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F0609
D

Failure to Report Alleged Abuse to Regulatory Agency

Palm Beach Gardens, Florida Survey Completed on 07-01-2025

Penalty

Fine: $25,945
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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 involving a resident who was admitted for rehabilitation services and assessed as independent with daily decision-making skills and no behaviors. The resident called 911, alleging that an aide had hit him over the head. Police and EMS responded, and the police reviewed a video provided by the resident, determining that no abuse had occurred. The resident was transported to the hospital for evaluation and returned to the facility the same day. The resident subsequently filed a grievance stating that the aide had harassed him multiple times. Documentation showed that the resident did not initially report the alleged abuse to nursing staff but instead contacted emergency services directly. The facility administrator stated that she contacted another state agency regarding the incident but did not complete the required reporting to the regulatory agency, as she did not believe the incident met the criteria for abuse. The administrator also indicated that she was unaware of the abuse allegation until after the fact, upon reviewing hospital records and learning of an open case involving alleged neglect by a family member. An investigator from the state agency confirmed that an investigation was conducted into the allegation of physical abuse, and it was determined that the facility failed to report the allegation to the appropriate regulatory agency as required by policy and federal regulations.

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