Failure to Timely Report Resident-to-Resident Abuse Allegation
Penalty
Summary
The facility failed to ensure that all allegations of abuse were reported to the state agency and other mandated entities within the required timeframe for two residents. On August 21, 2025, two residents with significant cognitive and behavioral diagnoses were involved in a resident-to-resident altercation in their shared room. One resident threatened to physically harm the other, and a CNA intervened to prevent escalation. Documentation by an LPN confirmed the incident, and the facility's own investigation later verified the allegation. Despite the altercation and the facility's policy requiring immediate reporting and investigation of suspected abuse, there was no evidence that the incident was reported to the appropriate state agencies or that an investigation was initiated immediately after the event. Interviews with staff revealed that the incident was only brought to the attention of facility leadership the following day through a 24-hour report, and staff acknowledged the importance of timely reporting. The clinical records and interviews confirmed the lack of immediate action in accordance with facility policy and federal guidelines.