F0609

D

Failure to Timely Report Allegations of Staff-to-Resident Abuse

Sewell, New Jersey Survey Completed on 01-29-2026

Penalty

No penalty information released

Summary

The facility failed to timely report allegations of staff-to-resident abuse to the State Survey Agency (SSA) for two residents. In the first case, a resident admitted for a respite stay with traumatic brain injury and anxiety, and assessed as cognitively intact with a BIMS score of 13, later disclosed an allegation of sexual abuse by a maintenance worker to a therapist after discharge. The facility became aware of the allegation when contacted by local law enforcement, and the administrator confirmed that the resident had not voiced any allegations during the stay. Although the facility verified that the accused staff member was removed from the schedule and subsequently resigned, the administrator stated the allegation was not reported to the SSA because the resident no longer resided at the facility.

In the second case, a resident with dementia and a BIMS score of 2, indicating severe cognitive impairment, was involved in an incident in which an LPN continued to attempt medication administration despite the resident’s refusal. When the resident threw juice at the LPN, the LPN grasped the resident’s left arm and roughly pushed the resident into another wheelchair, as observed by an activity aide and on video surveillance. The activity aide did not immediately notify the DON or nursing supervisor and instead left a written statement the following day. The DON confirmed that the facility did not become aware of the incident until that statement was found and that the initial notification to the SSA was not made until the day after the incident, contrary to the facility’s abuse prevention policy requiring covered individuals to report suspicions of abuse immediately, but no later than two hours after forming the suspicion.