Unverified Individual Allowed to Provide Direct Care Without Screening or Credential Verification
Summary
The deficiency involves the facility’s failure to implement its written abuse, neglect, exploitation, and misappropriation prevention policy by not ensuring employment screening and verification for an individual who presented as agency staff. On the morning in question, an individual identified as S12 entered the locked building after being allowed in by a CNA and initially inquired about job openings. She was directed to the back nurses’ station to speak with LPNs. After briefly leaving to change footwear at the request of an LPN, she re-entered the facility and then represented herself to multiple LPNs as an agency CNA arriving to cover an open shift. Facility staff did not verify her identity, employment with the staffing agency, or credentials before assigning her to resident care. S12 was handwritten onto the daily assignment sheet and assigned to provide direct care to ten residents, all of whom had significant medical conditions, including hemiplegia and hemiparesis following cerebrovascular events, COPD with acute exacerbation, gastrostomy malfunction, atrial fibrillation, non-traumatic subarachnoid hemorrhage, hypertensive urgency, acute infarction of the spinal cord, and encephalopathy. S12 reported that she rounded on residents, answered call lights, and obtained snacks from the kitchen for some residents. She specifically described answering a call light for one resident on barrier precautions, donning a gown and gloves, entering the room, rolling the resident to remove his brief, and becoming soiled with feces on her gloved hand and gown sleeve. She then requested assistance from two CNAs, removed her PPE, left the room, and did not return to complete care. Interviews with the two CNAs confirmed that S12 had been present in the resident’s room, had begun incontinence care, and then left after removing her gloves and gown, without returning, leaving them to complete the care. Both CNAs stated they did not know whether she was facility or agency staff. The resident involved confirmed that a female aide, who did not identify herself, answered his call light, called two male CNAs to assist with changing his brief, donned a gown and gloves, became soiled, and then left the room without removing his brief or returning. Review of the visitor log and personnel list showed S12 was not listed as a visitor and was not a current employee. The benefits coordinator, DON, and administrator all confirmed that S12 was not employed by the facility or the staffing agency, that no registry or background checks or credential verification had been completed for her, and that there was no existing process to screen, orient, or complete competency evaluations for agency staff upon entry before they began resident care. This failure to verify and screen S12 before assigning her to direct resident care led to an Immediate Jeopardy situation for the residents under her care. Additional interviews with nursing staff further demonstrated that the facility lacked an operational process to ensure agency staff were verified and oriented before working. One LPN stated that S12 was asked if she was agency staff and, upon her affirmative response, no further verification of agency employment or credentials was performed before she was placed on the assignment sheet. Another LPN acknowledged assigning S12 to care for the ten residents without confirming her agency status, screening, orientation, or competency. The DON confirmed that neither she nor other administrative staff had verified S12’s credentials or screening before S12 was allowed to provide care for approximately two hours. Staff also reported that agency personnel were generally expected to report to any hall, clock in through their agency on their phones, and check the daily assignment sheet, and that agency staff did not receive facility orientation, abuse/neglect training, or competency evaluations prior to being assigned resident care. These actions and inactions collectively demonstrate the facility’s failure to follow its own abuse prevention policy requiring screening of employees and contracted staff, resulting in an Immediate Jeopardy situation.
Removal Plan
- Conduct an immediate search of the facility to locate the unidentified individual and confirm she is no longer present in the building.
- Verify with the staffing agency that the individual is not employed by the agency and confirm through the facility staffing system that she is neither an active nor former employee.
- Instruct receptionist and front desk staff not to allow the individual entry should she return.
- Search the parking lot to ensure the individual has left the premises.
- Contact the Police Department to document the incident and obtain identifying information.
- Print and display a photograph of the individual throughout the facility with instructions to contact law enforcement if she returns.
- Establish a door monitor to ensure all individuals entering the facility are identified, verified, and logged prior to entering the building.
- Evaluate residents who could have potentially been affected by the unidentified individual.
- Interview residents residing in the area where the individual's name had been placed on the assignment sheet to determine whether the individual provided care or engaged in any abusive behavior.
- Interview all residents with a BIMS score of 8 or greater regarding any concerns related to abuse, neglect, or mistreatment.
- For residents with a BIMS score of less than 8, complete a head-to-toe assessment by a licensed nurse to evaluate any signs or symptoms of abuse.
- Implement a system for verification of employee and agency staff credentialing prior to working, including completing required pre-employment screening for facility employees consistent with the facility abuse policy.
