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F0609
D

Failure to Timely Report Alleged Abuse and Neglect to State Agency

Litchfield, Minnesota Survey Completed on 05-08-2025

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 report allegations of abuse, neglect, and theft to the state agency within the required two-hour timeframe for three residents who were named in an external complaint. The complaint, received via anonymous email, included specific allegations such as residents being neglected and abused daily, wounds not being treated, unlicensed staff performing nursing tasks, and staff members physically and verbally abusing residents. The administrator in training acknowledged receiving the email but did not report the allegations to the state agency, citing a belief that the information was invalid and that the allegations were unsubstantiated after an internal investigation conducted within two hours. The residents involved had significant medical histories, including dementia, anxiety, hypertension, diabetes, chronic obstructive pulmonary disease, cognitive communication deficits, post-traumatic stress disorder, Parkinson's disease, hemiplegia, epilepsy, adjustment disorder, major depressive disorder, and traumatic brain injury. Despite the facility's policy requiring immediate reporting of suspected abuse or neglect, the administrator did not notify the state agency as required, instead choosing to investigate first and report only if the allegations were substantiated.

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