Failure to Prevent Resident-to-Resident Abuse
Summary
The facility failed to ensure Resident #2 was free from an incident of resident-to-resident abuse. On 04/21/24, Resident #2 was physically assaulted by Resident #3 in the dining room where no staff were present. Resident #3 struck Resident #2 multiple times, resulting in two facial lacerations, a laceration to the lower lip, and multiple hematomas on the arms, upper breasts, and chest wall. Resident #2 also experienced psychosocial harm, expressing fear of reoccurrence and isolating herself from activities and meals. The facility did not provide timely medical evaluation, failed to notify the physician and authorities promptly, and did not implement appropriate interventions to ensure resident safety. Resident #2 had a history of schizoaffective disorder, bipolar type, anxiety, major depressive disorder, personality disorder, cognitive communication disorder, dysphagia, heart failure, muscle weakness, and seizure disorder. The care plan for Resident #2 included interventions for verbal behaviors and supervision during meals due to poor self-monitoring and impulsivity with eating. Despite these interventions, the incident occurred, and the facility's response was inadequate. The facility did not conduct a thorough investigation, failed to provide timely medical care, and did not offer psychosocial support to Resident #2 following the incident. Resident #3 had a history of diffuse traumatic brain injury, major depressive disorder, mood disorder, anxiety disorder, and muscle weakness. The care plan for Resident #3 included monitoring for anxiety, restlessness, poor impulse control, and fear/apprehension. Despite these interventions, Resident #3 exhibited aggressive behavior towards Resident #2. The facility did not provide adequate supervision in the dining room, failed to implement appropriate interventions to prevent further incidents, and did not conduct a comprehensive investigation following the altercation. The facility's failure to ensure resident safety and provide appropriate care resulted in Immediate Jeopardy and physical and psychosocial harm to Resident #2.
Removal Plan
- 1:1 supervision was initiated for Resident #3 with one staff member assigned for supervision of the resident. Additional staff were added to the shifts (as needed) to ensure monitoring occurred until the resident's discharge. The following staff provided 1:1 supervision through discharge: State tested Nursing Assistant (STNA) #130, #148, #160, and Activities Staff #160.
- An Ad-Hoc Quality Assurance Performance Improvement (QAPI) meeting was held. Regional DON #702 and VPCO #703 educated the Administrator, DON, Medical Director #701, Business Office Manager (BOM) #96, Therapy Manager #95, SSD #100, the ADON, LPN #132, Dietary Manager (DM) #92, Plant Operations (PO) #90, Activities Director #91 on the facility abuse policy, Centers for Medicare and Medicaid abuse reporting guidelines, future expectations with reporting abuse and completing investigations. Topics also discussed during the meeting were resident behaviors and care planned interventions as well as the facility removal plan. QAPI committee meetings would be held weekly for weeks, then monthly for recommendations and further follow-up regarding the removal plan based upon evaluation of audits and observations. Audits would continue to be submitted to the QAPI committee for review and to ensure compliance goals. QAPI committee reserved the right to modify or extend monitoring times according to outcomes. The Administrator was responsible for the oversight of this plan to ensure ongoing compliance. Any issues identified thru the audits would be reviewed and revised thru the facility QAPI process.
- The DON and Licensed Practical Nurse (LPN) #132 completed a record review for all 57 residents (the current census) for behavioral diagnosis including but not limited to traumatic brain injury (TBI), dementia and schizophrenia with no newly identified residents at risk for resident-to-resident abuse through diagnoses.
- LPN #132 reviewed residents (Residents #51, #27, #49, #20, #60, #9, #17, #35, #32, #36, #13, #2, #8, #29, #38, #23, #64, #6, #54, and #58) determined to be at risk for potential aggressive behaviors to ensure care planned interventions were appropriate.
- Resident #3 was placed in a private room by Plant Director #158 and Medical Records #126.
- The Director of Nursing spoke with Resident #6 (the resident who witnessed the incident between Resident #3 and Resident #2) to offer emotional/psychosocial support, but the resident declined.
- Facility resident profiles for residents at risk for potential aggressive behaviors (Residents #51, #27, #49, #20, #60, #9, #17, #35, #32, #36, #13, #2, #8, #29, #38, #23, #64, #6, #54, and #58) were updated to reflect care planned interventions to be followed when caring for a resident with a behavioral care plan by SSD #100, LPN #132 and/or the ADON.
