Failure to Implement Abuse Policy for Missing Fentanyl Patch
Summary
The facility failed to implement its abuse policy for a resident who was admitted with multiple diagnoses, including anxiety disorder, Alzheimer's disease, depression, scoliosis, delusional disorder, and was receiving palliative care. The resident had a physician's order for a fentanyl patch to be administered every 72 hours. On December 21, 2024, a registered nurse noted that the fentanyl patch was missing from the resident's body and applied a new patch earlier than scheduled. This incident was not reported or investigated as a potential misappropriation of a controlled substance, which is a requirement under the facility's abuse policy. The Director of Nursing (DON) admitted that no investigation into potential misappropriation had been conducted in the last three months, despite the missing fentanyl patch. The facility's policy mandates that staff notify the DON immediately if a fentanyl patch is missing, as it could indicate theft. An LPN confirmed that the protocol is to inform the DON and the administrator if such an incident occurs. The facility's abuse policy, effective since April 2020, aims to prevent abuse, neglect, exploitation, and misappropriation of property by training employees to recognize and report such occurrences. However, in this case, the policy was not followed, leading to a deficiency in the facility's compliance with its own procedures.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
The facility failed to implement its abuse prohibition policy and to ensure immediate reporting of suspected abuse, misappropriation, and injury of unknown origin. A resident with dementia and insomnia reported receiving diphenhydramine for several weeks from a nurse despite having only a one-time order, while an LPN and the supply clerk observed missing diphenhydramine stock and expressed concern it was being given without orders but did not report this to the administrator. Another cognitively intact resident with anxiety reported that two video games were missing and believed they were stolen, but the allegation was only shared with an unidentified staff member and was never reported to the administrator or state agency. In a separate case, a severely cognitively impaired resident was found with a large right forearm bruise of unknown origin that was first noted on a prior shift, not immediately reported to leadership, and subsequently reported to the state agency outside the required 2-hour timeframe.
The facility failed to follow its abuse, neglect, and investigation policies for multiple residents. One resident with severe cognitive impairment and total dependence for bathing was assessed on the MDS as needing a 2‑person assist, but the care plan did not specify this, and a CNA provided a shower alone, during which the resident fell from a gurney and sustained head injuries. Another resident with impaired mobility and skin integrity needs was the subject of a complaint about lack of repositioning and rectal blisters, yet the 5‑day investigation contained no interviews with staff, the resident, or the complainant. A dependent, neurologically impaired resident alleged injury by a male CNA and was sent to the ER with wrist pain and lip bleeding, but the facility’s investigation, despite suspending and later terminating the CNA, did not include interviews with family or other residents cared for by that CNA. In a separate case, a non‑verbal resident with penile edema prompted an abuse allegation from family, but the DON conducted no staff or resident interviews, relying solely on her own assessment. Additionally, an altercation between two behaviorally complex residents was documented, but the excerpted records do not show a comprehensive abuse investigation consistent with policy, despite leadership acknowledging that such investigations must include thorough interviews and alignment of care plans with MDS findings.
The facility did not follow its abuse-prevention policy requiring background and credential checks for potential employees when it hired an RN without documented verification of her professional license status. Review of the RN’s personnel file showed no evidence that her license had been checked to confirm it was current and free of disciplinary action, and the Nursing Home Administrator acknowledged that no such documentation could be found, resulting in noncompliance with state regulatory requirements.
The facility failed to follow its abuse prohibition and reporting policies when two cognitively intact residents in a relationship experienced repeated verbal and physical abuse incidents. One resident with a history of verbally aggressive behavior yelled at and belittled his visually impaired roommate, who reported being upset and wanting to change rooms, but after she recanted, the Administrator did not treat the event as an abuse allegation. Later, a CNA documented that the same resident called his roommate a severe derogatory name, but this was not recognized or reported to the Abuse Coordinator or state agency as required. On another occasion, a CNA and an MA saw the resident shove his roommate in her wheelchair into trash and dirty linen barrels, yet both stated they did not consider it abuse and did not report it. These inactions, despite clear policy definitions of verbal and physical abuse and required steps for resident-to-resident incidents, resulted in a cited deficiency and an Immediate Jeopardy finding.
