Pennsylvania Department of Health
HIGHLAND HILLS POST ACUTE
Patient Care Inspection Results

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HIGHLAND HILLS POST ACUTE
Inspection Results For:

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HIGHLAND HILLS POST ACUTE - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on an Abbreviated Survey in response to three incidents, completed on May 5, 2025, it was determined that Highland Hills Post Acute was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities and the 28 Pa. Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.




 Plan of Correction:


483.12(a)(1) REQUIREMENT Free from Abuse and Neglect:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§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;
Observations:

Based on review of facility documents, facility policy, clinical records, and staff interviews, it was determined that the facility failed to ensure that residents were free from abuse for two of three residents reviewed (Resident R1 and R2).

Findings include:

Review of facility "Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating" policy dated 11/1/24, indicated all reports of resident abuse, neglect, exploitation or theft/misappropriation of resident property are reported to local, state and federal agencies and thoroughly investigated by facility management. Findings of all investigations are documented and reported. Any employee who has been accused of resident abuse is placed on leave with no resident contact until the investigation is complete. Witness statements are obtained in writing, signed and dated. The witness may write statement, or the investigator may obtain a statement.

"Abuse," is defined at as "the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology."

"Sexual abuse," is defined at as "non-consensual sexual contact of any type with a resident."

Review of the clinical record indicated Resident R1 was admitted to the facility on 3/28/24.

Review of Resident R1's Minimum Data Set (MDS - a periodic assessment of care needs) dated 2/19/25, indicated diagnoses of high blood pressure, depression, and arthritis (swelling or tenderness in one or more joints). MDS Section H-Bladder and Bowel, H0300 Urinary Continence is coded as a "2", indicating frequent incontinence. H0400 Bowel Contience is coded as a "2", indicating frequent incontinence.

Review of Resident R1's care plan dated 12/4/24, indicated assist with daily hygiene, grooming, dressing, oral care, and eating as needed.

During a review of documentation provided by the facility on 5/5/25, at 9:00 a.m. indicated that resident reported an allegation of sexual abuse to Certified Occupational Therapy Assistant (COTA) Employee E1 on 4/24/25. Resident R1 indicated that Alleged Perpetrator (AP) Employee E2 was assisting with incontinence care and AP Employee E2, "touched my bottom and kept touching me there" and "I don't want him here anymore". COTA Employee E1 reported incident to supervisor immediately.

During a review of documentation provided by the facility on 5/5/25, at 9:30 a.m. revealed that the facility failed to recognize this allegation as sexual abuse from 4/24/25, and failed to investigate the alleged sexual abuse.

Review of the clinical record indicated Resident R2 was admitted to the facility on 2/28/25.

Review of Resident R2's MDS dated 3/7/25, indicated diagnoses of depression, heart failure (a progressive heart disease that affects pumping action of the heart muscles), and diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time). MDS Section H-Bladder and Bowel, H0300 Urinary Continence is coded as a "2", indicating frequent incontinence. H0400 Bowel Contience is coded as a "2", indicating frequent incontinence. MDS Section GG- Functional Abilities, GG01300 Self Care. Toileting hygiene is coded as a "3", indicating partial to moderate assistance (helper does less than half the effort). Shower/bath is coded as a "4", indicating Supervision or touching assistance (helper cues or touches). Upper body dressing is coded as "4". Lower body dressing is coded as a "2", indicating substantial/maximal assistance (helper does more than half the effort).

During a review of documentation provided by the facility on 5/5/25, at 9:45a.m. indicated that Resident R2 reported an allegation of sexual abuse to Certified Occupational Therapy Assistant (COTA) Employee E1 on 4/24/25. Resident R2 reported that AP Employee E2 "opened by house dress for no reason and looked at me", and "he ran his hand up and down by body, he scares me". Resident R2's roommate, Resident R1, reported an allegation of physical abuse to COTA Employee E1 in that AP Employee E2 pushed and shoved Resident R2 while transferring her into bed. COTA Employee E1 reported incident to supervisor immediately.

