F0609

D

Failure to Report Resident’s Verbal Abuse Allegation Involving DON

Eagle, Colorado Survey Completed on 03-10-2026

Penalty

Fine: $14,015

Summary

The deficiency involves the facility’s failure to report an allegation of verbal abuse to the State Agency as required by its own policy and federal regulations. The facility’s Occurrence Reporting–Vulnerable Adult policy, revised in October 2022, requires all alleged violations and substantiated incidents involving abuse, neglect, exploitation, mistreatment, injuries of unknown origin, or misappropriation of resident property to be reported immediately, but no later than two hours if abuse or serious bodily injury is involved, or within 24 hours if not. Despite this policy, an allegation by a resident that the DON had been verbally abusive was not reported to the State Agency.

The resident involved was under age 65 and had multiple diagnoses, including CVA (stroke), hemiparesis, spastic hemiplegia of the left side, coronary artery disease, hyperlipidemia, depression, ADHD, lower back pain, and muscle weakness. A recent MDS assessment documented that the resident was cognitively intact with a BIMS score of 15/15 and exhibited verbal behavioral symptoms such as yelling and cursing. The resident was independent in most ADLs, used a wheelchair for mobility, and had a behavior care plan addressing yelling and inappropriate language, as well as an abuse prevention care plan noting risk for abuse or neglect and the ability to report suspected abuse.

On the evening in question, the DON went to the resident’s room to oversee the move of facility-provided furniture to a new room. According to the resident’s interview and emails, the DON stood between the resident and the door with hands on hips, told the resident that staff would move only facility furniture and that the resident must move personal belongings, and argued with the resident when the resident stated she could not move her items due to left-sided paralysis. The resident reported feeling cornered, mocked, and provoked, and stated that the DON repeatedly demanded to know if she would move her belongings, raised her voice, and mocked the resident’s request for written communication and disabilities. The resident emailed the NHA that evening with a recording and written statement, stating she felt mocked and provoked, and the following morning explicitly stated she felt the DON’s behavior was verbally abusive.

The NHA received emails from both the resident and the DON describing the argument and reviewed the resident’s audio recording and written statements from the resident and the DON. The NHA also spoke with an RN who had been present and involved corporate personnel in reviewing the materials. After this internal review, the NHA, regional corporate director, and corporate compliance officer concluded that verbal abuse was not substantiated. Based on that conclusion, the NHA did not report the resident’s allegation of abuse to the State Agency. The NHA stated she believed that because she had already investigated and decided the allegation was not substantiated, she did not need to report it, resulting in the facility’s failure to report an allegation of verbal abuse as required by policy and regulation.