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F0609
E

Failure to Timely Report Abuse Investigation Results

Sheridan, Wyoming Survey Completed on 10-08-2025

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 the results of abuse investigations within 5 working days to the State Agency for four residents who were involved in allegations of abuse, neglect, or theft. In one case, an allegation of verbal abuse between a resident and a staff member was reported, but no investigation was completed or submitted to the State Agency as of over two months later. In another instance, an incident of abuse between two residents was reported, but again, no investigation was completed or reported. A third case involved an incident of abuse by a resident toward an LPN, with no investigation completed or reported within the required timeframe. Interviews with facility staff revealed that the investigations were not present in the facility, and the reportable investigations binder had gone missing. The administration had contacted the police regarding the missing binder. The DON confirmed that investigations should have been submitted by the former SSD but were not, and also stated that the DON did not have access to submit investigations. Review of facility policy confirmed the requirement to report investigation results within 5 working days, which was not followed in these cases.

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