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F0609
D

Failure to Report Alleged Abuse to State Survey Agency

Kingsport, Tennessee Survey Completed on 11-17-2025

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 to the State Survey Agency as required by its own policy. The policy mandates that the Abuse Coordinator, who is the Administrator, is responsible for reporting all allegations or suspicions of abuse, including mental abuse facilitated through technology, to the state survey agency. In this case, several staff members reported that a CNA had taken photos of a resident's back or wounds and sent them to the ombudsman. The resident involved, who was cognitively intact and required assistance with activities of daily living, stated that she did not give permission for any photos to be taken. The Director of Nursing documented that the resident reported photos were taken without her knowledge. The Administrator interviewed the CNA, who denied taking or sending any photos and denied using her phone in the facility. No staff reported actually seeing the photos on the CNA's or any other employee's phone. Despite the allegations and statements from staff and the resident, the Administrator did not report the incident to the State Survey Agency, stating that although it is normally done, it was not done in this instance. The ombudsman confirmed not receiving any photos or having any related discussions. The failure to report the allegation of abuse, as required by facility policy and regulation, constitutes the deficiency identified in the report.

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