Freedom from Abuse, Neglect, and Exploitation Deficiencies
Develop and implement policies and procedures to ensure (1) employees report any suspicion of a crime against any resident, according to timelines; (2) post the notice of employee rights; and (3) prohibit and prevent retaliation for reporting.
of F608 citations were written at actual harm or above. The mark is the share across all tags, 5.4%.
The harm level
How severely F608 is cited
12.5% of citations found actual harm or worse (level G and above).
Citations by CMS scope and severity. Rows are harm level, columns are how widespread the finding was.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
J26.3%
K26.3%
L—
Actual harm
G—
H—
I—
No harm, potential for more than minimal
D2268.8%
E412.5%
F—
No harm, potential for minimal
A—
B—
C26.3%
Every recorded F608 citation, by the harm level and scope the surveyor assigned.
In the surveyor’s words
What an F608 citation says
One finding from each severity level, most serious first.
Severity is as the surveyor wrote it. Some findings had already been corrected before the survey.
K · Immediate jeopardy, patternAugust 21, 2022
Based on interview, record review, and facility policy review, it was determined the facility failed to develop policies and procedures to ensure that reasonable suspicion of a crime against any resident was immediately reported to local law enforcement for four of five residents (R) (R#58, R#62, R#86, and R#277) reviewed for abuse. Specifically, the facility failed to ensure sexual assaults perpetrated by R#58 against R#62 and R#86 were reported to the police, and that an allegation of staff-to-resident abuse directed toward R#277 was reported to the police. Subsequently, the abuse continued. …
This citation pertains to intakes: MI 332 and MI 344:
Based on interview and record review, the facility failed to develop and implement policies and procedures to prevent abuse and neglect and report the reasonable suspicion of a crime according the the Elder Justice Act (EJA) for 2 residents (R 32 and R 119) reviewed for abuse, resulting a failure to thoroughly identify, protect residents, investigate, and report to the state agency and law enforcement allegations of abuse. This deficient practice has the potential to affect all vulnerable residents in this facility. …
D · No harm, potential for more than minimal, isolatedOctober 21, 2022
Based on interview and record review the facility failed to report an allegation of resident (R16) inappropriately touching resident (R10) to local law enforcement, affecting one resident (R10) out of 13 residents reviewed for abuse, resulting in R10's right to have an allegation of sexual abuse investigated by local law enforcement and the potential for feelings of helplessness.
Findings Include:
Record review of facility's documents titled Investigation of (R10) and (R16) dated 10/10/22 and Unusual Occurrence Report dated 10/10/22 revealed an allegation of R16 touching R10's penis and no documentation of local law enforcement being called and made aware of the sexual abuse allegation. …
C · No harm, potential for minimal, widespreadMarch 10, 2020
Based on observation, staff interview and facility document review, it was determined that the facility staff failed to post notice of employee rights regarding the reporting of suspicious crimes.
The findings include:
On 3/9/20 at 1:19 p.m., observation of the facility halls, lobby and employee only hall containing the employee break room and time clock was conducted. No posted notice of employee rights regarding the reporting of suspicious crimes was observed. On 3/9/20 at 1:29 p.m., observation of those same areas was conducted with ASM (administrative staff member) #1 (the executive director). ASM #1 could not locate the posted notice. …
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