Failure to Timely Report Allegation of Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to timely report an allegation of physical abuse to the State Survey Agency (SSA) as required by its own policy and federal expectations. The facility’s Abuse Prohibition – Reporting and Investigation policy, revised 12/27/2024, states that all allegations of abuse or those involving serious bodily injury must be reported immediately, but no later than 2 hours. A nurse’s note for Resident 6 dated 12/12/2025 at 7:36 p.m. documented that the nurse was summoned to the dining room regarding an altercation between Resident 6 and another male resident (Resident 7), during which witnesses stated that Resident 6 walked up to Resident 7 and started hitting him in the head. Resident 6 was escorted back to his room and assessed, and bleeding was noted from the index finger on the right hand from a previous injury. However, the Facility Incident Report Form (FRI) was completed with the incident date and time recorded as 12/13/2025 instead of 12/12/2025, and the follow-up report submitted to the SSA on 12/19/2025 also identified the incident date as 12/13/2025. This incorrect dating resulted in the allegation of abuse not being reported to the SSA within the required 2-hour timeframe from the actual occurrence on 12/12/2025. During an interview on 1/7/2026 at 11:35 a.m., the Administrator stated she was not sure why the FRI was reported late.
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