- Resident #2 was evaluated by Physician #810 regarding the incident with Resident #3 via telehealth. The provider's progress note indicated there were no lasting effects from the incident. There were no current updates made to the resident's care plan and no new orders were received.
- All 82 staff (17 nurses, 23 STNA, two Activity Aides, 14 Department Managers, two Agency Nurses, 12 therapy, seven dietary and five housekeeping/laundry) were educated by the Administrator, DON or ADON either in-person or by phone regarding the facility abuse policy and reporting abuse to the Administrator (the facility abuse coordinator).
- All nursing staff (17 nurses, 23 STNA and two agency nurses) were educated either in person or via phone on access to resident care plans by SSD #100, LPN #132, the DON, or the Assistant Director of Nursing (ADON). A hand-out was also provided regarding how to access the information and the staff who received education via phone will receive the hand-out on their next scheduled shift. Staff will also be required to show a return demonstration or recite the process on their next scheduled shift. The resident profiles are in the electronic medical record (EMR).
- The facility implemented a plan that any facility initiated Self Reportable Incident(s) and facility investigation(s) would be escalated to regional support, Regional DON #702, and [NAME] President of Clinical Operations (VPCO) #703 for review to ensure the facility policy was followed.
- A plan for Social Services Designee (SSD) #100 to conduct weekly psychosocial follow-up with Resident #2 was implemented to ensure no lingering effects from the incident had occurred. Follow up would be completed for four weeks.
- The DON, ADON, and/or LPN #132 would review all new admissions for behavior risks.
- Auditing would be completed by the Director of Nursing/Assistant Director of Nursing and/or LPN #132 five days a week for the next eight weeks then three times a week for four weeks for all residents, which includes all new admissions.
- The Director of Nursing, ADON and/or LPN #132 would review/audit all nursing staff documentation including progress notes, events, observations, and Care Assist documentation to ensure all residents with behaviors have care planned interventions to ensure safety. Auditing would be completed on all current residents five days a week for eight weeks, then three times a week for four weeks.
- Resident #3 was discharged to a sister facility related to the resident's behavioral health needs.
- The Administrator, DON, Medical Director #701, Business Office Manager (BOM) #96, Therapy Manager #95, SSD #100, the ADON, LPN #132, Dietary Manager (DM) #92, Plant Operations (PO) #90, and Activities Director #91 conducted an audit (questionnaire) of current interviewable residents, whose Brief Interview for Mental Status (BIMS) score was eight and higher with no reported incidents of abuse and the residents interviewed indicated they felt safe within the facility.
- Non-interviewable residents (#27, #71, #47, #9 and #58), received a skin assessment.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A CNA aggressively slapped and grabbed a resident’s wrist during lunch feeding assistance, then roughly pulled the resident’s hand off his shirt sleeve after she had grabbed it. The CNA had prior disciplinary actions, including a previous feeding incident in which a resident choked and required the Heimlich maneuver. A nurse later assessed the resident and found no bruises or cuts.
A facility failed to protect two residents from resident-to-resident physical abuse. In one incident, a resident with dementia and cognitive impairment was struck during a dispute over TV volume and responded by scratching the other resident. In another, a resident with dementia and physically aggressive behaviors scratched a roommate’s face, leaving superficial marks. Staff interviews and clinical records confirmed both altercations and the resulting injuries.
A resident with a left ankle fracture, muscle weakness, and total-assist transfer needs was supposed to receive 2-person assistance and remain NWB on the left leg. Instead, a nurse aide transferred the resident with only one staff member during a toilet-to-wheelchair transfer, and the resident heard a pop and developed increased pain. X-ray and hospital imaging confirmed fractures of the distal R tibia and fibula, and the facility substantiated neglect for not following the care plan.
Failure to Protect Resident from Repeated Room Intrusions: A cognitively intact resident with depression and hip OA was repeatedly frightened when another resident with dementia and wandering behaviors entered her room, took belongings, and could not be reliably redirected. Staff used a stop sign banner and other barriers, but the other resident continued to enter the room, and the resident became so fearful that she requested discharge before completing her therapy goals.
