Failure to Investigate Fracture of Unknown Origin
Summary
The facility failed to ensure that a resident, who was cognitively impaired and had a diagnosis of aphasia, received the necessary protective oversight to prevent potential abuse and/or neglect. The resident experienced a fracture of unknown origin, which was not identified or investigated as a potential abuse or neglect situation. The resident had a history of wandering behaviors and was noted to have a non-injury fall, after which multiple assessments reported no apparent injury. However, later observations revealed the resident limping with a swollen knee, leading to an X-ray that initially showed no remarkable findings. It was only after the resident's pain intensified that a hip X-ray was conducted, revealing a fracture. The facility's staff failed to initiate an investigation to determine the cause of the fracture, which was a serious injury of unknown origin. Despite the resident's severe cognitive impairment and inability to communicate effectively, the facility did not implement protective measures to prevent ongoing abuse while an investigation was conducted. The resident's care plan documented various diagnoses, including dementia, osteoporosis, and a history of falls, but the facility did not adequately address these risks or update the care plan to reflect the resident's need for increased assistance. Interviews with facility staff revealed a lack of awareness and action regarding the resident's condition and the potential for abuse or neglect. The facility's abuse policy required thorough investigation of all allegations, but the staff did not suspect abuse or neglect and did not report the incident to the appropriate authorities. The facility's failure to identify and investigate the fracture as a potential abuse or neglect situation placed the resident in immediate jeopardy.
Removal Plan
- R65 is being monitored every shift using the appropriate pain scale.
- Staff conducted an immediate observation of R65 for identification of any current injuries as appropriate, and ongoing monitoring of R65 and other residents at risk, including conducting unannounced management visits.
- The Administrator will notify any alleged violations to the appropriate agency or law enforcement authority.
- An immediate assessment would be conducted on any resident with cognitive deficit issues if any signs of pain, discomfort, or alteration in the skin such as bruising, or discoloration are identified.
- If any of the above is identified, then a formal investigation will be initiated by the DON/ and or designee.
- Conduct interviews with cognitively intact residents to ensure residents are free of abuse, neglect, and exploitation.
- The facility enhanced its internal incident reporting and escalation program, by creating a real-time notification system for staff, visitors, or residents to utilize.
- Enhanced reporting program includes a focus for falls, abuse, and unusual occurrences/injuries of unknown source.
- Upon completion of the incident report, automated notification will be provided to facility leadership including but not limited to the Administrator and DON.
- The facility created an informational flyer displaying the internal incident reporting program and provides a QR code that can be scanned for immediate reporting/escalation.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Failure to Investigate Allegation of Misappropriation: A resident with COPD, anxiety, and PTSD reported $1,600 missing and believed another resident had taken the money, but the SSD told him it was too late to investigate. The grievance record and reporting portal contained no misappropriation report for the resident, and the CNO recalled hearing about missing funds from a family member but did not follow up, while the CEO stated the allegation should have been reported and investigated.
The facility failed to complete a thorough investigation after a resident sustained a 7 cm penile laceration associated with a condom catheter. The resident had a stroke, contractures, cognitive communication deficit, and non-healing pressure ulcers, and the incident record lacked a full investigation or staff statements to determine the root cause and rule out abuse or neglect.
Incomplete Abuse Investigation: The DON investigated an allegation that a resident with dementia, depression, and a prior femur fracture was treated roughly during a shower, but only interviewed one CNA named on the abuse report. Another CNA was also assigned to the resident and documented providing the shower, yet was not interviewed, and no other residents cared for by either CNA were interviewed. The facility's abuse policy required thorough investigation, including staff and resident interviews, and the DON stated the policy was not followed.
Incomplete Investigation of Alleged Staff-to-Resident Sexual Abuse: The facility failed to thoroughly investigate an allegation that a CNA raped a resident during incontinence care. The resident, who had intact cognition and significant medical diagnoses, reported genital and anal touching and later said embarrassment affected how they described the event. The record lacked a written or recorded resident statement, and the facility concluded abuse did not occur based on conflicting accounts rather than documenting a comprehensive investigation of all evidence.
