Failure to Report Allegations of Abuse and Misappropriation to State Agency
Penalty
Summary
The deficiency involves the facility’s failure to timely report allegations of abuse and misappropriation to the State Survey Agency, the Office of Health Care Quality (OHCQ), as required. Review of facility concern forms for October 2025 showed that one resident submitted a concern form on 10/30/2025 alleging that an assigned geriatric nursing assistant was roughly handling the resident. The facility documented that the geriatric nursing assistant was removed from the assignment and that the Director of Nursing was made aware, but there was no report of this allegation of suspected abuse/neglect to OHCQ. This omission was identified during the recertification/complaint survey through document review. A second concern form from October 2025 documented an allegation from another resident’s complainant that a wallet/purse and wigs were missing from the resident’s belongings, constituting an allegation of misappropriation. The facility’s documented response was to search the room and for the Unit Manager RN to request a receipt from the complainant, but the allegation was not reported to OHCQ. During interviews, the Administrator, who serves as the Grievance Officer, described the grievance process and acknowledged that these specific allegations of abuse, neglect, and misappropriation were not reported to OHCQ. The DON also confirmed that rough handling of a resident is considered physical abuse and that a missing purse or wallet is considered misappropriation, and both are mandatory reportable events that were not reported.
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