Failure to Timely Report Injury of Unknown Origin
Penalty
Summary
The facility failed to ensure that all alleged violations of abuse, specifically injuries of unknown origin, were reported to the state survey agency within the required two-hour timeframe. On the morning of 08/26/2025, a resident with severe cognitive impairment and total dependence for activities of daily living was observed with a bruise to the right eye and right arm. The initial observation was made by an LPN, who notified another LPN and the Nurse Practitioner. The Nurse Practitioner assessed the resident, noted additional swelling and bruising, and determined the injuries were consistent with a fall. The Assistant Director of Nursing was informed and began an investigation into the cause of the injuries. Despite the facility's policy requiring immediate reporting of suspected abuse or injuries of unknown origin, the incident was not reported to the state agency until 11:05 PM, well beyond the two-hour requirement. Interviews with the DON, Administrator, and Assistant DON confirmed awareness of the policy and the event, but the report was delayed until after a CNA provided a statement late in the evening. The deficiency was cited for failure to report the incident in a timely manner as required by regulation.