The facility failed to implement its own abuse/neglect and exploitation policies requiring screening and identity verification of employees and contracted temporary staff. An agency CNA used her mother’s identity and worked multiple AM, PM, and NOC shifts on different floors under a false name, after the staffing agency uploaded valid credentials for the mother to a shared portal. The NHA reported that the facility relied on the agency’s background checks and did not request photo ID from new agency staff at orientation or before their first shift, despite a contract clause stating the facility retained its own obligations to verify credentials. Police investigating a fraudulent food order discovered that the CNA working under the assumed name did not match the photo ID on file, and the CNA admitted she was using her mother’s identity to work. During this period, a resident filed a grievance alleging that a CNA left her wet and did not perform check-and-change per the care plan, and this grievance was attributed to the CNA known by the false name. The facility did not report a suspicion of a crime to the state survey agency and made no changes to its process for verifying the identity of new agency personnel after learning of the false identity.
Staff did not follow the facility’s investigation policy after a cognitively intact resident reported a missing tablet. The concern was recorded in the grievance log and staff searched for the item, but no thorough investigation was documented, and required interviews and reporting steps were not completed. The resident reported not receiving a response to the grievance, and the administrator acknowledged knowing about the missing tablet, speaking only with staff, and not conducting a full investigation as required by the misappropriation of property policy.
Failure to Implement Abuse Policy and Immediately Report Suspected Abuse, Misappropriation, and Injury of Unknown Origin
Penalty
Summary
The deficiency involves the facility’s failure to ensure staff implemented the abuse prohibition policy and procedures, resulting in multiple incidents of potential abuse, neglect, and misappropriation not being reported immediately to the abuse coordinator/administrator. For one resident with vascular dementia and insomnia, the record showed only a single one-time order for diphenhydramine 25 mg (two tablets) by mouth, with no ongoing order. Despite this, the resident reported that a male nurse had been giving him diphenhydramine for at least a few weeks to help him sleep, and that another nurse later told him the medication was not recommended for people with dementia because it could worsen cognitive skills. The resident stated he did not want any more of the medication because he did not want his memory to worsen. Staff interviews further described concerns that diphenhydramine was being administered without a physician’s order and that these concerns were not reported as required. One LPN reported she was concerned another LPN was giving residents in the memory care unit diphenhydramine without orders, after a male resident repeatedly requested the medication and stated that “the other nurse” gave it to him. The same LPN found an opened bottle of diphenhydramine in the memory care medication room, noted that a significant amount was missing while no residents on that unit had orders for it, and reported that the other LPN had commented, “We’ll be ok tonight. I made sure everyone is going to sleep tonight.” She removed the open bottle, but a new bottle appeared the following night. She then instructed the supply clerk to stop stocking diphenhydramine in that medication room due to her concern that it was being given without orders. Neither the LPN nor the supply clerk reported these concerns to the administrator, despite the facility’s abuse policy requiring immediate reporting of suspected abuse or adverse events. The deficiency also includes failure to report an allegation of misappropriation of resident property and failure to immediately report an injury of unknown origin. A cognitively intact resident with generalized anxiety disorder reported that two video games valued at $160 were missing and believed they had been stolen. He stated he told an unidentified staff member, who responded that the games were not on his inventory list and would not be replaced. The resident did not report the issue to the administrator because he believed nothing could be done, and the administrator later confirmed that staff had never informed him of this allegation and that it was never reported to the state agency or investigated. In a separate incident, a resident with severe cognitive impairment, dementia, bipolar disorder, and generalized anxiety disorder was found to have a large bruise of unknown origin on the right forearm, extending from the wrist to the top of the forearm and covering most of the dorsal surface. The former DON learned of the bruise only after seeing it documented in CNA alert charting the day after it was first identified, and an incident report indicated the bruise was first noted on night shift the previous day. The CNA reported that she was told about the bruise by off‑going staff the following morning and then alerted the DON. The provider documented a new right dorsal forearm bruise of unknown mechanism, and the facility-reported incident was not submitted to the state agency within the required 2-hour timeframe, despite the facility’s policy requiring immediate reporting of suspected abuse, neglect, misappropriation, and adverse events.
