Failure to Report Alleged Neglect After Improper Transfer Resulting in Femur Fracture
Summary
The deficiency involves the facility’s failure to immediately report an allegation of neglect related to a serious injury sustained by a resident during a transfer, as required by regulation and by the facility’s own abuse/neglect policy. The resident was an older female with a history of stroke and end-stage renal disease, with moderately impaired cognition (BIMS score of 10) but no diagnosis of dementia or Alzheimer’s disease, and no documented inattention, disorganized thinking, altered level of consciousness, or behavioral issues. Her MDS and care plan documented that she was non-ambulatory, used a wheelchair for mobility, did not attempt to stand due to medical/safety concerns, and required substantial/maximal assistance. The care plan specified that all transfers were to be done with a mechanical Hoyer lift and two or more staff due to impaired mobility. On the day of the incident, the resident was transferred from her bed to her wheelchair at the facility prior to going to dialysis. The resident later consistently reported to multiple individuals that facility aides had manually transferred her instead of using the Hoyer lift, and that her left leg became twisted between a staff member’s legs during the transfer, causing immediate severe pain. She stated she told staff at the time, saying she thought they had broken her leg, but she was nonetheless placed in the wheelchair, transported by van, and sent to dialysis. At the dialysis center, multiple dialysis staff (RN, tech, nurse manager, and case manager) observed the resident crying in severe pain, unable to move her leg, and still sitting in her wheelchair with a Hoyer sling under her. The resident told them that nursing home staff had twisted her leg during the transfer to the wheelchair and that she had reported her pain to facility staff before being sent to dialysis. Dialysis staff did not transfer her to a dialysis chair due to her pain and arranged for EMS transport to the hospital. Hospital records documented an acute comminuted fracture of the distal left femur, with the admission assessment noting that the patient’s leg had twisted during a transfer and that she had not fallen. Facility nursing notes show that the DON and LVN C were informed by hospital staff that the resident had a femur fracture and that the injury was reported as occurring during transfer at the dialysis center. The DON later documented a late entry describing a call from the dialysis RN about the resident’s complaints of leg pain and transfer to the hospital. Interviews with facility staff revealed that the resident was known to require a Hoyer lift for all transfers, that the Hoyer lift was reportedly broken that day, and that multiple CNAs manually transferred the resident using a sling and/or drawsheet. One CNA acknowledged assisting with the transfer and hearing the resident complain of leg pain afterward but did not report this to a nurse, assuming the primary aides would do so. Other CNAs gave conflicting or limited recollections of the transfer. Despite the resident’s repeated statements to dialysis staff and to her family that the injury occurred during a manual transfer at the facility, the Administrator stated the incident was not reportable because it was believed to have occurred at the dialysis center, and the facility did not report the allegation of neglect to the State Survey Agency as required by policy and regulation. The facility’s written policy on Abuse, Neglect, and Exploitation required that all staff ensure alleged violations involving abuse, neglect, exploitation, mistreatment, injuries of unknown source, and misappropriation of resident property are reported to the Administrator (Abuse Coordinator), that the Abuse Coordinator initiate an investigation, and that reportable allegations be reported to the State Regulatory Agency. The report shows that the DON was informed of the resident’s severe leg pain and subsequent hospital transfer, and that the resident’s statements to dialysis staff implicated facility staff in twisting her leg during transfer. However, the DON did not contact the dialysis center to clarify events, relied on staff statements that “nothing happened,” and concluded there was no incident at the facility. The Administrator similarly concluded the event was not reportable because they believed it occurred at the dialysis center. As a result, the allegation of neglect—specifically, failure to follow the resident’s care plan requiring Hoyer lift transfers and the resident’s report that staff twisted her leg during a manual transfer—was not reported to the State Survey Agency within the required timeframe, constituting the cited deficiency.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A resident exited the building through a bedroom window, walked off the property, and was observed and redirected by staff with assistance from law enforcement, who encountered the resident down the road and helped escort the resident back. The facility’s internal documentation lacked staff or witness statements and characterized the event as the resident remaining on facility grounds without injury. Despite the resident’s account, a police report, and a maintenance staff report confirming that the resident left the premises and that law enforcement responded, the DON did not report the incident to required state and federal agencies, even though the DON acknowledged that any incident involving law enforcement response must be reported.
