Resident Elopement Due to Door Malfunction
Summary
The facility failed to ensure that a resident diagnosed with dementia was free from neglect, resulting in the resident eloping from the facility. The resident, who had a history of vascular dementia, cognitive communication deficit, altered mental status, and a history of falling, was found in the parking lot near a major highway after being unaccounted for during bedtime. The resident had a Brief Interview for Mental Status (BIMS) score indicating severe cognitive impairment and was known to exhibit exit-seeking behavior, particularly during the evening when sundowning behaviors were more pronounced. On the day of the incident, the resident was noted to be continuously attempting to leave the facility and was redirected multiple times by staff. Despite these efforts, the resident managed to exit the facility through the front door, which was not properly aligned and failed to lock, allowing the resident to elope. The resident was found outside by a CNA, who heard the alarm going off by the front door but could not hear it from the resident's unit due to its location at the back of the facility. The CNA found the resident in the parking lot with another resident's family member and managed to convince the resident to return inside. Interviews with staff revealed that the resident's exit-seeking behavior was known, and an Electronic Monitoring Device (EMD) had been placed on the resident's ankle to prevent elopement. However, the door's malfunction allowed the resident to exit despite the EMD. The facility's Administrator and Director of Nursing were informed of the incident, and it was noted that the door had ongoing issues that had not been resolved, contributing to the resident's ability to elope.
Removal Plan
- R1 was brought back into the facility immediately and safely by the Certified Nursing Assistant (CNA) and the Nurse.
- A body audit was completed which revealed no injuries.
- R1 was assisted to bed where he fell asleep and remained for the remainder of the night.
- R1 responsible party was notified, and a 100% resident head count was completed for all residents with all residents being accounted for, Medical Director/provider made aware.
- Facility Administrator was on-site within an hour of the reporting of the incident.
- The Maintenance Director was contacted and arrived at the facility minutes later to repair the front door.
- All other doors checked and verified for proper egress/ingress functioning to include alarming the electronic medical device system.
- The front door was monitoring continuously until the repairs were completed and appropriate functionality of the door was confirmed.
- The front door continued to be monitored for 24 hours after the event with no recurrence.
- All staff are to receive education on Code Pink/ Missing Residents which include neglect of a resident; how to handle malfunctioning doors by the Administrator, Clinical Competency Coordinator (CCC), Director of Health Services (DHS), and/or licensed designated charge nurse initiated.
- All new hires will receive education in orientation.
- Any partner that is on leave will receive education prior to their next scheduled shift.
- Replacement of the front door has been approved and the work order has been requested by the vendor, awaiting date/time of replacement to be scheduled.
- All doors not limited to the front door is in working order to secure the facility properly and functioning properly.
- The Maintenance Director or designee will verify the proper functioning of all doors twice daily times one month or until replacement of the door is complete.
- Results will be reviewed in the Quality Assurance and Performance Improvement (QAPI) monthly for three months and/or until substantial compliance is achieved.
Penalty
Resources
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Two residents were subjected to verbal abuse by nursing staff. One cognitively impaired, fully dependent resident with dementia and other comorbidities was recorded on video while an LPN loudly scolded her during incontinence care, threw soiled washcloths onto the floor, and shouted about not being an aide, while CNAs later referred to the resident’s daughter as a "spy" and discussed her visitation restrictions within the resident’s hearing during a mechanical lift transfer. Another cognitively intact resident with multiple medical conditions and elected video monitoring was the subject of a personnel report documenting that an LPN was seen on video shouting at him and using foul language, and a family member later submitted a written concern about the LPN’s behavior, which was characterized in the counseling as disrespectful, abusive, and unprofessional.
A resident with severe dementia and a documented history of aggressive behaviors, including hitting and wandering into other residents’ rooms, was in a common area when this resident struck another cognitively impaired resident in the chest. A CNA heard yelling, observed the strike, and intervened, and the injured resident immediately reported pain. Over subsequent days, the injured resident continued to complain of significant left chest and breast pain, with high pain scores and documented discoloration, requiring repeated assessments, imaging, and pain management, and was ultimately sent to the ER where additional traumatic findings were identified. Despite a written abuse policy defining physical abuse as hitting and requiring prompt reporting of alleged abuse to the state agency, the DON acknowledged that the facility did not self‑report the resident‑to‑resident altercation because the resident was considered not injured, demonstrating a failure to provide adequate supervision to prevent abuse and to follow abuse reporting procedures.