Failure to Implement Abuse/Neglect Policies and Conduct Thorough Investigations
Penalty
Summary
The deficiency involves the facility’s failure to implement and follow its abuse, neglect, and investigation policies for multiple residents, resulting in incomplete care planning, inadequate supervision, and insufficient investigations of alleged abuse or neglect. For one resident with a persistent vegetative state and severe cognitive impairment, MDS assessments in June and September documented total dependence for bathing with a required 2‑person assist, but the care plan did not specify a 2‑person assist for bathing until mid‑December. Staff reported that they relied on room indicators and the care plan to determine assist levels, and a CNA stated she provided a shower alone because the resident was considered a 1‑person assist at that time. During that shower, the resident jerked his legs, went over the gurney rail, and fell, sustaining head injuries and oral bleeding, and was sent to the ER. The DON and Administrator acknowledged that the care plan did not match the MDS and that providing 1‑person assist when 2‑person assist was required would constitute neglect. The facility also failed to conduct thorough investigations into allegations of neglect and possible abuse for other residents. For a resident with multiple comorbidities and impaired mobility who required frequent turning and repositioning and comprehensive skin care, a complaint alleged the resident had not been repositioned and developed blisters in the rectal area. The 5‑day investigation report documented that the allegation was received via voicemail on a weekend and retrieved the following Monday, but there was no evidence that staff, the resident, or the complainant were interviewed. The Nurse Manager and DON both stated that policy required thorough investigations with interviews, and the DON admitted she did not interview anyone in this case, relying instead on her own observations of the unit process. For another resident with significant neurologic deficits and dependence for all ADLs, including a 2‑person Hoyer lift, an allegation was made that a “tall man” hurt her, and she was found crying in pain with right wrist pain and blood on her lip. She was sent to the ER, where EMS reported the injury was from staff moving her, and imaging was performed. The facility’s 5‑day report noted that a male CNA was suspended and later terminated, but the investigation was deemed inconclusive based on imaging results and new diagnoses of decreased bone mineralization and osteoarthritis. The investigation lacked interviews with the resident’s family, other residents cared for by the alleged CNA, or the roommate’s family/guardian, despite the resident’s guardian later confirming a prior wrist fracture during a transfer and limited information from the facility. Another resident, non‑verbal with a trach, ventilator, and G‑tube, was completely incontinent and dependent for all ADLs. Nursing notes documented penile edema, with a physician assessment and topical nystatin ordered. The resident’s family later alleged abuse due to the swollen penis, prompting a 5‑day investigation. However, the investigation contained no evidence of interviews with witnesses, staff who provided care, the staff member identified as responsible, other residents cared for by that staff member, or any review of events leading up to the swelling. The DON stated she did not interview staff or residents because she believed she knew the cause of the swelling from her own assessment, despite acknowledging that the abuse policy required interviews during investigations. The facility also failed to fully investigate an altercation between two residents with significant psychiatric and behavioral histories. One resident had schizoaffective disorder, PTSD, a history of physical and verbal aggression, and was on a secured unit with interventions for redirection and behavior management. The other resident had schizoaffective and personality disorders, anxiety, major depressive disorder, and a history of yelling, self‑hitting, delusions, hallucinations, and was on 2:1 for cares due to false accusations and safety concerns. Nursing documentation described an incident where one resident, seated in a wheelchair at a doorway, turned and struck the other resident in the chest with his forearm, and the other resident struck back with a closed fist, with a CNA present who separated them. Although the event was self‑reported as an altercation, the report excerpt does not show that a comprehensive abuse investigation with required interviews and analysis of antecedent behaviors was completed in accordance with facility policy. Across these cases, staff interviews, including those with the DON, MDS/Care Plan Coordinator, Nurse Manager, and Administrator, confirmed that facility policy required thorough abuse/neglect investigations with interviews of involved staff, residents, and others, and that care plans should accurately reflect MDS findings. Nonetheless, the documented investigations for the cited residents lacked required interviews and failed to reconcile assessment data with care plans and actual care practices, leading to the cited deficiency for failure to implement and follow policies and procedures to prevent abuse, neglect, and to conduct complete abuse investigations.
Failure to Complete Required Licensure Check Prior to RN Hire
Penalty
Summary
The facility failed to ensure that a licensure check was completed prior to hire for one of five employee files reviewed, specifically for a registered nurse. The facility’s abuse policy dated February 27, 2026, required that potential employees be screened for a history of abuse, neglect, exploitation, or misappropriation of resident property, and that background, reference, and credential checks be conducted on potential employees, contracted temporary staff, students, volunteers, and consultants. Review of the personnel file for the registered nurse, who was hired on December 29, 2025, showed no documented evidence that her professional license had been checked to verify it was current and free of disciplinary action. In an interview, the Nursing Home Administrator confirmed they could not locate any documentation that a licensure check had been obtained prior to the nurse’s hire, resulting in noncompliance with 28 Pa. Code 201.14(a) and 201.18(e)(1).
