Failure to Report Alleged Resident-to-Resident Abuse to State Agency
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of resident-to-resident abuse to the State Agency as required by its Abuse Prevention and Reporting Policy. The facility’s policy, revised 10/24/22, states that when an allegation of abuse has occurred, the resident’s representative and the Department of Public Health’s regional office shall be informed by telephone or fax, and Public Health shall be informed that an occurrence of potential abuse has been reported and is being investigated. A nurse’s note dated 2/25/2026 by an LPN documented that one resident (R5) had an alleged altercation with another resident (R2), but the note did not document any notification to the abuse coordinator. The Administrator later stated that he did not report the incident between these two residents because he was not aware of it and that staff should have reported it to him. The residents involved had known behavioral issues and cognitive impairments documented in their care plans and assessments. One resident (R2) had care plans initiated on 8/25/2025 and 3/2/2026 indicating problematic behavior characterized by ineffective coping, verbal and physical aggression related to cognitive impairment and physiological brain changes, and a potential to be physically aggressive related to anger, dementia, depression, history of harm to others, and poor impulse control. Staff interviews described this resident as verbally and sometimes physically aggressive, primarily toward staff, with attempts to become physical with other residents. The other resident (R5) had care plans initiated on 3/3/2026 documenting problematic behavior with verbal and physical aggression related to cognitive impairment, Alzheimer’s disease, mood disorder, vascular dementia, anxiety, and inability to differentiate others’ belongings, as well as hoarding and rummaging behaviors. A RN described this resident as usually angry and mostly verbally aggressive. Despite these documented behaviors and the alleged altercation between the two residents, the incident was not reported to the State Agency as required by facility policy.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.