During a review of documentation provided by the facility on 5/5/25, at 11:00 a.m. indicated that AP Employee E2 was suspended on 4/24/25, and was brought back to work 4/25/25, after receiving education. The facility failed to investigate and complete all three allegations (one physical, two sexual) prior to AP Employee E2 returning to work to ensure that all residents were free from abuse or neglect.

During an interview on 5/5/25, at 11:30 a.m. Nursing Home Administer (NHA) stated " We suspended him on 4/24/25, brought him back to work and then on 4/30/25, we realized that not all allegations of abuse were investigated so we suspended him again".

During an interview on 5/5/25, at 3:00 p.m. NHA confirmed that the facility failed to keep AP Employee E2 on leave with no resident contact until all three allegations of abuse were investigated to ensure that residents were free from abuse for Resident R1 and R2.

28 Pa. Code 201.14(a) Responsibility of licensee.
28 Pa. Code 201.18(b)(d)(1)(3)(e)(1) Management.







 Plan of Correction - To be completed: 05/28/2025

Corrective Action for Affected Residents:
On 4/30/25, AP Employee E2 was immediately suspended pending a complete investigation of all abuse allegations. The Director of Nursing (DON)/designee completed comprehensive head-to-toe assessments of Residents R1 and R2 on 4/30/25. Both residents were interviewed by the Social Services Director to assess for any emotional or psychological impact and were offered counseling services. The facility completed thorough investigations of all three allegations of abuse involving Residents R1 and R2.

Identifying other Residents having the Potential to be Affected:
On 4/24/25, the DON/designee conducted interviews with all alert and oriented residents to identify any other potential incidents of abuse.

Measures put into place or Systemic Changes:
Staff will be in-serviced on:
- Abuse recognition, prevention, and reporting requirements
- Proper investigation procedures for abuse allegations
- Protocol requiring staff accused of abuse to remain suspended until all investigations are complete
- Immediate reporting of any suspected abuse to administration
The facility's abuse policy was revised on 04/30/2025 to strengthen investigation procedures and ensure accused staff members remain suspended until all investigations are complete.

Plan to Monitor Performance:
The Administrator will audit all abuse allegations daily for 1 week, weekly for 2 weeks and monthly thereafter to ensure:
- Proper immediate response to allegations
- Complete investigations before staff return to work
- Appropriate resident protection measures
- Compliance with reporting requirements

Findings will be reported through the QAPI committee will evaluate the effectiveness of interventions and make changes as needed until substantial compliance is achieved and maintained.

483.12(b)(1)-(5)(ii)(iii) REQUIREMENT Develop/Implement Abuse/Neglect Policies:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§483.12(b) The facility must develop and implement written policies and procedures that:

§483.12(b)(1) Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property,

§483.12(b)(2) Establish policies and procedures to investigate any such allegations, and

§483.12(b)(3) Include training as required at paragraph §483.95,

§483.12(b)(4) Establish coordination with the QAPI program required under §483.75.

§483.12(b)(5) Ensure reporting of crimes occurring in federally-funded long-term care facilities in accordance with section 1150B of the Act. The policies and procedures must include but are not limited to the following elements.

§483.12(b)(5)(ii) Posting a conspicuous notice of employee rights, as defined at section 1150B(d)(3) of the Act.

§483.12(b)(5)(iii) Prohibiting and preventing retaliation, as defined at section 1150B(d)(1) and (2) of the Act.
Observations:

Based on review of facility documents, facility policy, clinical records, and staff interviews, it was determined that the facility failed to implement written policies and procedures to ensure a complete and thorough investigation of three allegations of abuse for two of three residents (Resident R1 and R2).