Failure to timely report alleged verbal abuse: A volunteer reported that an activities staff member yelled at a resident during bingo, told the resident to stop interrupting, and also yelled at the volunteer when she intervened. The resident later described the staff member as rude and said the comment made him/her angry. Survey review found no evidence the allegation was reported, and the RCD confirmed the facility had no evidence of reporting despite policy requiring immediate reporting of abuse allegations.
The facility failed to ensure that alleged abuse and serious injuries were reported to the State Survey Agency as required, instead either reporting only to a state patient safety system or not reporting at all. One resident with severe cognitive impairment sustained bilateral femur fractures after a fall, another cognitively impaired resident with Parkinson’s disease was later found to have a femur fracture after being discovered on the floor, and a third cognitively impaired resident required ORIF surgery for fractures following a fall; none of these incidents were reported through the State Survey Agency’s incident reporting website, per the ADM. In addition, an allegation that a resident with dementia and sensory impairments may have been molested was documented in the abuse binder but not in the medical record, and the ADM did not report the allegation to agencies or law enforcement after deeming it not credible, despite interviewing the resident and family. These actions and omissions resulted in multiple unreported events that met criteria for immediate reporting of alleged abuse and injuries of unknown source.
The facility failed to timely complete and document the results of an abuse investigation after a resident with TBI, anxiety, and mild neurocognitive disorder became increasingly agitated, allegedly attacked staff, and was subsequently taken to the floor by a nurse, resulting in severe left hip pain with leg shortening and external rotation and transfer to the ED. Although an event report was submitted to the State Agency, the investigation report produced later lacked the required PB-22 and did not include the outcome of the investigation, and the DON confirmed the investigation remained incomplete beyond the required timeframe.
A resident with altered mental status developed bilateral wrist discoloration and swelling during ADL care when a CNA reported the resident was resisting and bumped both wrists against a wheelchair during transfer. An RN completed an incident report and nursing note documenting the injury, assessment, and physician notification with an order for x-ray. Facility leadership later acknowledged that this event, which met their policy criteria for an allegation requiring reporting within two hours if involving abuse or serious bodily injury, was not reported to the state survey agency, contrary to the facility’s written abuse, neglect, and exploitation policy.
The facility failed to report an allegation of physical abuse to law enforcement as required by its abuse reporting policy. A cognitively intact resident with dementia, anxiety, bipolar disorder, and major depressive disorder reported refusing a shower when a NA placed a lift sling under them, after which the situation escalated and both the resident and the NA exchanged punches. Skin assessments documented multiple new bruises on both of the resident’s arms and hands that were not present the prior day. Although facility policy required timely notification of law enforcement for such allegations, documentation in the abuse report form and EHR showed no law enforcement notification, and facility leadership confirmed that the incident and bruising were not reported to police.
Failure to Report Elopement Incident Involving Law Enforcement
Penalty
Summary
The deficiency involves the facility’s failure to report an elopement incident to required state and federal agencies as mandated by 42 CFR 483.12(c). On the referenced date, Resident #5 exited the building through his bedroom window around 12:15 PM and walked across the facility property toward the perimeter fence. A CNA observed the resident outside and called for assistance, after which staff redirected and escorted the resident back into the building and placed him on one-to-one supervision. The facility’s internal incident documentation noted the window exit and subsequent maintenance inspection of the window seals but did not include any staff or witness statements. The DON later stated that the resident never left facility grounds and was returned without injury, and therefore the incident was not considered reportable. However, interviews and external records showed that the resident did leave the facility premises and that law enforcement was involved. Resident #5 recalled being outside the facility, being brought back by staff and a “police man,” and being told by the officer not to leave again. A police report from the local police department confirmed an encounter with the resident outside the facility and that an officer assisted staff in escorting him back. Maintenance staff (Staff G) also reported that the resident climbed out the window, left the facility property, and was stopped “down the road,” then redirected back with law enforcement assistance. In interviews, the DON initially denied that law enforcement had been notified or involved, then later acknowledged that law enforcement had responded but asserted they did not come into the facility. The DON also confirmed awareness that any incident in which law enforcement investigates or responds is required to be reported, yet the elopement and law enforcement involvement were not reported to the State Survey Agency or other required officials within the required time frames.
