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.
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.
The facility did not report multiple incidents of unexplained injuries—including skin tears, hematomas, abrasions, and discolorations—affecting several cognitively impaired residents, as required by policy and state regulations. Despite documentation of these injuries and internal notifications, the incidents were not reported to the state agency, and the Administrator confirmed that such reporting did not occur.
A resident with severe cognitive impairment and multiple medical conditions was found with unexplained facial injuries, including scratches and discoloration. The injuries were not present the previous day and could not be explained by the resident or staff. Despite facility policy requiring immediate reporting of injuries of unknown origin to authorities, the incident was not reported as required.
Staff failed to report an allegation of sexual abuse involving a resident with severe cognitive impairment within the required two-hour timeframe. Multiple staff members became aware of the resident's and her family's concerns but did not notify administration or authorities as required by policy, resulting in a delay until the police informed the facility and an investigation was initiated.
A resident with severe cognitive impairment and total dependence on staff was found with a painful knot on the right thigh, later diagnosed as a comminuted and displaced femur fracture. Although the facility conducted an internal investigation and staff interviews, the injury of unknown origin was not reported to the state agency as required by policy.
A facility failed to report an allegation of abuse involving a resident with cognitive capacity and complex medical needs, after staff reported that a CNA had taken unauthorized photos of the resident and allegedly sent them to the ombudsman. The resident stated she did not consent to the photos, and the DON documented the resident's concerns. Despite these reports, the Administrator did not notify the State Survey Agency as required by policy.
A resident with cognitive impairment and multiple medical conditions developed unexplained bruising and a fractured right humerus after staff-assisted repositioning. The injury was not witnessed, and the cause was not documented at the time. Despite facility policy requiring immediate reporting of injuries of unknown origin, the incident was not reported to authorities. Leadership interviews confirmed the lack of reporting and absence of investigation documentation.
A resident with severe cognitive impairment and total care needs developed multiple bruises and bilateral femur fractures of unknown origin. Despite escalating pain, visible injuries, and family concerns, staff did not report the incident to state authorities within the required timeframe. The facility's investigation was incomplete, and the administrator did not consider the injuries to be of unknown origin, resulting in a failure to comply with abuse reporting regulations.
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