Failure to Report Alleged Verbal Abuse to State Agency
Penalty
Summary
The facility failed to report an allegation of verbal abuse involving a resident to the State Agency as required by its Abuse, Neglect, and Exploitation policy. On 9/3/25, a resident (R8) reported that a Certified Nursing Assistant (CNA-E) yelled at another resident (R7), who was R8's spouse, after an alarm was triggered when R7 attempted to get a remote while in a wheelchair. The incident was documented as a grievance, and the Nursing Home Administrator (NHA-A) conducted an internal investigation. However, there was no follow-up or confirmation of the incident, and the facility did not report the allegation to the State Agency within the required timeframe. R7, the resident involved, had a history of hemiplegia and hemiparesis following a cerebral infarction, as well as dysphagia, and was assessed to have moderate cognitive impairment. R8, the reporting resident, was not cognitively impaired. Despite the facility's policy requiring all alleged violations to be reported to the Administrator and State Agency within specified timeframes, the NHA-A did not report the incident, citing personal knowledge of the individuals involved and a belief that the CNA's tone was misinterpreted. The deficiency was confirmed during a surveyor interview with the NHA-A.