Staff Returned to Work Before Completion of Neglect Investigation
Penalty
Summary
The deficiency involves the facility’s failure to prevent further potential abuse, neglect, exploitation, or mistreatment while an investigation into an allegation of neglect was still in progress. An allegation of neglect was reported involving Resident #61 and a Geriatric Nursing Assistant (GNA #5). The Administrator submitted the initial report of the allegation to the Office of Health Care Quality on 10/29/2025 and later submitted the final investigation report on 11/04/2025. Documentation showed that GNA #5 was suspended on 10/29/2025 following the allegation. Record review on 01/07/2026 revealed that the investigation file contained statements from the RN Unit Manager and RN #30, both dated 11/04/2025, indicating that investigative activities were still occurring on that date. During interviews, the Administrator confirmed that the investigation was completed on 11/04/2025 but also confirmed that GNA #5 had been allowed to return to work on 11/01/2025. When questioned, the Administrator stated that by 11/01/2025 he had determined the allegation could not be verified and therefore permitted the employee to resume work. Surveyors identified that because key witness statements were not obtained until 11/04/2025, the investigation was still ongoing when GNA #5 returned to work, meaning the staff member accused of neglect was allowed to resume duties before the investigation was completed.
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