The facility failed to ensure that all staff received required abuse prevention and reporting training after a confirmed abuse incident involving a resident with dementia, bipolar disorder, anxiety disorder, and impulse disorder who was resistant to care and appeared anxious when approached. Following an event in which a nurse aide verbally abused and struck this resident during incontinence care, the facility initiated whole-house education on abuse and staff reporting responsibilities. Review of in-service records and interviews with the NHA and DON showed that one activities aide hired before the incident, and still working with residents, had no documented completion of these abuse-related trainings, contrary to facility policy requiring ongoing abuse education for all staff.
The facility failed to fully implement abuse prohibition procedures when it did not ensure required criminal background screening documentation was obtained and maintained for an external RN before the RN provided resident care and accessed resident medical records. Facility policy required background checks, including a PA State Police criminal history check and, when applicable, an FBI check, and the external IV therapy agreement assigned background screening and exclusion checks to the outside company. Review of the employee file did not show a PA PATCH clearance for the RN.
A resident with severe cognitive impairment and diagnoses including MS and dementia was found on a different floor while looking for breakfast, with a wander guard in place, and was redirected and monitored by staff. Facility policy required that any suspected abuse or neglect, including such incidents, be promptly reported to designated authorities and fully investigated. The DON at the time was unaware of the event until months later, and no complete, thorough investigation was conducted, demonstrating a failure to implement the written abuse/neglect prevention and investigation procedures.
The facility failed to follow its abuse policy by not removing a nurse aide from duty or investigating after multiple residents, a family member, and staff reported sexually inappropriate touching and serious privacy violations during incontinence and nighttime care. A cognitively intact resident who was continent reported being awakened with a hand placed inside her pants without explanation, another resident reported being left naked with the door and curtain open while the aide made sexualized comments and discussed prior accusations against him, and a third resident reported being startled awake when the aide put his hand inside her brief instead of asking about her continence. A fourth cognitively intact resident’s family member reported that the resident called crying and said the aide had put his hand inside her brief and that his fingers penetrated her vagina on multiple occasions. Staff repeatedly relayed these allegations up the chain to an LPN, RNs, the Director of Social Services, the Assistant DON, and the Nursing Home Administrator, yet leadership treated the matter as a grievance rather than abuse, did not initiate an abuse investigation, and allowed the aide to continue working.
Failure to Complete Background Checks Before Hire: Review of the facility policy, personnel files, and staff interview showed that two NA employees began work before criminal background checks were completed. The files showed the background check requests were made after the hire dates, and the NHA confirmed the screening was not done prior to employment for two of five personnel files reviewed.
Failure to report and investigate resident-to-resident physical abuse: A resident was struck in the face by another resident while eating supper, and the initial assessment noted slight bruising and redness to the cheek. The facility's investigation had no witness statements, and the DON and NHA confirmed the incident was not reported to the appropriate authorities as required by policy.
The facility failed to fully screen four of five newly hired employees, including LPNs and nurse aides, to determine eligibility for employment. Personnel files showed applications listing prior employers, but there was no documentation that former employers were contacted, and the DON could not provide evidence that past work history was verified for these staff members.
The facility did not follow its abuse-prevention policy requiring background and credential checks for potential employees when it hired an RN without documented verification of her professional license status. Review of the RN’s personnel file showed no evidence that her license had been checked to confirm it was current and free of disciplinary action, and the Nursing Home Administrator acknowledged that no such documentation could be found, resulting in noncompliance with state regulatory requirements.
Failure to Complete Pre-Employment Criminal Background Check: The facility failed to complete a state criminal background check before hiring a Nurse Aide. Review of the personnel file showed the employee was hired without the required background check in place, and the HR Director confirmed the screening was not completed prior to the start of employment.
A resident with Major Depressive Disorder and intact cognition reported that a CNA verbally, physically, and mentally abused the resident, and further stated that the CNA frequently argued with the resident. Facility policy required immediate protection of residents upon identification of suspected abuse, including prompt reporting, investigation, and suspension of the alleged perpetrator. However, a substantiated verbal abuse incident between the CNA and the resident was not reported to the DON or NHA at the time it occurred, no timely investigation documentation was available, and the CNA continued working until a later physical abuse incident was reported. This sequence of unreported and unaddressed abuse incidents led to a failure to immediately protect the resident from staff-to-resident abuse.
Self-audit
Pick a level of detail and, optionally, what to focus on — then generate a survey-ready checklist distilled from the most recent citations.
Beta · AI-generated — for reference only, not professional advice. Verify against current CMS guidance before relying on it. Assisto accepts no responsibility for how this checklist is used.
Citations used to create this checklist
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Get More From Your Search Results
Create an account to access advanced search filters, save your searches, and get unlimited access to detailed Plan of Corrections.
Create an Account