A CNA with a documented history of poor customer service and unprofessional behavior repeatedly used a rude, loud, and disrespectful tone toward residents and staff, including telling a resident that if she could not be patient she would be moved to a “bad hall” where it would take longer to receive help. Staff, including an LPN and a unit manager, reported witnessing the CNA raising her voice in hallways, yelling in the halls and at the nurses’ station, and making loud, demeaning comments about a resident who refused a shower. These actions occurred despite a facility policy requiring immediate reporting of suspected abuse or neglect to administration and state authorities.
A resident with anxiety, major depressive disorder, and a history of childhood sexual abuse reported becoming emotionally upset after receiving an incest-themed YouTube video from a staff member through Facebook. The cognitively intact resident stated the video was triggering given her past abuse, and also reported hearing that others had complained about her body odor on social media. The staff member admitted being Facebook friends with the resident and sending the video because he thought it was humorous, while denying making comments about her odor. The facility’s investigation, confirmed by the DON and Administrator, found that the staff member’s social media interaction and transmission of the video constituted emotionally abusive conduct toward the resident.
An LPN who appeared impaired, was falling asleep while standing, dozing off during conversations, and dropping medications was allowed to continue working a full shift despite multiple reports from residents and staff to an on‑call LPN. The DON and Administrator were not fully informed that day, and the LPN was not removed from resident care. As a result, multiple residents with complex conditions such as COPD, DM2, CHF, seizures, anoxic brain damage, CKD, and depression did not receive numerous ordered medications, tube feedings, PEG flushes, respiratory treatments, blood glucose checks, insulin doses, pain assessments, behavior monitoring, head‑of‑bed elevation, enhanced barrier precautions, and other prescribed interventions during that shift, as later confirmed by EMR, MAR, and TAR review by the DON.
A cognitively impaired hospice resident with dementia and significant ADL needs was subjected to inappropriate physical interactions by a CNA during incontinence care, as captured on in-room video. The CNA was seen kicking the side of the resident’s mattress twice, causing the resident’s legs to lift, pulling back covers and tapping the resident’s leg with a gloved fist without explanation, and speaking in a loud, aggressive tone while directing the resident to sit and "sit back" when the resident attempted to get up. The resident repeatedly expressed gratitude and positive comments during care without receiving verbal responses. Family viewing the camera reported to police that the CNA appeared to strike the resident’s leg and either kick the leg or mattress forcefully. Staff who later viewed the videos described the actions as an aggressive slap and purposeful kick, and documentation showed a subsequent skin tear/scratch on the resident’s pinky toe. Surveyors concluded the facility failed to ensure the resident was free from physical abuse.
Failure to Protect Residents From Verbal Abuse by Nursing Staff
Penalty
Summary
The facility failed to protect residents from verbal abuse, affecting two residents. One resident with Alzheimer's disease, CHF, anxiety, seizures, cognitive deficit, and total dependence for care had a family-installed camera and a personal care companion. Video from the resident's room showed an LPN assisting a CNA with incontinence care, loudly telling the resident to stop squeezing her buttocks and yelling to the resident's daughter to tell the resident to stop. The LPN threw dirty washcloths over the bed onto the bare floor and loudly stated she was not an aide and was doing the best she could. During this care, the resident, who was non-verbal, was observed grunting, moaning, crying out, and swinging her arms until the family caregiver came to comfort her. In a separate video, two CNAs providing care and transferring the same resident via mechanical lift were heard referring to the resident's daughter as a "spy" and stating they had to do care a certain way because that was how the "spy" wanted it done, and further stating that the daughter was not allowed in the facility and could not visit on the resident's birthday, all while providing care in the resident's presence. Another resident, with diagnoses including atrial fibrillation, obesity, tremor, need for assistance with personal care, and Parkinsonism, had intact cognition and had elected to have video monitoring in his room. Review of the personnel file for an LPN revealed a Corrective Action Report documenting that, on one date, the LPN was observed on video shouting at this resident and using foul and cursing language, and on another date a family member submitted a written concern regarding the LPN's behavior toward them. The written counseling described the LPN's behavior as disrespectful, abusive, and unprofessional. The facility's abuse policy defined verbal abuse as oral, written, or gestured communication or sounds that willfully include disparaging and derogatory terms to residents or their families, or within hearing distance, regardless of age, ability to comprehend, or disability.
