§483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must:
§483.12(c)(2) Have evidence that all alleged violations are thoroughly investigated.
§483.12(c)(3) Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress.
§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, review of facility documentation, review of clinical records, and staff interviews it was determined that the facility failed to ensure a complete and thorough investigation was completed for allegations of potential abuse and neglect for one out of two residents reviewed (Resident R1).
Findings include:
Review of the facility policy, "Abuse Prevention Program," with a review date of 11/30/22 indicated that all abuse neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source (abuse) shall be promptly reported ... and thoroughly investigated by facility management. Findings of abuse investigations will also be reported.
Review of Resident R1's May 2026 physician orders included the following diagnoses: atrial fibrillation (irregular heart rhythm which can cause fatigue, heart palpitations, shortness of breath, and dizziness), high blood pressure, osteoarthritis (aging and wear and tear on a joint); acute pulmonary edema (fluid accumulation in the lungs); chronic obstructive pulmonary disease (COPD a group of lung diseases that block airflow and make it difficult to breathe); and diabetes (the body's impaired ability to regulate blood sugars).
Review of Resident R1's Comprehensive Minimum Data Set (MDS- a periodic assessment of a resident's needs) dated March 18, 2026, indicated that the resident was awake, alert and oriented.
Review of Resident R1's clinical notes indicated that the resident was admitted into the facility on March 11, 2026, for rehabilitation services, and discharged to the hospital on May 2, 2026.
Review of information submitted to the State Survey Agency on May 12, 2026, revealed on May 11, 2026, the facility was made aware of the following concerns regarding the care and services provided for Resident R1: missed doses of eyedrop for treatment of glaucoma (eye damage that can cause vision loss); wrong medications ordered; ineffective pain management; edema care not provided; not getting incontinence care in a timely manner; staff attitude; staff rough during care; closet door with missing hinges; and no management of Resident R1's atrial fibrillation.
Review of the facility's investigation regarding the above referenced concerns did not show evidence that Resident R1 and/or the complainant were contacted for further information that may be needed for the investigation in an attempt to establish possible dates/times, names of staff and other details to ensure that a complete and thorough investigation was completed regarding the alleged allegations.
In this investigation, the facility determined that Resident R1's eye drops were given and that the resident did not miss a dose, and that this allegation was unsubstantiated. However, a review of Resident R1's clinical record indicated that the medication Azopt Ophthalmic Suspension 1% (Brinzolamide), for the treatment of glaucoma, was not marked as administered in the Medication Administration Record (MAR) on March 21, 2026, at 9:00 a.m. and March 21st at 2:00 p.m.,as ordered by the physician.Continued review Resident R1's MARdid not show evidence that the medication Latanoprost 0.005 % Solution, for the treatment of glaucoma, was administered on March 31, 2026, at 21:00 (9:00 p.m.), as ordered by the physician.
Continued review of the facility investigation did not show evidence that the facility contacted Resident R1 and/or the complainant for an interview regarding the alleged incidents (wrong medication given, delay in pain management, not assisted with incontinence care, rude staff) to see if a date/time/medication/ description and or name of staff members could be determined to ensure and complete and thorough investigation regarding the allegations was completed.
During a discussion with the Director of Nursing (DON), Employee E2, on May 29, 2026, at 2:47 p.m., it was discussed that there was no evidence that the facility contacted Resident R1 and/or the complainant to see if they can provide additional details regarding the allegations that could assist the facility in a conducting a complete and thorough investigation regarding concerns related to care and services.
During the discussion the DON, Employee E2, reported that she has never contacted residents or complainants regarding any of their concerns after they have left.
28 Pa. Code 201.14 (a) Responsibility of licensee.
28 Pa. Code 211.10 (d) Resident care policies.
28 Pa. Code 211.12 (d)(5) Nursing services.
| | Plan of Correction - To be completed: 06/24/2026
F610
1) The facility reached out to the complainant on 6/19/2026 to ensure there were no other concerns regarding the complaint. The investigation was completed and closed by the facility on May 27, 2026.
2) The NHA completed a thorough review of facility abuse allegations for the past 90 days to ensure that investigations were completed thoroughly including follow up calls if needed. Any additional concerns identified were addressed immediately.
3) The NHA and DON will be re-educated by the Regional Nurse on ensuring that a complete and thorough investigation is completed for allegations of potential abuse and neglect to include follow up interviews/phone calls if the complainant is no longer residing in the facility. The education will also include completing a thorough investigation of any concern regarding missing medication.
4) The NHA and/or designee will audit reportable events to ensure the entire investigative process was completed. Audits will occur 2x a month 1 month then 1x a month x2 months.
Results of these audits will be reported to the monthly Quality Assurance Performance Improvement Committee until monthly and/or substantial compliance is met. Adjustments to the plan of corrections will be made by the Interdisciplinary Team as needed.
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