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F0609
D

Failure to Immediately Report Alleged Abuse

Holland, Pennsylvania Survey Completed on 05-16-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

An incident occurred involving a resident with dementia, psychotic disturbance, mood disturbance, and anxiety, who required assistance with personal care. During the incident, the resident became agitated, removed her pants, and urinated in the hallway. While staff attempted to assist her back to her room, the resident slapped a nursing aide, who then retaliated by slapping the resident across the face. The aide who witnessed the event did not immediately report the incident to the nursing supervisor, instead waiting until the following day to do so. This delay in reporting resulted in the facility failing to immediately notify the Pennsylvania Department of Health of the alleged abuse, as required by policy and regulation. The internal investigation and suspension of the involved staff were also delayed by approximately 24 hours due to the late report. The deficiency was identified through review of facility policies, clinical records, and staff interviews, confirming that the facility did not ensure immediate reporting of the abuse allegation.

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