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F0609
D

Failure to Timely Report Allegations of Abuse to State Agency

Manchester, Maryland Survey Completed on 06-26-2025

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 timely report allegations of abuse involving two residents to the state survey agency as required by its own policy. In the first instance, a resident with intact cognition and a history of acute confusional episodes reported to a registered nurse that a staff member pushed their head, causing them to fall back into bed. Despite the resident being tearful and making the allegation directly to the nurse, the incident was not reported to the state agency until the following day, well beyond the required timeframe. Staff, including the RN, Assistant Director of Nursing, and Director of Nursing, did not report the allegation promptly, citing inconsistencies in the resident's story and a history of accusatory behaviors. The Administrator was not informed of the incident until the next day, delaying the required notification to authorities. In the second case, another resident reported to the social worker that a male staff member was rough during a transfer and mocked them for expressing pain. The social worker did not interpret the complaint as abuse because the resident did not use the word "abuse," and therefore did not report the incident. The Director of Nursing later stated that any suspicions of abuse or neglect should be reported, and the Administrator acknowledged that more questions should have been asked and the incident should have been reported as an allegation. Both cases demonstrate a failure to follow facility policy and regulatory requirements for timely reporting of abuse allegations.

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