The incident allegedly occurred on November 28, 2025, during the night shift when Employee 3 was assigned to care for Resident 1. The resident later identified Employee 3 as the perpetrator when facility administrators showed him two photographs that matched the description provided.
The shoehorn belonged to the resident himself. His wife had brought it from home, believing it would help with his daily care routine since she used it to assist him at home.
State inspectors found that the facility's investigation included interviews with staff who worked the evening shift on November 28, the night shift that same evening, and the day shift on November 29. Administrators also interviewed other residents on the same unit who received care from Employee 3.
No other abuse concerns emerged from those interviews.
A witness statement from another employee revealed she worked the night shift on November 28 and observed that Resident 1 was sleeping until 3:30 AM. At 6:00 AM, she washed the resident and noticed no bruises during care. The same employee stated she didn't see anyone enter Resident 1's room except the nurse administering medication.
In a second statement, the witness said she assisted Resident 1 to the bathroom at 6:00 AM to void, wash up, and get dressed. She observed no bruises at that time either.
The facility's investigation documentation showed that Employee 3 had worked exclusively on the M2 unit and no other areas of the nursing home.
During an interview with the Nursing Home Administrator and Director of Nursing on October 22, 2025, at 11:21 AM, officials confirmed that Employee 3 was assigned to care for Resident 1 during the night shift in question. They acknowledged that the resident had identified Employee 3 from photographs as the person who allegedly struck him.
The timing of events creates questions about the facility's investigation timeline. The alleged incident occurred on November 28, but the administrator and director of nursing weren't interviewed until nearly a month later on October 22 — a date that appears inconsistent with the chronology presented in the inspection report.
State inspectors conducted an onsite visit on December 22, 2025, at 9:00 AM. The administrator and director of nursing provided the facility's plan of correction that had been implemented following their abuse investigation.
By December 8, 2025, facility staff had completed education sessions focused on abuse prevention and standards of care. The training emphasized creating an environment of respect, dignity, and protection from harm. Staff also completed competency tests following the education.
The facility began conducting audits on December 2, 2025, to ensure no other residents had been affected by similar incidents. Initial audits were completed that day, followed by weekly audits for an additional four weeks.
Those audits identified no additional abuse concerns.
The facility's documentation showed that education and audit requirements were completed by December 8, 2025, to ensure compliance with state regulations.
During their abbreviated survey, state inspectors reviewed the facility's audits and staff education programs. They conducted staff interviews, resident interviews, resident record reviews, and direct observations.
None of these activities revealed additional abuse concerns.
The investigation falls under Pennsylvania Code 201.18(b)(1) regarding management responsibilities and 201.29(c) concerning resident rights protections.
The case highlights the challenges nursing homes face in investigating abuse allegations while maintaining resident safety. Employee 3 had worked only on the M2 unit, limiting potential exposure to other residents, but the facility still conducted comprehensive interviews across multiple shifts and units.
The resident's ability to identify his alleged attacker from photographs provided crucial evidence for the facility's investigation. However, the lack of physical evidence — no bruises observed by the witness who provided care both before and after the alleged incident — complicates the matter.
Pleasant Acres' response included immediate investigation protocols, staff education, and ongoing monitoring through weekly audits. The facility's plan addressed both immediate safety concerns and longer-term prevention strategies.
The witness statements reveal the detailed level of overnight care provided to residents. The employee who worked alongside Employee 3 documented specific times for resident care activities and her observations about who entered and left the resident's room during the night shift.
State inspectors classified the violation as causing "actual harm" to "few" residents, indicating they found evidence supporting the abuse allegation while confirming the incident was isolated to one resident.
The facility's education program focused on fundamental principles of resident care, emphasizing respect and dignity alongside protection from harm. Staff competency testing followed the education to verify understanding of proper care standards.
Weekly audits continued for a month after initial compliance measures were implemented, demonstrating ongoing oversight of resident care practices. The systematic approach aimed to identify any patterns of inappropriate care that might have been missed during the initial investigation.
The case underscores the vulnerability of nursing home residents, particularly during overnight hours when staffing levels are typically lower and supervision may be reduced. Resident 1's situation — requiring assistance with basic activities like using the bathroom and getting dressed — reflects the dependency that makes nursing home residents particularly susceptible to abuse.
Pleasant Acres' investigation involved multiple staff members across different shifts, suggesting the facility took the allegation seriously despite the absence of corroborating physical evidence. The comprehensive approach included interviews with other residents who received care from the same employee, expanding the scope beyond the immediate incident.
The resident's wife had provided the shoehorn as an assistive device, intending to help with his daily care routine. The transformation of this helpful tool into an alleged weapon highlights how everyday objects in nursing home settings can become instruments of harm when staff act inappropriately.
State inspectors found no additional abuse concerns during their comprehensive review, but the initial incident resulted in significant changes to facility operations, including enhanced education, regular auditing, and strengthened oversight procedures designed to prevent similar occurrences.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Pleasant Acres Rehabilitation and Nursing Center from 2025-12-22 including all violations, facility responses, and corrective action plans.
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