Based on interview and record review, conducted during a site visit on 03/12/24 and 03/13/24, it was confirmed the facility failed to immediately notify the local Department office, or the local AAA, of any incident of abuse or suspected abuse. Findings include, but are not limited to:

During an interview on 03/13/24, Staff 1 (ED) indicated, there had been a resident-to-resident altercation with Resident 1 and Resident 2 that had not been reported timely.  

A review of Resident 1's incident report for a resident-to-resident altercation which occurred on 12/28/23 had not been reported until 01/08/24.

A review of Resident 1's progress notes dated 12/20/23 through 01/09/24, indicated on 12/28/24. Resident 1 was on alert charting for a resident-to-resident altercation with Resident 2. On 01/09/24 a skin note indicated a purplish bruising on left eye as a possible result of altercation on 12/28/23.

A review of the med tech training manual indicated [When an unusual even such as falls, injuries, or altercations, occurs, the first responder must prepare an incident report. The MT was responsible for completing the action steps, including progress notes, IPS, alert charting, notifications, and adult protective services reporting.]

It was confirmed the facility failed to immediately notify the local Department office, or the local AAA, of any incident of abuse or suspected abuse.

On 03/13/24, the findings were reviewed with and acknowledged by Staff 1.

Verbal plan of correction: The facility is signed up to have training by APS on the 03/25/24.