Failure to Define and Manage Resident‑to‑Resident Abuse, Leading to Unrecognized and Unreported Assaults
Summary
The deficiency involves the facility’s failure to develop and implement abuse policies and procedures that clearly define all forms of abuse, including resident‑to‑resident abuse, which led to multiple resident‑to‑resident physical and alleged sexual assaults not being recognized, reported, or investigated as abuse. The facility’s written abuse P&P, incident management P&P, and related training materials explicitly limited abuse definitions to acts committed by someone other than another patient, and sexual abuse to employee‑patient contact or employee‑facilitated patient contact. As a result, staff, including the Standards Compliance Director, Standards Compliance Supervising RN, Program Director, RN Shift Lead, and other nursing staff, consistently stated that resident‑to‑resident physical or sexual assaults were not considered abuse and therefore did not trigger abuse investigations, SOC 341 completion, or 2‑hour reporting to CDPH. One incident involved a resident with significant physical impairments, including absence of the left eye, a tracheostomy, a gastrostomy tube, difficulty communicating, and wheelchair dependence, who sustained a 1.2 cm laceration above the right eyebrow with bruising after being punched in the face while sleeping by another resident. The aggressor resident had schizophrenia, a criminal history of assault with force likely to produce great bodily injury, and was assessed as a moderate risk for violence against others. Staff documented that the aggressor stated he punched the other resident because the resident “tried to have sex with me,” and the injured resident reported the attack was unprovoked. Despite this, the incident was treated as a physical altercation rather than abuse, the alleged sexual component was not treated as sexual assault or abuse, no abuse investigation was conducted, and the report to CDPH was delayed until three days later because the facility did not consider resident‑to‑resident events to meet its definition of abuse. The covering psychiatrist did not evaluate either resident at the time and was unaware of the sexual abuse allegation, and there was no treatment plan or interventions in place to address the aggressor’s known aggressive behaviors or to protect other residents. A second incident involved a resident with gastrostomy status, pulmonary fibrosis, nonfunctional ambulation, and a high risk for violence against others, who kicked another resident using a front‑wheel walker in the buttocks, prompting the second resident, who had unsteadiness on feet, blindness in one eye, and a healing femur fracture with a past history of danger‑to‑others behaviors, to turn and punch the first resident in the face three times. This event was documented in the interdisciplinary notes as a physical altercation in the day hall. The facility’s leadership confirmed that resident‑to‑resident abuse was not included in the abuse P&P and that there was no separate P&P addressing protection and prevention of resident‑to‑resident abuse. The altercation was not reported to CDPH within 2 hours but instead two days later, and the resident who retaliated did not receive medication changes or enhanced monitoring after the incident, despite later having another aggressive outburst toward staff. A third incident involved two residents both assessed as moderate risk for violence against others, one with a back fracture, epilepsy, and a significant history of danger‑to‑others behaviors, and the other with a history of verbalizing thoughts of harming another resident. Staff heard yelling in the day hall and found the two residents in a verbal altercation when one resident struck the other, who reported being hit in the chin. The striking resident later stated he used a closed fist to touch the other resident’s chin to make him stop cursing and yelling. This event was also treated as a resident‑to‑resident altercation rather than abuse, resulting in delayed reporting to CDPH by two days and delayed completion of the SOC 341 until several days after the incident, instead of by the end of the shift. The psychologist later confirmed that one resident had an extensive history of verbal aggression with prior alleged physical altercations and no behavioral care plan, and that another resident’s behavioral care plan had not been updated in over a year despite aggressive incidents and stated intent to harm another resident. Across these incidents, the facility’s P&P, definitions, and staff training excluded resident‑to‑resident acts from the abuse framework, leading to failures in recognizing, preventing, investigating, protecting, and timely reporting abuse, and placing all residents at risk of unreported and unmitigated abuse. On 3/5/2026, surveyors declared an Immediate Jeopardy related to the lack of written policies and procedures prohibiting and preventing abuse that included resident‑to‑resident abuse, and to staff competency in identifying, preventing, screening, investigating, protecting, and reporting abuse under F607.
Removal Plan
- Treat physical altercations, sexual allegations, possible mental or psychological abuse, and exploitation in the SNF area as potential abuse allegations.
- Complete an SOC 341 form for each allegation of an abuse incident.
- Verify completion of SOC 341 by the RN Health Services Specialist/Supervising Registered Nurse prior to the end of the shift.
- Update reporting of unusual occurrences related to possible abuse incidents to ensure compliance with the reporting requirement.
- Program VI management/Unit Shift Lead will notify Standards immediately upon identification of a possible abuse incident to ensure reporting requirements are completed within the required timeframe.
- Program VI manager on call/unit shift lead will notify CNS for HSS to complete reporting within the required timeframe.
- Issue a written memorandum for all SNF nursing staff outlining federal regulatory requirements related to abuse recognition, screening and reporting, clarifying resident-to-resident incidents must be treated as potential abuse, and including CMS SOM reference, recognition/identification, screening, prevention/protection measures, early intervention/behavioral monitoring expectations, investigation/documentation requirements, reporting requirements, and SOC 341 completion.
- Require SRN attestation that staff can verbalize understanding of the memo/education, track training via a tracking log, and provide clarification as needed to ensure staff understand the abuse screening and reporting process.
- Issue a written memorandum for all registry nursing staff outlining federal regulatory requirements related to abuse recognition, screening and reporting.
- Provide training via memorandum to non-nursing clinical staff and ancillary staff on federal regulatory requirements related to abuse recognition, screening and reporting.
- Provide additional staff training regarding intervention protocols to enhance behavioral monitoring and intervention strategies for residents identified as high risk for behavioral escalation or aggression, including identification of high-risk residents, enhanced monitoring/supervision strategies, early interventions/de-escalation techniques, implementation of individualized behavioral interventions, documentation, and communication to the interdisciplinary team.
- Conduct an analysis of the physical environment, staffing, supervision, and resident assessment/care planning/monitoring to identify, correct, and intervene in situations where possible abuse, neglect, or misappropriation of resident property is more likely to occur.
- Update Administrative Directive 3308 to include resident-to-resident physical and verbal assaults, possible mental or psychological abuse, sexual allegations, and exploitation as potential abuse, including expectations for abuse screening, investigations, and reporting requirements.
- Conduct an ongoing review of all incident reports involving resident-to-resident altercations or allegations to ensure SOC 341 reports are completed and reporting timelines are met.
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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