Northampton County-gracedale

F 0600 Level of Harm - Actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Review of facility documentation dated October 6, 2025, revealed that Resident 2 was observed in Resident 1's room and was noted to be naked with skin tears to the top of his head, right side of the forehead, and left elbow, and ecchymosis (bruising) to the left eye. There was also blood noted coming from his right elbow and top of his buttocks. Resident 1 was observed with blood on the front of his shirt and bruising to the knuckles of his left hand. No injuries to cause bleeding were observed on Resident 1. There was also blood observed on the bed sheets, floor, and wall of Resident 1's room. When questioned about

the incident by law enforcement, Resident 1 stated that someone was in his room. Resident 2 was transferred to the hospital with injuries that required treatment. Review of the hospital Discharge summary dated [DATE REDACTED], revealed that the resident was assessed due to being the victim of an assault with head injury and required wound care for soft tissue injuries. Clinical record review revealed that on October 14, 2025, Resident 2 was observed with altered mental status, increased confusion, was unable to feed himself, and was stumbling during ambulation. The resident was sent to the hospital for evaluation and found to have a hematoma (collection of blood outside of the blood vessels) to the left gluteal (buttocks) region and an acute fracture of the coccyx (bone of the pelvis). Review of facility documentation dated October 15, 2025, confirmed that the resident sustained a fracture of the coccyx, which was documented as believed to be from the assault from Resident 1 on October 6, 2025. There was a lack of evidence to support that the facility provided adequate interventions for Resident 1, who had known and continuing aggressive behaviors, and did not wish for others to enter his room, resulting in physical abuse with actual harm to a cognitively impaired resident (Resident 2) who wandered into Resident 1's room. In an interview

on October 17, 2025, at 1:33 p.m., Registered Nurse (RN) 1 confirmed that there was no evidence that interventions were in place to prevent other residents from entering Resident 1's room. Clinical record

review revealed that Resident 3 was admitted to the facility on [DATE REDACTED], and had diagnoses that included mood disorder, dementia, frontotemporal neurocognitive disorder (brain disorder that mainly affects the frontal and temporal regions of the brain), and hallucinations. On August 15, 2025, nursing staff documented that Resident 3 was wandering around the unit and following staff. On August 16, 2025, nursing staff documented that the resident was confused, wandered into the nurse's station, was touching everything, and was difficult to redirect. On the same date, nursing staff documented that the resident continued to wander the nursing unit, entered another resident's room, and was rummaging through the closet. On August 16, 2025, the physician documented that the resident had a history of shadowing caregivers and occasional inappropriate behavior. Clinical record review revealed that Resident 4 had diagnoses that included anxiety and depression. Review of the Minimum Data Set assessment (a periodic assessment of resident care needs) dated August 2, 2025, revealed that the resident did not have cognitive impairment. Review of facility documentation dated August 16, 2025, revealed that Resident 4 reported to staff that Resident 3 entered his bathroom, touched his penis, and only left the room when he repeatedly told her to get out. On August 16, 2025, at 11:35 p.m., nursing staff documented that the resident was agitated and anxious from the incident with Resident 3 and requested an anti-anxiety medication (Ativan).

There was no evidence that the facility implemented interventions for increased monitoring for Resident 3, a resident with wandering behaviors, to protect other residents on the nursing unit from abuse, resulting in sexual abuse to Resident 4. Based on the findings, the facility failed to ensure that Residents 2 and 4 were free from physical and sexual abuse, which resulted in actual harm to Resident 2. CFR 483.12 (a)(1) Freedom from abuse, neglect, and exploitation Previously cited 6/25/2025. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 201.29(a) Resident rights 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

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