Failure to Implement Abuse Reporting and Protection Policies for Resident-to-Resident Incidents
Penalty
Summary
The deficiency involves the facility’s failure to implement its written abuse prohibition policies and procedures to identify, report, and protect residents from abuse, specifically in relation to two cognitively intact residents who were in a relationship and shared a room. The facility’s Abuse Prohibition Policy defined abuse to include physical, mental, and verbal abuse, and required that any allegation of abuse made by residents, staff, or visitors be reported immediately to the Abuse Coordinator and investigated. The policy also required immediate protection of residents, monitoring of staff and resident behaviors to identify potential abuse, and specific steps for resident‑to‑resident incidents, including separating residents, assessing for injury, notifying the physician and family, completing incident reports, and contacting the Abuse Coordinator. One resident, an adult male with paraplegia, major depressive disorder, and anxiety disorder, and another resident, an adult female with cerebral infarction, severe visual impairment, bipolar disorder, and anxiety disorder, both had intact cognition with BIMS scores of 15/15 and had requested to room together. The male resident had care plan entries documenting a history and potential for verbally aggressive and accusatory behavior toward staff and residents, and episodes of verbal aggression/irritability when care for his girlfriend/roommate was not provided immediately. On one occasion, nursing notes documented that the female resident reported crying and being upset because her boyfriend yelled at and belittled her in front of others, and she expressed a desire to move out of the shared room. The LVN reported this to the social worker, who spoke with the resident; the resident later recanted and stated she loved him, and the male resident stated he had only told her to tell the nurse about her stomach pain. The Administrator was aware of this incident but, based on the recantation, did not consider it reportable and did not treat it as an abuse allegation under the policy. On a subsequent date, a CNA completed a written witness statement indicating she had observed the male resident yell at the female resident and call her a derogatory term, specifically “[f‑ing retard].” The CNA believed the Abuse Coordinator would see this in the statement, but the Administrator later stated she had not seen that portion of the statement. The Administrator acknowledged that such language would constitute verbal abuse and would be reportable to the state agency, yet the incident was not reported to the Abuse Coordinator or to the state agency as required by policy. Later, both a CNA and a medication aide witnessed the male resident pushing the female resident in her wheelchair and shoving her into trash and dirty linen barrels in the hallway. Both staff members stated they did not consider this to be abuse and therefore did not report it to the Administrator or Abuse Coordinator. The Administrator reported she was unaware of this physical incident until informed by the CNA shortly before the surveyor interview and acknowledged that it could be considered physical abuse and would be reportable. These failures to recognize, report, and respond to resident‑to‑resident verbal and physical abuse incidents, despite clear policy requirements and prior knowledge of the male resident’s behavioral history, led to the cited deficiency and the identification of an Immediate Jeopardy situation.
Removal Plan
- Attempted to separate Residents #14 and #55; both residents refused a room change.
- Initiated 1:1 monitoring for Resident #14 due to refusal to change rooms; monitoring to continue until risk is fully mitigated and IDT determines supervision can be safely reduced.
- Reviewed and updated care plans for Residents #14 and #55 to reflect supervision needs and behavioral concerns.
- Provided education to Residents #14 and #55 regarding personal safety and boundaries, risks associated with unsupervised interactions, and the facility’s responsibility to intervene when safety concerns arise; ongoing reinforcement planned.
- Completed a trauma-informed psychosocial assessment for Resident #55 to evaluate for emotional distress, coercion, or unmet needs; continued monitoring initiated.
- Assessed both residents for physical and psychosocial harm; no additional injury identified.
- Completed life satisfaction rounds to ensure no other residents were negatively affected; no negative findings.
- Notified the Medical Director regarding the alleged failure to follow abuse policies and procedures.
- In-serviced Administrator and DON on abuse policy and reporting procedures; competency validated via quiz.
- In-serviced facility staff on abuse policy and reporting procedures; competency validated via quiz; staff not allowed to work next scheduled shift until training completed.
- Incorporated the abuse training material into new hire orientation and ongoing.
- Audited incident reports for the last 3 months to ensure no other reportable incidents were missed; no negative findings.
- Audited grievances for the last 3 months to ensure no other reportable issues were missed; no negative findings.
- Implemented a protocol for resident-to-resident abuse when both residents refuse room change: immediate enhanced supervision, revise care plans, complete IDT review, assess capacity and risks, involve physician and responsible parties, and consider alternative interventions; ongoing reassessment until risk is fully mitigated.