- Verify active license/certification prior to the staff member's first shift and maintain documentation.
- Require final clearance by designated facility leadership before marking any employee as cleared for scheduling.
- For agency/contract staff, verify with the staffing agency that the individual has been screened to the same or substantially similar standards and maintain documentation prior to scheduling.
- Prohibit placement of any employee or agency staff member on the daily work schedule until required credentialing and screening verification is completed and documented.
- Conduct a daily schedule review prior to each shift to confirm all scheduled staff have been cleared to work and that any replacements/changes are verified prior to working.
- Validate facility entry at the start of each shift by reviewing identification, confirming the person matches the daily schedule/approved list, and requiring sign-in on the daily staff log.
- Prevent any unverified individual from providing resident care and require immediate follow-up by designated leadership to re-check records, contact the agency, validate licensure/certification, determine eligibility, and remove/replace if verification cannot be confirmed.
- Maintain an ongoing system to monitor employee and agency credentials for expirations/status changes and remove staff from assignment if credentials are expired or unverifiable until resolved.
- Maintain documentation of credentialing verification activities with Administrator and DON oversight and corrective action for failures.
- Have regional staff routinely audit the verification process and trend/correct variances through QAPI.
- Require all people, including staff, entering the facility to sign in and out at the front desk.
- Ensure the front desk is not left unattended by arranging staff coverage for continuous monitoring.
- Change keypad door codes throughout the facility, delete previously stored codes, and input new codes to prevent unauthorized access.
- Provide education for all staff in all departments on abuse/neglect/exploitation prevention, responsibility to identify and report unknown individuals, verification of agency staff prior to resident care, facility entry procedures, and sign-in requirements.
- Verify abuse training requirements for agency staff by obtaining a copy of the training from the agency and providing facility abuse training at the beginning of the agency staff member's first scheduled shift.
- Validate staff competency following abuse prevention education via verbal return demonstration and staff interviews and provide re-education before returning to resident care duties if needed.
- Conduct random staff interviews during supervisory rounds to confirm ongoing staff knowledge of abuse reporting requirements and monitor results through QAPI.
- Monitor the entry log and door monitoring process to ensure all individuals entering the facility are properly verified.
- Conduct random audits of the sign-in log and staffing assignments to ensure only verified staff are providing resident care.
- Complete verification of agency staff credentials and employment status prior to any agency staff member providing resident care, with assigned responsibility.
- Ensure the Manager on Duty and Nurse Supervisor complete abuse training with agency staff secured for nights or weekends.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
The facility failed to properly identify, report, and investigate abuse allegations involving two residents. One resident reported a staff member yelled at them and was rough with their roommate, but the incident was not documented or reported, and an LPN admitted not reporting it because they did not believe the resident. Another resident reported inappropriate touching by a peer, but the investigation lacked witness or resident statements, and ordered 1:1 supervision was not consistently provided despite repeated behaviors documented by staff and observations showing the resident unsupervised.
Failure to Report and Document Alleged Neglect: A Nursing Student reported that a CNA did not provide cares to residents, including residents being left soaking wet and unchanged. The concern was relayed to facility leadership, but the allegation was not reported to the SA within the required timeframe and the investigation was not documented, despite the facility’s abuse/neglect policy requiring prompt reporting and a written investigation record.
Failure to investigate resident-to-resident sexual abuse allegation: Two residents with dementia, one moderately cognitively impaired and the other severely cognitively impaired, were involved in an incident where a nurse aide observed one resident with his hands inside the other resident’s brief in the genital area. Staff did not obtain timely written statements, did not document resident assessments or investigative findings at the time, and there was no documented evidence that physicians or resident representatives were notified or that protective interventions were implemented until the resident was later moved to another unit.
Failure to Report Injury of Unknown Origin: A resident with aphasia, dementia, hemiplegia, and extensive ADL dependence developed a large area of bruising, swelling, and a blistered injury on the chest, axilla, shoulder, and extremities. Staff noted the injury but did not document or report it immediately, and an RN later stated she saw bruising on the night shift but assumed someone else had reported it. The resident was nonverbal and unable to explain what happened, and hospital and police records described the injuries as unknown in origin.
Failure to Complete Required Background and Registry Checks Before Hire: The facility failed to follow its background screening policy for an RN and the DON. Record review showed both were hired before criminal history checks were completed, and the RN’s EMR and NAR checks were also completed after hire. Interviews with the BOM, RN, and DON confirmed the employees had already been working at the facility when the required screening was not yet done.
