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F0609
D

Failure to Report Alleged Abuse to State Authorities

Estherville, Iowa Survey Completed on 11-10-2025

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

The facility failed to report an allegation of abuse involving a resident with moderate cognitive impairment and a history of an ankle fracture. According to documentation, the resident was heard screaming and accused a nurse of hitting her, while the nurse was reportedly at the nurse station charting. The incident was documented by an LPN, who stated she notified a supervisor but could not recall who. The administrator and DON later confirmed that the allegation was documented, but the administrator stated they were not notified at the time and only became aware when the resident's son and a police officer arrived. The police reviewed video footage and found no evidence of abuse, and the resident did not sustain any injury or trauma. Despite the facility's policy requiring immediate reporting of alleged or suspected abuse to the administrator and designated agencies, including the State Survey and Certification Agency, the incident was not self-reported to the state. The administrator decided not to self-report because the police had already investigated and found the allegation unfounded. The facility's records showed that self-reports had been made in other cases, but in this instance, the required notification to state authorities did not occur as outlined in the facility's abuse and neglect policy.

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