Failure to Report Alleged Abuse and Neglect to State Authorities
Penalty
Summary
The deficiency involves the facility’s failure to report alleged abuse and neglect to the proper authorities as required. A complaint intake from Adult Protective Services, filed on behalf of a resident’s family, indicated that the family often found the resident in a saturated, wet brief or soiled while at the facility. Review of the facility’s grievance logs showed that on 12/08/2025, staff documented that the resident’s family reported the resident had been left sitting in a very wet brief, and that staff had delayed care due to the resident’s agitation. The documentation reflected an internal review and referral to psychiatric services, but there was no evidence that this allegation of neglect was reported to the Office of Health Care Quality (OHCQ). Further review of the grievance documentation revealed another grievance dated 09/31/2025 in which a Geriatric Nursing Assistant (GNA) was reported to have raised a fist toward a resident and stated, “Don’t tell me what to do. I know how to do my job.” There was no evidence that this allegation of staff mistreatment was reported to OHCQ. During interview, the Nursing Home Administrator acknowledged that allegations of abuse and neglect are reportable and could not provide a rationale for why these grievances were not reported as Facility Reported Incidents. The administrator also confirmed that the facility was using a templated, non–facility-specific policy. No additional evidence was provided to the surveyor before the conclusion of the survey.
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