Failure to Report Allegations of Verbal Abuse to State Authorities
Penalty
Summary
The facility failed to ensure that all allegations of suspected abuse were reported immediately to the state agency as required by its abuse, neglect, and exploitation policy. The policy required reporting all alleged violations to the Administrator, state agency, adult protective services, and other required agencies within specified timeframes: immediately, but not later than two hours after the allegation is made if the events involve abuse or result in serious bodily injury, or not later than 24 hours if the events do not involve abuse and do not result in serious bodily injury. Review of the Pennsylvania Department of Health (DOH) Event Reporting System (ERS) and facility documentation showed that two of three allegations of suspected abuse were not reported to DOH or entered into the ERS. One unreported allegation involved a grievance submitted for Resident R10 on February 7, 2026, describing an ongoing alleged incident of verbal abuse, most recently occurring on February 6, 2026, by Employee E10. The allegation stated that Employee E10 threatened to have the resident removed from the facility because the resident accused her of disclosing his mental health diagnosis. Another unreported allegation involved Resident R2, who, along with her daughter, reported to the DON that on February 3, 2026, a nurse aide wearing black scrubs threatened her to stop ringing her call bell or she would "end up dead." The DON recalled the conversation and noted that the black scrubs suggested the aide was likely from an agency, but confirmed that this allegation was also not reported to DOH or entered into the ERS. Review of the DOH ERS confirmed no reported events for either resident.
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