Failure to Report and Investigate Allegations of Neglect
Penalty
Summary
The facility failed to ensure that allegations of neglect involving a resident were immediately reported to the Administrator and/or Grievance Officer and submitted to the State Survey Agency as required by policy. Record review and interviews revealed that a grievance dated 8/27/25 documented multiple concerns, including incomplete showers, refusal by a CNA to assist a resident with cleaning up spilled food, and another resident being left unattended when requesting assistance to prepare for therapy. Despite these documented allegations, the facility did not submit an Alleged Nursing Home Resident Mistreatment, Neglect, and Abuse Report or a Misconduct Incident Report to the State Survey Agency. The facility's Abuse Prevention and Abuse Investigation and Reporting policies require that all alleged violations involving abuse, neglect, exploitation, or mistreatment be reported to the Administrator or designee and to the State Agency within specified time frames. The policies also require that findings of investigations be reported in writing within five working days. However, interviews with facility staff, including the Social Worker and Nursing Home Administrator, confirmed that there was no formal grievance process in place and that the allegations of neglect were not reported or thoroughly investigated as required. The resident involved had a history of significant medical conditions, including atherosclerotic heart disease, paroxysmal atrial fibrillation, iron deficiency anemia, hypothyroidism, major depressive disorder, and dementia. The resident was moderately cognitively impaired but alert and oriented at the time of the survey. The surveyor found that the facility's failure to report and investigate the allegations of neglect constituted a deficiency in compliance with regulatory requirements.