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F0609
D

Failure to Timely Report Alleged Resident-to-Resident Abuse

Missoula, Montana Survey Completed on 08-28-2025

Penalty

Fine: $17,215
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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 resident-to-resident abuse to the State Survey Agency within the required 24-hour timeframe. Specifically, two residents were involved in a physical altercation in which one resident reported that another had touched his groin. The incident was initially reported by the resident to nursing staff on the evening it occurred, and this was documented in the nursing progress notes. The staff communicated the incident internally to social services and the DON, but the allegation was not reported to the State Survey Agency until several days later. Staff interviews revealed a lack of awareness regarding the reporting requirement and confusion about the need to report when the resident later denied the incident occurred. Facility policy requires immediate reporting of suspected abuse, including sexual abuse, to the State Survey Agency and other authorities within specified timeframes. Despite this, the initial allegation was not reported as required, and the facility's video surveillance of the incident was no longer available for review at the time of the survey. The deficiency was identified through interviews, record review, and examination of facility policy, which clearly outlines the obligation to report such incidents promptly.

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