A cognitively intact resident with multiple medical conditions allegedly experienced abuse involving someone placing a pillow over the face with a sour substance. A complainant reported this allegation by phone to the Social Services Director, who, contrary to facility policy and staff expectations, did not notify the SA, APS, Ombudsman, or the Administrator because she did not believe abuse had occurred based on the medical record. Other staff, including a CNA, an LPN, the DON, and the Administrator, reported that their understanding of policy was that all abuse allegations must be reported within specified time frames, but they were not informed of this allegation, and no self-report was made to state agencies.
A resident with severe cognitive impairment and multiple medical conditions had a missing wallet, bank card, and cash, and the resident’s son reported unexplained recurring financial charges. The son informed Social Services of these concerns, and Social Services contacted the Business Office and discussed the issue with the interdisciplinary team, while the son planned to cancel the card. Although APS was eventually contacted and the facility assisted with canceling the card, there was no documentation in progress notes or grievance logs of the initial allegation, and no evidence that the state agency or the Administrator were notified when the concern was first reported, contrary to facility policy requiring immediate reporting of suspected misappropriation to the Administrator and appropriate state agencies.
The deficiency centers on the facility’s failure to recognize and report an incident of sexual abuse involving a minor resident and an adult resident in accordance with federal requirements. An LPN discovered the two residents in another resident’s bathroom in a position consistent with oral sex, and both residents later described a sexual encounter that was interrupted by staff. Although the facility knew one resident was a minor and the other an adult with serious mental illness, its initial and 5‑day reports characterized the event as a consensual encounter between cognitively intact individuals, omitted the minor’s status, and did not classify the incident as sexual abuse. The incident was reported to police nearly a day after it occurred, was not reported by the facility to child protective authorities, and the internal investigation lacked key details and documentation, leading to a cited failure to properly identify, document, and report the abuse and to assess and monitor other residents at risk.
A resident with multiple neurologic and medical conditions, but intact cognition, reported feeling neglected after being left in a wet brief for several hours and requested that law enforcement be called. The resident’s wife alleged that an RN and CNA provided rough incontinence care after a urinal spill, ignored the resident’s pleas to stop, then ignored him for the rest of the night and left his bed remote out of reach; she stated that police reports were filed for two separate incidents and that the later allegation was not reported to any state agency. The Executive Director documented the concern, interviewed the resident and his wife, obtained staff statements, and concluded that care had been provided, deciding not to report the later allegation to the State Survey Agency, APS, or other required officials. This decision conflicted with facility policy, which required that all alleged violations of abuse or neglect, whether or not explicitly labeled as such and regardless of conflicting accounts, be reported within specified timeframes to the administrator and appropriate state authorities.
Surveyors found that the facility lacked required clinical and investigation records for multiple residents involved in alleged abuse, resident‑to‑resident altercations, and misappropriation of property. For several residents with dementia, psychiatric disorders, traumatic brain injury, and other comorbidities, there were no care plans, nursing progress notes, MDS assessments, or 5‑day investigation reports covering the time of the alleged incidents. In some cases, the facility’s EHR contained no record of the alleged victim or alleged perpetrator, and staff stated that records for residents and incidents occurring before a change of ownership were not available, despite policies requiring long‑term retention of health records and abuse investigations and immediate reporting of all allegations to the Administrator and state and federal agencies.
A resident with multiple chronic conditions and intact cognition repeatedly alleged neglect, racial mistreatment, and mental abuse by staff, including not receiving medications as expected and feeling demeaned by an LPN. These concerns were reported by CNAs and an LPN up the chain of command to the DON, ADON, and Administrator, and the DON acknowledged being aware of at least one allegation and discussing it with others. However, the facility did not document these discussions, did not report several oral allegations of abuse and neglect to the state agency as required, and leadership determined the concerns did not meet their understanding of abuse or neglect despite facility policies mandating immediate reporting of all alleged violations to appropriate authorities.
A resident with right-sided hemiplegia, contractures, and a documented need for two-person Hoyer lift transfers reported right shoulder pain, which led to imaging that showed a moderately displaced comminuted fracture of the surgical neck of the humerus. Staff interviews indicated the resident was always a two-person Hoyer lift transfer, while the resident later alleged that a CNA had manually lifted her from wheelchair to bed, during which she heard a crack and felt pain, and that she reported this pain and bruising to a CNA, an LPN, and the DON. The DON confirmed the resident reported shoulder pain and an incorrect transfer and that an investigation was initiated, but the DON did not notify the state agency, APS, Ombudsman, or police as required by facility policy for alleged abuse or serious bodily injury, delaying the report to the state agency until 26 days after the fracture was identified and only after APS contacted the facility.
A resident with dementia, severe to moderate cognitive impairment, and multiple comorbidities had a care plan addressing impaired cognition and communication. A CNA observed the resident’s friend assisting with feeding and flicking the resident’s nose in an aggressive manner, then yelling at the CNA when redirected. The CNA reported the incident to an RN, who reported it to the DON; the DON and the Administrator/Abuse Coordinator decided not to treat the event as abuse and did not report it to state or federal agencies or law enforcement, despite facility policy requiring reporting of such allegations involving visitors. No documentation of reporting or a grievance related to the incident was found in the record or grievance log.
A cognitively intact resident with multiple medical conditions reported that an unknown male staff member inappropriately touched her breasts and genitals during the night prior to her hospital transfer. While hospitalized, the resident disclosed the alleged sexual assault to law enforcement, and a sheriff's deputy later informed facility staff that the resident had accused a tall Hispanic male of assault on the night of her fall, though he noted inconsistencies and altered mental status. Facility leadership, including the administrator/abuse coordinator and the DON, were aware of the concerns and of regulatory requirements and facility policy mandating that abuse allegations be reported to the state agency within two hours, but the allegation was not reported within the required timeframe.
A cognitively impaired resident with dementia and behavioral symptoms was allegedly abused during a night shift, but the LPN who witnessed the incident did not report it to the administrator before going home, later citing shock and misunderstanding of the reporting timeframe. The allegation was reported to the administrator the following afternoon, rather than immediately, despite regular abuse training and a facility policy requiring immediate reporting of suspected abuse to the administrator or designee and prompt notification of the State Agency.
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