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:
Missing FBI Background Check for Agency Nurse Aide: The facility failed to complete an updated FBI background check for an agency NA before allowing the aide to work on the nursing unit. The aide had lived outside PA within the past two years, but the personnel file only contained an older FBI check and no updated check before the aide worked two shifts. The facility policy required background checks for all employees in accordance with State law.
Failure to follow abuse policy after a resident-on-resident assault. A resident with dementia and physically aggressive behaviors scratched another resident’s face, causing superficial marks to the chin and cheek. The injured resident had significant cognitive impairment and later reported that the other resident ran fingernails across her face. Staff confirmed the incident was abuse, but the clinical record contained inconsistent documentation and the behavior note did not include details of the assault.
Failure to properly investigate and report allegations of verbal abuse and involuntary seclusion. Multiple grievances described an RN yelling at residents, blocking a resident from his room, and scolding residents for self-transferring, while an LPN made rude and inappropriate comments to a resident and his representative. The facility’s investigations were limited, with little evidence of broader interviews, incomplete documentation, delayed escalation, and no immediate suspension of the involved RN or timely reporting to the SA as required by policy.
Failure to Complete Timely Criminal Background Checks: The facility failed to properly screen employees by not completing timely criminal background checks before employment for three of five personnel files reviewed, including an RN, a COTA, and a NA. Facility policy required screening during the hiring process for a history of abuse, neglect, or mistreating residents, including criminal background checks. HR confirmed that one employee's checks were completed too far in advance to rule out criminal activity in a timely manner and another employee's background check was not completed before the start of employment.
Incomplete Abuse Investigation and Reporting: A cognitively intact resident reported that a nurse aide grabbed her and yanked off her gown, leaving bruising on her arms. The DON and nursing staff documented the allegation and substantiated abuse, but the investigation was limited to one hall and did not include a resident statement, a statement from the accused aide, or broader interviews and skin checks. The facility notified DHSR and law enforcement, but APS/DSS notification was not documented.
A resident with dementia and severe cognitive impairment developed bruising, hematoma, and multiple bilateral rib fractures with hospital concerns for neglect and/or abuse. The facility did not immediately investigate or report the injury of unknown origin, and staff could not explain how the injuries occurred. The resident’s condition worsened over several days before transfer to the ER and hospital admission.
Missing FBI Background Check for Agency Nurse Aide
Penalty
Summary
The facility failed to conduct an FBI background check on an agency nurse aide before allowing the aide to work on the nursing unit. The facility’s personnel abuse policy stated that it would not employ or otherwise engage individuals found guilty of abuse, neglect, or mistreatment of residents and that it would undertake background checks of all employees in accordance with State law. Review of the agency nurse aide’s personnel record showed the aide was hired and completed orientation at the facility on 7/15/26, and then worked two shifts on 7/26/26 and 8/1/26. The personnel record also showed that the agency nurse aide had lived outside Pennsylvania within the past two years, but the file contained only an FBI background check dated 6/1/23 and did not include an updated FBI background check before the aide started at the facility. During interview, the Director of Human Resources confirmed that the aide had lived outside Pennsylvania within the past two years. The deficiency was discussed with the NHA, DON, and Regional Director of Clinical Services, who were informed that the facility had failed to conduct the required FBI background check prior to the aide working on the nursing unit.
Failure to Follow Abuse Policy After Resident-on-Resident Assault
Penalty
Summary
The facility failed to follow its abuse policy for one resident involved in an incident with another resident who had dementia, anxiety, impaired safety awareness, verbal behavior, and physically aggressive behaviors. The perpetrating resident was documented as having a BIMS score of 07 and a care plan that included interventions to protect the rights and safety of others, such as intervening as necessary, speaking calmly, diverting attention, and removing the resident from the situation when needed. On July 26, 2026, a CNA reported that the resident clawed a roommate in the face while the nurse was on break. The injured resident was assessed and found to have superficial scratches under the right side of the chin and red marks on the cheek, with no active bleeding. The perpetrating resident was also observed kicking another resident’s wheelchair in an apparent attempt to get that resident to move out of the way. A behavior note entered shortly afterward documented increased escalated behaviors and redirection, but it did not include details of the incident described in the struck-out progress note, and no additional details about the incident were found in the clinical record. The injured resident had significant cognitive impairment with a BIMS score of 08 and subsequent documentation showed ongoing monitoring for scratches to the chin and neck area, including skin assessments and change-of-condition notes. During interview, the injured resident stated another resident ran fingernails across her face and that she cried because she did not know why the other resident was being mean to her. Staff interviews confirmed the perpetrator was the other resident and described the event as abuse, while the DON stated the struck-out note and inconsistent documentation were unfortunate and did not meet expectations or policy.