Findings include:

Review of facility "Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating" policy dated 11/1/24, indicated all reports of resident abuse, neglect, exploitation or theft/misappropriation of resident property are reported to local, state and federal agencies and thoroughly investigated by facility management. Findings of all investigations are documented and reported. Any employee who has been accused of resident abuse is placed on leave with no resident contact until the investigation is complete. Witness statements are obtained in writing, signed and dated. The witness may write statement, or the investigator may obtain a statement.

"Abuse," is defined at as "the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology."

"Sexual abuse," is defined at as "non-consensual sexual contact of any type with a resident."

Review of the clinical record indicated Resident R1 was admitted to the facility on 3/28/24.

Review of Resident R1's Minimum Data Set (MDS - a periodic assessment of care needs) dated 2/19/25, indicated diagnoses of high blood pressure, depression, and arthritis (swelling or tenderness in one or more joints). MDS Section H-Bladder and Bowel, H0300 Urinary Continence is coded as a "2", indicating frequent incontinence. H0400 Bowel Continece is coded as a "2".

Review of Resident R1's care plan dated 12/4/24, indicated assist with daily hygiene, grooming, dressing, oral care, and eating as needed.

During a review of documentation provided by the facility on 5/5/25, at 9:00 a.m. indicated that resident reported an allegation of sexual abuse to Certified Occupational Therapy Assistant (COTA) Employee E1 on 4/24/25. Resident R1 indicated that Alleged Perpetrator (AP) Employee E2 was assisting with incontinence care and AP Employee E2, "touched my bottom and kept touching me there" and "I don't want him here anymore". COTA Employee E1 reported incident to supervisor immediately.

During a review of documentation provided by the facility on 5/5/25, at 9:30 a.m. revealed that the facility failed to recognize this allegation of sexual abuse on the date it was reported and failed to investigate the alleged sexual abuse.

Review of the clinical record indicated Resident R2 was admitted to the facility on 2/28/25.

Review of Resident R2's MDS dated 3/7/25, indicated diagnoses of depression, heart failure (a progressive heart disease that affects pumping action of the heart muscles), and diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time). MDS Section H-Bladder and Bowel, H0300 Urinary Continence is coded as a "2", indicating frequent incontinence. Section H0400 Bowel Continence is coded as a "2". MDS Section GG- Functional Abilities, GG01300 Self Care. Toileting hygiene is coded as a "3", indicating partial to moderate assistance (helper does less than half the effort). Shower/bath is coded as a "4", indicating Supervision or touching assistance (helper cues or touches). Upper body dressing is coded as "4". Lower body dressing is coded as a "2", indicating substantial/maximal assistance (helper does more than half the effort).

During a review of documentation provided by the facility on 5/5/25, at 9:45 a.m. indicated that Resident R2 reported an allegation of sexual abuse to Certified Occupational Therapy Assistant (COTA) Employee E1 on 4/24/25. Resident R2 reported that AP Employee E2 "opened by house dress for no reason and looked at me", and "he ran his hand up and down by body, he scares me". Resident R2's roommate, Resident R1, reported an allegation of physical abuse to COTA Employee E1 in that AP Employee E2 pushed and shoved Resident R2 while transferring her into bed. COTA Employee E1 reported incident to supervisor immediately.

During a review of documentation provided by the facility on 5/5/25, at 11:00 a.m. indicated that AP Employee E2 was suspended on 4/24/25, and was brought back to work 4/25/25, after receiving education. The facility failed to investigate and complete all three allegations (one physical, two sexual) prior to AP Employee E2 returning to work to ensure that all residents were free from abuse or neglect.

During a review of Resident R2's clinical record on 5/5/25, at 11:15 a.m. indicated that the facility failed to assess the resident after alleged abuse occurred, failed to notify the physician and family. Resident R2's clinical record failed to indicate that a physician assessed resident after an allegation of abuse occurred.

During an interview on 5/5/25, at 3:00 p.m. NHA confirmed that the facility failed to implement written polices and procedures to ensure a complete and thorough investigation of three allegations of abuse for Resident R1 and R2.

