F0607

D

Failure to Immediately Report and Act on Allegation of Verbal Abuse

Haverhill, Massachusetts Survey Completed on 01-20-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure staff consistently implemented and followed its abuse policy regarding immediate protection and reporting of abuse allegations. The facility’s written policy, dated 03/01/25, required that all allegations of abuse, neglect, exploitation, or mistreatment be reported immediately to the Administrator and that policies and procedures be operationalized for resident protection and reporting. Despite this, a certified nurse aide (CNA) who witnessed an alleged incident of verbal abuse did not report it at the time it occurred and delayed reporting for three days.

The resident involved had diagnoses including dementia with behavioral disturbance and anxiety, with a quarterly MDS showing severely impaired cognition, disorganized thinking, and daily rejection of care. The resident’s care plan, updated with the November 2025 MDS, identified risk for mood alterations such as agitation and tearfulness due to dementia and disorientation, with interventions including medications, behavioral health consults as needed, and monitoring for acute episodes of sadness. On the evening of 12/13/25, while supervising residents with severe cognitive impairment in the activity room, CNA #2 observed an interaction in which the resident loudly told CNA #1 to get out of my uncle’s restaurant, and CNA #1 responded loudly to mind your own business, I am not talking to you. The resident then called CNA #1 an ugly bitch, and CNA #1 repeated the insult back to the resident before leaving the room with another resident.

CNA #2 did not confront CNA #1 and did not immediately report the incident to any supervisor or designated person. She later stated she believed allegations of abuse needed to be reported to the DON or Administrator within two hours but did not do so because the incident occurred on an evening over a weekend when they were not in the facility, and she had not received instruction on what to do in their absence. She did not report the incident until the morning of 12/16/25, first to a unit manager and a nurse (who both later denied recalling such a report), and then to the Scheduling Coordinator, who immediately informed the Human Resource Director. During the three-day delay, CNA #1 continued to work on the unit on multiple shifts. The Human Resource Director also did not immediately relay the allegation to the DON upon first receiving it, waiting until after a meeting to do so. The DON stated that staff were expected to immediately report any alleged incidents of abuse per facility policy.