Failure to Prevent Resident-to-Resident Physical Abuse and Inadequate Response to Resulting Injury
Penalty
Summary
The deficiency involves the facility’s failure to protect a cognitively impaired resident from physical abuse by another resident with known aggressive behaviors and to provide adequate supervision to prevent such abuse. One resident with severe dementia and a documented history of delusions, physical and verbal behaviors, rejection of care, wandering, and physical aggression toward others was care planned for multiple behavioral symptoms, including hitting, kicking, pushing, grabbing, and entering other residents’ rooms. Interventions in the plan of care included medication management, calm approaches, communication before care, leaving and returning if the resident resisted care, observing and documenting inappropriate behaviors, notifying the practitioner when behaviors persisted, providing psychological/psychiatric services as needed, offering choices, and providing a calm, safe environment and structured daily schedule. Despite this, the resident with aggressive behaviors was in a common area where another severely cognitively impaired resident was present. On the date of the incident, a CNA reported hearing yelling in a common area and then observed the aggressive resident strike another resident in the left side of the chest. The CNA immediately intervened and separated the residents. The nurse assessed the resident who was struck and initially found no redness or bruising, with stable vital signs. The resident reported that it hurt and did not know why the other resident had hit her. Over the following days, the resident continued to complain of left chest and breast pain, with pain scores documented as high as 9–10 out of 10. Multiple assessments and diagnostic tests were performed, including chest x‑rays and pain assessments, and the resident was repeatedly administered acetaminophen and topical agents for pain. Notes documented ongoing pain, intermittent anxiety, and discoloration to the left chest. The resident’s pain and chest symptoms persisted, leading to additional diagnostic workup including a STAT chest x‑ray, EKG, troponin level, and eventually transfer to the emergency room after family involvement and insistence on hospital evaluation. In the ER, imaging identified findings including an abdominal aortic dissection and other abnormalities, and the family reported that the ER physician questioned whether the injury pattern could be related to trauma. The family member also reported that the resident had slight discoloration to the chest from being hit and that the hospital took photographs. The DON later stated that the facility did not complete a self‑reported incident to the state agency regarding the altercation between the two residents because the resident was considered not injured. The facility’s abuse policy defined physical abuse to include hitting and punching and required reporting alleged violations to the state agency within specified timeframes, including immediately but not later than two hours after an allegation involving abuse or resulting in serious bodily injury. Despite this policy and the known aggressive behaviors of the resident who struck the other resident, the facility did not self‑report the incident.
Failure to Protect Resident From Verbal Abuse by CNA
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from verbal abuse and to ensure a verbal abuse–free environment. Certified Nursing Aide (CNA) #114 had a documented history of poor customer service and unprofessional behavior, including being rude and negative toward residents and coworkers, as reflected in multiple corrective action and employee counseling forms. On at least two occasions in late 2025, CNA #114 was counseled for failing to maintain respect for residents and for poor customer service. Staff statements described ongoing concerns that CNA #114 used a rude, dismissive, and disrespectful tone with residents and staff, lacked empathy and patience when providing care, and yelled in the hallways. A specific incident involved Resident #75, who reported to the Administrator that CNA #114 had been mean to her since admission. The resident stated that when she asked for help, CNA #114 told her that if she could not learn to be patient, she would be moved to the “bad hall,” where there were more residents and it would take even longer to receive help. Other staff corroborated concerns about CNA #114’s verbal interactions with residents. A typed statement from an LPN described having to verbally educate CNA #114 about her tone of voice toward a resident in a dining room, reminding her that the facility was the residents’ home and that discussions should occur privately due to residents and family members being present. Additional staff statements from a Unit Manager and another LPN detailed observations within the preceding weeks of CNA #114 being loud, rude, and unprofessional toward both residents and staff. The Unit Manager reported witnessing CNA #114 raising her voice in hallways and discussing residents loudly enough for others to overhear, including a comment that a resident who refused a shower “stinks and needs to shower.” Another LPN reported witnessing CNA #114 yelling in the halls and at the nurses’ station on several occasions. The Director of Nursing stated that CNA #114 was no longer allowed to work on a particular unit because she was not allowed to care for a resident there and noted that other staff experienced her as rude and disrespectful when asked to complete tasks. These events occurred despite a facility policy requiring immediate reporting of suspected abuse, neglect, or related concerns to the Administrator and state authorities.
