Failure to Investigate Unwitnessed Fall and Injuries
Summary
The facility failed to initiate and complete a thorough investigation when a resident on one-to-one (1:1) monitoring experienced an unwitnessed fall and sustained injuries of unknown origin. The incident involved a resident with cognitive impairments and a history of schizoeffective disorder and bipolar disorder, who was on 1:1 monitoring due to being combative and a fall risk. On 8/13/23, an incoming staff member noted an abrasion on the resident's knee, but the investigation was not initiated until the following day, 8/14/23, when further injuries were discovered. The resident was found with blue discoloration on both ears, a 3 cm x 3 cm abrasion on the right knee, and discoloration on the right side of the face and mid-arm. The resident screamed in pain when turned, prompting a physician to order an emergency room evaluation, which revealed a fracture in the lower spine. Despite being on 1:1 monitoring, the fall was unwitnessed, and there was a lack of clarity regarding the exact timing of the incident. The facility's investigation process, as described by the Director of Nursing (DON), involves interviewing staff and obtaining statements, but there were inconsistencies in the monitoring logs and statements from the Certified Nursing Assistants (CNAs) involved. The facility's failure to promptly investigate the initial abrasion and the subsequent unwitnessed fall highlights deficiencies in their monitoring and investigation processes. The 1:1 monitoring logs showed discrepancies, and not all CNAs provided statements. The facility's policy mandates that reports of abuse, neglect, or injuries of unknown origin be promptly and thoroughly investigated, which was not adhered to in this case. The lack of immediate investigation and the inability to determine how the resident sustained the injuries indicate a significant oversight in ensuring resident safety and compliance with regulatory standards.
Penalty
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The facility failed to complete thorough investigations into abuse allegations involving two cognitively intact residents. In one case, a resident reported being turned violently and hit by two CNAs during nighttime care, but the investigation lacked interviews with other staff or residents on the unit. In another case, a resident with a history of verbal aggression alleged that an RN used unprofessional, racially charged language, which was partially corroborated by the ADON and social worker, yet no statement was obtained from the resident or other residents. The DON acknowledged that additional interviews were not conducted and that investigation documents were fragmented across multiple staff and locations, contrary to facility policy requiring comprehensive, factual documentation and witness statements.
The facility failed to follow its abuse investigation policy when responding to an allegation that a male resident wandered into a female shared room, allegedly sat on a resident’s bed, inappropriately touched her leg, stared at another resident, and opened the bathroom door to watch a third resident brushing her teeth. The allegation was reported by a cognitively intact resident and involved residents with varying levels of cognitive impairment. The investigation, conducted by the Administrator and former DON, relied only on interviews with a RN and a CNA, did not obtain required written, signed, and dated witness statements, and did not include interviews with other residents to assess their sense of safety. Despite these omissions and incomplete documentation, the facility’s final report concluded the allegation was unsubstantiated.
A resident with moderate cognitive impairment and mobility limitations sustained an unwitnessed fall in a hallway, reported hitting the head, and later was found to have a left proximal humerus fracture. Dietary staff discovered the resident on the floor, were unable to locate a nurse, and lifted the resident into a rolling desk chair before nursing staff assessed the resident, while CNAs and an RN later confirmed hearing that dietary staff had assisted the resident from the floor. Although dietary aides reported completing witness statements, the facility’s investigation included only statements from a CNA and an LPN who was on break at the time, and omitted the dietary staff accounts and any examination of the lack of RN assessment prior to moving the resident, contrary to facility policy requiring prompt, comprehensive incident investigations.
The deficiency involves the facility’s failure to thoroughly investigate two separate allegations of potential abuse and mistreatment. In one case, a resident with dementia and a known fall risk sustained a hip fracture after contact with a medication cart; documentation and multiple staff interviews conflicted about who witnessed the event and whether the cart struck the resident, yet the administrator relied primarily on an LPN’s account, conducted only a brief inquiry, and did not interview all identified witnesses. In the second case, a resident with vascular dementia reported receiving diphenhydramine for sleep from a male nurse despite having no order, and an LPN described finding opened and replaced bottles of diphenhydramine in the memory care medication room and statements suggesting it was being used to make residents sleep, but the facility’s investigation did not include interviewing this LPN and no incident report was submitted to the state agency.