Failure to Complete Required Pre-Employment Screening: The facility failed to complete required pre-employment screening for two LVNs and the DSD before hire. Reference checks were incomplete or limited to a spouse, friends, and co-workers, with no documented contact with former employers or HR, and the ADM stated a criminal background check alone was sufficient for one employee despite the facility policy requiring background, reference, and credential checks with documentation of screening.
Failure to Report and Supervise Resident Abuse Allegations
Penalty
Summary
The facility failed to implement policies and procedures for identifying, reporting, and investigating resident-to-resident abuse for 2 residents. Resident 114, who was admitted with kidney failure and a bladder infection and was able to make needs known, reported that about two weeks earlier a staff member yelled at them and was rough with their roommate. The resident said they told another staff member but did not hear anything further. The EHR and May 2026 incident log contained no documentation of the incident. During interview, the administrator stated they were not aware of the allegation and would start an investigation. The facility investigation later showed an LPN was aware of the allegation but did not report it because they did not believe the resident, stating the resident makes things up. Resident 150, who was readmitted with depression, anxiety, and heart failure and was able to make needs known, reported that Resident 102 touched them inappropriately on three occasions and entered their room at 3 AM to touch their shoulders from behind. Resident 150 stated staff were aware and that they did not feel as safe as they used to, and they reported keeping a fork on their bedside table to use if needed. Resident 102 had an order to monitor and document inappropriate sexual behaviors, and the facility investigation showed no witness statements or statement from Resident 102. The intervention plan required one-to-one supervision, but observations showed Resident 102 in the hall or room without staff supervision, the TAR documented repeated inappropriate sexual behaviors in April and May 2026, and the staffing schedule showed no one-to-one supervision assigned on multiple days. The DON stated the facility had not been able to implement the planned one-to-one supervision due to lack of staffing.
Failure to Report and Document Alleged Neglect
Penalty
Summary
The facility failed to implement its Abuse, Neglect, & Exploitation Policy after an allegation of neglect was made by a Nursing Student and relayed to RN/Staff #2. The allegation stated that a CNA did not provide cares to residents on the unit, including residents being left soaking wet and not changed. Staff #2 reported the concern to the former Administrator, and a complaint/grievance form was completed and texted to facility leadership, but the original form later could not be located in the abuse binder. The facility did not report the allegation of neglect to the State Agency within the required timeframe. The report indicates the initial allegation was made on March 27, 2026, but the facility’s first report to the SA was not made until April 17, 2026, approximately 21 days later. Staff #41 stated allegations of neglect are to be reported to the SA within 24 hours, and Staff #44 confirmed the allegation was not reported until after corporate office became involved. The investigation of the alleged neglect was also not documented. Staff #9 reportedly told Staff #44 that he had investigated by speaking with residents and staff and concluded the neglect had not occurred, but no written documentation of that investigation was produced. Staff #44 stated the standard process requires the investigation to be documented. The facility policy required the administrator or supervisor to protect residents from continued neglect, investigate the incident as soon as practicable, maintain a written record of the investigation, and report the allegation externally to the SA.
Failure to Investigate Resident-to-Resident Sexual Abuse Allegation
Penalty
Summary
The facility failed to implement abuse prevention and investigation procedures after an allegation of resident-to-resident sexual abuse involving two residents. One resident had diagnoses including dementia and was assessed as moderately cognitively impaired with a BIMS score of 11, while the other resident also had dementia and was assessed as severely cognitively impaired with a BIMS score of 03. Facility policy required staff to immediately separate residents, assess for injury, initiate an investigation, obtain written statements from staff on duty, notify the administrator, physician, resident representative, law enforcement, and report the incident to the Pennsylvania Department of Health and local Area on Aging within 24 hours. Facility documentation and staff interviews showed that two nurse aides observed one resident with his hands inside the other resident’s brief in the area of the resident’s genitals, creating an allegation of sexual abuse. The nurse aides stated they were not asked to provide written statements at the time of the incident, and a registered nurse supervisor stated she did not interview or debrief them. The clinical records contained no documented evidence of resident-specific observations, evaluations, assessments, or investigative documentation at the time of the incident, and there was no documented evidence that physicians or resident representatives were notified. The records also lacked evidence of additional interventions to address the resident’s behavior or to protect the other resident and others from further unwanted contact until the resident was transferred to another nursing unit approximately 16 days later.