28 Pa. Code 201.14(a) Responsibility of licensee.
28 Pa. Code 201.18(e)(1) Management.


 Plan of Correction - To be completed: 05/28/2025

Corrective Action for Affected Residents:
The Interim Director of Nursing (DON) conducted comprehensive assessments of Resident R1 and R2 for any signs of abuse or trauma. The residents' physicians and responsible parties were notified of the allegations. The facility immediately removed Alleged Perpetrator (AP) Employee E2 from resident care pending a thorough investigation of all three abuse allegations. A complete investigation was initiated including obtaining detailed statements from all involved parties and interviewing other residents who received care from AP Employee E2.

Identifying other Residents having the Potential to be Affected:
The DON/designee conducted interviews with all alert and oriented residents to identify any other potential incidents of abuse. Care staff schedules were reviewed to identify any residents who received care from AP Employee E2.

Measures put into place or Systemic Changes:
Ad-hoc QAPI Committee revised the facility's abuse investigation policy including a detailed investigation
checklist. The DON/designee will in-service all department managers and licensed staff on:
- Proper abuse investigation procedures
- Immediate reporting requirements
- Resident protection measures
- Documentation requirements
- Staff suspension protocols
- Return-to-work criteria following abuse allegations
The facility implemented a new abuse checklist to ensure all required steps are completed before closing any investigation. The Administrator or designee must approve all staff returns to work following abuse allegations.

Plan to Monitor Performance:
The DON/designee will audit 100% of abuse allegations daily for 1 weeks, then weekly for 1 month, then monthly for 3 months to ensure:
- Immediate resident protection measures are implemented.
- Proper notifications are made.
- Thorough investigations are conducted.
- Complete documentation is maintained
- Appropriate corrective actions are taken

The Administrator will report monitoring results to the Quality Assurance and Performance Improvement (QAPI) committee monthly. The QAPI committee will analyze data and make recommendations for additional interventions if needed until substantial compliance is achieved and maintained.

483.12(b)(5)(i)(A)(B)(c)(1)(4) REQUIREMENT Reporting of Alleged Violations:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§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.
Observations:

Based on review of facility policy, resident clinical record, incident reports, reports submitted to the State, and staff interview it was determined that the facility failed to report an allegation of abuse for one of three residents (Resident R1).

Findings include:

Review of facility "Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating" policy dated 11/1/24, indicated all reports of resident abuse, neglect, exploitation or theft/misappropriation of resident property are reported to local, state and federal agencies and thoroughly investigated by facility management. Findings of all investigations are documented and reported. Any employee who has been accused of resident abuse is placed on leave with no resident contact until the investigation is complete. Witness statements are obtained in writing, signed and dated. The witness may write statement, or the investigator may obtain a statement.

"Abuse," is defined at as "the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology."

"Sexual abuse," is defined at as "non-consensual sexual contact of any type with a resident."

Review of the clinical record indicated Resident R1 was admitted to the facility on 3/28/24.

Review of Resident R1's Minimum Data Set (MDS - a periodic assessment of care needs) dated 2/19/25, indicated diagnoses of high blood pressure, depression, and arthritis (swelling or tenderness in one or more joints). MDS Section H-Bladder and Bowel, H0300 Urinary Continence is coded as a "2", indicating frequent incontinence. H0400 Bowel Continence is coded as a "2".

Review of Resident R1's care plan dated 12/4/24, indicated assist with daily hygiene, grooming, dressing, oral care, and eating as needed.

During a review of documentation provided by the facility on 5/5/25, at 9:00 a.m. indicated that resident reported an allegation of sexual abuse to Certified Occupational Therapy Assistant (COTA) Employee E1 on 4/24/25. Resident R1 indicated that Alleged Perpetrator (AP) Employee E2 was assisting with incontinence care and AP Employee E2, "touched my bottom and kept touching me there" and "I don't want him here anymore". COTA Employee E1 reported incident to supervisor immediately.