A cognitively impaired, functionally dependent resident with hemiplegia developed significant bruising on the right leg and later vaginal bleeding and genital bruising while a family representative (treated as DPOA) remained almost constantly in the room with the door closed. CNAs repeatedly reported bruising and vaginal bleeding to RNs/LNs, but the initial nurse accepted the representative’s explanation, did not thoroughly assess or document the injuries, and ordered antifungal treatment for presumed yeast infection without investigation. Oncoming nurses delayed assessment despite reports of bleeding, and when assessments were finally completed, staff found extensive bruising to the hip, thighs, lower abdomen, and labia, with lacerations and active vaginal bleeding, while staff statements described the representative as nervous, intrusive during intimate care, and always present. The resident made concerning statements implying harm by a male, yet no immediate protective measures were implemented, and the resident was left alone with the representative for many hours before the situation was reported as potential abuse.
The facility failed to thoroughly investigate an allegation of physical abuse involving a resident with dementia and severe cognitive impairment (BIMS 5/15). A construction foreman reported that construction staff had previously heard crying and pleas for help from the resident’s room and believed they saw a staff member striking an elderly wheelchaired patient, and later again heard crying, pleas for help, and slapping sounds from the same room before notifying facility staff. The DON identified the alleged perpetrator as a private duty assistant hired by the resident’s family and acknowledged that the facility had no HR records for this individual, including abuse training, background checks, or licensing information, and that the facility’s investigation did not include separate interviews with each construction staff member.
Incomplete Abuse Investigations for Two Cognitively Intact Residents
Penalty
Summary
The deficiency involves the facility’s failure to conduct complete and thorough investigations into allegations of abuse for two cognitively intact residents. Facility policy states there is zero tolerance for abuse, neglect, and exploitation and that documentation of abuse investigations must be objective and factual, including who, what, when, where, and witness statements. Despite this, the investigations did not include all relevant interviews or comprehensive documentation as required by the policy and federal regulation. For one resident with dementia but a BIMS score of 15, the resident reported that on a late evening two staff members, identified as a male and a heavy-set female nursing assistant, turned the resident violently while providing incontinence care, that the male staff member hit the resident, and that there was swearing by both the resident and the male staff member. The resident stated the male staff member had a very strong grip and that the female staff member was the aide who cared for the resident that night. The investigation documentation included a nursing supervisor’s note that the resident denied pain or injury and that no bruising was observed, and that the male aide was identified by another aide. However, there was no documented evidence that other staff or residents on the unit were interviewed regarding the alleged incident. For another resident admitted with a left fibula fracture and a BIMS score of 15, who had a care plan for verbal aggression and inappropriate verbal behavior, a grievance was filed alleging that a registered nurse spoke to the resident in an unprofessional manner and cursed at the resident. The investigation file contained statements from the ADON and social worker indicating they heard a commotion and heard the nurse refer to the resident as “boy,” followed by the resident’s upset response, and that there was no observed physical contact. Despite these accounts, there was no documented statement from the resident involved or from other residents on the unit. The DON confirmed that no interviews were conducted with the resident or other residents after the incident and described investigation materials as being scattered among different staff and offices rather than compiled.
Plan Of Correction
1. A thorough investigation of allegations of abuse was conducted for Resident R1 and Resident R3. Interviews and witness statements as applicable with other staff and/or residents completed for alleged abuse for Resident R1 and R3. 2. A review of facility investigation procedures was reevaluated. Facility administration will ensure thorough investigations including but not limiting to collecting witness statements and conducting staff/resident interviews for any alleged abuse cases are completed. 3. The Director of Nursing was educated and in-serviced by the Administrator on ensuring a complete and thorough investigation is complete for all allegations of resident abuse. Statements and interviews to be conducted where applicable and ensure timely reporting of incidents and documentation to the Administrator and the Department of Health. 4. The Administrator/Designee will monitor all reportable incidents pertaining to resident abuse/neglect and any identified non-compliance with reporting procedures will be reported to the QAPI committee.
