Failure to Submit Final Abuse Investigation Report Within Required Timeframe
Penalty
Summary
The deficiency involves the facility’s failure to submit the final results of an abuse investigation to the State Agency (SA) within the required five working days. The facility’s Abuse/Neglect/Exploitation policy states that the Administrator will confirm the initial report was received and report the results of the investigation to government agencies within five working days of the incident, as required by state agencies. For one resident, R4, the facility submitted an initial allegation of abuse to the SA on 11/22/25 following a reported concern involving possible illicit substances provided by a family member. The final investigative report, documented on the facility’s Misconduct Incident Report, was not completed and submitted until 12/3/25 at 1:55 PM by the Chief Nursing Officer, which exceeded the required timeframe. R4’s admission record showed that R4 had been admitted earlier in the month, and the admission MDS with an ARD of 11/16/25 documented a BIMS score of 15/15, indicating intact cognition. The incident prompting the abuse allegation occurred after a family visit on 11/22/25, during which R4 exhibited a significant escalation in behavior, and a family member reported that another family member may have previously provided R4 with illicit substances. Staff interviews confirmed that the facility understood the requirement to submit the final investigative report within five working days of the initial report, with the CNO stating the report was due on 11/28/25 and the Administrator stating it was due on 12/1/25. Both acknowledged that the final report was not submitted to the SA within the required timeframe.
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