Failure to Prevent Emotional Abuse via Staff Social Media Interaction
Penalty
Summary
The facility failed to protect a cognitively intact resident from emotional/verbal abuse when a staff member engaged with the resident through personal social media and sent her an upsetting video. The resident, who had diagnoses including generalized anxiety, major depressive disorder, and insomnia and used a motorized wheelchair, reported to nursing staff that she was emotionally upset after receiving a YouTube video titled "Folgers Incest Commercial" via Facebook from an employee with whom she was Facebook friends. The video depicted a brother and sister in a romantic and sexual relationship. The resident also reported that she had used vaginal soap to eliminate odors after hearing that others had complained about her smell and posted about it on Facebook. During the facility’s investigation, the resident consistently stated that she found the video emotionally upsetting and triggering due to her personal history of sexual abuse by her father and brother during childhood. The employee acknowledged being Facebook friends with the resident and confirmed that he had sent her the video because he thought it was funny, stating he was unaware of her sexual abuse history and denying that he had made any comments about her body odor. The DON and Administrator confirmed that the investigation substantiated that the employee had sent the incest-themed video to the resident via social media, and the facility concluded that the employee’s actions were emotionally abusive and upsetting to the resident.
Failure to Remove Impaired LPN Resulting in Widespread Missed Medications and Care
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from neglect by allowing an LPN who appeared to be under the influence of an unknown substance to continue providing care and medications throughout a full shift. Multiple residents and staff observed the LPN on a specific date appearing impaired, including falling asleep while standing, dozing off mid-conversation, appearing disheveled and very tired, and dropping medications on the floor before administering them. Residents reported late medication administration and, in at least one case, receiving pain medication after it had been dropped on the floor. Staff, including another LPN and a CNA, repeatedly contacted the on‑call manager (an LPN) to report the LPN’s erratic behavior and residents’ complaints about not receiving medications, tube feedings, treatments, and other ordered interventions. Despite these reports, the impaired LPN was not removed from resident care during that shift, and the DON and Administrator were not directly notified of the extent of the behavior on that date. The on‑call LPN spoke with the impaired LPN by phone, accepted the explanation that the LPN was tired from lack of sleep, and did not escalate the concerns to the Administrator that day. The DON later stated she was not made aware of the full extent of the erratic behavior at the time and confirmed that the LPN completed the scheduled shift and returned to work the following day. Residents subsequently reported the LPN’s behavior and the missed or improperly administered medications to the DON and Administrator. Record review showed that numerous residents assigned to this LPN did not receive multiple physician‑ordered medications, treatments, assessments, monitoring, and safety interventions during that day shift. For example, one cognitively intact resident with alcohol abuse, depression, anxiety, HTN, insomnia, and vitamin deficiencies did not receive ordered doses of cholecalciferol, cyanocobalamin, hydrochlorothiazide, paroxetine, or a required pain assessment. Another resident with severe cognitive impairment, anoxic brain damage, heart failure, CKD3B, chronic respiratory failure, seizures, PBA, depression, anxiety, and dysphagia missed multiple cardiac, antiplatelet, anticonvulsant, psychotropic, pain, and behavioral medications, as well as ordered head‑of‑bed elevation, pain assessment, behavior monitoring, diet communication, and clothing interventions. Additional residents with complex conditions such as anoxic brain damage with PEG tube and tracheostomy, severe malnutrition, COPD, DM2, CVA, seizures, CHF, prostate cancer, and other chronic diseases did not receive ordered cardiac, anticoagulant, antiplatelet, respiratory, diabetic, seizure, GI, nutritional, and pain medications, PEG tube feedings and flushes, oxygen saturation checks, blood glucose monitoring, insulin administration, head‑of‑bed elevation, enhanced barrier precautions, behavior monitoring, and safety signage during that shift, as confirmed by the DON through EMR, MAR, and TAR review. The DON verified that, for each of the affected residents, the specific physician‑ordered medications and treatments listed in the EMR, MAR, and TAR were not provided during the day shift covered by the impaired LPN. These omissions included, but were not limited to, antihypertensives (such as amlodipine, carvedilol, lisinopril, metoprolol, minoxidil), antiplatelet and anticoagulant agents (aspirin, clopidogrel, apixaban), anticonvulsants (levetiracetam, valproic acid, clobazam, Depakote Sprinkles), psychotropics and anxiolytics (sertraline, duloxetine, quetiapine, buspirone, diazepam, paliperidone), diabetic medications and insulin (metformin, glipizide, insulin glargine, insulin aspart), respiratory medications and inhalers (Anoro Ellipta, Breo Ellipta, Incruse Ellipta), GI agents and supplements (omeprazole, pantoprazole, lactulose, MiraLAX, Jevity tube feedings, PEG flushes, vitamins, potassium, magnesium), pain medications and lidocaine patches, as well as ordered assessments such as pain scales, behavior monitoring, head‑of‑bed elevation, oxygen saturation checks, blood sugar checks, PEG placement and residual checks, diet communication, enhanced barrier precautions, and safety signage. These documented failures occurred while the LPN was reported by residents and staff to be acting impaired and while the facility did not effectively intervene to remove the LPN from resident care or ensure completion of the ordered care during that shift.