Failure to Thoroughly Investigate Allegation of Sexual Abuse
Penalty
Summary
The deficiency involves the facility’s failure to conduct a thorough investigation of an allegation of sexual abuse in accordance with its policy titled “Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating.” The policy required that all allegations be thoroughly investigated, including reviewing documentation and evidence, interviewing any witnesses, interviewing staff on all shifts who had contact with the resident, and completely documenting the investigation, with written, signed, and dated witness statements. A facility-reported incident documented that a male resident was wandering into a female three-bed room, allegedly inappropriately touching one resident, staring at another for a length of time, and then opening the bathroom door and staring at a third female resident while she was brushing her teeth. The allegation was initially reported by a cognitively intact resident (BIMS score 15) and involved another resident with moderate cognitive impairment (BIMS score 8) and a resident with severe cognitive impairment (BIMS score 99). The Administrator reported that the investigation of this incident was conducted by the former DON and herself after the allegation was reported by a RN. She stated that this was not the first time the alleged male resident had wandered into other residents’ rooms and described the allegation as the male resident entering a resident’s room, sitting on the resident’s bed, and allegedly touching the resident’s leg. Staff interviews for the investigation were limited to the RN and a CNA, and the Administrator acknowledged that no written witness statements were obtained, contrary to facility policy. She also confirmed that no additional residents were interviewed to assess their sense of safety following the incident. The facility’s final investigation report concluded that the allegation was unsubstantiated, despite the lack of comprehensive interviews, written statements, and full documentation required by the facility’s abuse investigation policy.
Failure to Thoroughly Investigate Resident Fall and Involve All Witnesses
Penalty
Summary
The deficiency involves the facility’s failure to conduct a thorough investigation of a resident fall to rule out abuse or neglect. Facility policy required the nurse supervisor/charge nurse and department director or supervisor to promptly initiate and document an investigation of any accident or incident, including circumstances, witness names and accounts, and other pertinent data, with review by the safety committee. Resident 4 had moderate cognitive impairment, used a wheelchair, and had diagnoses including difficulty walking and generalized muscle weakness. On March 21, 2026, nursing documentation indicated the resident sustained a fall in the hallway, reported hitting his head, complained of severe left shoulder pain, and had a hematoma to the back of the head; the family requested transfer to the emergency department for evaluation. Multiple staff interviews revealed that dietary staff, not nursing staff, first encountered the resident on the floor and physically assisted him before a nurse assessed him, but this information was not fully captured in the facility’s investigation. Nurse Aide 1 and Nurse Aide 2 reported that kitchen/dietary staff had picked the resident up off the floor, and Nurse Aide 3 stated she was told by a kitchen staff member that a resident was on the floor; when she arrived, the resident was already in a rolling desk chair, and she later assisted in transferring him to his wheelchair and submitted a witness statement. Dietary Aide 5 and Dietary Aide 6 each confirmed that they found the resident on the floor, could not locate a nurse, and together lifted him from the floor to a desk chair, with both indicating they completed witness statements. Registered Nurse 4, who was on another floor at the time of the fall, later assessed the resident in his wheelchair, noted he was guarding his arm, crying out in pain, and had hit his head, and sent him to the emergency room. Despite these accounts, the facility’s written investigation of the unwitnessed fall included only witness statements from Nurse Aide 2 and LPN 7 and did not contain statements from the dietary aides who actually assisted the resident from the floor. Nurse Aide 2’s statement described finding the resident already in a wheeled desk chair and transferring him to his wheelchair, while LPN 7’s statement focused on environmental conditions and resident behaviors around the time of the incident and acknowledged she was on break when the fall occurred, returning after RN 4 was already assessing the resident. An orthopedic consultation later documented that the resident had a left proximal humerus fracture after a fall on cement. The Director of Nursing confirmed she did not obtain witness statements from dietary staff because she did not believe they would have assisted the resident in that way and also acknowledged she did not investigate the lack of RN assessment prior to the resident being moved to a rolling desk chair, despite the administrator’s statement that all staff were trained to report resident changes in condition to a nurse.
