Failure to Protect Resident from Physical Abuse
Summary
The facility failed to protect a resident's right to be free from physical abuse when a nurse aide (NA) punched a resident in the face. The incident occurred when the NA was providing care, and the resident, who had severe cognitive impairment and was dependent on staff for various activities, became combative. The NA responded by pushing the resident, causing the resident to hit his head on the bed rail, resulting in significant injuries including fractures to the nasal bone, maxillary sinus wall, maxilla, and orbital rim. The resident was later found with blood on his face and was sent to the emergency department for evaluation, where the extent of the injuries was confirmed through a CT scan. The resident required surgical intervention for the injuries sustained during the incident. The initial response from the facility staff included cleaning the resident's injuries and contacting the Director of Nursing (DON) and the Administrator. The DON and Administrator initially suspected that the injuries were the result of an unwitnessed fall. However, further investigation revealed inconsistencies in the accounts provided by the staff. The NA initially lied about the incident but later admitted to pushing the resident during a polygraph test conducted by law enforcement. The NA was subsequently terminated from employment. Interviews with other staff members and the resident's family indicated that the resident's injuries were not consistent with a fall. The family member expressed concerns about the explanation provided by the facility and contacted law enforcement, leading to an investigation. The law enforcement detective's investigation, including a failed polygraph test and a confession from the NA, confirmed that the resident had been physically abused. The facility's initial handling of the incident, including the delay in sending the resident to the hospital and the failure to immediately recognize the abuse, contributed to the deficiency.
Removal Plan
- The facility initiated an investigation of the incident and suspected the injury occurred from Resident #1 attempting to self-transfer resulting in an unwitnessed fall.
- Nurse Aides (NAs) were interviewed including NA #1 and revealed Resident #1 was last seen by NA#1 and he was in bed with no concerns noted.
- The Administrator and Director of Nursing met with Resident #1's family member to discuss the incident. Per Administrator and Director of Nursing report, Resident #1's family member stated that she called the police per instruction from another family member. She stated she had no specific complaints or allegations with specific person but thought the police could investigate to find the cause of the injury. The Administrator and Director of Nursing stated during the meeting that they suspected that resident sustained an unwitnessed fall while trying to get into bed, resulting in documented injury.
- Two employees from Adult Protective Services (APS) entered the facility and interviewed the Administrator and Director of Nursing regarding Resident #1. Health care records for Resident #1 were provided per request. The APS employees visited Resident #1 in his room and exited the building with no allegation or concern of abuse made.
- A Detective with the police department arrived at the facility to begin investigation on the report filed. Several staff members were interviewed in-person and via telephone by the Detective at this time. The Detective indicated to the Administrator that he was just investigating the incident and did not indicate abuse had been alleged.
- The Detective entered the facility to further interview Nurse Aide (NA) #1, NA #1 was the last one to provide care to Resident #1 before NA #2 found him with injuries.
- The Detective informed the Administrator there were inconsistencies regarding his investigation. Upon the Detectives exit, the Regional Operator put in a call to the Detective to try and obtain further detail as to what was being alleged. It was reported they were investigating abuse per what was reported from Resident#1's family member to the police. Nurse Aide #1 was suspended pending investigation. The facility began abuse investigation and submitted 24-hour report to DHSR. Resident's responsible party, law enforcement, Ombudsman and Adult Protective Services were notified that facility investigation of abuse was initiated.
- The facility was notified that during Nurse Aide#1's voluntary polygraph test he told the detective he pushed Resident #1 when he became combative during care. Nurse Aide #1 was terminated effective and was interviewed during a call with Administrator to notify of termination. During interview with NA#1, he stated, I went in to change Resident#1 and he was already in bed. He lunged at me, and I pushed him back and he hit the bed rail. He had one little skin tear with a small amount of blood, and I wiped it with a paper towel. He appeared fine and I left the room.
- Facility abuse investigation continues. Staff interviews were conducted. They were asked if they were aware of any abuse, neglect or exploitation of residents and if they were aware of any concerns related to abuse. Staff working on Resident #1's unit (B Hall) provided written statements regarding this allegation and day.
- A 5-day investigation report was made to DHSR which included the facility investigation.
- All residents with a Brief Interview of Mental Status (BIMS) of 12 or above were interviewed by the Administrator or designee to determine if they have experienced any type of resident abuse or were fearful in any way. No concerns were found.
