Failure to Report Alleged Abuse and Possible Mistreatment to Law Enforcement
Penalty
Summary
The deficiency involves the facility’s failure to report allegations of staff-to-resident abuse and possible mistreatment to local law enforcement as required. In the first incident, the facility became aware on 08/20/25 at 2:30 p.m. of an allegation that a staff member had physically abused a resident. The allegation was reported to the facility by a construction company foreman who stated that one of the construction staff had witnessed a staff member hitting the resident in the head sometime during the previous week. The foreman later documented in an email that on 08/20/25 at 2:25 p.m. they heard crying and pleas for help, along with noises resembling slapping, coming from the resident’s room and felt strongly that someone in the room was being assaulted. At 2:50 p.m. that same day, the foreman reported what they heard and what had been reported to them earlier to a facility staff member in the parking lot. Despite this information, the allegation of staff-to-resident physical abuse was not reported to local law enforcement. In the second incident, the facility became aware on 07/11/25 at 9:27 p.m. that another resident had sustained a fractured right distal femur, identified as an injury of unknown source and reported as a possible mistreatment incident. This resident had vascular dementia, glaucoma, a history of bilateral knee replacements, and had been deemed incapable of making medical decisions by two physicians in November 2022. The resident was unable to provide any information about when or how the fracture occurred. The facility’s investigation documented the injury as an injury of unknown source and an allegation of possible mistreatment; however, the local police were not notified. During an interview on 03/30/26 at 2:10 p.m., the DON confirmed that the facility did not report either of these allegations to the local police.
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