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F0609
D

Failure to Timely Report Alleged Abuse and Neglect

Avoca, Iowa Survey Completed on 05-16-2025

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 concerns regarding the treatment of a resident within the required two-hour timeframe after the alleged incident was observed. According to the records, a resident with a BIMS score indicating no cognitive impairment, who required substantial assistance for toileting and was frequently incontinent, was involved in an incident where two CNAs were observed neglecting call lights, delaying rounds, and interacting with residents in a condescending and dismissive manner. The CNAs were also reported to have refused to assist the resident to the bathroom without the use of a mechanical lift, despite the resident's insistence that she did not need it, and ultimately denied her request to use the bathroom. The LPN who witnessed these events reported that the CNAs left call lights unanswered for extended periods, failed to perform regular rounds, and did not provide basic care such as turning hospice residents or passing out ice water. The LPN observed the CNAs speaking to residents in a manner she found inappropriate and witnessed them laughing at and dismissing the resident's needs. The LPN did not immediately report these concerns to facility management or the appropriate authorities, instead waiting until after her next shift to provide a written statement to the DON. The facility's policy required that any suspicion of abuse, neglect, or exploitation be reported immediately, defined as within two hours, to the administrator and other officials as required by law. However, the initial report to the State Agency was not made until several days after the incident, and the LPN acknowledged uncertainty about the reporting process and who to contact at the time. The delay in reporting was confirmed by both the LPN and the DON, who stated that the LPN was educated on the need for immediate reporting after the fact.

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