- An audit consisting of thorough skin assessment of all residents with a BIMS of 11 or less was completed by licensed nurses to determine if there is evidence of abuse. No concerns were found.
- An ad hoc Quality Assurance (QA) meeting was held to discuss the deficient practice and to initiate a plan of correction and education for staff regarding abuse and neglect, audits and inclusion in QA.
- Education was provided to the Administrator and the Assistant Director of Nursing by the Regional Operations Manager, regarding the definition of abuse as defined in the abuse policy and the resident's right to be free from abuse.
- After being reeducated as outlined above, education for all staff was completed in person and via phone by the Administrator or designee. The education consisted of the following: The definition of abuse, neglect and misappropriation of property and the need to immediately notify the Administrator or Director of Nursing of all issues related to these infractions. If Administrator or Director of Nursing are not present in the facility, supervisors must be notified, and they must inform the Administrator or Director of Nursing immediately in person or by phone.
- Signs and symptoms of abuse and mental anguish such as loss of interest, change in routine, mood alterations, or difficulty eating.
- Our facility does not condone and has zero tolerance for resident abuse by anyone, including staff members, physicians, consultants, volunteers, staff of other agencies serving the resident, family members, legal guardians, sponsors, other residents, friends, or other individuals.
- The education focused on tactics to deal with difficult residents such as walking away to allow for de-escalation, providing time/place orientation, using a soothing tone of voice, providing gentle tactile cueing, use of gestures, offering distractions, and seeking assistance from other staff members.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A facility failed to protect two residents with severe cognitive impairment from sexual abuse by not completing a comprehensive assessment of each resident’s capacity to consent after repeated sexual encounters were discovered. Staff found the residents together in bed or in the bathroom, often unclothed, and allowed privacy based on their behavior without documenting a structured consent assessment. The facility also did not fully investigate unexplained bruising and reported vaginal bleeding for one resident in the setting of the known relationship, and the MD was not notified of the incidents or injuries.
Failure to protect a resident from resident-to-resident physical abuse: one resident entered another resident’s area, got into her belongings, and then grabbed, hit, and scratched her left wrist/hand, causing a skin tear, bruise, swelling, and pain. The injured resident said she was afraid of the other resident, while staff heard yelling, found both residents in the room, separated them, and documented the wound and bruising. The other resident had dementia with behavioral disturbance and used a walker and wheelchair.
Failure to protect a resident from resident-to-resident abuse: a resident with PTSD and a long history of physical and sexual abuse reported another resident repeatedly entered their room at night, then later exposed himself, blocked the resident from leaving, and used meth in front of them. The record lacked an investigation, trauma assessment, psychosocial monitoring, and documented behavior-based monitoring for the other resident, and staff interviews confirmed the concerns were not fully addressed in the chart.
A resident with dementia, CKD, HF, and severe cognitive impairment was involved in a physical abuse allegation when a CNA struck or batted his arm/hand during care after he grabbed at staff. A witness reported that the CNA hit the resident hard and yelled at him, while the CNA said she only tapped his hand away and did not consider it abusive. The resident could not answer questions about the event, and the facility’s records showed the allegation was not promptly escalated through the abuse reporting chain.
A resident with impaired cognition, stroke-related deficits, and constipation was subjected to manual stool removal by an LPN after a suppository did not work. Staff interviews and the resident’s statements indicated she said stop and begged the LPN to stop while he continued the procedure, and she later described the care as painful, violating, and demeaning. The LPN said he manually removed the stool in the bathroom, did not complete an abdominal assessment, and did not contact the provider for further direction.
A resident with CKD, CHF, ESRD, DM, and multiple foot wounds did not receive ordered daily wound care, and the TAR and progress notes lacked documentation that the treatments were completed on multiple occasions. The resident was later hospitalized for worsening wound infection, with purulent drainage and concern for osteomyelitis; the wound care provider also reported concerns that ordered dressing changes were not being done and noted worsening skin breakdown to the buttocks.