The facility failed to thoroughly investigate two resident abuse allegations. In one case, an altercation with a scratch injury was recorded as an accident/incident, but the final report had no abuse conclusion and the Abuse Coordinator did not interview the residents, observe the injury, or document staff witness statements. In another case, the final report also lacked a conclusion, interview notes could not be produced, and CNAs who were present or witnessed the altercation were not interviewed despite progress notes showing CNA presence.
Failure to Thoroughly Investigate Allegations of Neglect and Possible Abuse: A resident with significant care needs alleged a CNA left her on a bedpan too long, spilled urine/feces in bed, and performed an unsafe hoyer transfer, while another resident was heard screaming during a one-person hoyer transfer. The facility did not complete a thorough abuse/neglect investigation because it did not interview the second resident, other potentially affected residents, or assess non-interviewable residents.
Failure to Investigate Allegation of Misappropriation
Penalty
Summary
The facility failed to ensure an allegation of misappropriation was investigated as required for Resident #23, who was admitted with diagnoses including COPD, anxiety, and PTSD. Resident #23 stated that approximately two months earlier he reported $1,600.00 missing to the SSD and told the SSD he believed another resident had taken the money. He reported that when he explained the incident had occurred about one and a half months earlier, the SSD told him it had been too long ago to investigate. Review of the facility grievance records from February 2026 through June 2026 showed no documented allegation of misappropriation involving Resident #23, and review of the Long-Term Care Reporting Portal showed no report of misappropriation involving him. The CNO stated she recalled a family member mentioning Resident #23's missing funds but did not ask further questions, and the CEO stated the allegation should have been reported and investigated for potential misappropriation.
Incomplete Investigation of Penile Laceration
Penalty
Summary
The facility failed to conduct a thorough investigation to rule out the potential for abuse or neglect for one resident after a penile laceration was identified in connection with a condom catheter. The resident had diagnoses including stroke, contractures, cognitive communication deficit, and non-healing pressure ulcers of the buttocks and coccyx, and the condom catheter had been used to decrease moisture and help prevent worsening of the coccyx/buttocks wound healing. During review of the incident, the resident was found to have a 7 cm laceration of the penis from the condom catheter. The catheter had become dislodged during an assessment when the nurse aide noted low urine output, and the nurse supervisor later had an LPN reapply a new condom catheter. The facility’s incident documentation did not include a full investigation or staff statements to identify the root cause of the laceration and rule out abuse or neglect, and the Nursing Home Administrator confirmed that the investigation was not completed thoroughly.
Incomplete Abuse Investigation
Penalty
Summary
The facility failed to thoroughly investigate an allegation of abuse involving one resident who was admitted with diagnoses including a right femur fracture, difficulty walking, dementia, and depression. The resident reported that a CNA who assisted with her shower was "very rough," had "pushed me around," and became "nasty" when questioned. The allegation was documented in the facility's incident report and reported on the SOC 341 as suspected dependent adult/elder abuse. The DON stated she investigated the allegation and interviewed only CNA 1 because CNA 1 was named on the SOC 341 report and was believed to be involved based on staffing. However, the record showed CNA 2 was also assigned to the resident and documented that she showered the resident on the date of the alleged incident. CNA 2 was not interviewed, and no other residents cared for by CNA 1 or CNA 2 on that date were interviewed. The facility's policy required all allegations to be thoroughly investigated, including interviews with staff on all shifts who had contact with the resident and interviews with other residents cared for by the accused employee, and the DON stated the policy was not followed.
