F0609

J

Failure to Immediately Report Alleged Abuse and Injuries of Unknown Origin

Corbin, Kentucky Survey Completed on 01-19-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to immediately report multiple allegations and incidents of potential abuse, including injuries of unknown origin, to external authorities such as law enforcement and the State Survey Agency (SSA), as required by federal regulations and the facility’s own Abuse Reporting and Prevention policy. The policy required all staff to immediately report any observation, suspicion, or information related to possible abuse to facility leadership, and required the Executive Director (ED) or designee to report all alleged abuse to state agencies within two hours. Abuse was defined broadly to include physical, mental, and sexual abuse, neglect, involuntary seclusion, and mistreatment, including abuse perpetrated by other residents. The policy also specified that any willful act in a resident‑to‑resident physical altercation that resulted in physical injury, mental anguish, and/or pain was reportable.

One key incident occurred when an LPN observed a male resident with a history of sexual behaviors physically restraining a severely cognitively impaired female resident in her bed. The LPN saw the male resident positioned over the female resident, holding her hands down with one hand and pushing her left shoulder back into the bed with the other while attempting to get on top of her. The LPN reported this to the Social Services Director/Assistant ED and the DON, but was told the situation was speculation and not to “make a mountain out of a molehill.” Facility documentation and SSA records showed no evidence that this allegation was reported to law enforcement or the SSA. The SSD/Assistant ED, ED, and DON later stated they had decided the incident did not need to be reported because they did not believe it met the definition of abuse and believed the severely cognitively impaired resident could consent to being touched, although they could provide no evidence to support this belief. The ED, who was the abuse coordinator, acknowledged the policy required reporting within two hours if abuse was suspected but stated that recent incidents, including this one, had not been reported because leadership did not determine that abuse had occurred.

Additional unreported events included a resident’s allegation that her roommate pushed her to the floor, which was reported by a laundry aide to nursing staff but not reported to the SSA. Several residents with severe cognitive impairment were found with bruises or injuries of unknown origin: one resident had dark purple bruising to the inner thigh extending to the knee and a small outer thigh bruise without an identified cause; another had a pale yellow bruise to the outer knee with no clear link to a prior incident where she had hit her hand, not her knee; another had a bruise to the right eye/cheek area; and another had a bruise to the left upper arm. In each of these cases, the DON documented awareness of the injuries and conducted some level of internal review or investigation, but there was no evidence in facility or SSA records that these injuries of unknown origin were immediately reported to the SSA at the time they were first identified. The SSD/Assistant ED stated that she, the ED, and the DON reviewed these incidents and decided they did not need to be reported because they did not feel they met the definition of abuse. The DON also stated she was not aware she was supposed to report allegations or suspicions of alleged abuse immediately to state agencies, and the ED confirmed that the facility’s practice was to investigate and substantiate incidents before reporting, contrary to policy and federal requirements that all alleged violations, including injuries of unknown origin, be reported immediately.

The surveyors determined that this pattern of failing to immediately report allegations and incidents of potential abuse, including the witnessed incident of a resident physically restraining another resident in bed and multiple injuries of unknown origin, constituted noncompliance with 42 CFR §483.12 (F609 – Freedom from Abuse, Neglect, and Exploitation). The failure to report the 01/05/2026 incident involving the male and female residents was identified as Immediate Jeopardy at scope and severity J and also constituted Substandard Quality of Care under 42 CFR §483.12. The facility’s leadership, including the ED, DON, SSD/Assistant ED, and a corporate representative, acknowledged that they often decided internally, sometimes with corporate input, whether an occurrence met their definition of abuse before reporting, and that in these cases they had concluded the events were not reportable, despite policy and regulatory requirements to immediately report all allegations and injuries of unknown origin.