Failure to Report Allegations of Abuse and Neglect
Penalty
Summary
The facility failed to ensure that allegations of abuse, neglect, or mistreatment for 14 residents were reported to the state agency as required. Multiple grievances were filed by residents and their family members, describing incidents where staff told residents to use the bathroom in their briefs or diapers due to lack of time, denied assistance with toileting, or made dismissive and inappropriate remarks. In several cases, residents reported feeling humiliated, degraded, or emotionally harmed by these interactions. Some residents also described being denied showers, not being offered the option to wear their own underwear, or being left without timely care for personal needs. Despite these grievances, the facility's administrative staff, including the administrator and DON, did not identify these incidents as allegations of abuse. Instead, they categorized them as customer service or care concerns and addressed them through staff education or reassignment, without reporting them to the state agency as required by policy. The facility's grievance policy specified that concerns related to alleged abuse, neglect, or mistreatment should be immediately forwarded to supervisory staff, but this procedure was not followed in these cases. Interviews with the administrator and DON confirmed that they were aware of the grievances and the nature of the complaints but did not consider them to be abuse. As a result, none of the allegations were reported to the appropriate authorities, and the required investigation and reporting process was not initiated. The failure to recognize and report these allegations represents a breakdown in the facility's abuse reporting protocol and a violation of regulatory requirements.