F0835

D

Administrative Failure to Prevent Sexual Abuse Between Residents

Nanticoke, Pennsylvania Survey Completed on 01-16-2026

Penalty

No penalty information released

Summary

Facility administration failed to effectively use its resources to promote resident safety and maintain residents’ highest practicable physical and mental well-being, resulting in a resident being subjected to sexual abuse by another resident. The Nursing Home Administrator’s job description required fostering a safe environment, providing emotional and psychological support, overseeing day-to-day operations to ensure quality care in accordance with state and federal standards, and implementing and enforcing company policies and procedures. The DON’s job description required assuring resident safety through nursing staff, evaluating the effects of care delivered, assigning special treatments when indicated, and reviewing and revising care plans and assessments as necessary. However, review of facility documentation and staff interviews showed that administrative oversight did not ensure effective coordination, monitoring, and implementation of systems designed to protect residents from abuse.

The facility did not identify, mitigate, or manage known and foreseeable risks associated with resident interactions, particularly among residents with cognitive impairment, which limited their ability to understand, process, or make safe decisions. This failure in administrative oversight, including failure to ensure appropriate supervision, consistent implementation of resident safety and abuse prevention policies, and timely administrative intervention when safety risks were present, allowed one resident to sexually abuse another. The deficient practice was directly related to an Immediate Jeopardy citation under F600 (Freedom from Abuse, 42 CFR §483.12), with leadership’s lack of effective oversight, monitoring, and enforcement of policies contributing to the Immediate Jeopardy situation.