Failure to Timely Report Alleged Staff-to-Resident Abuse
Penalty
Summary
The deficiency involves the facility’s failure to ensure that an alleged incident of staff-to-resident abuse was reported immediately to facility administration and to the State agency within required time frames. Facility policy dated January 2023 required all employees to report any act of resident abuse by a staff member or another resident immediately to their supervisor upon knowledge of the alleged abuse. Resident #1, who had dementia, severe cognitive impairment, and a history of verbal and physical behaviors including combativeness during care and hitting staff, was the subject of the allegation. The resident’s care plan directed staff to intervene to protect the resident and others, redirect negative behaviors, and remove the resident from situations as needed. On the evening of 02/18/2026 at approximately 9:30 PM, Certified Nurse Aide (CNA) #2 reported later that they witnessed CNA #1 choking Resident #1, calling the resident expletive names, and pushing the resident out of the room in an aggressive manner. CNA #2 removed the resident from the situation but did not report the allegation to a supervisor or charge nurse that night. Instead, CNA #2 reported the incident to Registered Nurse Resident Care Coordinator #1 the following morning at about 10:40 AM, stating they did not realize what they had seen until the next day. The Resident Care Coordinator then reported the allegation to the Administrator at approximately 10:45 AM. Interviews with supervisory staff and the Administrator confirmed that no abuse allegation was reported during the evening shift when the incident allegedly occurred, and that staff were expected to report suspected abuse immediately, which did not occur in this case.
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