§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.
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Observations:
Based on review of select facility policies and procedures, clinical record review, and staff interview, it was determined that the facility failed to thoroughly investigate and report to the appropriate agencies an injury of unknown origin and potential neglect for one of seven records reviewed (Resident CR1).
Findings include:
The policy entitled "Injury of Unknown Origin," last reviewed without changes on February 1, 2025, revealed it is the policy of the facility to immediately investigate all injuries of unknown origin to determine the cause, ensure resident safety, and comply with federal and state reporting requirements, including mandatory notifications to the Department of Health.
The nurse discovering or notified of the injury must perform an assessment including pain, location, size, color, and pattern of injury. The attending physician or on-call provider will be notified promptly for evaluation and treatment orders. The facility will remove the resident from potential harm if indicated and ensure supervision until the resident's safety is assured. The Director of Nursing and Nursing Home Administrator will be notified immediately. The responsible party will be notified promptly of the injury and findings. If abuse, neglect, or misappropriation is suspected, the incident must be reported within two hours if there is serious bodily injury, or within 24 hours to the Department of Health. The Director of Nursing or designee initiates a root cause investigation reviewing staffing assignments, supervision, and the environment. Interviews with residents, staff, and potential witnesses and review of recent events will be completed. The Director of Nursing or designee with evaluate potential abuse, neglect, or accident-related causes, including the abuse coordinator when abuse cannot be ruled out. The facility will complete and submit investigation results within five business days to the Department of Health.
Closed clinical record review revealed the facility admitted Resident CR1 on October 29, 2020. Nursing documentation dated October 12, 2025, at 10:08 AM revealed hospice was contacted for further instructions on Resident CR1's condition with bruising to her forehead. Documentation at 10:17 AM revealed the certified nurse practitioner noted that Resident CR1's forehead was raised and discolored, she also noted a bruise to Resident CR1's right hand.
Documentation dated October 13, 2025, at 12:35 AM noted Resident CR1's bruising on her forehead had moved under her left eye.
Review of the facility investigation dated October 12, 2025, at 6:00 AM revealed that Resident CR1 was found with a discolored area and swelling on her forehead on October 11, 2025 (second shift). Resident CR1 stated she fell and was picked up off the floor. The registered nurse assessed and found erythema (redness or discoloration of skin) on her forehead.
Review of Employee 1's (nurse aide) witness statement dated October 12, 2025, indicated yesterday when Employee 1 was giving Resident CR1 a shower he saw a bruise around her head and hand, but did not report it immediately. Employee 1 noted in the morning when he was washing her up, the bruise got worse, so he notified the licensed practical nurse. When the nurse asked Resident CR1 what happened Resident CR1 said she fell yesterday, but she could not remember who picked her up.
Further review of Resident CR1's clinical record revealed a significant change MDS (Minimum Data Set, an assessment completed at specific intervals to determine resident care needs) dated September 26, 2025, noting staff assessed Resident CR1 as dependent on staff for all activities of daily living.
Interview with the Director of Nursing on November 8, 2025, at 1:37 PM confirmed these findings. She stated it is the facility policy for staff to report all injuries of unknown origin at the time of identification.
The facility failed to thoroughly investigate and report to the appropriate authorities Resident CR1's bruises to rule out neglect or prevent further injuries.
28 Pa. Code 201.18(e)(1) Management
28 Pa. Code 201.29(a)(c) Resident rights
| | Plan of Correction - To be completed: 12/12/2025
Unable to retroactively correct, as the resident is now deceased.
NHA/designee will review skin incidents and injuries of unknown origin from the past 30 days to ensure that a thorough investigation has been carried out and abuse/ neglect has been ruled out.
NHA/designee will provide education to staff regarding reporting of abuse & neglect, as well as any skin alterations, including but not limited to bruises, redness, scratches, skin tears and open areas.
NHA/designee will complete audits of skin incidents and injuries of unknown origin weekly x4 weeks, then monthly x2 months to ensure that a thorough investigation has been completed and abuse & neglect have been ruled out. The results of these audits will be presented to the QA steering committee for 3 months, at which time the committee will determine the need for future audits.
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