Failure to Timely Report Alleged Resident-to-Resident Abuse
Penalty
Summary
The facility failed to report an alleged abuse incident within the required two-hour timeframe for two residents. On the evening of 5/1/2025, an altercation occurred between two residents in the smoking patio, during which one resident reportedly hit the other and attempted to throw a slipper. The incident was witnessed by an activities aide, who intervened and separated the residents, but did not immediately report the event to the facility administration or supervisor as required by facility policy. The incident was only brought to the attention of the Administrator the following morning when one of the residents reported it directly. Both residents involved had significant mental health diagnoses, with one having impaired cognitive functioning and the other diagnosed with depression and schizophrenia but with intact cognition. The facility's policy required immediate reporting of suspected abuse to the Director of Nursing or supervisor, but this protocol was not followed. As a result, the alleged abuse was not reported to the State Survey Agency until the day after the incident, outside the mandated reporting window.