Failure to Thoroughly Investigate Allegation of Neglect
Penalty
Summary
The facility failed to thoroughly investigate an allegation of neglect involving one resident and a CNA. The facility’s Abuse, Neglect and Exploitation policy, revised 7/15/22, requires that a designated leader report allegations of abuse or neglect to the state agency and that immediate investigations occur when allegations or suspicions arise. An allegation was made that on 12/23/25, between 2:00 PM and 9:00 PM, a CNA did not provide care to a resident. The resident had dementia, chronic kidney disease with heart failure, anxiety, depression, and a BIMS score of 0/15 indicating severely impaired cognition, and had an activated POA. On 1/28/26, the surveyor reviewed the facility’s investigation, which consisted of an emailed allegation from an RN, four summarized staff interviews, one summarized interview with the resident’s POA, and an investigative narrative written by the NHA. The investigation did not include interviews with additional residents to determine if others had similar concerns and did not include staff education related to neglect. The surveyor was unable to interview the resident due to cognitive impairment. During interview, the NHA stated they believed staff education had been provided and additional residents had been interviewed, but no proof of these actions was provided, and the NHA indicated the facility had determined the incident was a miscommunication issue.
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