§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 interview, it was determined that the facility failed to immediately report an injury of unknown origin to the State Survey Agency for one of six sampled residents. (Resident 2)
Findings include:
Review of the facility policy entitled, "Resident Abuse," last reviewed August 1, 2025, revealed that all incidents and allegations of abuse, including injuries of unknown source were to be reported immediately to the Administrator, Director of Nursing, and to the State Agency.
Clinical record review revealed Resident 2 had diagnoses that included hemiplegia (paralysis that affects one side of the body), stroke, and dementia. The Minimum Data Set assessment dated November 14, 2025, indicated that the resident was cognitively impaired, required staff assistance with toileting and personal hygiene, and was dependent on staff for transfers. A review of nursing notes revealed that on November 28, 2025, at 1:19 p.m., a nurse aide observed bruising to Resident 2's right arm and right hip. A registered nurse assessed the bruises and indicated that two "faded" purple bruises were observed to resident's right hip and right upper arm and that the resident was unable to recall how the bruises occurred. There was a lack of evidence to support that the facility reported the injury of unknown source to the State Survey Agency.
In an interview at 1:00 p.m., the Director of Nursing confirmed the facility did not report the incident to the State Survey Agency.
28 Pa. Code 201.18(e)(1) Management.
28 Pa. Code 211.12(d)(1)(5) Nursing services.
| | Plan of Correction - To be completed: 02/26/2026
1. Resident has been discharged. Event report has been submitted for R2.
2. To identify others with the potential to be affected, DON completed a 30 day review of events related to bruises to verify there have been no other events that require a report.
3. To prevent from reoccurring, NHA educated DON on the reporting requirements for injuries of unknown origin.
4. Ongoing monitoring for compliance, NHA/designee will review twenty four hour report daily to identify any injuries of unknown origin and will ensure investigation and reporting as needed.
5. Results will be reviewed and revised as needed during monthly QAPI.
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