Failure to Report Injury of Unknown Origin
Penalty
Summary
The facility failed to implement its Abuse Prevention Policy by not reporting an injury of unknown origin for one resident who was reviewed for abuse, neglect, and injuries of unknown origin. The resident had multiple significant medical conditions, including aphasia, hemiplegia, weakness, abnormal posture, contractures of both knees and ankles, and dementia. The care plan documented that the resident was nonverbal, unable to communicate effectively, and considered at risk for abuse or neglect due to mood, cognition, weakness, and behavioral/physical deficits. The MDS also documented that the resident was rarely or never understood, had memory problems, was dependent for many activities of daily living, and was always incontinent of bowel and bladder. Nursing documentation showed that a nurse was called to the resident’s room after staff noticed an area on the resident’s chest. The nurse found a large raised, firm, warm, dried popped blistered area extending from the right armpit to the right upper chest and shoulder, with severe pain. The nurse also noted bruising and swelling on the chest, bruising on the right side, scattered bruises, scabs, discoloration on both lower extremities, and a very swollen and painful right elbow. The nurse documented that there had been no prior progress note or risk management documentation and notified administration. The administrator was told that a CNA said a night nurse had noticed the areas on Sunday night, and the administrator later informed the nurse that a police officer would come to the facility. Hospital records and police documentation described bruising and unknown injuries with no documented explanation. The hospital noted significant bruising and swelling of the right chest wall, right axilla, and right upper arm, with an associated scrape in the axilla, and staff reported the bruising had been noted on Sunday and Monday without documentation of any injuries. The police report stated the resident had a large amount of bruising and unknown injuries, and the responding nurse reported that a night nurse on Sunday had verbally stated she noticed bruising. Interviews later showed one RN stated she saw bruising on the night of 5/10/26 but did not report it to administration because she assumed someone else had already done so, while a CNA stated the RN showed pictures of the bruises and did not report them that night. The administrator stated she was first notified on 5/13/26 and expected staff to report any allegation of abuse, neglect, or injury of unknown origin immediately.
Failure to Complete Required Background and Registry Checks Before Hire
Penalty
Summary
The facility failed to implement written policies and procedures to prevent abuse, neglect, exploitation, and misappropriation of resident property for 2 of 3 employees reviewed for employability. Record review showed the RN had a hire date of 05/06/2026, but there was no evidence the facility completed a criminal history check before hire. The BOM provided documentation showing the RN’s criminal history was checked on 05/28/2026 during the on-site investigation. The RN’s file also showed the Employee Misconduct Registry and Nurse Aide Registry were checked on 05/07/2026, after the hire date. Record review also showed the DON had a hire date of 04/28/2026, but there was no evidence the facility completed a criminal history check before hire. The BOM provided documentation showing the DON’s criminal history was checked on 05/28/2026 during the on-site investigation. During interviews, the RN said she had been employed at the facility for about three weeks, and the DON said she had been employed for about a month. The BOM stated she understood that criminal history and registry checks were to be completed before a person was hired and given access to residents, but said she was overwhelmed after the facility switched to a new payroll company. The facility policy required background screening and criminal conviction checks for applicants with direct access to residents, including registry checks for nursing staff and licensed professionals.
Failure to Complete Required Pre-Employment Screening
Penalty
Summary
Develop and implement policies and procedures to prevent abuse, neglect, and theft was cited after the facility failed to complete required pre-employment screening before hiring three of six sampled employees: two LVNs and the DSD. For LVN 1, the personnel file and Reference Check Control Form dated 3/25/2025 showed the employment reference section was left blank, and the date of hire was 3/26/2025. During interview and record review with the ADM and DON, the DON stated the facility did not document attempts to contact former employers such as HR or the DSD, and that the references obtained were only from a friend and co-workers who could not provide relevant information such as length of employment, work performance, history of resident abuse, or re-hire eligibility. For LVN 4, the Reference Check Control Form dated 5/11/2025 showed the facility contacted the potential employee's wife and two co-workers, with a date of hire of 5/12/2026. During interview and record review, the ADM and DON stated the documentation did not identify the titles or positions of the individuals contacted, and the DON stated the facility should verify work experience and document the name and title of each person contacted. For the DSD, the personnel file contained Confidential Reference Checks signed 10/30/2020 showing contact with friends and a co-worker, with a date of hire of 11/3/2020. The ADM stated a criminal background check had been completed and showed no criminal offenses, and further stated that friends or co-workers could provide information about a history of resident abuse, so former employers did not need to be contacted. The facility's Abuse, Neglect, and Exploitation policy required background, reference, and credential checks and documentation that screening occurred.
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