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F0609
D

Failure to Report Alleged Abuse Involving Resident with Dementia

Saxonburg, Pennsylvania Survey Completed on 11-13-2025

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 facility failed to report an allegation of abuse involving a resident with dementia, high blood pressure, and anxiety. According to the facility's policy, all allegations of abuse, neglect, or exploitation must be reported to the Administrator and the Department of Health within 24 hours. On the date in question, the Nursing Home Administrator (NHA), accompanied by a sheriff's deputy, confronted the resident in a public hallway about an alleged debt, repeatedly stating the amount owed and referencing issuing 30-day notices. The resident became visibly distraught, crying and expressing confusion about the situation. Multiple staff members, including the Former Director of Nursing (FDON), Former Activities Director (FAD), and Former Social Worker (FSW), witnessed the incident and described it as emotional or mental abuse. Written statements were submitted by at least two staff members, detailing the resident's distress and the intimidating nature of the encounter. Despite these reports and the facility's policy, the incident was not reported to the state agency as required. The FDON acknowledged awareness of the situation but claimed not to have received any written statements, while other staff confirmed they submitted statements and were discouraged from pursuing the matter further. The NHA later confirmed that the facility failed to report the abuse allegation. A review of incidents submitted to the state agency showed no record of the staff-to-resident abuse allegation for the incident in question.

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