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F0607
D

Failure to Immediately Report Witnessed Resident Abuse

Sudbury, Massachusetts Survey Completed on 06-10-2025

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

Staff failed to follow the facility's Abuse Prohibition Policy when two separate certified nurse aides (CNAs) witnessed another CNA slap a resident with severe cognitive impairment and did not immediately report the incidents as required. The resident, who was dependent on staff for care and had diagnoses including dementia, heart failure, and delusional disorder, was subjected to physical abuse on at least two occasions. In both instances, the witnessing CNAs delayed reporting the abuse, with one waiting 12 days and the other approximately one month before informing management. The facility's internal investigation revealed that both CNAs acknowledged in interviews and written statements that they should have reported the abuse immediately but failed to do so. The abuse incidents occurred while the resident was being provided care and was described as combative. The delayed reporting of these incidents meant that the facility was not made aware of the abuse in a timely manner, contrary to the requirements outlined in their abuse policy.

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