered individuals will be trained through orientation and on-going training sessions on topics that included abuse prevention and appropriate interventions to deal with aggressive and/or catastrophic reactions of residents.
The facility policy entitled, "Staff Screening, Operational Manual, Abuse and Neglect," last reviewed February 3, 2026, revealed that if the facility uses registry staff or permits students from affiliated academic programs to train on-site, the facility will validate that these individuals undergo the same screening as is required of individuals employed directly by the facility. Upon hire, facility employees will participate in orientation that includes, but is not limited to, training related to abuse and neglect, and resident rights. The facility will also offer orientation to volunteers, registry/temporary staff, students, and contractors/consultants to the extent it applies to their job function.
Clinical record review for Resident 1 revealed his diagnoses list included the need for assistance with personal care and unspecified dementia with other behavioral disturbance (brain disorder that impairs memory, thinking, and the ability to perform everyday activities that contributes to behaviors such as agitation, aggression, delusions, and resistance to care).
Review of Resident 1's plan of care initiated by the facility on May 4, 2026, to address his resistance to care revealed interventions that included, "If resident resists with ADLs (activities of daily living), reassure resident, leave and return five to 10 minutes later and try again."
Review of Resident 1's bedside Kardex (electronic documentation of care needs available to nurse aide staff providing direct care to the resident) dated June 5, 2026, revealed no directive to leave the resident when he is resisting care.
Nursing documentation by Employee 2 (registered nurse) dated June 5, 2026, at 7:53 PM revealed that a nurse aide observed Resident 1, "upside down on the bed," with Employee 1 (nurse aide) on top of Resident 1 while Resident 1 was yelling, out of breath, and shaking. The documentation indicated that Employee 1 was attempting to put Resident 1's incontinence brief on. The nurse aide asked Employee 1 to leave the room, after which he completed Resident 1's care. Employee 1 was escorted from the facility by the registered nurse.
A skin assessment completed by Employee 2 dated June 5, 2026, at 7:25 PM noted that Resident 1 presented with, "Red raised welts on abdomen and back, and lower ext. (extremities)."
Nursing documentation by Employee 3 (registered nurse) dated June 6, 2026, at 10:46 AM noted, "Follow up skin assessment completed upon resident care, see skin assessment."
Review of a Skin Observation/check dated June 6, 2026, at 11:00 AM identified 12 sites of bruising, abrasion, redness, swelling, or tenderness of Resident 1's scalp, chest, abdomen, back of head, right and left shoulders, back, buttock, wrist, rib, and lip as follows:
Top of scalp, bruise, 2 cm (centimeters) by 2 cm
Chest, bruising to mid chest, 4 cm by 2 cm
Abdomen, right lower quadrant scattered bruising
Back of head, bruise, 1 cm by 1 cm
Right shoulder (front), red area, 2 cm by 0.5 cm
Left shoulder (rear), bruise, 1 cm by 1 cm
Lower back, bruise, 4 cm by 3 cm
Left wrist, red/purple area, 2 cm by 2 cm
Middle/left back, abrasion, 2 cm by 2 cm
Right buttock, ecchymotic (bruised) area, 1 cm by 1 cm
Right inner lip, bruise, 0.5 cm by 0.5 cm with small open area in the center
Right side rib cage, swelling and tender to touch with complaints of discomfort
Nursing documentation by Employee 3 dated June 6, 2026, at 12:11 PM noted physician notification of Resident 1's skin assessment and complaints of discomfort to his right rib area for which the physician ordered an x-ray of Resident 1's right side/rib cage and chest.
Nursing documentation dated June 8, 2026, at 11:14 PM noted that received x-ray results for Resident 1 included an "Acute displaced fracture of the (right) 7th (seventh) rib (type of rib fracture where the broken ends of the rib are not aligned property, often caused by trauma)."
Review of the radiology report with an examination date of June 8, 2026, at 3:28 PM noted findings as, "Acute displaced fracture of the lateral right seventh rib."
A review of the facility's PB22 (Provider Bulletin 22 form, a standardized Pennsylvania Department of Health document used to report and investigate allegations of abuse, neglect, or misappropriation of property in long-term care facilities) investigation of the above incident noted that the facility substantiated the allegation of staff-to-resident physical abuse and removed Employee 1 from the facility.
Review of available personnel record documentation for Employee 1 revealed no evidence that he completed education related to the facility's Abuse Prevention and Prohibition Program.
Interview with the Director of Nursing on June 26, 2026, at 12:47 PM confirmed that nursing staff on the June 26, 2026, deployment schedule included several staff from the nurse staffing agency that employed Employee 1 without evidence of completion of the facility's Abuse Prevention and Prohibition Program education. The Director of Nursing immediately implemented on-the-spot in-servicing for all agency nurse staff present in the building and reported a plan for all agency employees to report to the nursing supervisor before their on-unit shift to complete the facility Abuse Prevention and Prohibition Program education. The interview also confirmed that the intervention to reapproach Resident 1 when refusing or resistant to care was not included on the bedside Kardex instructions until June 22, 2026.
Interview with the Nursing Home Administrator on June 26, 2026, at 6:00 PM confirmed that staff scheduled to work in the facility through a contracted staffing agency are considered contractors and would be subject to orientation training regarding the facility's abuse prevention program. The facility did not have evidence of this training for Employee 1 or those staff on the nursing deployment schedules for the date of the onsite survey until following the surveyor's questioning.
28 Pa. Code 201.14 (a) Responsibility of licensee
28 Pa. Code 201.18 (b)(1)(2)(e)(1) Management
28 Pa. Code 201.19(7) Personnel policies and procedures
28 Pa. Code 201.20(b)(d) Staff development
28 Pa. Code 201.29 (a)(c) Resident rights
28 Pa. Code 211.12(c)(d)(1)(5) Nursing services
| | Plan of Correction - To be completed: 07/26/2026
1. Unable to retro-correct deficient practice. Employee #1 was terminated for substantiated abuse. The DON/Designee did educate the agency staff on the facility's policy for abuse and abuse prevention.
2. All residents have the potential to be affected. DON or designee will audit all staff (in house & agency) to ensure education on facility abuse prevention and prohibition policy. DON or designee will complete an in house audit of care plans for all residents with known behaviors to ensure interventions that affect resident care are located on the residents' kardex. The DON/Designee will interview residents with BIMS of 12 or above to ensure that they have not reported any abuse and/or seen any abuse.
3. All nursing staff will receive directed in-service thru CMS Training Video-Freedom from Abuse, Neglect, and Exploitation.
4. DON or designee will complete weekly audits to ensure all new nursing staff have completed education on facility abuse, prevention and prohibition. DON or designee will complete weekly audits on any residents with new behaviors to ensure kardexs are updated with interventions to address behaviors that affect resident care. Audits will be completed weekly x 4 weeks. The results of audits will be reviewed by the QAPI committee.
5. Date of compliance 7/26/26
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