F0609

D

Failure to Report Alleged Physical Abuse to State Agencies

Glasgow, Kentucky Survey Completed on 02-04-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to report allegations of abuse to state agencies as required by its own policy and federal regulations for two sampled residents. The facility’s abuse policy, reviewed in June 2025, required all alleged violations to be reported immediately, but no later than two hours after the allegation is made when abuse or serious bodily injury is involved, and to report investigation results to the appropriate state agency within five working days. Despite this, multiple staff interviews and record reviews showed that serious allegations involving two residents were not reported to the Administrator or state agencies, and in at least one case staff believed the incident was not investigated.

For one resident with severe cognitive impairment, dementia with behavioral disturbance, bipolar disorder, and other conditions, records showed an event report dated mid‑June 2025 describing the resident being "assisted to floor due to behaviors" in the bathroom with no injuries noted. Progress notes over the next days documented complaints of right hand and wrist pain, an x‑ray, and a bruise on the right index finger attributed to a recent fall. In a later interview, the resident stated that a male staff member pushed him out of his wheelchair onto the bathroom floor, bent his arm back, and hurt his hand and wrist, and that he told multiple nurses about the incident. One LPN reported hearing that the resident threw himself on the floor, that a CNA refused to pick him up and told him to get up on his own, and that the resident hurt his hand; this LPN stated she did not think the incident was ever investigated, although she believed the DON and Administrator knew about it. A CNA who was orienting at the time reported witnessing the CNA screaming at the resident, threatening to put him on the floor, and then putting him on the bathroom floor, and stated she reported this to the DON. The former social services director stated the resident told her that the CNA put him on the floor and threw him in bed, hurting his wrist, and that she informed the DON and Administrator.

For another resident with Alzheimer’s disease, hearing loss, and a history of falls, documentation from August through October 2025 contained no record of eye bruising. However, multiple staff and the resident described an incident in which the resident had a black eye and alleged that a male CNA hit her in the eye. One CNA stated that the resident told her and another CNA that the CNA had hit her eye, and that dayshift staff said it had been reported to the DON and Administrator; she also stated HR told her to stay out of it. The resident reported that a black male staff member hit her left eye with the back of his hand, causing a large bruise, and that no one later questioned her about it. An LPN reported hearing a scream, seeing the CNA in the hallway, then finding the resident screaming that the CNA hit her in the eye, with bruising beginning; she stated the DON instructed her to chart that the bruising was from the resident rubbing her eye, which she refused to do, and that the incident was not investigated or reported as abuse. Other staff, including another CNA and the former social services director, recalled the resident having a black eye and stating that the CNA hit her, but were told by leadership that the resident had been rubbing or scratching her eye. The current DON and Administrator both stated in interviews that they were never informed of the abuse allegations involving these two residents, despite the facility policy requiring immediate reporting of all alleged abuse and the Administrator’s role as abuse coordinator.

The combined record review and interviews demonstrate that, although multiple staff and both residents described events they believed to be physical abuse by the same CNA, these allegations were not reported to the Administrator or state agencies within the required time frames, and in some instances staff believed the incidents were not investigated at all. The facility’s own policy required immediate reporting of all alleged violations, including to state agencies, and mandated that investigation results be reported within five working days, but there was no evidence that the allegations involving these two residents were reported as required.