Failure to Timely Report Allegation of Neglect
Penalty
Summary
The facility failed to report an allegation of neglect to the State Survey Agency within the required 24-hour timeframe. On 09/23/25, a resident with chronic obstructive pulmonary disease, chronic respiratory failure with hypoxia, pulmonary fibrosis, Alzheimer's disease, and on hospice care, was found without oxygen and diaphoretic, with an oxygen saturation of 71% on room air. Oxygen was reapplied, and the resident's saturation improved. The incident was initially not considered neglect by facility staff, and therefore was not reported as required by facility policy and federal regulations. Further review and discussion with the regional director led to the decision to report the incident in good faith, but this did not occur until 09/30/25, several days after the event. The delay was attributed to the acting administrator being new and not recognizing the situation as neglect at the time. The facility's policy requires all alleged violations involving abuse, neglect, exploitation, mistreatment, misappropriation of resident property, or injuries of unknown source to be reported to the State Survey Agency within 24 hours.