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F0609
D

Failure to Timely Report Allegations of Abuse and Neglect

Rolla, Missouri Survey Completed on 11-19-2025

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

Facility staff failed to report allegations of abuse and neglect involving two residents to the Department of Health and Senior Services (DHSS) within the required two-hour timeframe. The facility's policy mandates immediate investigation and reporting of such allegations, but documentation showed delays in reporting both incidents. In the first case, a resident with severe cognitive impairment reported being slapped by an employee, but the incident was not reported to DHSS until ten days after the initial report. The Director of Nursing (DON) indicated that responsibility for reporting was transferred to the Regional Nurse Consultant due to shift changes, but the required notification was not completed in a timely manner. In the second case, a cognitively intact resident was subjected to verbal neglect when a CNA refused to toilet the resident and made an inappropriate comment. Although the DON stated the incident was reported by phone to DHSS on the day it occurred, there was no documentation to support this claim, and the official report was not submitted until several days later. During the administrator's absence, the Regional Nurse Consultant was responsible for investigations and reporting but failed to ensure timely submission due to an email issue. The administrator was unaware of the late reporting until after returning from vacation.

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