Failure to Assess Consent and Investigate Injury With Resident Sexual Activity
Penalty
Summary
The facility failed to protect two cognitively impaired residents from sexual abuse by not completing a comprehensive assessment of each resident’s capacity to consent to sexual activity after becoming aware that they were engaging in sexual contact. One resident had diagnoses including Alzheimer’s disease, neurocognitive disorder with Lewy bodies, dementia, and anxiety, with documentation showing severe cognitive impairment, wandering, hallucinations, confusion, and inability to consistently orient to time or place. The other resident also had diagnoses including Alzheimer’s disease and dementia with psychotic disturbance, with repeated BIMS scores showing severe cognitive impairment and care plan documentation noting cognitive loss and a history of wandering and checking doors. The record showed repeated incidents in which the two residents were found together in bed or in the bathroom, often unclothed, and staff documented that they appeared calm or did not show obvious distress. Staff notes and interviews showed that the residents were allowed privacy and continued access to each other without documentation of a formal assessment of whether either resident understood the nature of the relationship or could knowingly and voluntarily consent. Staff interviews also reflected that they relied on the residents’ behavior, such as whether they pushed away or said no, rather than documenting a structured assessment of capacity after each incident. The facility also failed to investigate unexplained bruising and reported vaginal bleeding for one resident in the context of the known sexual activity. The record documented bruises on the forearms and thigh in various stages of healing, along with a report of bloody vaginal discharge, but there was no evidence of a physical assessment or investigation to determine whether the findings were related to abuse, coercion, trauma, or another cause. Interviews with the RN, LPN, DON, MD, and family showed that the physician had not been notified of the sexual incidents, the bruising, or the vaginal bleeding, and that staff had not documented a formal assessment after the incidents.
Failure to Protect Resident from Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect a resident from resident-to-resident physical abuse when one resident attacked another during the night, causing a skin tear to the left wrist, bruising to the left thumb, swelling, pain, and fear for safety. The injured resident was admitted with diagnoses including type 2 diabetes mellitus, unsteadiness on feet, need for assistance with personal care, and muscle weakness, and had a BIMS score of 15/15 indicating cognitive intactness. The other resident involved had diagnoses including type 2 diabetes mellitus, dementia with other behavioral disturbance, and essential hypertension, and used a walker and wheelchair for locomotion. According to the injured resident, she returned from the bathroom and found the other resident in her area getting into her refrigerator. When she told the other resident to get out of her things, the other resident became angry, grabbed her left wrist, hit her left hand, and scratched her, causing the injury. The injured resident stated she was afraid of the other resident and was glad the other resident had been moved to another unit so she could not hurt her again. At observation the next day, the resident’s left wrist/hand was bandaged, an observable bruise was present at the base of the left thumb, and the hand/wrist was slightly swollen and painful to touch. Facility documentation and staff statements confirmed that staff heard yelling from the room, found the residents in the room, and separated them. Nursing notes documented a skin tear with partial skin flap loss to the left wrist/forearm and bruising to the left thumb, with the wound cleansed and steri-strips applied. Staff statements described the other resident as being in the injured resident’s area and making unwanted contact, while the administrator stated the investigation was still ongoing and could not yet determine whether resident-to-resident abuse had occurred. The facility’s abuse prevention policy states residents are to be free from abuse by anyone, including other residents, and defines physical abuse as willful infliction of injury resulting in physical harm or pain.
Failure to Protect Resident from Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect residents from abuse and failed to provide adequate supervision and effective interventions when Resident 7 reported fear and unsafe interactions with another resident. Resident 7 was admitted with COPD and PTSD and had a documented history of childhood through adulthood abuse, including physical and sexual abuse, domestic violence, and trafficking. A trauma questionnaire showed Resident 7 had previously tried to avoid reminders of past events and reported that nothing made them feel worse at that time. In one incident, Resident 7 told staff they were afraid to go to sleep because another resident came to their room at night and shook them awake. The resident admitted going to the room and waking Resident 7, and staff educated that resident about safety and respect. The progress note did not appear in the incident log or grievance log, and the record did not show an investigation, monitoring for negative psychological social outcomes, a trauma assessment, or care plan interventions to promote a sense of security. Staff interviews confirmed the social service department was unaware of the situation and that a trauma assessment should have been completed. In a second incident, Resident 7 reported that the same resident blew methamphetamine smoke in their face in the smoking shed, blocked them from leaving with a wheelchair, and exposed and masturbated in front of them. Resident 7 stated the event triggered past childhood trauma and made them feel trapped. The facility investigation documented a separation plan and one-to-one supervision for Resident 7, while the other resident was placed on alert status with increased monitoring and behavior risk. However, the record did not show implementation of behavior-based monitoring for the other resident, and observations later showed Resident 7 without staff supervision.
