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F0835
F

Failure to Implement Abuse Policy and Report Alleged Criminal Activity Creates Immediate Jeopardy

Chicora, Pennsylvania Survey Completed on 11-10-2025

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

The Nursing Home Administrator (NHA) and Director of Nursing (DON) failed to effectively manage and implement the facility's abuse and neglect policy, and did not report alleged criminal activity involving an LPN to the appropriate authorities. This failure was identified through a review of job descriptions, clinical records, and staff interviews. The NHA's job description required oversight of day-to-day operations, ensuring compliance with federal, state, and local standards, and maintaining effective systems for resident care and safety. The DON's responsibilities included nursing management, setting care standards, and ensuring regulatory compliance. Despite these outlined duties, both the NHA and DON did not fulfill their essential roles in upholding the facility's policies and legal requirements. As a result of these actions and inactions, all 95 residents were placed in an immediate jeopardy situation. The facility did not implement its abuse and neglect policy and failed to report the alleged criminal activity, as required by regulations. The deficiency was confirmed during an interview with the Chief Nursing Officer, who was notified of the failures by the NHA and DON. The report cites specific Pennsylvania Codes related to the responsibilities of the licensee, management, and nursing services, which were not adhered to in this instance.

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