F0610

E

Failure to Thoroughly Investigate 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 conduct thorough investigations into multiple allegations of abuse and injuries of unknown origin, as required by its Abuse Reporting and Prevention policy. The policy, reviewed in July 2025, required that any report of abuse or injury of undetermined origin trigger a full investigation by the Executive Director (ED) or designee, including immediate resident examination for injury, obtaining written statements from all persons with knowledge of the incident, and conducting pertinent interviews with residents, staff on duty, and others present. Surveyors found that these steps were not consistently followed for several residents with alleged abuse or unexplained injuries.

In one case, a laundry aide found a resident on the floor between the bed and recliner; the resident stated her roommate had pushed her, and the aide reported this to the nurse. A notepad “investigation” by the DON documented the allegation, the roommate’s denial, and a staff reenactment concluding the event could not have occurred as described, but there was no written statement from the laundry aide and no evidence of skin assessments for either resident. Another resident was found with a pale yellow bruise on the left outer knee; the DON’s handwritten note linked this to an incident 10 days earlier when the resident was aggressive and hit her hand on a table, with RN documentation that the resident had been kicking her legs but without witnessing contact with any object. There were no witness statements, no interviews with other staff who had provided care around the time of the injury, and no documented skin assessment, yet the cause of the bruise was attributed to the earlier incident without sufficient supporting facts or exploration of other possible causes.

Additional residents with injuries of unknown origin also lacked thorough investigations. One resident was noted by an LPN to have dark purple bruising on the inner left thigh down to the knee and a small bruise on the outer thigh, with the resident unable to state the cause; the incident report contained no skin assessment and no staff statements. Another resident had a bruise to the right eye/cheek area; the DON’s notepad entry stated staff interviews were conducted and concluded the resident caused it by rubbing his face, but there were no written witness statements or complete skin assessment documented. A further resident with contractures was reported to have a bruise on the left upper arm; the DON documented staff interviews and concluded the bruise occurred during a gown change with no suspicion of abuse, yet there were no written statements from direct care staff and no evidence of a skin assessment. Interviews with the SSD/Assistant ED, ED, and DON confirmed that investigations were based on interviews and team discussion, and the DON stated that once they determined how injuries happened, they did not pursue further investigation, despite the lack of documentation required by facility policy.