Deficiencies per Year
4
3
2
1
0
Moderate
Inspection Report
Complaint Investigation
Deficiencies: 2
Jan 14, 2025
Visit Reason
The inspection was conducted as an investigation of facility reported incidents and allegations of employee to resident abuse.
Findings
The facility failed to report serious incidents/accidents to the Department within 24 hours for 2 of 4 residents reviewed, and failed to develop and submit a complete written report of an abuse allegation within the required timeframe. The facility's policies were not consistent with current state regulations, and key report elements were missing.
Complaint Details
The investigation was triggered by allegations of employee to resident abuse against resident R1. The allegation was not substantiated, but the facility failed to submit a complete written report with all required information within the regulatory timeframe.
Severity Breakdown
Type 3 Violation: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to submit serious incidents/accidents to the Department within 24 hours after occurrence for 2 of 4 residents reviewed. | Type 3 Violation |
| Failed to develop and submit a complete written report within 14 days and 24 hours after completion for an allegation of employee to resident abuse. | Type 3 Violation |
Report Facts
Residents reviewed for incident reporting: 4
Residents reviewed for abuse report: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| E1 | Executive Director | Interviewed regarding awareness of reporting regulations and plan to update policy |
| E2 | Resident Care Director | Interviewed regarding knowledge of reporting requirements; was not aware prior to 10/11/24 |
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