F0609

D

Failure to Timely Report Allegations of Abuse and Neglect to State Agency

Saint Helens, Oregon Survey Completed on 03-10-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to timely report allegations of abuse and neglect to the State Agency as required. For one resident with an anoxic brain injury, severe cognitive impairment, and a BIMS score of 0, staff first noted swelling of the right knee on 10/11/25. An RN later observed significant bruising and swelling and ordered an x-ray, which identified a right knee fracture. The facility’s investigation concluded the injury was likely self-initiated from kicking the bed’s footboard, but the RN stated the resident did not know how the injury occurred and she did not believe it was self-inflicted. The DNS stated staff became aware of the knee swelling on 10/11/25, but administration did not report the incident until 10/13/25, and she acknowledged she was aware of the incident but had not reported it to the State Agency because staff failed to report it to management. An LPN confirmed she was initially made aware of the suspected injury on 10/11/25 and did not report it to administration, assuming the facility was already aware. The Administrator confirmed the facility did not report the incident within the required time.

The deficiency also includes a separate neglect allegation involving another resident with dementia, a BIMS score of 11 indicating moderate impairment, and dependence on toileting and personal hygiene. A facility-reported incident documented that on 3/15/25 a CNA allegedly failed to complete incontinence care for this resident throughout an eight-hour shift. The DON confirmed the facility reported this neglect allegation to the State Agency on 3/17/25, acknowledging it should have been reported within two hours. The Administrator also confirmed the facility did not report this neglect allegation within the required time frame.