Failure to protect a resident from alleged physical abuse: A resident with COPD, speech disturbances, and dysphagia reported that an LPN pushed them in the chest during med pass after they refused meds, causing them to fall. The resident had no visible injuries, but the report was documented by nursing staff and the NP, and the resident later reiterated by writing/gestures that the LPN pushed them. The LPN denied pushing the resident and described the contact as accidental, while the facility concluded there was no evidence of abuse.
A resident-to-resident sexual abuse allegation was not thoroughly investigated, and the resident was not promptly protected or monitored after the allegation. In a separate issue, a handwritten sign with personal care instructions was posted above another resident's bed, and an RT, LPN, RN, and CNA all acknowledged it was a privacy and dignity concern and against facility policy.
Failure to Protect Resident from Abuse During Feeding Assistance
Penalty
Summary
The facility failed to ensure a resident’s right to be free from abuse during lunch assistive feeding. While standing about 3 feet from the lunch table, the surveyor heard a CNA aggressively slap Resident #56’s left wrist and observed the CNA grab the resident’s left wrist and roughly pull her hand off of his shirt sleeve after she had grabbed it. The surveyor then continued observing the meal and later reported the incident to the DON and Administrator. Resident #56 was assessed by a licensed nurse after the incident, and no bruises or cuts were found on her wrists. The CNA involved had been hired by the facility in 2024, had signed the facility’s Resident Abuse Procedural Summary, and had attended behavior training in 2026. The CNA also had three prior disciplinary actions, including a prior incident in which a resident choked after being given too large a bite during assistive feeding and required a Heimlich maneuver.
Failure to Protect Residents from Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to ensure two sampled residents were free from physical abuse by other residents. One resident with dementia, anxiety, chronic pain, visual hallucinations, and moderate cognitive impairment was involved in an altercation with a roommate after a disagreement about TV volume. The incident escalated when the roommate attempted to take the TV remote and struck the resident with an open hand, and the resident responded by scratching the roommate. The record also documented a new scratch on the resident’s left hand and later noted that the resident no longer wanted to share a room with the other resident. The other incident involved a resident with dementia and significant cognitive impairment who had a behavior care plan for impaired safety awareness and physically aggressive behaviors. The record stated that the resident clawed a roommate in the face, leaving superficial scratches and red marks on the roommate’s chin and cheek. The roommate’s record reflected ongoing monitoring for scratches to the chin and neck, and the roommate stated that the other resident reached up and ran fingernails across her face while they were getting up for breakfast. Facility documentation and staff interviews confirmed both resident-to-resident incidents. Staff described the first event as a physical altercation triggered by conflict over TV volume, and the second as an incident in which one resident scratched another resident’s face. The DON stated the facility investigated and reported the incidents, and also acknowledged that the documentation surrounding the second event was inconsistent and did not meet expectations or policy. The cited deficiency was based on the facility’s failure to ensure the residents were protected from physical abuse by other residents.
Failure to Follow Two-Person Transfer Plan Resulted in Resident Fractures
Penalty
Summary
The facility failed to protect a resident from neglect when staff did not follow the resident’s individualized transfer plan requiring assistance from two staff members. The resident was admitted with a left lower leg trimalleolar fracture, polyosteoarthritis, and muscle weakness, and the MDS indicated the resident was cognitively intact but required total assistance for transfers and toileting. The comprehensive care plan and physician orders both directed staff to provide two-person assistance for transfers and to maintain non-weight-bearing status on the left lower extremity. During a transfer from the toilet to a wheelchair, one nurse aide assisted the resident without a second staff member. According to the documentation, the resident stood without difficulty, but during the pivot transfer the resident’s right foot turned inward and both the resident and the aide heard a loud pop. The resident immediately reported increased pain. Later that day, x-ray findings identified an acute fracture of the right tibia, and the resident was transferred to the hospital emergency department for further evaluation and treatment. Hospital imaging confirmed fractures of the distal right tibia and fibula, and the resident was scheduled for surgical repair. The facility’s investigation determined that the aide transferred the resident with only one staff member despite the care plan and physician order requiring two staff members, and that this failure directly resulted in the resident sustaining the fractures. The facility substantiated caregiver neglect and terminated the employee following the investigation.