Failure to Properly Investigate and Report Allegations of Verbal Abuse
Penalty
Summary
The facility failed to follow its abuse and neglect policy when multiple grievances described verbal abuse and threats of involuntary seclusion involving two nurses and six residents. The grievances included reports that an LPN spoke rudely and made inappropriate comments to a resident and his representative, and that an RN yelled at residents, scolded them for self-transferring, blocked a resident from entering his room, and told residents they were going into a “time-out.” The report also described concerns that residents were upset by the RN’s tone, volume, and behavior, including statements that she was bossy, assertive, and made residents feel inadequate. The facility’s responses were limited to interviews with the residents directly named in the grievances and the involved nurses, with little evidence of broader fact gathering. In one grievance, the investigation noted the LPN admitted her word choice was not the best, but there was no documentation of interviews with other residents, representatives, or staff to determine whether similar conduct had occurred or whether the resident experienced any psychosocial or physical effects. In another grievance, the RN denied yelling, but the record did not show that the facility explored the reported comments to another resident, interviewed additional witnesses, or documented whether the resident who complained felt safe or had any psychosocial impact. The report also identified that the facility did not handle the allegations as abuse-related concerns under its policy. The policy required allegations of employee-to-resident abuse to be reported immediately, no later than 2 hours after the allegation, and required the employee to be removed from direct care and placed on suspension pending investigation. Instead, the grievances were not promptly escalated, the administrator’s sign-off was delayed on some reports, and the investigations were incomplete or left with blank resolution and follow-up sections. The report further noted that the facility did not immediately suspend the RN during the recurring complaints, did not timely report the allegations to the SA, and did not complete thorough investigations that included broader interviews and documented follow-up.
Failure to Complete Timely Criminal Background Checks
Penalty
Summary
Develop and implement policies and procedures to prevent abuse, neglect, and theft was cited after the facility failed to properly screen employees by not completing timely criminal background checks before employment for three of five personnel files reviewed. The personnel files reviewed were for RN Employee E4, COTA Employee E7, and NA Employee E8, and the facility policy stated that all potential employees would be screened during the hiring process for a history of abuse, neglect, or mistreating residents, including criminal background checks. Review of RN Employee E4's file showed a date of hire of 4/20/26 and two criminal background checks, one requested on 11/25/25 and another requested on 7/29/26. Review of COTA Employee E7's file showed a date of hire of 5/1/26 and a criminal background check requested on 6/25/26, after the start of employment. Review of NA Employee E8's file showed a date of hire of 5/12/26 and a criminal background check requested on 10/14/26. During interview, Human Resources Employee E9 confirmed that Employee E4's background checks were completed too far in advance to rule out criminal activity in a timely manner prior to employment and that Employee E7's background check was not completed prior to the start of employment.
Incomplete Abuse Investigation and Reporting
Penalty
Summary
The facility failed to implement its abuse policy for investigation and reporting after an allegation of staff-to-resident abuse involving a cognitively intact resident admitted with anxiety disorder and insomnia. The resident reported that a nurse aide grabbed her and yanked her gown off, causing bruising to her arms. Bruising in various stages of healing was documented on both arms and the right hand, and the facility substantiated the allegation of abuse. The investigation was limited and did not include a written or signed statement from the resident or a written statement from the accused nurse aide. The nurse aide denied the allegation during a later telephone interview and stated he was never asked to complete a statement or interviewed by the facility, his agency, or law enforcement. The investigation also did not include documented interviews from other cognitively intact residents the nurse aide had worked with or skin assessments for all moderately and severely cognitively impaired residents in the facility; instead, the DON instructed staff to limit interviews and assessments to one hall. Reporting was also incomplete. The facility submitted the initial report to DHSR and notified law enforcement, but there was no documentation of notification to APS/DSS on the initial report. During interview, the DON stated she did not realize APS was supposed to be notified within 24 hours and acknowledged that a more thorough investigation could have been completed. The Administrator stated she would expect the DON to follow reporting regulations and complete a thorough investigation before substantiating the allegation.
Failure to Investigate and Report Injury of Unknown Origin
Penalty
Summary
The facility failed to implement its abuse prohibition policy related to an injury of unknown origin for a resident with dementia, transient cerebral ischemic attack, severe cognitive impairment, and dependence on staff for activities of daily living. The resident’s record showed new diagnoses of multiple bilateral rib fractures and a right thorax contusion after bruising and hematoma were identified on the chest and upper body. The resident also had impaired upper and lower extremities and required two-staff assistance for ADLs and transfers. The resident’s skin changes were first documented as bruising under the right breast, right nipple, and middle of the chest, followed by spread of bruising to the right upper extremity, shoulder, and breast, along with pain and edema. A chest x-ray showed no acute findings, but the resident later required transfer to the hospital for further evaluation because of worsening bruising, hematoma, redness, edema to the right hand, and increased pain. Hospital paperwork documented multiple bilateral nondisplaced rib fractures and a large intramuscular hematoma, with concerns of neglect and/or abuse, and noted that bruising had started earlier than the facility documented. The facility did not initiate its investigation until after the resident was admitted to the hospital and did not report the incident immediately. The facility’s own timeline showed several days between the first observed skin change and the initiation of the self-reported incident. Staff interviews confirmed that no explanation for the injuries was identified, that the facility believed a bear-hug type repositioning may have occurred even though that technique was not taught or used, and that the facility reported the injury of unknown origin after the resident’s hospital admission. The administrator confirmed there was no immediate reporting and that the investigation began only after the hospital admission.
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