Failure to Timely Report Allegations of Resident-to-Resident Abuse: The facility did not report allegations of potential resident-to-resident abuse within the required timeframe for two separate incidents involving four residents. One report was sent 18 hours after the event, and another was not reported until 5 days later, despite the DON confirming the reports were not made within 2 hours of the facility becoming aware of the allegations.
Delayed reporting of abuse allegations: The facility failed to report multiple abuse allegations to the state agency within the required 2-hour timeframe. Incidents involved a resident-to-resident sexual contact allegation, a resident-to-resident physical contact allegation, a physical abuse allegation involving a resident and a CNA, a mental abuse allegation, and a verbal abuse allegation between roommates. The DON stated staff were expected to report allegations immediately, but the Administrator repeatedly said she believed allegations without harm could be reported within 24 hours.
Failure to Report Allegations of Abuse: The facility did not timely report allegations of abuse involving two residents. One resident with impaired communication and total ADL dependence was involved in an allegation that a CNA made inappropriate comments in front of the resident, which the DON later described as a customer service issue. Another cognitively intact resident with MS reported harsh care during bowel assistance by a CNA. The DON confirmed both allegations were not reported to the proper state entities as required by policy.
Failure to Timely Report Abuse Allegations and Investigation Results: The facility did not report resident-to-resident abuse allegations and investigation results within required timeframes for multiple incidents involving several residents. In one event, an LPN witnessed two residents in a physical and verbal altercation, with one resident pushing the other and both falling; the initial report to the state agency was submitted after the 2-hour window, and no 5-day follow-up was documented. The DON and Administrator stated reporting delays occurred because they were waiting for a response, had trouble uploading the report, or believed they had 24 hours to report when there was no harm.
Failure to Report Suspected Misappropriation: A cognitively intact resident reported that an unknown person opened accounts in her name without permission. The Administrator learned of the concern when police came to speak with the resident but did not report the suspected misappropriation to the state agency, stating the facility did not think the resident had anything to lose. The DON stated that suspected abuse, including misappropriation, would be expected to be reported in a timely manner, and the facility could not provide documentation that the allegation was reported to all required agencies.
The facility failed to report an allegation of staff-to-resident physical and verbal abuse to the state survey agency within the required two-hour timeframe. A resident with severe dementia, muscle weakness, and difficulty walking, who required two-person assistance for ADLs, became combative during perineal care, and multiple CNAs later reported that a CNA had roughly grabbed the resident’s arms, slammed the resident’s wrists onto the chest, used profanity, made threats, and stated the resident belonged in a psychiatric ward. These CNAs did not report their concerns immediately, and the allegation was not submitted to the state reporting agency until two days after the incident, contrary to facility policy and the expectations stated by the DON and ADM.
Failure to report suspected abuse related to unexplained bruising on a resident’s upper arm. The resident had severe cognitive impairment and total ADL dependence, and the facility policy required immediate reporting of suspected abuse or injuries of unknown origin. An LPN, the treatment nurse, and CNAs observed or were shown the bruising by the resident’s sister, but none reported it to the DON or other officials, and the Administrator was unaware of the concern until surveyor interview.
Delayed reporting of staff-to-resident abuse allegation. A resident with severe dementia and severe cognitive impairment was involved in an incident during shower care when the resident struck a CNA and the CNA struck the resident back. CNA staff did not report the allegation immediately, and the ADM and DON stated abuse was expected to be reported right away.
Failure to Report Alleged Verbal Abuse: A resident with dementia, severe cognitive impairment, prior stroke, and COPD was involved in an allegation that a CNA used profanity and yelled at the resident during care. An LPN was notified and informed the Administrator and DON, but the DON said the resident denied the incident and the facility did not treat it as abuse. The allegation was not reported to the State Agency, and there was no documentation of an investigation.
A resident with multiple medical conditions and intact cognition reported that a blonde CNA on night shift jerked off the resident’s brief and slapped the resident’s inner thigh and arm during care, later telling a PTA that the CNA was mean and that the resident did not feel safe. The PTA notified the UM, who informed the Administrator and DON and began an internal investigation, but the allegation was never reported to APS, the LTC Ombudsman, local law enforcement, or the state survey agency, and the required 5‑day follow‑up report was not completed, contrary to facility policy and federal reporting timeframes.
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