Health inspection·March 13, 2025

REGULATION VIOLATION(S) 1418.91(a) A long-term health care facility shall report all incidents of alleged abuse or suspected abuse of a resident of the facility to the department immediately, or within 24 hours 1814.91(b) A failure to comply with the requirements of this section shall be a class "B" violation. The facility failed to report an allegation of abuse to the Department within the required timeframe. On 1/24/25 at 12:19 p.m., an unannounced visit was conducted at the facility to investigate a facility reported incident. A review of a facility document, dated 12/19/24 and received by the Department on 12/19/24, indicated it was a follow-up summary of a reported allegation of abuse related to an altercation between Resident 1 and Resident 2 which had occurred on 12/15/24. The facility failed to report this allegation of abuse to the department within 24 hours. During an interview, on 1/14/25 at 4:28 p.m., the Assistant Director of Nursing (ADON) stated it was the facility's policy to report an allegation of abuse to the Department within two hours. The ADON confirmed the allegation of abuse had not been reported to the Department within 24 hours. A review of a facility policy titled, "Abuse Prevention," revised 6/23, stipulated, "The allegation will be reported within two hours to the appropriate state agency, the Department of Health..." Therefore, the facility failed to report all incidents of alleged abuse or suspected abuse of a resident of the facility to the department immediately, or within 24 hours, including but not limited to failure to report an allegation of abuse within prescribed timeframes. This violation had a direct or immediate relationship to the health, safety, or security of patients or residents.