Failure to Protect Resident from Repeated Room Intrusions
Penalty
Summary
The facility failed to protect a cognitively intact resident with osteoarthritis of the right hip and major depressive disorder from mental abuse by another resident. The resident was admitted as a vulnerable adult and her care plan identified a goal of being free from abuse, neglect, or financial exploitation, but it did not include interventions to protect her from abuse. The resident later reported that another resident repeatedly entered her room, scared her, and took belongings, and she asked staff to contact her lawyer. She also began using a stop sign banner across her door and later barricaded her room with a walker, closet door, and bedside table because she was afraid of the other resident. The other resident had moderate cognitive impairment, vascular dementia with agitation, and Alzheimer’s disease, and his care plan documented restlessness, agitation, sundowning, wandering into other residents’ rooms, and urinating in public. Progress notes showed repeated episodes of wandering into other residents’ rooms, difficulty with redirection, aggression toward staff, and disruptive behavior in resident rooms. Notes also documented that he entered the affected resident’s room on multiple occasions, and staff observed that he could move barriers out of the way and continue entering the room despite attempts to block access. Staff interviews confirmed that the resident was very scared of the other resident and that the repeated room intrusions continued over several days. Staff stated that stop sign banners did not stop him, closed doors did not stop him, and that it often took two or more staff to remove him from rooms. The resident requested discharge from the facility and left before reaching her maximal level with therapy services. Therapy documentation stated she was improving but still needed higher-level therapy before discharge, and the therapy director stated her early discharge was because she could not remain in the facility due to the other resident coming into her room. Facility records also showed staffing levels that were below the facility assessment on several shifts, and the assignment sheets did not identify a staff member assigned to 1:1 observation for the wandering resident.
Failure to Protect Resident from Alleged Physical Abuse
Penalty
Summary
The facility failed to ensure that a resident was free from physical abuse when a nurse allegedly made physical contact with the resident during medication administration. Resident #7, who had diagnoses including COPD, speech disturbances, and dysphagia, had intact cognition on the MDS dated 03/18/2026 and was care planned as at risk for misappropriation, neglect, abuse, and/or exploitation. On 04/08/2026, the resident reported to the RN supervisor that an LPN pushed them in the chest after they refused medications, causing them to fall to the floor. The resident was assessed and no visible injuries were noted. The resident’s report was documented in nursing and medical progress notes, and the facility’s investigation recorded that the resident was visibly upset while describing the incident. The LPN denied the allegation and stated that any contact was accidental, describing that the resident was close behind them as they left the room and that the resident’s chest contacted their back or shoulder. The RN supervisor, DON, and NP each documented interviews and assessments in which no bruising, swelling, or visible injury was found, and the resident later communicated by writing and gestures that they had told the LPN to leave the room and that the LPN pushed them in the chest and they fell. The facility concluded there was no evidence of abuse, neglect, exploitation, or mistreatment, despite the resident’s allegation and the conflicting accounts from the LPN and resident. The RN supervisor stated law enforcement was notified and police interviewed the resident and the LPN, but no report was filed. The DON later stated the contact was accidental and that the resident’s reporting was inconsistent regarding whether a fall occurred.
Failure to Protect Resident from Abuse and Maintain Privacy
Penalty
Summary
The facility failed to ensure a resident was free from abuse when a resident-to-resident sexual abuse allegation was not thoroughly investigated and the resident was not promptly protected or monitored after the allegation. The report states this involved 1 of 52 sampled residents, Resident 45, and that the deficient practice had the potential to place the resident at risk for continued abuse, emotional distress, fear, anxiety, a diminished sense of safety, and delayed implementation of interventions necessary to protect the resident from further abuse. The facility also failed to protect the privacy and confidentiality of Resident 58. Resident 58 was admitted with diagnoses including chronic obstructive pulmonary disease. During observation, a handwritten sign reading, "Attention please no briefs chucks only!!" was posted above the resident's bed and remained there on a later observation. Staff members including a Respiratory Therapist, LPN, RN, and CNA each acknowledged the sign was visible above the bed and stated it was a privacy, dignity, and policy issue. A facility Residents Rights policy stated residents have the right to privacy and confidentiality with personal care and medical records, and that resident medical and personal care information is private and staff are required to respect and uphold resident privacy at all times.
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