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F0609
D

Failure to Timely Report and Investigate Alleged Abuse and Neglect

Richmond, Virginia Survey Completed on 04-28-2025

Penalty

Fine: $93,440
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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 implement the abuse policy and report an allegation of abuse in a timely manner for one resident. The resident, who had multiple chronic conditions including chronic embolism, mood disorder, and was bedbound requiring extensive assistance with activities of daily living, reported that some CNAs were rude and rough during care. She described incidents where staff snatched blankets, lifted and dropped her leg, and left her feeling neglected and helpless. The resident also stated that she waited 12 hours for incontinent care and that staff would turn off her call light without providing assistance. She reported these concerns to the DON a few days prior to the survey interview. The DON acknowledged awareness of the incident and stated that additional staff were assigned to observe care for the resident, recognizing that the situation should be considered an allegation of abuse and/or neglect. However, the facility did not report or investigate the allegations in a timely manner as required by their abuse policy, which mandates immediate reporting and investigation of suspected abuse or neglect. The facility's failure to promptly address and report the resident's allegations constituted a deficiency in following established procedures for abuse prevention and reporting.

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