F0835

J

Failure in Administration, Care Planning, Abuse Prevention, and Reporting

Corbin, Kentucky Survey Completed on 01-19-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to administer operations effectively to meet residents’ needs in the areas of care planning, protection from abuse, and immediate reporting of alleged abuse. The facility admitted a resident with schizophrenia who, according to multiple psychiatric evaluations and behavioral nursing notes beginning in mid‑August 2025, exhibited escalating aggressive and sexually inappropriate behaviors and was identified as being at risk for sexually acting out. Despite this documented pattern of behavior during the look‑back period for the resident’s annual MDS assessment dated late August 2025, the facility did not identify behavioral symptoms toward others on the MDS, and the behavioral care area did not trigger for care planning. The comprehensive care plan created from that assessment did not include a problem or interventions related to behaviors, and no behavioral care plan was developed until January 9, 2026, after a serious incident had already occurred.

During this period without a behavioral care plan, the resident continued to display aggressive behavior, mood instability, irritability, and psychotic symptoms, as documented in subsequent psychiatric evaluations, behavioral notes, and Behavior Review Committee documentation through November 2025. The Unit Manager later confirmed that the resident did not have a behavioral care plan prior to the January 5, 2026 incident and stated that both she and the DON should have been updating the care plan but did not. The Unit Manager reported that the DON had asked her not to document resident behaviors and that when she did document them, the documentation was changed, which contributed to the absence of a behavioral care plan. The DON acknowledged that behavioral care plans were expected to be reviewed and revised when incidents were reported, that it was important to have a behavioral care plan in place so staff would be aware of behavioral risks, and that the resident’s behaviors were not documented in the Kardex. The DON stated she assumed the Unit Manager was updating the care plan and Kardex but did not review them and did not know how the resident lacked a behavioral care plan until four days after the incident and two days after the state survey agency began its investigation.

On January 5, 2026, an LPN entered the room of a severely cognitively impaired female resident and observed the male resident positioned over her, with one leg on the bed, holding her hands down with one hand and pushing her back into the bed with the other while attempting to get on top of her. The LPN reported this to the SSD/Assistant ED and the DON and was told the situation was speculation and not to make a mountain out of a molehill. Subsequent documentation for the female resident, including behavior notes, a psychiatric evaluation, and social services notes, showed that after the incident she was very upset and crying, fearful, uncomfortable, did not want to remain at the facility, and exhibited increased anxiety and worsening emotional symptoms. The SSD/Assistant ED stated that she, the ED, and the DON decided the witnessed incident did not meet the definition of abuse and believed that the severely cognitively impaired resident could consent to being touched. The ED, who served as the abuse coordinator, similarly stated that she, the DON, and SSD/Assistant ED had not determined that abuse had occurred and believed the cognitively impaired resident could consent to the male resident coming into her room and touching her, but could provide no evidence to support this belief. The DON also stated she did not identify the incident as abuse because she believed the severely cognitively impaired resident could consent to being touched.

The facility also failed to immediately report this allegation of abuse and other allegations or injuries of unknown origin as required. The LPN’s report of the January 5, 2026 incident to the DON and SSD/Assistant ED was not reported to outside agencies, including law enforcement or the state survey agency. The SSD/Assistant ED stated that facility practice was to gather information, discuss as a team, and then decide whether to report to the Office of Inspector General, and that the leadership team decided the incident did not need to be reported because they did not feel it met the definition of abuse, again citing the belief that the cognitively impaired resident could consent. The ED acknowledged that policy required suspected abuse to be reported within two hours but stated they decided the incident was not reportable for the same reason. The DON initially expressed uncertainty about whether the incident should have been reported and, after reviewing the Abuse and Reporting Policy, stated that a leadership member should have reported it and confirmed that incidents involving alleged sexual misconduct between residents should be reported.

Further review of facility investigations showed additional failures to immediately report allegations of abuse or injuries of unknown origin that did not rise to the level of immediate jeopardy. These included resident‑to‑resident abuse on December 26, 2025, and injuries of unknown origin for several residents on dates in 2025 and early 2026. The DON stated she was not aware she was supposed to report allegations or suspicions of alleged abuse immediately to state agencies. The ED stated there had not been any recent incidents requiring reporting and that she, the SSD/Assistant ED, and the DON made decisions not to report incidents, and that she often reached out to corporate for direction. A corporate Director of Clinical Reimbursement confirmed that allegations of abuse should be reported within two hours but was aware the facility would investigate first before reporting, and indicated that in the case of the incident between the two residents, corporate determined it was not a reportable allegation and characterized it as “just touching.” These combined failures in care planning, abuse prevention, and mandatory reporting led surveyors to identify immediate jeopardy under 42 CFR §483.70 (F835).