Failure to Identify and Investigate Allegations of Abuse and Neglect
Penalty
Summary
Surveyors identified that the facility failed to implement its abuse, neglect, and exploitation policy for three residents when allegations were documented but not treated as reportable abuse/neglect events. The written policy dated 01/2026 required the facility to prohibit and prevent abuse, neglect, and exploitation of residents with ongoing oversight and supervision of staff to ensure policies were implemented. Review of the grievance log from 07/01/2025 through 01/25/2026 showed multiple entries that involved potential abuse or neglect concerns, but these were only logged as staff concerns or grievances and not identified, reported, or investigated as allegations of abuse or neglect. For one resident, a staff concern was logged regarding lack of assistance and care from an LPN when asked. For another resident, a staff concern was logged regarding a verbal confrontation with a nursing assistant. For a third resident, the resident’s representative reported the resident was left with a soiled face and clothing and a brief so saturated with urine that it dripped down the hallway. Record review showed that none of these three incidents were entered into the facility’s reporting log, which is used to document incidents that may involve abuse, neglect, or mistreatment of residents, and there was no evidence of thorough investigation to rule out abuse or neglect. Completion dates on the grievance log, when present, were several days after the concerns were reported, and one concern had no completion date at all. During interviews, the administrator and DON acknowledged confusion among staff about which concerns should be placed on the grievance log versus the reporting log and confirmed that the concerns involving these three residents were not identified as allegations of abuse or neglect and were not investigated as such, meaning the residents were not provided protection from the possibility of ongoing abuse or neglect.
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