- Established monitoring/QA process: Administrator/DON daily review of all incidents, grievances, and behavior notes, then weekly, then monthly; random staff interviews to validate understanding of abuse reporting; QAPI Committee review; immediate re-education and disciplinary action as indicated.
Failure to Implement Screening Procedures Allowed Agency CNA to Work Under False Identity
Penalty
Summary
The deficiency involves the facility’s failure to implement its written policies and procedures for screening staff, specifically agency CNAs, before they worked with residents. The facility had policies titled “Compliance with Reporting Allegations of Abuse/Neglect/Exploitation” and “Abuse, Neglect and Exploitation,” which required screening of potential employees, contracted temporary staff, students, volunteers, and consultants for histories of abuse, neglect, exploitation, or misappropriation of resident property. These policies also required background, reference, and credential checks, and documentation that such screenings occurred. However, the policies had no documented implementation, revision, or review dates, and the facility relied on the staffing agency’s processes without independently verifying the identity of agency staff upon arrival for orientation or their first shift. The events leading to the deficiency began when an agency CNA, later identified as CNA S, worked 12 shifts at the facility while posing as another CNA, identified as CNA T. The staffing agency had provided the facility with background and credential information for the person identified as CNA T, including a photocopy of an out-of-state driver’s license, and all credentials for that identity were verified and valid. The facility’s Nursing Home Administrator (NHA) stated that the agency obtained all required background information and uploaded it to a shared portal, and that the facility did not ask agency staff to provide identification at orientation because they had no reason to suspect the person was not who they claimed to be. The contract between the facility and the staffing agency specified that the agency would verify credentials, including photo identification, criminal background checks, and license verification, but also stated that this did not relieve the facility of its own statutory, regulatory, or contractual obligations to independently verify credentials and information. On one evening, local police investigated a fraudulent food order that had been delivered to the facility and identified the payer as the agency CNA known at the facility as CNA T. When police returned to the facility the next day to arrest this individual, they compared the woman presenting as CNA T with the photocopied driver’s license on file and noted that the woman did not match the photo. Further questioning revealed that the woman was actually CNA S, who admitted she was a travel CNA who had previously worked for the staffing agency but was suspended for attendance issues. She stated she created an account for her mother, CNA T, and had been working under her mother’s identity. During this period, she had worked multiple AM, PM, and NOC shifts on different floors under the false identity. The facility did not report this incident as a suspicion of a crime to the state survey agency, and the NHA acknowledged that no changes had been made to the process for verifying the identity of new agency personnel after the false-identity issue was discovered. During the surveyor’s review of facility records, it was also noted that a resident filed a grievance alleging that on one date a CNA left her wet and did not check and change her according to her plan of care. The facility’s investigation determined that the staff member involved was new, and the grievance was filed against the CNA identified as CNA T. Documentation of education provided to this CNA described her as new to the CNA occupation and a phenomenal worker who answered call lights and did not complain about tasks. This grievance occurred during the time period when the individual working under the name of CNA T was actually CNA S. The surveyor concluded that, due to the facility’s failure to implement its abuse/neglect and misappropriation policies and to confirm the proper identity of an agency CNA prior to work, an individual was able to work under a false identity for multiple shifts without proper screening by either the staffing agency or the facility, and that the facility did not change its screening practices even after learning of the false identity.
Failure to Investigate Allegation of Misappropriated Resident Property
Penalty
Summary
Facility staff failed to follow their 2017 Investigation policy requiring that every allegation of abuse, neglect, exploitation, mistreatment, injuries of unknown source, and misappropriated resident property be thoroughly investigated and reported to the administrator and State Survey Agency within five days. The policy specified that residents, employees, family members, visitors, and others may be interviewed about their knowledge of events, and emphasized that all health care workers are mandatory reporters of abuse. Despite this, when a cognitively intact resident reported a missing tablet, staff only documented the concern in the grievance log and noted they were still searching for the item, without initiating or documenting a formal investigation as required by policy. The resident’s quarterly MDS showed the resident was cognitively intact and had been admitted earlier in the year. The grievance log entry indicated the resident reported the tablet missing, but the medical record for the relevant month contained no documentation of an investigation into the missing property. In an interview, the resident stated the tablet had been missing for about a month, that it had been reported to an unknown staff member, and that there had been no response to the grievance. In a separate interview, the administrator acknowledged awareness of the missing tablet and stated that staff searched for the item and that he/she spoke with staff, but admitted not conducting a full investigation, not following the misappropriation of property policy, and not interviewing other residents, believing instead that the item would likely turn up as missing items typically do.
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