During a review of documentation provided by the facility on 5/5/25, at 9:30 a.m. revealed that the facility failed to recognize and report this allegation of sexual abuse on 4/24/25, and failed to investigate the alleged sexual abuse.

During an interview on 5/5/25, at 11:10 a.m. the Nursing Home Administrator (NHA) stated that the Director of Nursing (DON) was made aware of the allegations on 4/24/25.

During an interview on 5/5/25, at 11:15 a.m. the NHA confirmed the facility was unable to provide an investigation for reported abuse allegation from 4/24/25, for Resident R1, and the NHA confirmed that the facility did not report it.

During an interview on 5/5/25, at 3:00 p.m. the NHA confirmed that the facility failed to report an allegation of abuse for one of three residents (Resident R1).

28 Pa Code: 201.14 (a)(c )(e ) Responsibility of management

28 Pa Code: 201.18 (b)(1) (e)(1) Management.


 Plan of Correction - To be completed: 05/28/2025

Corrective Action for Affected Residents:
The facility immediately removed AP Employee E2 from resident care duties and initiated a thorough investigation of the allegation made by Resident R1. The allegation was immediately reported to the State Survey Agency and appropriate authorities. A skin assessment was completed for Resident R1, and the resident was assessed by Social Services for any signs of emotional distress. The resident was provided with counseling services, and the care plan was updated to reflect current interventions.

Identifying other Residents having the Potential to be Affected:
The Interim Director of Nursing (DON)/designee conducted interviews with alert and oriented residents to identify any other potential incidents of abuse without concern.

Measures put into place or Systemic Changes:
The DON/designee will in-service all department managers on abuse reporting requirements, including time frames, as well as:
- Recognition of abuse
- Immediate reporting requirement
- Protection of residents during investigations
- Documentation requirements the facility's abuse policy was revised to include a clear reporting protocol and chain of command.

Plan to Monitor Performance:
The Administrator/designee will conduct weekly audits of all incident reports and grievances daily for 1 week, weekly for 1 month and monthly for 3 months to ensure proper reporting and investigation of abuse allegations. The DON/designee will conduct random interviews with 10% of alert and oriented residents biweekly for 1 week, weekly for 1 month and monthly for 3 months to ensure no unreported allegations exist. The Administrator will review all abuse allegations daily to ensure proper reporting timeframes are met.

The Administrator will report monitoring results to the Quality Assurance and Performance Improvement (QAPI) committee monthly for 3 months. The QAPI committee will evaluate the effectiveness of interventions and make changes as needed until substantial compliance is achieved and maintained.

483.12(c)(2)-(4) REQUIREMENT Investigate/Prevent/Correct Alleged Violation:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§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.
Observations:

Based on review of facility documents, facility policy, clinical records, and staff interview, it was determined that the facility failed to conduct a thorough investigation of three allegations of abuse for two of three residents (Resident R1 and R2).

Findings include:

Review of facility "Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating" policy dated 11/1/24, indicated all reports of resident abuse, neglect, exploitation or theft/misappropriation of resident property are reported to local, state and federal agencies and thoroughly investigated by facility management. Findings of all investigations are documented and reported. Any employee who has been accused of resident abuse is placed on leave with no resident contact until the investigation is complete. Witness statements are obtained in writing, signed and dated. The witness may write statement, or the investigator may obtain a statement.

"Abuse," is defined at as "the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology."

"Sexual abuse," is defined at as "non-consensual sexual contact of any type with a resident."

Review of the clinical record indicated Resident R1 was admitted to the facility on 3/28/24.

Review of Resident R1's Minimum Data Set (MDS - a periodic assessment of care needs) dated 2/19/25, indicated diagnoses of high blood pressure, depression, and arthritis (swelling or tenderness in one or more joints). MDS Section H-Bladder and Bowel, H0300 Urinary Continence is coded as a "2", indicating frequent incontinence. H0400 Bowel Continence is coded as a "2".

