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F0609
D

Failure to Timely Report Allegations of Abuse and Neglect

Harrisonburg, Virginia Survey Completed on 04-11-2025

Penalty

Fine: $116,624
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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

Facility staff failed to timely report allegations of abuse and neglect for two residents. In the first case, a resident's daughter discovered her father had not been changed for approximately eight hours, as evidenced by a marked brief and photographs. The resident was found with a saturated brief, red and irritated skin, and poor grooming. Although the incident was reported to a charge nurse and later discussed with a unit manager, neither staff member escalated the allegation to upper management or regulatory authorities in a timely manner. Documentation and witness statements were delayed, and the issue was not brought to the administrator's attention until days after the incident. In the second case, a resident reported to a CNA and later to the ADON that she had been left in a soiled brief with feces for nearly two hours, resulting in skin irritation and visible soiling of her bed and body. The resident expressed emotional distress over the incident and provided photographic evidence. The ADON acknowledged being informed but did not immediately report the allegation to appropriate authorities. The administrator was not made aware of the situation until after the resident had already been visited by Adult Protective Services. In both cases, the facility failed to follow timely reporting protocols for suspected abuse and neglect.

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