Failure to Timely Report Allegations of Abuse to State Agency
Penalty
Summary
The deficiency involves the facility’s failure to timely report multiple allegations of abuse to the State Agency in accordance with its April 2025 policy on reporting alleged violations of abuse, neglect, exploitation, or mistreatment. The policy required that all alleged violations involving abuse be reported immediately, but no later than two hours after the allegation is made, to the Administrator, State Survey Agency, and Adult Protective Services as appropriate. Despite this requirement, allegations involving three cognitively intact residents were not reported within the required timeframe. Resident 3, who had diagnoses including acute kidney failure, COPD, and UTI and was assessed as cognitively intact and independent in dressing, toileting, and personal hygiene, was the subject of an allegation that a CNA had spoken inappropriately about the size of the resident’s penis. This allegation was relayed to a CNA by another CNA but was not immediately reported to the DON or Administrator as required. Resident 4, who had acute kidney failure, type 2 diabetes mellitus, and muscle weakness, and required substantial/maximal assistance for bathing, lower body dressing, and toileting hygiene, was involved in a separate incident in which a CNA allegedly grabbed her own breasts in front of the resident and asked if they looked good. The CNA who witnessed this behavior considered it sexual harassment but did not report it promptly to leadership, instead waiting several days before informing an LVN, who then informed the Administrator. Resident 9, who had atrial fibrillation, muscle wasting and atrophy, and hypertensive chronic kidney disease, and required substantial/maximal assistance for bathing, lower body dressing, and toileting hygiene, reported that a CNA was aggressive, rude, told the resident to shut up, and argued with the resident. The resident reported this behavior to an LVN, who acknowledged receiving the allegation and stated that the LVN reported it to the Administrator in October 2025; however, the Administrator later stated being unaware of these allegations. The LVN also stated that neither the allegation involving Resident 4 nor the allegation involving Resident 9 was reported to the State Agency. The Administrator confirmed that an allegation involving inappropriate behavior toward a resident by a CNA was investigated internally and determined not to be abuse, and therefore was not reported to the State Agency, contrary to the facility’s policy requiring reporting of all alleged violations within the specified timeframes.
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