Review of Resident R1's care plan dated 12/4/24, indicated assist with daily hygiene, grooming, dressing, oral care, and eating as needed.

During a review of documentation provided by the facility on 5/5/25, at 9:00 a.m. indicated that resident reported an allegation of sexual abuse to Certified Occupational Therapy Assistant (COTA) Employee E1 on 4/24/25. Resident R1 indicated that Alleged Perpetrator (AP) Employee E2 was assisting with incontinence care and AP Employee E2, "touched my bottom and kept touching me there" and "I don't want him here anymore". COTA Employee E1 reported incident to supervisor immediately.

During a review of documentation provided by the facility on 5/5/25, at 9:30 a.m. revealed that the facility failed to recognize this allegation as sexual abuse from 4/24/25, and failed to investigate the alleged sexual abuse for Resident R1.

Review of the clinical record indicated Resident R2 was admitted to the facility on 2/28/25.

Review of Resident R2's MDS dated 3/7/25, indicated diagnoses of depression, heart failure (a progressive heart disease that affects pumping action of the heart muscles), and diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time). MDS Section H-Bladder and Bowel, H0300 Urinary Continence is coded as a "2", indicating frequent incontinence. H0400 Bowel Continence is coded as a "2". MDS Section GG- Functional Abilities, GG01300 Self Care. Toileting hygiene is coded as a "3", indicating partial to moderate assistance (helper does less than half the effort). Shower/bath is coded as a "4", indicating Supervision or touching assistance (helper cues or touches). Upper body dressing is coded as "4". Lower body dressing is coded as a "2", indicating substantial/maximal assistance (helper does more than half the effort).

During a review of documentation provided by the facility on 5/5/25, at 9:45a.m. indicated that Resident R2 reported an allegation of sexual abuse to Certified Occupational Therapy Assistant (COTA) Employee E1 on 4/24/25. Resident R2 reported that AP Employee E2 "opened by house dress for no reason and looked at me", and "he ran his hand up and down by body, he scares me". Resident R2's roommate, Resident R1, reported an allegation of physical abuse to COTA Employee E1 in that AP Employee E2 pushed and shoved Resident R2 while transferring her into bed. COTA Employee E1 reported incident to supervisor immediately.

During a review of documentation provided by the facility on 5/5/25, at 9:57 a.m. revealed that the facility failed to complete a thorough investigation for the abuse allegations for Resident R2. No witness statements or interviews of staff or residents were completed.

During an interview on 5/5/25, at 11:22 a.m. the Nursing Home Administrator (NHA) stated that the allegations were being completed by the Director of Nursing from 4/24/25. The NHA reviewed the abuse investigation and confirmed that the facility did not complete a thorough investigation for all three abuse allegations.

During a review of Resident R2's clinical record failed to have a documented assessment after an abuse allegation was made and the physician and family were not notified.

During an interview on 5/5/25, at 3:00 p.m. the NHA confirmed that the facility failed to conduct a thorough investigation of three allegations of abuse for two of three residents (Resident R1 and R2).

28 Pa Code: 201.18 (e)(1)(2) Management.
28 Pa Code: 201.29 (a)(c) Resident Rights.
28 Pa Code: 211.12 (a)(c)(d)(1)(3)(5) Nursing services.


 Plan of Correction - To be completed: 05/28/2025

Corrective Action for Affected Residents:
The Administrator completed thorough investigations for all three allegations of abuse involving Residents R1 and R2. The investigations included obtaining written witness statements, conducting staff and resident interviews, and completing physical assessments of both residents. The residents' physicians and responsible parties were notified. AP Employee E2 was immediately removed from resident care duties pending investigation completion. Both residents were assessed for any physical or psychological effects and provided appropriate care and support services.

Identifying other Residents having the Potential to be Affected:
Interim DON/designee interviewed all alert and oriented residents to identify any unreported concerns of abuse with no additional concern noted.

