Failure to Immediately Report and Recognize Potential Abuse Incident
Penalty
Summary
The facility failed to recognize and immediately report a potential abuse incident involving unauthorized individuals entering the building and interacting with residents. On the evening of 6/18/25, a group of men entered the facility by following employees, smoked marijuana, used obscene language, and filmed a music video in the hallway. Two residents were included in the video without their permission, and the video was later posted on social media, where it was viewed by over 67,000 people. Staff members, including the receptionist and dietary aides, observed the men in the facility and noted that they felt unsafe during the incident. The receptionist did not attempt to stop the men or call the police, citing fear for her own safety. Instead, one of the residents called the police after witnessing the commotion and feeling threatened by the group’s behavior. One of the residents involved, who is cognitively intact according to his most recent MDS assessment, reported being awoken by loud noises and witnessing the group cursing and smelling of marijuana. He expressed feeling unsafe and anxious, stating that neither he nor other residents could defend themselves. Staff interviews confirmed that several employees and residents felt uncomfortable and unsafe during the incident, and that the men were not known to staff or residents. Despite these observations and the clear distress caused to at least one resident, the facility did not immediately recognize the situation as a potential abuse incident or report it to the Department as required by policy and federal law. The facility’s final investigation report indicates that the initial report to authorities was not made until seven days after the incident, after the video surfaced on social media. The facility’s abuse prevention policy requires immediate reporting of any allegations or events that may constitute abuse, neglect, or exploitation. However, the delay in reporting and the failure to recognize the incident as potential abuse resulted in noncompliance with regulatory requirements. The incident had the potential to affect all 91 residents in the facility.