Failure to Thoroughly Investigate Potential Abuse and Misuse of Medication
Penalty
Summary
The deficiency involves the facility’s failure to identify and thoroughly investigate potential abuse in two separate situations involving two residents. For the first resident, who had dementia with anxiety and was care planned as being at risk for fall-related injury due to poor safety awareness, the resident sustained a right femoral neck fracture after contact with a medication cart. Facility documentation in the fall report and post-fall evaluation stated that a nurse pushing a medication cart collided with the resident, that the fall was witnessed, and that the cart pushed in the hall tripped the resident. The post-fall evaluation listed a CNA as a staff/witness present and a laundry aide as the primary assistant interviewed for the three hours prior to the fall, and identified environmental factors as the root cause. However, interviews revealed discrepancies and incomplete investigation. The CNA listed as a witness reported she was not present at the time of the fall and only saw the resident later that evening, contradicting the post-fall documentation. The laundry aide reported she was in the hallway at the time of the fall, saw the resident walking next to a CNA, and observed the LPN, the medication cart, and the CNA all together when the resident fell, but stated she did not know if the cart hit the resident and that she was never interviewed by the administrator about what she saw. A former CNA reported she directly witnessed the fall, describing that she was pushing another resident in a wheelchair while the injured resident walked beside her, and that an LPN approached rapidly from behind with the medication cart, appeared not to have control of it, and that the cart struck the back of the resident’s leg, causing the fall. This CNA also reported she had told the administrator and DON by phone that she believed the resident was injured due to the LPN’s reckless actions, but that her concerns were disregarded and she was never interviewed. The LPN involved stated that both she and the resident were in motion and that the resident backed into the cart, causing loss of balance and a fall, and confirmed the resident’s hip fracture. The administrator’s written summary reflected only the LPN’s account, characterizing the event as an accident and documenting that the resident backed up and clipped the corner of the cart. In interview, the administrator described his investigation as brief, stated that when an LPN calls and tells him exactly what happened there was little need for further investigation, and could not confirm speaking to other witnesses such as the laundry aide. He acknowledged that the CNA had mentioned a concern that the nurse may not have accurately reported what happened but did not elaborate or explore whether any earlier interaction might have contributed to the incident. These actions and omissions demonstrate that the facility did not conduct a thorough investigation into a potential abuse or mistreatment situation involving a fall with major injury. The second situation involved an allegation of improper administration of diphenhydramine to residents without physician orders. One resident with vascular dementia, moderate cognitive impairment, and a history of insomnia reported that a male nurse had been giving him diphenhydramine for at least a few weeks to help him sleep, and that another nurse later told him the medication was not recommended for people with dementia because it could worsen cognitive skills. The resident stated he had used the medication nightly before admission but now did not want anything that could make his memory worse. A nurse practitioner confirmed that none of the residents on the memory care unit had orders for diphenhydramine and that its use in dementia patients increased fall risk and had a sedating effect. An LPN reported concerns that another LPN was giving residents diphenhydramine without physician orders. She stated that a male resident repeatedly requested the medication and told her that another nurse gave it to him, and that she found an opened bottle of diphenhydramine in the memory care medication room with a significant amount missing despite no residents having orders for it. She also reported that the other LPN told her he had made sure everyone was going to sleep that night, and that after she removed the open bottle, a new bottle appeared the following night. She did not report this to the administrator at the time because she felt she lacked proof. The administrator later stated he was aware of an allegation of misuse of diphenhydramine and that an investigation was underway, but the soft file showed only 9 of 27 licensed nurses had been interviewed and there was no record that this LPN, who had direct knowledge of the concern, was interviewed. The administrator stated that the LPN had expressed only general concerns about finding diphenhydramine in the medication room and denied that she had reported an allegation that another nurse was giving it to residents without orders to make them sleep. Review of the state agency’s facility-reported incidents database showed that no investigation related to the accusation of a nurse giving residents diphenhydramine without an order had been submitted. These facts show the facility did not fully identify, investigate, and report an allegation of potential abuse and misuse of medication as required by its abuse prohibition policy.
