Health inspection·December 30, 2021

F 609 § 483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: § 483.12(c)(1) Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. § 483.12(c)(4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken. On 10/07/2021, the Department of Public Health (State Survey Agency [SSA]) made an unannounced visit to the facility to investigate a complaint related to quality of care. The facility failed to report to the SSA, the local Long-Term Care Ombudsman (assist residents in the long-term care facilities with issues related to day-to-day care, health, safety, and personal preferences), and local law enforcement an allegation of abuse Resident 1 made against a facility employee (unidentified). As a result, there was a delay in the SSA investigation and specifics of the alleged incident (date, time, staff involved) could not be obtained placing Resident 1 at risk for further abuse. A review of Resident 1's Admission Record indicated the facility re-admitted the resident on 9/8/2021 with diagnoses including kidney stones (hard, pebble-like pieces of material that form in one or both of your kidneys) and sepsis (the body's extreme response to an infection). A review of Resident 1's Minimum Data Set (MDS - a standardized assessment and care-screening tool) dated 7/21/2021 indicated Resident 1 had severely impaired cognition (when a person has trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life). Resident 1 required extensive assistance with two-person physical assist with bed mobility, dressing, toilet use, and personal hygiene. On 10/13/2021 at 12:50 p.m. during a telephone interview, Family Member 1 (FM 1) stated that sometime in 9/2021, Resident 1 told her that a staff pulled her necklace when she wanted to go back to bed. FM 1 stated that upon learning of the allegation, she immediately reported the allegation to the Administrator (ADM). On 10/21/2021 at 10:57 a.m. during an interview and concurrent review of the Abuse Prevention and Management policy, ADM confirmed FM 1 made him aware of Resident 1’s abuse allegation. ADM acknowledged he did not report the abuse allegation to the SSA, Ombudsman and law enforcement as indicated in the Abuse Prevention policy. A review of facility's policy and procedure titled, "Abuse Prevention and Management" with revised date of 7/2021, indicated that it is the policy of this facility that each resident has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion. The administrator is designated as the abuse prevention coordinator and each facility staff is considered as mandatory reporter who shall promptly report any incident of abuse to the appropriate agency which includes but not limited to the department of public health and to the ombudsman's office. The facility failed to report to the SSA, the local Long-Term Care Ombudsman, and local law enforcement an allegation of abuse Resident 1 made against a facility employee (unidentified). As a result, there was a delay in the SSA investigation and specifics of the alleged incident (date, time, staff involved) could not be obtained placing Resident 1 at risk for further abuse. The above violation had a direct relationship to the health, safety, and security of Resident 1.