Deficiency Summary  

The facility received a deficiency for W154 §483.420(d)(3), Staff Treatment of Clients.

The facility must have evidence that all alleged violations are thoroughly investigated.

This requirement was not met as evidenced by:

Based on interviews and record reviews, the facility failed to ensure that the documentation of facility investigation reports reflected that all serious injuries of unknown origin were thoroughly investigated for 9 of 11 reported serious injuries of unknown origin involving seven individuals (Individuals # 14, 38, 44, 45, 49, 56, and 69).

The facility failed to ensure that the documentation of incident reports reflected that all non-serious injuries of unknown origin were thoroughly investigated for 88 of 105 reported injuries of unknown origin involving 66 individuals.