Failure to Protect Resident From Suspected Sexual Abuse and Investigate Injuries of Unknown Origin
Penalty
Summary
The deficiency involves the facility’s failure to implement protective measures and conduct timely assessment and investigation after injuries of unknown origin and signs of potential sexual abuse were identified for a cognitively impaired resident. The resident had hemiplegia and hemiparesis following a cerebral infarction affecting the right dominant side, severe cognitive impairment with a BIMS score of three, dependence on staff for nearly all ADLs, and no documented prior skin conditions. Her care plan did not address the alleged perpetrator’s (AP’s) involvement in care and listed another son as DPOA, while the AP was treated as the primary caregiver and remained in the room with the resident almost continuously, often with the door closed. Staff had previously felt awkward and uncomfortable performing care with the AP present and reported that he frequently remained in the room, watched cares closely, and sometimes took over intimate care, but these concerns were not acted upon. On the evening and night shift, CNAs observed significant bruising on the resident’s right leg and later vaginal bleeding, and reported these findings to the nurse. Around 10:30–11:00 PM, CNA staff reported significant bruising down the resident’s right leg to the nurse, who briefly assessed the bruises in the presence of the AP, accepted the AP’s explanation that the bruising might be from therapy or wheelchair positioning, and did not document the bruising in the EMR at that time. The resident was left alone in the room with the AP. Around 4:20 AM, CNA staff reported bright red blood in the resident’s brief and around the vaginal area to the same nurse, who did not assess the resident but instructed the CNA to apply antifungal cream or powder for a suspected yeast infection, again without further investigation or protective measures. The resident remained alone in the room with the AP with the door closed after care was completed. On the following day shift, multiple staff continued to identify concerning findings without immediate protective action. At approximately 6:00 AM, the night nurse told two oncoming nurses that the resident had vaginal bleeding suspected to be from itching or yeast infection, but no assessment was done at that time. Around 8:00 AM, a CNA providing peri care with the AP present observed dried blood all over the vaginal area and reported it to a nurse, who assessed the resident at about 8:30 AM, noted dried blood, bruising on the labia and vaginal opening, and bruising on the hip, but attributed the injuries to itching and did not suspect abuse; the resident was again left in the room with the AP. Later that afternoon, a two-nurse assessment revealed extensive bruising on the right hip and leg, bruising and lacerations to the labia and vaginal area, bruising on the lower abdomen, and active vaginal bleeding, with the bruising on the hip described as resembling the shape of a hand. During this assessment the AP left the room, which staff noted was unusual. Witness statements documented that throughout this period the AP remained in the room during cares, the door was mostly closed, staff felt unsettled and had previously reported discomfort with the AP’s presence, and the resident made statements such as “why I let that man do that?” and “Son, why would you do this to me?” during or after care. Despite these observations and escalating physical findings, the resident remained alone in the room with the AP for approximately 16 hours after the initial report of bruising and subsequent vaginal bleeding before the situation was reported to administrative staff as potential abuse. The EMR lacked timely documentation of the initial bruising and early vaginal bleeding, and a late entry note regarding the bruising was not entered until several days later, after surveyor interviews had begun. The facility’s abuse, neglect, and exploitation policy stated that the facility would ensure the health and safety of each resident regarding visitors such as family members or resident representatives, but staff did not remove or restrict the AP, did not initiate immediate protective measures when injuries of unknown origin and signs of possible sexual abuse were first identified, and did not promptly report or investigate the concerns. The deficiency was cited at a level of past noncompliance with actual harm, based on the existence of physical sexual abuse injuries that progressed while the resident was left alone with the AP and the likelihood of severe psychosocial trauma related to sexual abuse.
Failure to Thoroughly Investigate Allegation of Physical Abuse by Private Duty Assistant
Penalty
Summary
The deficiency involves the facility’s failure to thoroughly investigate an allegation of staff-to-resident physical abuse. The facility became aware of an allegation on 08/20/25 at 2:30 pm, when a construction company foreman reported that one of the construction staff had witnessed a staff member hitting Resident #1 in the head sometime during the previous week. Resident #1 was admitted with dementia with aggression and had a BIMS score of 5/15, indicating severe cognitive impairment. The construction foreman later sent an email on 08/22/25 elaborating that the construction staff had previously heard crying and pleas for help from Resident #1’s room and, upon approaching, believed they saw a staff member striking an elderly wheelchaired patient. In the same email, the foreman reported that on 08/20/25 at approximately 2:25 pm, they again heard crying, pleas for help, and noises resembling slapping from Resident #1’s room and felt strongly that someone in the room was being assaulted. At 2:50 pm that day, the foreman informed a facility staff member in the parking lot about what they heard and what had been reported days earlier. During interviews, the DON identified the alleged perpetrator as a private duty assistant hired by Resident #1’s family and stated that the facility did not have any human resources records for this individual, including abuse training, background checks, or licensing information. The DON also stated that the facility’s investigation did not include separate, facility-conducted interviews with each of the construction staff, demonstrating that the allegation of physical abuse was not thoroughly investigated.
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