Measures put into place or Systemic Changes:
Ad-hoc QAPI Commitee revised the facility's abuse investigation policy including a detailed investigation
checklist. The DON/designee will in-service all department managers and staff on:
- Proper identification and reporting of abuse allegations
- Required components of thorough abuse investigations
- Documentation requirements for abuse investigations
- Immediate protective measures during investigations
- Required notifications to physician, family, and officials
- Timeline requirements for investigation completion and reporting
A new Abuse Investigation Checklist was implemented to ensure all investigation components are completed. The Administrator appointed the Assistant Director of Nursing as the facility's Abuse Investigation Coordinator.

Plan to Monitor Performance:
The Abuse Investigation Coordinator will audit 100% of abuse investigations weekly for 4 weeks, then 50% monthly for 2 months to ensure thoroughness of investigations and compliance with facility protocol. The Director of Nursing will review all abuse investigation documentation daily during morning clinical meeting. The Administrator will review all abuse investigations weekly to ensure completion of all required components.

The Administrator will report monitoring results to the Quality Assurance and Performance Improvement (QAPI) committee monthly. The QAPI committee will monitor compliance until substantial compliance is achieved and maintained for 3 consecutive months.

483.25 REQUIREMENT Quality of Care:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§ 483.25 Quality of care
Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices.
Observations:
Based on review of facility policy, clinical records, and staff interview it was determined that the facility failed to notify a physician, failed to notify family, and failed to complete an assessment of a resident after an abuse allegation was made for three abuse allegations for two of three residents (Resident R1 and R2).

Findings include:

Review of facility "Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating" policy dated 11/1/24, indicated all reports of resident abuse, neglect, exploitation or theft/misappropriation of resident property are reported to local, state and federal agencies and thoroughly investigated by facility management. Findings of all investigations are documented and reported. Any employee who has been accused of resident abuse is placed on leave with no resident contact until the investigation is complete. Witness statements are obtained in writing, signed and dated. The witness may write statement, or the investigator may obtain a statement.

"Abuse," is defined at as "the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology."

"Sexual abuse," is defined at as "non-consensual sexual contact of any type with a resident."

Review of the clinical record indicated Resident R1 was admitted to the facility on 3/28/24.

Review of Resident R1's Minimum Data Set (MDS - a periodic assessment of care needs) dated 2/19/25, indicated diagnoses of high blood pressure, depression, and arthritis (swelling or tenderness in one or more joints). MDS Section H-Bladder and Bowel, H0300 Urinary Continence is coded as a "2", indicating frequent incontinence.

Review of Resident R1's care plan dated 12/4/24, indicated assist with daily hygiene, grooming, dressing, oral care, and eating as needed.

During a review of documentation provided by the facility on 5/5/25, at 9:00 a.m. indicated that resident reported an allegation of sexual abuse to Certified Occupational Therapy Assistant (COTA) Employee E1 on 4/24/25. Resident R1 indicated that Alleged Perpetrator (AP) Employee E2 was assisting with incontinence care and AP Employee E2, "touched my bottom and kept touching me there" and "I don't want him here anymore". COTA Employee E1 reported incident to supervisor immediately.

During a review of documentation provided by the facility on 5/5/25, at 9:30 a.m. revealed that the facility failed to recognize this allegation as sexual abuse from 4/24/25, and failed to investigate the alleged sexual abuse for Resident R1.

Review of the clinical record indicated Resident R2 was admitted to the facility on 2/28/25.

Review of Resident R2's MDS dated 3/7/25, indicated diagnoses of depression, heart failure (a progressive heart disease that affects pumping action of the heart muscles), and diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time). MDS Section H-Bladder and Bowel, H0300 Urinary Continence is coded as a "2", indicating frequent incontinence. MDS Section GG- Functional Abilities, GG01300 Self Care. Toileting hygiene is coded as a "3", indicating partial to moderate assistance (helper does less than half the effort). Shower/bath is coded as a "4", indicating Supervision or touching assistance (helper cues or touches). Upper body dressing is coded as "4". Lower body dressing is coded as a "2", indicating substantial/maximal assistance (helper does more than half the effort).