Incomplete Investigation of Alleged Staff-to-Resident Sexual Abuse
Penalty
Summary
The facility failed to conduct a thorough investigation of an allegation of staff-to-resident abuse for 1 of 1 residents reviewed for abuse. The resident, who had diagnoses including obstructive and reflux uropathy and hemiplegia and hemiparesis following cerebral infarction, was documented as having intact cognition. The allegation involved a CNA during incontinence care, and the resident reported that the CNA raped them and touched and rubbed their genital and anal area, causing them to feel unsafe in the facility. The facility’s investigative record did not include a written or recorded statement from the resident detailing the allegation, limiting the ability to objectively investigate the complaint. The facility’s accident/incident report documented that the resident told an LPN they had been raped, and an RN supervisor noted redness in the perineal area during assessment. However, the report also stated the facility concluded abuse did not occur because the resident gave conflicting statements, rather than documenting a comprehensive investigation of all available evidence. Additional statements in the record showed the resident later explained they felt embarrassed and ashamed when law enforcement and a male nursing supervisor were present, which affected how they described the event. The CNA stated they provided incontinence care and applied ointment, but denied doing anything beyond what was requested. The DON stated the facility obtained a statement from the resident, while the RN supervisor stated no statement was obtained or documented from the resident.
Incomplete Abuse Investigations and Missing Conclusions
Penalty
Summary
The facility failed to thoroughly investigate allegations of abuse involving two separate resident altercations. For one incident involving two residents, the final Facility Reported Incident classified the event as an accident/incident rather than resident abuse, even though the report documented an alleged altercation and that one resident sustained a scratch on the right cheek requiring first aid. The final form did not include a conclusion stating whether abuse or assault did or did not occur. During review of the investigation file, the Administrator, who was also the Abuse Coordinator, could provide only the initial and final reports submitted to the state survey agency and could not provide additional evidence such as staff interviews, witness statements, or documentation of observations after the alleged abuse. She stated she did not interview either resident, did not observe the injured resident’s scratch, and only spoke with the ADON and an RN, both of whom said they did not witness the altercation. She also did not attempt to interview a CNA she believed may have pulled the injured resident from the other resident’s room, and there was no documentation showing staff interviews were completed. The injured resident’s EHR also did not show documentation of the scratch assessment, appearance, treatment orders, or any documentation that the abuse with injury occurred. A second altercation between two other residents was also not thoroughly investigated. The Administrator and DON provided only the initial and final reports and resident face sheets, and the final report did not include an investigation conclusion. Although the Administrator stated she had completed all interviews before submitting the final report, she could not produce handwritten interview notes or other investigation documentation. One resident said he discussed the incident with staff present at the time, while another resident could not recall the altercation. A CNA stated she was present during the incident and was never interviewed, and another CNA stated he witnessed the incident and reported it to the ADON but was never interviewed by the Administrator. Progress notes for both residents documented CNA presence during the altercation, yet the Administrator stated she did not interview any CNAs because she was told none were present. The facility policy required prompt and aggressive investigation of all abuse allegations, including interviews of the reporter, anyone with direct knowledge, and the resident if interviewable, and required the final report to contain a conclusion based on known facts.
Failure to Thoroughly Investigate Allegations of Neglect and Possible Abuse
Penalty
Summary
The facility did not thoroughly investigate allegations of abuse and neglect involving two residents. One resident, who had complex regional pain syndrome, mononeuropathy, muscle wasting and atrophy, pruritus, and required assistance with personal care, submitted a written grievance stating that a CNA left her on a bedpan for over an hour, questioned her about re-wearing a soiled brief, spilled the bedpan in bed, attempted a hoyer transfer without ensuring the sling was properly secured, and did not clean her skin after she had lain on a wet pad. The resident and her representative described the event as neglect, and the facility’s self-report also documented the allegation as neglect. A second resident, who had rheumatoid arthritis, polyneuropathy, non-[NAME] lymphoma, osteoarthritis, and dependence on enabling machines and devices, was heard screaming from behind a closed bedroom door while a CNA was transferring her alone with a hoyer lift. Staff reported hearing the resident yell, "Help me" and "Oww," and when they entered the room they found the resident in the lift and sling, leaning to one side, while the CNA was unhooking her. The resident’s care plan required two staff for bed mobility, toileting, and hoyer transfers. The facility’s investigation did not include a statement or interview from the second resident, did not include interviews of other residents cared for by the CNA during the shift, and did not include skin assessments of non-interviewable residents who may also have been affected. Facility leadership later stated the investigation was not thorough and should have included those interviews and assessments. The acting administrator also stated that hearing a resident screaming behind a closed door would make her suspicious of abuse, and that the incident should have been investigated as an additional allegation involving the same CNA.
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