Failure to Investigate and Report Allegations of Neglect
Penalty
Summary
The facility failed to thoroughly investigate and report an allegation of neglect involving a resident, as required by its own policies and federal and state regulations. The surveyor reviewed a grievance dated 8/27/25, which documented several concerns: showers not being completed with one CNA documenting multiple refusals while other staff were able to accomplish the task, a resident reporting that a CNA refused to help clean up spilled food, and another resident stating that a CNA left her unattended when she wanted to get up for therapy. Additionally, a grievance from 8/8/25 noted that a resident was late to lunch because a CNA paused care to use the phone. These grievances were entered into the facility's log, and at least one resulted in a documented counseling session for the CNA involved. Despite these documented concerns, 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 policies require immediate reporting and thorough investigation of all allegations of abuse, neglect, or mistreatment, including interviews with the resident, witnesses, and staff, as well as submission of findings to the appropriate agencies within specified timeframes. However, the surveyor found that these steps were not followed, and the allegations were not reported as required. Interviews with facility staff revealed that the social worker was only involved in entering grievances into a spreadsheet and not in the investigation process. The Nursing Home Administrator confirmed that there was no formal grievance process in place at the time and acknowledged that the allegations of neglect were not thoroughly investigated or reported to the State Survey Agency. No additional information was provided to explain the lack of investigation and reporting.