During a review of documentation provided by the facility on 5/5/25, at 9:45a.m. indicated that Resident R2 reported an allegation of sexual abuse to Certified Occupational Therapy Assistant (COTA) Employee E1 on 4/24/25. Resident R2 reported that AP Employee E2 "opened by house dress for no reason and looked at me", and "he ran his hand up and down by body, he scares me". Resident R2's roommate, Resident R1, reported an allegation of physical abuse to COTA Employee E1 in that AP Employee E2 pushed and shoved Resident R2 while transferring her into bed. COTA Employee E1 reported incident to supervisor immediately.

During a review of documentation provided by the facility on 5/5/25, at 9:57 a.m. revealed that the facility failed to complete a thorough investigation for the abuse allegations for Resident R2. No witness statements or interviews of staff or residents were completed.

During an interview on 5/5/25, at 11:22 a.m. the Nursing Home Administrator (NHA) stated that the allegations were being completed by the Director of Nursing from 4/24/25. On 4/30/25, the NHA reviewed the abuse investigation and confirmed that the facility did not complete a thorough investigation for all three abuse allegations.

During a review of Resident R2's clinical record failed to have a documented assessment after an abuse allegation was made and the physician and family were not notified.

During an interview on 5/5/25, at 3:00 p.m. the NHA confirmed that the facility failed to notify a physician, failed to notify family, and failed to complete an assessment of a resident after an abuse allegation was made for three abuse allegations for two of three residents (Resident R1 and R2).


28 Pa. Code 201.18 (b)(1) Management

28 Pa. Code 201.29(a) Resident Rights

28 Pa. Code 211.10 (c)(d) Resident Care policies

28 Pa. Code 211.12 (d)(1)(2)(3)(5) Nursing services


 Plan of Correction - To be completed: 05/28/2025

Corrective Action for Affected Residents:
The Interim Director of Nursing/Social Services completed comprehensive physical and emotional assessments for Residents R1 and R2. The residents' physicians and family members were immediately notified of the abuse allegations. A thorough investigation was initiated including obtaining witness statements from staff and residents. AP Employee E2 was immediately removed from resident care duties pending investigation. Social Services conducted follow-up emotional support visits with both residents.

Identifying other Residents having the Potential to be Affected:
The Interim Director of Nursing and Services conducted interviews with all alert and oriented residents regarding potential abuse concerns without concern.

Measures put into place or Systemic Changes:
Ad-hoc QAPI Committee revised the facility's abuse investigation policy.
The DON/designee will in-service center staff on:
- Proper identification and immediate reporting of abuse allegations
- Requirements for thorough abuse investigations
- Protocol for resident assessments following abuse allegations
- Requirements for physician and family notification
- Documentation requirements
The facility's abuse investigation protocol has been revised to include a comprehensive checklist ensuring all required steps are completed, including:
- Immediate removal of alleged perpetrator from resident care
- Completion of resident assessment
- Physician and family notification
- Collection of witness statements
- Documentation requirements

Plan to Monitor Performance:
The Director of Nursing and/or designee will audit all abuse allegations daily for 1 weeks, then weekly for 1 month, then monthly for 3 months to ensure:
- Proper reporting and investigation
- Completion of resident assessments
- Physician and family notification
- Required documentation

The Director of Nursing/designee will conduct weekly interviews with 10% of alert and oriented residents regarding any abuse concerns for 3 months.

The Administrator will report monitoring results to the Quality Assurance Performance Improvement (QAPI) committee monthly. The QAPI committee will analyze data and make recommendations for additional interventions if needed until substantial compliance is achieved and maintained.


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