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F0609
D

Failure to Timely Report Alleged Abuse to Mandated Entities

Glendale, Arizona Survey Completed on 12-04-2025

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 ensure that an allegation of abuse involving a resident was reported immediately and within the required 2-hour timeframe to mandated entities. The incident involved a resident with multiple medical diagnoses, including fractures, urinary tract infection, and acute kidney failure, who had a moderately impaired cognitive status. The resident's family reported to nursing staff that the resident claimed to have been raped by a male night shift staff member. Upon being informed, the nurse assessed the resident for injuries and found none, and notified nursing management, administration, and the local police. Documentation and interviews revealed that the incident was reported to the local police and the facility administrator on the same night it was disclosed. However, the notification to the State Agency and Adult Protective Services (APS) was delayed and occurred outside the mandated 2-hour window. The administrator attempted to submit the report to the State Agency via the online portal but encountered a server error, resulting in the report being sent by email later than required. The facility's policy, as well as statements from staff, confirmed that allegations of abuse are to be reported immediately and within 2 hours to all required authorities. Staff interviews consistently indicated an understanding of the need for immediate reporting to ensure resident safety and prompt investigation. Despite this, the actual reporting to the State Agency and APS did not occur within the required timeframe, as confirmed by timestamps on the reports and emails. This delay constituted a failure to follow both regulatory requirements and facility policy regarding the timely reporting of abuse allegations.

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