Failure to Timely Report Injury of Unknown Origin and Staff–Resident Exploitation
Penalty
Summary
The deficiency involves the facility’s failure to timely report an injury of unknown origin for one resident. One resident reported left leg pain on January 14, 2026, was evaluated by the facility provider, and had an X-ray completed on January 15, 2026. The X-ray showed chronic fractures of the proximal tibia and fibula and a possible acute fracture of the distal fibula, with a recommendation for follow-up imaging or MRI. Facility administrative staff confirmed they were aware of the radiology findings on January 15, 2026, but review of the incident reporting log showed the report to the State Survey Agency was not submitted until January 19, 2026, four days after the facility became aware of the fractures. The DON acknowledged in interview that the reportable incident was reported late and that the facility delayed reporting while attempting to clarify whether the injury was pre-existing. The deficiency also involves the facility’s failure to timely report an incident of resident exploitation and an inappropriate staff–resident relationship. A resident reported to the Administrator that they had been in an on-and-off sexual relationship with a GNA for about a year, with sexual intercourse occurring on occasions, and that the GNA had requested approximately $400, which the resident stated was given willingly. The resident had a BIMS score of 15 and was deemed capable. Witness statements documented that one staff member was aware of an inappropriate personal relationship between the GNA and the resident as of December 22, 2025, and another LPN heard a rumor of the relationship about a week before January 1, 2026, but did not report it at that time. In interviews, the LPN stated she did not initially report the rumor because she believed the alert and oriented resident was in a consensual relationship, and the DON stated she believed the relationship was mutual and not coerced, while also acknowledging that staff are expected to maintain professional boundaries and not exchange money with residents.
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