Friendship Rehab: Abuse Investigation Left Incomplete - PA
The April 30 inspection at Friendship Rehab and Health on Friendship Circle documented one central failure: the facility never finished its own investigation into what happened to the man identified in records as Resident R1.
It took inspectors less than a day on site to find it.
The night of April 23 started with a call for supervisors. At 8:30 p.m., staff were urgently summoned to Unit 2 Main for a resident attacking staff. When supervisors stepped off the elevator, the resident was already on the floor, lying on his right side, screaming, and complaining of pain in his left hip.
He told them what happened in his own words: "Big mother------ tackled me. I was going to knock his ass out."
The nurse's account differed in framing but not in substance. According to a nursing progress note dated April 23, the resident had been growing increasingly agitated throughout the evening and had attempted to punch the nurse and nursing aides. When the resident swung at him, the nurse grabbed the resident's arm and shoulder and took him to the floor.
What happened next was not in dispute. The resident reported 10 out of 10 pain in his left hip. His left leg was shortened and rotated outward, which are the clinical signs of a hip fracture. A physician was notified, and the resident was sent to a local emergency room that night.
The facility filed an event report with the state agency at 8:44 the following morning. That part of the process worked.
What did not work was everything after.
Under the reporting requirements the facility's own policies described, a written investigative report was due to all appropriate agencies within five working days of the incident. That put the deadline at April 30, the same day inspectors arrived for their complaint inspection.
When inspectors reviewed the investigation file that morning, they found no completed report. There was no PB-22, which is Pennsylvania's required abuse investigation form. There was no outcome documented. There was no determination of whether the allegation of physical abuse had been substantiated or not.
At 2:00 p.m. that afternoon, inspectors sat down with the Director of Nursing.
She confirmed the investigation was not complete. Then she explained why.
"I have been working on a plan of correction and have not completed the investigation," she said. "I am not going to substantiate, at what point do we protect our employees."
That statement is now part of the federal inspection record.
It is worth pausing on what the Director of Nursing said, and what she didn't say. She did not say the investigation was ongoing and nearly complete. She did not say there had been a staffing crisis or a documentation backlog. She said she had been working on a plan of correction, which is the remediation document that comes after a finding, while simultaneously indicating she had already decided how the investigation would conclude. The investigation, in her framing, was something between unnecessary and inconvenient.
The resident at the center of this had a traumatic brain injury, anxiety, and a mild neurocognitive disorder with behavioral disturbance, according to his most recent clinical assessment from January 2026. Those diagnoses matter here. A resident with a traumatic brain injury and documented behavioral disturbance is not a resident whose agitation appears without cause, and the circumstances that escalated to a physical confrontation at 8:30 at night were not examined in any completed report.
Whether the nurse acted in self-defense, whether de-escalation protocols were followed, whether the resident's care plan adequately addressed his behavioral needs, whether what happened constituted abuse under the regulatory definition, none of that was formally determined. The investigation was simply not finished.
The regulatory definition the facility's own policy cited describes abuse as "the infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish." A resident sent to the emergency room with a suspected hip fracture, screaming at 10 out of 10 pain, fits within the plain language of that definition. Whether the injury was the result of abuse is exactly what the investigation was supposed to determine.
The five-working-day deadline exists because memories fade, witnesses disperse, and physical evidence disappears. A week after an incident where a resident was taken to the floor and sent to the hospital, the window for a thorough investigation is already narrowing. The Director of Nursing's comments suggested she was not primarily concerned with that window.
Inspectors cited the facility under four Pennsylvania Department of Health regulations covering licensee responsibility, management, resident rights, and resident care policies. The federal citation was for failure to timely complete an investigative report for an allegation of physical abuse resulting in serious bodily injury.
The harm level was assessed as minimal harm or potential for actual harm, a designation that reflects the regulatory classification of the documentation failure rather than the physical harm the resident had already experienced. He was already in an emergency room with a fractured hip by the time any of this was being assessed.
The inspection was a complaint survey, meaning someone had already contacted the state about what happened before inspectors arrived. The report does not identify who filed the complaint or what specifically prompted it. What it shows is that when inspectors came to look, the investigation that should have been complete by the time they walked through the door had not been started in any meaningful way.
The Director of Nursing confirmed the failure herself, on the record, and framed it as a choice.
The resident, described in the nursing note as lying on the floor screaming, asking for someone to explain why he had been taken down, was transported to a local hospital that night. The inspection report does not say what the emergency room found, whether surgery was required, or what his condition was in the days and weeks that followed.
His name is not in the report. His outcome is not in the report. What is in the report is the nurse's account of what happened, the resident's own words from the floor, and a Director of Nursing explaining, a week later, that she hadn't finished looking into it because she already knew what she wasn't going to conclude.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Friendship Rehab and Health from 2026-04-30 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 19, 2026 · Our methodology
Friendship Rehab and Health in BEAVER, PA was cited for abuse-related violations during a health inspection on April 30, 2026.
It took inspectors less than a day on site to find it.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.