Failure to Timely Report Alleged Verbal Abuse
Penalty
Summary
The facility failed to ensure an allegation of verbal abuse was reported timely for resident #55. A volunteer submitted a grievance stating that during bingo on 2/14/26, activities staff member #1 yelled at resident #55 after the resident called out bingo and told the resident to stop interrupting while she was talking. The volunteer reported that the staff member continued yelling for a couple of minutes, and when the volunteer intervened and told the staff member to stop yelling at the resident, the staff member yelled at the volunteer as well. The grievance also stated that two residents, including resident #55 and resident #66, reported that the activities staff member yells at them all the time and speaks to them the same way every time they play bingo. Resident #55 later stated that the issue involved the activities staff member being rude during bingo and saying, in a smart-ass way, "weren't you paying attention?" The resident said the comment made him/her angry and that [he/she] called the staff member names. The volunteer confirmed hearing the staff member speak loudly and rudely to the resident and then yell at the volunteer before storming off. Review of the state survey agency incident database showed no evidence the allegation was reported, and the regional clinical director confirmed the facility had no evidence the verbal abuse allegation was reported. The facility policy required alleged abuse to be reported to the Administrator, state agency, adult protective services, and other required agencies within specified timeframes, immediately but no later than 2 hours when the allegation involved abuse or serious bodily injury.
Failure to Report Alleged Abuse and Serious Injuries to State Survey Agency
Penalty
Summary
The deficiency involves the facility’s failure to ensure that all alleged violations of abuse, including injuries of unknown source and incidents involving major injuries, were reported immediately to the State Survey Agency and other officials as required by state law. For four sampled residents, the Administrator acknowledged that incidents were reported only to the state’s patient safety website and not to the State Survey Agency’s incident reporting website. This omission meant that the State Survey Agency did not receive timely notice of serious events, including an allegation of sexual abuse and multiple incidents resulting in significant fractures and surgery. For one resident with severely impaired cognition and diagnoses including hemiplegia and hemiparesis, nursing notes documented that the resident was found on the floor after attempting to get out of bed, was sent to the ER, and returned with immobilizing braces on both legs due to bilateral femur fractures. The resident’s bones were not strong enough for surgery, and he was placed on comfort care. Despite the seriousness of the injuries and the requirement to treat such events as potential abuse or neglect until ruled out, the Administrator stated that this incident was reported only to the state’s patient safety website and not to the State Survey Agency’s incident reporting system. Another resident with Parkinson’s disease and severely impaired cognition was found on the floor after a wheelchair alarm sounded, initially with no visible injury and able to bear weight. A few days later, staff documented complaints of left leg pain, tenderness, and wincing with movement, leading to an order for x‑rays and transfer for imaging. X‑ray results revealed a femur fracture, and surgery was not pursued. The Administrator reported this incident to the state’s patient safety website but not to the State Survey Agency’s incident reporting website. A third resident with severe cognitive impairment experienced a fall with complaints of pain in the left knee, left elbow, and fingers, and later underwent ORIF surgery for fractures of the right fourth and fifth metacarpals; this incident also was not reported to the State Survey Agency’s incident reporting system, according to the Administrator. For another resident with dementia, adjustment disorder with anxiety, hearing and visual loss, and age‑related debility, a document in the facility’s abuse binder described a possible molestation allegation originating from a phone call by the resident’s nephew. The nephew reported that his mother, the resident’s sister and then‑POA, was emotionally unstable and had stated she felt the resident had reported being molested. The Administrator documented that the nephew did not believe the allegation was credible, that the sister had dementia and emotional issues, and that the Administrator considered the report “not a viable allegation.” The Administrator noted that he interviewed the resident, who denied being touched, and that the sister could not provide more details beyond stating that a man had groped the resident’s breast. The Administrator concluded the allegation was not credible and did not report it to any agencies or law enforcement. The incident was not documented in the resident’s medical record, and the Administrator confirmed in interview that he did not report this sexual abuse allegation to the State Survey Agency’s incident reporting website. Across these four residents, the common deficiency was the facility’s failure to treat serious injuries and a sexual abuse allegation as reportable events to the State Survey Agency, as required. Instead, the Administrator limited reporting to the state’s patient safety website or chose not to report at all when he personally judged an allegation as not credible. This pattern of inaction regarding mandated reporting requirements formed the basis of the cited deficiency.
