Failure to Report Resident’s Abuse Allegation to State Agency
Penalty
Summary
The facility failed to report an allegation of abuse and neglect to the State Survey Agency for one cognitively intact resident. The resident, admitted with diagnoses including heart failure and kidney disease, had a care plan dated 12/24/25 indicating that if the resident made accusatory comments about family or staff not treating them well or denying medications, staff were to alert the nurse to assess for signs and symptoms of a urinary tract infection. On 1/12/26 at 2:13 PM, the resident reported that a CNA/CMA had abused them, stating the staff member spoke meanly, was rough, and treated them like a “bad dog.” The resident also expressed fear of retaliation from the staff member and fear of being discharged from the facility. At 2:16 PM the same day, an LPN stated that the staff member identified by the resident was a CNA/CMA and acknowledged hearing this staff member be rude to the resident. The LPN further reported that this staff member’s demeanor changed when rushed or having a bad day and that she had heard the staff member be rude to other residents, with other staff also observing this behavior, but she did not report it to management. At 2:42 PM, the Administrator and DNS were notified that the resident felt abused by this staff member, and the Administrator indicated this was the first time he had heard of the allegation. At 2:52 PM, the Administrator and DNS stated their expectation that when a resident feels abused by a staff member, staff must notify them immediately, notify the provider and family, and ensure resident safety; however, the allegation had not been reported to the State Survey Agency as required.
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