F0609

D

Failure to Timely Report and Investigate Allegations of Abuse and Rough Treatment

Eckert, Colorado Survey Completed on 01-06-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to timely report and investigate multiple allegations and indications of abuse or rough treatment toward three residents, despite a written policy requiring immediate reporting of alleged abuse or neglect to supervisory staff, the NHA, and the State Agency within specified timeframes. The facility’s policy states that all employees must immediately report alleged abuse or neglect to a supervisor or building supervisor, that the executive director or designee and DON must be contacted immediately, and that suspected abuse must be reported to the state within two hours if it involves abuse or bodily injury, or within 24 hours if it does not. Surveyors found that these procedures were not followed for allegations and concerns involving three residents, and that there was no timely documentation, reporting, or formal abuse investigation for these events.

For one resident with moderate cognitive impairment, hemiplegia, aphasia, Parkinson’s disease, and dependence on staff for all ADLs, staff reported that a CNA was rough with the resident and that the resident expressed fear of this CNA. A CNA stated that the resident told her he was scared, that the CNA in question pushed and grabbed his arm too hard, and that he had marks on his arm; she reported this to the former DON and human resources but was later told there was no investigation and that the concerns were attributed to the resident’s dementia. An LPN reported that several months earlier the same resident told her a CNA was verbally mean and that he felt scared; she believed she completed a grievance form and gave it to leadership, but later acknowledged she may have only verbally reported it to the former DON and did not document it in a progress note. The NHA reported she never received a grievance form or report of this allegation, and record review showed no abuse report, investigation, or grievance documentation related to these concerns.

For a second resident with severe dementia, behavioral challenges, and total dependence on staff for care, documentation showed repeated episodes of screaming, yelling, pushing staff away during care, and fearfulness during repositioning and movement over several months. A staff member reported that a CNA was needlessly rough with this resident, including ripping the resident’s hands off the bed or equipment during ADLs, and described the CNA as preferring a more physical approach and skipping a gentle approach for speed. The staff member stated she mentioned these concerns to an LPN and another nurse but did not file an abuse report because she did not feel the incidents were serious enough. The LPN acknowledged that the CNA could be “a little rough,” that the resident became scared when moved suddenly and would grab the bed, and that he did not report or document what he observed or offer alternative care approaches. Review of State Agency reports showed no abuse allegations reported for this resident.

For a third resident who was cognitively intact, quadriplegic, and fully dependent on staff for transfers and positioning, the resident reported that during a Hoyer lift transfer, a CNA pushed his leg off the lift rather than holding and lowering it, causing his foot to hit the wheelchair foot pedal. The resident stated he told the CNA this was unsafe and asked for his leg to be adjusted, but the CNA responded dismissively and referenced her upcoming retirement. The resident asked another CNA and night shift staff to assess his foot for injury and expressed that he felt the CNA’s actions were inappropriate, dangerous, neglectful, and abusive, and that he did not want to work with her. Another staff member reported having seen the same CNA be rough with this resident during transfers, not being careful with his feet so that they slipped off the lift and became caught on equipment, and described the CNA as mean and forceful. Record review showed no documentation of the Hoyer lift incident or assessment of the resident’s foot in the EMR, and the allegation was not reported to the State Agency until it was brought forward during the survey.

Additional interviews with leadership and staff confirmed that the NHA and current DON were not made aware of the earlier concerns involving the first and second residents, and that no abuse reports had been submitted to the State Agency for those situations. Staff, including the ADON and human resources director, stated they were not aware of prior concerns related to the CNAs involved. The DON acknowledged that statements of feeling scared, reports of staff being too rough, or reports of disrespect or demeaning speech should trigger an abuse investigation, and the NHA acknowledged that the resident’s statements of fear would have met the definition to prompt an investigation and immediate protective actions if they had been reported. Despite existing policies and staff education on abuse recognition and reporting, multiple staff members either did not recognize these events as potential abuse or did not escalate them beyond informal verbal reports, resulting in the facility’s failure to timely report and investigate allegations of abuse and rough treatment for three residents.