Failure to Timely Report Alleged Verbal Abuse Incident
Penalty
Summary
The deficiency involves the facility’s failure to ensure staff immediately reported an allegation of verbal abuse in accordance with its abuse reporting policy. The facility’s policy, dated September 2022, required that any suspicion of abuse be reported immediately to the administrator and appropriate agencies, defining “immediately” as within two hours of an allegation involving abuse. Resident #1, who had diagnoses including dementia with behavioral disturbance and anxiety and was described as severely cognitively impaired, was involved in an altercation with a CNA on 12/13/25 in the activity room. During this incident, Resident #1 told CNA #1 to get out of his/her uncle’s restaurant, and CNA #1 responded loudly for the resident to mind his/her own business. Resident #1 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, who witnessed the exchange, did not report the incident at the time it occurred. She later stated that she did not report it until the morning of 12/16/25 because the incident occurred on an evening over the weekend when the DON and Administrator were not in the facility, and she forgot about it until overhearing a discussion about Resident #1. On 12/16/25, CNA #2 reported the incident to the Unit Manager and Nurse #1, though both later said they did not recall receiving this information. CNA #2 also reported the incident to the Scheduling Coordinator, who then reported it to the Human Resource Director, who in turn informed the DON later that day. The DON acknowledged that staff were expected to immediately report any alleged incidents of abuse so the facility could report to the State Agency within two hours of the allegation being known. The state reporting system showed the facility’s report of the alleged verbal abuse was created on 12/16/25 at 5:37 P.M., three days after the incident occurred, demonstrating the failure to follow the facility’s abuse reporting policy and required time frames.
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