Failure to Timely Submit Investigation Results for Abuse, Neglect, and Elopement Incidents
Penalty
Summary
The deficiency involves the facility’s failure to submit investigative findings for multiple reportable abuse and neglect incidents to the State Survey Agency within the required five working days. For one resident, an incident report submitted on 10/2/25 documented mistreatment in the dining room through verbal comments from other residents, but the facility did not submit the investigative findings until 10/10/25, one day past the deadline. For another resident, an incident involving reported inappropriate touching by another resident was submitted on 1/3/26, but the investigative findings were not reported until 1/11/26, two days late. A third resident reported inappropriate and unwanted touching by another resident in an incident submitted on 1/25/26, and the facility did not submit the investigative findings until 1/31/26, one day after the deadline. The facility also failed to timely submit final investigation reports for multiple elopement incidents involving another resident. An allegation of neglect related to an elopement on 11/1/25 at 10:20 a.m. was reported on 11/1/25, but the final investigation was not submitted until 11/10/25, three days late. A second elopement for the same resident on 11/1/25 at 5:40 p.m. and a third elopement on 12/3/25 were similarly reported, with final investigations submitted on 11/10/25 and 12/11/25, respectively, each beyond the five-day requirement. Interviews with staff responsible for submitting these reports confirmed that the final investigations for these incidents were submitted late, with one staff member attributing a delay in one case to being reassigned to work in the kitchen. Facility policies on abuse, neglect, and exploitation, and on compliance with reporting allegations, require the administrator or designee to report the results of investigations to appropriate agencies within five working days of the incident.
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