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F0609
D

Failure to Timely Report Allegations of Abuse and Neglect

Bremerton, Washington Survey Completed on 11-18-2025

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 allegations of abuse within the required timeframes for two residents. For one resident with anxiety and post-traumatic stress disorders, a CNA documented that the resident claimed to have received nude photos from staff and to have had romantic relationships with several staff members. The Director of Nursing and the Administrator were unaware of these allegations until they read the progress notes the following day. The Director of Nursing acknowledged that this was an allegation of sexual abuse and should have been reported immediately to management and the state agency, but it was not reported until after the delay was discovered. For another resident with depression, anxiety, and muscle weakness, the resident reported physical abuse by a CNA and neglect by another CNA to an Activities Aide, who then notified the Administrator and Assistant Director of Nursing. The facility's investigation into the abuse allegation began the same day, but the mandatory report to the state was not submitted until the following afternoon, exceeding the 24-hour reporting requirement. The Assistant Director of Nursing stated they did not initially report the allegation because they did not believe it constituted abuse or neglect, and the Director of Nursing believed the next-day reporting was within the appropriate timeframe.

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