Physical abuse allegation involving a resident during care
Penalty
Summary
The facility failed to ensure a resident was free from physical abuse when a CNA slapped the resident’s arm during care. The resident was a male with dementia without behavioral disturbance, chronic kidney disease, and heart failure. His care plan identified that he could be physically aggressive due to poor impulse control and resistive to care because of impaired cognition, and his quarterly MDS showed severely impaired cognition with a BIMS score of 2, extensive assistance needs for most ADLs, and bowel and bladder incontinence. According to the incident documentation, the event occurred in the resident’s room during care when one CNA reported that another CNA hit the resident’s hand after the resident grabbed her. A written statement from the witnessing CNA said the CNA hit the resident hard on the arm and then yelled at him. The resident was unable to answer questions about the event because of his stroke and cognitive impairment, and the incident report noted that he had a history of hitting staff. The CNA involved stated that the resident struck her arm and that she tapped his hand gently, comparing her action to what one would do with a child. The facility’s investigation summary described the contact as the CNA batting the resident’s hand away, while the witness described it as striking the resident on the arm. The report also showed that the allegation was not immediately escalated through the facility’s abuse reporting process, as the witness said she reported it to an LVN and was told the DON had been notified, but the abuse coordinator did not receive the information until later. The facility’s records also reflected that the incident was ultimately treated as an unsubstantiated allegation of abuse.
Abuse During Manual Stool Removal
Penalty
Summary
The facility failed to ensure a resident was free from abuse during bowel care when an LPN performed manual removal of impacted stool from the rectum without consent and continued after the resident asked him to stop. The resident had moderately impaired cognition, was dependent on staff for transfers and toileting hygiene, and had a history of constipation. Her diagnoses included stroke, atrial fibrillation, hemiplegia/hemiparesis, adjustment disorder, and mixed anxiety and depressed mood. Her care plan identified limited physical mobility and the need for two staff with a stand lift for transfers. On the day of the incident, the resident had not had a bowel movement for several days and had received constipation medications and a rectal suppository. Progress notes documented that a rectal check found hard stool and that manual evacuation was performed with removal of large amounts of stool. Staff interviews described that the resident cried, said stop, and begged the LPN to stop while he continued the manual removal for additional time. The resident later reported that the procedure was painful, that she felt violated, embarrassed, and demeaned, and that she believed the nurse was smiling and laughing at her during the care. Multiple staff interviews confirmed that the resident was distressed during the procedure and that the LPN did not stop when she requested it. Staff also stated the procedure was invasive and should have been stopped when the resident expressed pain. The LPN stated he manually removed the stool in the bathroom, did not complete an abdominal assessment, did not administer an enema before manual removal, and did not contact the provider for further direction. The report also states the facility failed to ensure the resident was free from abuse during cares, and the immediate jeopardy was identified based on this event.
Failure to Complete Ordered Wound Care
Penalty
Summary
The facility failed to provide wound care services as ordered by the physician for one resident with multiple chronic conditions, including CKD, CHF, HTN, ESRD, muscle wasting/atrophy, anemia, and diabetes-related foot wounds. The resident’s records showed a BIMS score of 15, indicating cognitive intactness, and documented multiple wounds, including ulcers on both feet, a diabetic foot ulcer, and a wound infection. Physician orders required daily wound care to the left calcaneus, right calcaneus, right plantar foot, right medial foot, and daily povidone-iodine application to the right foot, but the TAR did not document completion of these treatments on multiple dates in May 2026, and the progress notes also lacked documentation that the treatments were completed. The resident was hospitalized on 5/26/26 with worsening wound infection. The hospital history and physical documented ESRD on daily dialysis, CHF, COPD, DM, depression, HTN, prior MI with stenting, oxygen use, chronic wound status, and ulcers of both feet with necrosis of muscle. The hospital record stated the resident reported the nursing home should have been changing wound dressings daily but said that was not done. The wound care provider stated the right foot wound had purulent drainage, she was concerned about osteomyelitis, and she sent the resident to the emergency room. She also stated she had concerns that the facility was not completing the ordered dressing changes and that the resident had worsening buttocks skin breakdown, while the DON stated treatments should be completed as ordered and documented on the TAR or in progress notes.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release July 29, 2026) and official state health department websites — never guesswork.
In your survey window? See what surveyors are citing.
The Survey-Prep Report maps your facility's risk from 12 months of CMS and state citation data — what's being cited around you and what to check first. $129 one-time.