Failure to Protect Cognitively Impaired Hospice Resident From Physical Abuse by CNA
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from physical abuse. The resident had diagnoses including neurocognitive disorder with Lewy Bodies dementia, generalized anxiety disorder, and late-onset Alzheimer’s disease, and was receiving hospice services. An admission MDS showed severe cognitive impairment and a need for maximum assistance with toileting hygiene, and the care plan documented self-care deficits and functional decline requiring staff assistance with ADLs. On the evening of the incident, a nursing progress note documented that a skin sweep revealed no areas of concern, no signs of pain or distress, and that the resident was resting in bed, with no indication that the family had reported abuse or provided an in-room video at that time. Video surveillance from the resident’s room on the date of the incident showed multiple interactions between the resident and a CNA. In one video, the CNA entered the room and kicked the right side of the resident’s mattress twice with her right foot, causing the resident’s legs to lift up and down with each kick, then removed the covers without speaking. The resident stated, “You don’t like me,” to which the CNA replied, “Yes, I do,” and then walked toward the bathroom door; when the resident repeated, “No, you don’t like me,” the CNA did not respond. In another video, the CNA entered, pulled back the covers, and tapped the resident’s left leg with a gloved fist without appearing to speak, while the resident’s hands were up as if in confusion, and the CNA left the room without further interaction, leaving the resident appearing confused. A third video showed the CNA providing incontinence care. During this care, the resident repeatedly expressed gratitude and positive comments such as “Thank you,” “I like you a lot,” and “You’re so good at what you do,” without receiving any verbal response from the CNA. Later in the same video, the CNA told the resident to stand up; as the resident moved toward the edge of the bed and asked for clarification, the CNA, walking toward the bathroom, told her in a loud and aggressive tone to “Hold on, hold on.” When the resident attempted to get out of bed and placed her leg on the wheelchair seat, the CNA told her “No, sit down” and then ordered her in a loud aggressive manner to “Sit back.” A police report documented that the family reported seeing, via an in-room camera, the CNA appear to strike the resident’s leg with her hand and, in a second video, appear to either kick the resident’s leg twice or kick the mattress more forcefully than the hand strike. The police officer viewed the videos, spoke with the CNA, and noted the CNA denied striking the resident, stating she had used the bed frame to scratch an itchy foot while wearing gloves and that she did not lose her temper or patience. The facility’s self-reported investigation described the CNA contacting the bed frame with her foot in a non-aggressive manner and touching the resident’s leg as a cue during care, and concluded the allegation as unsubstantiated. However, interviews with facility staff, including an LPN and an RN coordinator who viewed the videos, described the CNA’s actions as an aggressive slap to the leg and a purposeful kick to the bed, and indicated they did not feel the CNA’s care was appropriate. Additional documentation showed that a skin assessment the day after the incident identified a skin tear to the resident’s left pinky toe, later documented as a scratch to the right foot pinky toe with treatment ordered and then discontinued when healed. Interviews revealed that another CNA working on the unit was not asked for a witness statement, the resident was unable to provide information due to severe cognitive impairment, and the social worker reported the resident was not provided psych services following the incident. The hospice RN stated hospice was not notified of the abuse allegation, and the medical director did not recall being notified. The facility’s abuse, neglect, exploitation, and misappropriation policy required investigation of all alleged violations and immediate reporting to the administrator and, when a crime is suspected, to law enforcement. The surveyors determined that the facility failed to ensure the resident was free from physical abuse based on the observed actions on video and corroborating staff interviews.
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