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F0609
D

Failure to Report Resident Abuse Allegation as Required

Berea, Ohio Survey Completed on 04-08-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to report an allegation of abuse as required by its policy and regulatory standards. A resident with a history of schizoaffective disorder, bipolar disorder, anxiety, depression, and chronic obstructive pulmonary disease made an allegation that staff twisted her arm behind her back. The resident's statements about the incident changed multiple times, and she later retracted her allegation and apologized to staff. Despite this, the facility's policy required all allegations of abuse to be reported to the State agency immediately, but the facility did not do so. The investigation was documented in a soft file, and the interdisciplinary team determined the allegation was false based on witness statements, a timeline, behavioral history, and a head-to-toe assessment. Interviews with facility staff, including the DON, administrator, and CNAs, confirmed that the allegation was not reported to the State agency because the resident retracted her statement and was known for making false allegations. The administrator stated that the incident was investigated internally, but not reported externally as required. The facility's policy clearly stated that all allegations, regardless of perceived credibility or retraction, must be reported to the State agency within two hours, and the results of the investigation must be reported within five days. This failure to report the allegation constituted noncompliance with both facility policy and regulatory requirements.

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