F0609

D

Failure to Investigate and Report Allegations of Abuse and Neglect

Mifflintown, Pennsylvania Survey Completed on 01-22-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to follow its Abuse Investigation and Reporting policy by not thoroughly investigating and reporting allegations of abuse and neglect for two residents. The policy, last reviewed on November 20, 2025, required that all reports of abuse, neglect, exploitation, misappropriation of property, mistreatment, and injuries of unknown origin be promptly reported to specified local, state, and federal agencies and thoroughly investigated by facility management. Contrary to this policy, the facility did not treat certain resident and family reports as allegations of abuse or neglect and therefore did not initiate required investigations or notifications.

For one resident (CR1), a concern/grievance report dated January 8, 2026 documented that the resident reported a female staff member entered her room the previous night, was grumpy, and stated, “you asked for it, now you got it” after the resident requested a wedge behind her back. The resident reported that a pad was placed on her spine, that she could not find the call bell, and that she was scared. A summary by the DON indicated that the DON and social services director met with the resident, who stated someone was being rough with her at night, did not place a wedge under her back, and that she was afraid to use the call bell in case the person returned. The resident could not identify the staff member because her eyes were closed. The DON reviewed staff and obtained written statements from two night-shift nurse aides, and those aides felt the resident was hallucinating. Subsequently, clinical notes documented a purplish area on the resident’s right flank/hip extending below the right abdominal fold, an ultrasound-confirmed hematoma in that area, and an emergency room visit for a large bruise/hematoma to the right abdomen and hip. The facility was unable to provide any information showing that it investigated the cause of the hematoma to rule out abuse.

For another resident (CR2), who was assessed on the admission MDS as frequently incontinent of bowel and bladder and dependent on staff for personal and toileting hygiene, nursing documentation on November 10, 2025 recorded that the resident’s granddaughter informed the nurse that no nurse aide staff had been in the room all day to provide care. The documentation indicated that a nurse aide went into the room at approximately 2:10 PM and was refused entry by the granddaughter, and when the aide later returned to provide care, the resident was found soaked from incontinence through the sheets and bed pads. The Nursing Home Administrator stated that the facility did not identify the granddaughter’s report of no care all day as an allegation of neglect, did not obtain statements from staff who provided or attempted to provide care that day to rule out potential neglect, and did not report the allegation to the appropriate agencies. The DON and Administrator also stated that they did not more thoroughly investigate or report the events involving CR1 because they did not feel there was any allegation of abuse.