Failure to Timely Complete Abuse Investigation After Staff–Resident Altercation With Serious Injury
Penalty
Summary
The deficiency involves the facility’s failure to timely complete and report an investigative report for an allegation of physical abuse resulting in serious bodily injury. Facility policy on Reporting Unusual Occurrences requires that suspected, alleged, or actual abuse, neglect, misappropriation of resident property, fractures, incidents requiring transfer for medical evaluation, and staff-to-resident altercations be reported to appropriate agencies, with a written report forwarded within five working days. Federal regulation at 42 CFR §483.12(c)(4) similarly requires that, at the conclusion of the investigation and no later than five working days of the incident, the facility must report the results of the investigation. The facility’s Abuse policy states that each resident has the right to be free from abuse, including infliction of injury with resulting physical harm, pain, or mental anguish. Clinical record review showed that the resident had diagnoses including traumatic brain injury, anxiety, and mild neurocognitive disorder with behavioral disturbance. A nursing progress note documented that supervisors were urgently called to a unit for a resident attacking staff; upon arrival, the resident was found lying on his right side, screaming, and complaining of left hip pain. The resident stated that a staff member had “tackled” him and that he had intended to “knock his ass out.” Witness accounts indicated the resident had increasing agitation and attempted to punch the nurse and nurse aides; the nurse reported that when the resident swung at him, he grabbed the resident’s arm/shoulder and took him down to the floor. The resident had 10/10 left hip pain with left leg shortening and external rotation, and the physician ordered transfer to a local emergency room. An event report was submitted to the State Agency the following morning, but the facility’s investigation report produced a week later did not include a PB-22 or the outcome of the investigation. In an interview, the DON confirmed the investigation was not complete and acknowledged the facility failed to timely complete the investigative report for this allegation of physical abuse with serious bodily injury.
Failure to Timely Report Allegation of Potential Abuse-Related Injury
Penalty
Summary
The facility failed to timely report an allegation of potential abuse related to an injury sustained by Resident 94 during ADL care. Resident 94, who had a diagnosis including altered mental status, was admitted on an unspecified date and later developed discoloration and swelling of both wrists during clothing changes and transfer by a CNA. An incident report dated 03/20/25 at 9:45 PM, written by an RN, documented that the CNA reported the resident developed bilateral wrist discoloration during ADL care while the resident was resisting, and that the resident bumped both wrists against the wheelchair during transfer. The RN’s documentation noted assessment of the resident’s wrists, presence of discoloration and swelling, and that the physician was notified and ordered an x-ray to rule out fracture, with ice applied to the affected areas. Interviews with facility leadership confirmed that this incident was not reported to the state survey agency (SSA). The CEO stated that the incident from 03/20/25 was not reported to the SSA. The Administrator, who was the DON at the time of the incident, stated that the facility’s practice was to report all allegations of abuse or injury of unknown origin within two hours, but acknowledged that this allegation was not reported because they determined it was not an injury of unknown origin or abuse. Review of the facility’s Abuse, Neglect and Exploitation policy, revised 11/2021, showed a requirement to report all alleged violations to the Administrator, state agency, adult protective services, and other required agencies within specified timeframes, including immediately but not later than two hours after the allegation is made if the events involve abuse or result in serious bodily injury.
Failure to Report Alleged Physical Abuse and Resulting Bruising to Law Enforcement
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of physical abuse to law enforcement within the required timeframe. Facility policy, revised 08/08/2024, required the administrator or designee to notify multiple entities, including law enforcement, no later than two hours after an allegation involving serious bodily injury or within 24 hours if there was no serious bodily injury. The policy also specified notification of the state licensing authority, Ombudsman, resident representative, APS, the resident’s attending physician, and the facility medical director. Despite this written requirement, documentation showed that law enforcement was not notified following an allegation of physical abuse involving a resident. The resident involved had been admitted in 2019 and had diagnoses including moderate vascular dementia with agitation, generalized anxiety disorder, bipolar disorder, and major depressive disorder. A recent MDS showed a BIMS score of 15, indicating the resident was cognitively intact, and noted episodes of care rejection but no documented physical behavioral symptoms toward others. On the date of the incident, a NA entered the resident’s room, placed a lift sling under the resident, and informed the resident they would be taking a shower; the resident reported refusing the bath and stated that the situation escalated into both the resident and the NA exchanging punches. Subsequent skin assessments documented multiple bruises on both upper extremities that were not present the day before. A Potential Resident Abuse Report Form and the EHR contained no evidence that law enforcement was notified, and both the Administrator and Social Services Supervisor confirmed in interviews that the allegation of physical abuse and associated bruising were not reported to law enforcement, contrary to facility policy and reporting requirements.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
