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F0609
D

Failure to Timely Report Allegation of Verbal Abuse

Mystic, Connecticut Survey Completed on 11-25-2025

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

Staff failed to promptly report an allegation of verbal abuse involving a resident who was dependent for toileting, transfers, and bed mobility, and had a history of stroke, anxiety, and major depression. The incident occurred when a nursing assistant (NA) made disparaging and vulgar remarks to the resident regarding their incontinence and dietary intake. Two other staff members witnessed or overheard the incident and reported it to the charge nurse and supervisor. Despite being informed of the incident, the nursing supervisor did not initiate an incident report, notify the Director of Nursing (DON), or remove the accused staff member from duty to protect residents. The supervisor also did not gather specific details about the interaction or recognize the need for immediate escalation, even though she acknowledged that such behavior would be considered abusive. The DON was not notified of the allegation until the following day, resulting in a delay in the investigation and appropriate response. Facility policy required immediate reporting of suspected abuse to management, but this protocol was not followed, leading to a failure in timely reporting and response to the abuse allegation.

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