Failure to Protect Resident from Sexual and Physical Abuse by Another Resident
Summary
The facility failed to protect a cognitively impaired resident from sexual and physical abuse by another resident with a known history of sexually inappropriate, agitated, and hostile behaviors. The resident who was abused had diagnoses including schizoaffective disorder, bipolar disorder, Alzheimer's, and major depressive disorder, and was assessed as having moderate cognitive impairment. The perpetrating resident had diagnoses of anxiety disorder, mild intellectual disabilities, and was newly diagnosed with hypersexuality. This resident had a documented history of making sexually inappropriate statements, attempting to enter other residents' rooms, and displaying aggressive behaviors toward both staff and other residents. Despite the perpetrating resident's ongoing behavioral issues, including documented incidents of sexual aggression and physical violence, the facility did not implement adequate interventions or monitoring as outlined in their own policies and behavioral health recommendations. The care plan for the perpetrating resident identified inappropriate sexual behaviors and wandering, but interventions were limited to behavior monitoring without clear evidence of effective preventive strategies. Staff and leadership were aware of the resident's behaviors, including recent threats to staff, but failed to communicate these risks effectively or to update care plans and interventions accordingly. The incident occurred when the perpetrating resident entered the victim's room, physically assaulted her, and committed sexual abuse. The event was witnessed by an LPN, who intervened and separated the residents. The victim was assessed and sent to the hospital, where a sexual assault was confirmed. Law enforcement was notified, and the perpetrating resident was arrested. The facility's failure to implement and communicate appropriate interventions and to follow up on behavioral health recommendations directly contributed to the occurrence of this abuse.
Removal Plan
- R48 was assessed for injury, changes in behavior, trauma, and pain. NP gave orders to send R48 to the Hospital for evaluation and treatment. The patient was sent to the hospital for evaluation and treatment. MD and family were notified. R48 was discharged back to the center from the hospital. Center nurses began observation on the patient to ensure feelings of safety with no noted distress. Patient had a visit with behavioral health for a psychosocial support visit. Patient refused to see the behavioral health NP. Patient did have visit by hospice. Behavior health visit for the patient completed.
- R121 was immediately removed from R48 room by the LPN Charge Nurse and placed on one-on-one observation by a CNA until police arrived at the center to test the patient. Patient R121 was arrested.
- Skin audits were conducted on all residents to evaluate for any signs of abuse by the facility charge nurses and nurse managers. R48 noted with bruising to the thigh. No other adverse findings for other patients were audited.
- Resident with BIMs of 10 and above were interviewed by licensed nursing staff.
- In-service education was initiated for staff and to include abuse prohibition, abuse reporting, burnout, and de-escalation for all staff of the facility. Education was provided by the Administrator, Director of Nursing (DON) Assistant Director of Nursing (ADON), Nurse Manager, or Social Services Director.
- A Resident Council Meeting was held. Abuse & Neglect Prevention to include Residents Rights reviewed by Activities Director. R48 was in attendance at the meeting.
- Interviews were completed on all residents who are interviewable to identify any concerns for abuse by the Social Services Director, Director of Nursing (DON), Activity Director (AD), and Nurse Managers. All denied any type of abuse or neglect.
- R48 was interviewed by the Administrator. Expressed no problems at this time and was happy and planning to attend activities.
- A Root Cause Analysis was completed for the Abuse Prevention. Root Cause identified that the center failed to implement interventions to protect the residents as outlined on the behavior health visit. A communication tool was developed to improve the communication between the behavior provider and center to provide notification of any recommendations timely. The behavior provider will meet with the DON, ADON, and or nurse supervisor upon entrance and exit to make aware of any new recommendation and to receive report of new adverse events. Education of this process has been provided to the nurse leadership, SSD, and behavior provider by the DON.
- Education was provided to all cognitive residents regarding the Elder Justice Act and reporting of abuse by the Social Services Director and the Director of Social Services.
- Education provided to the center leadership team by the Governing Body on abuse prohibition policy to reviewing adverse events during Quality Assurance Performance Improvement (QAPI), recognizing trends to create proactive measures to reduce further reoccurrences, and utilization of non-pharmacological interventions as warranted for patients to promote safety of all patients.
- Re-education was completed for staff and to include abuse prohibition, abuse reporting to include physical and sexual aggression, burnout, and de de-escalation for all staff of the facility. Education was provided by the Director of Nursing (DON) Assistant Director of Nursing (ADON), Nurse Manager, or Social Services Director. All staff have been in serviced which totals 100%. No staff shall work until they have completed in-service education. Contract and newly hired associates will be educated upon hire on abuse prohibition, abuse reporting, burnout, and de-escalation by the Nurse Manager, DON, or ADON.
- Audits started by the social service director to interview residents to ensure they feel safe, and associates' interviews have been completed to ensure they know the process for reporting and can identify abuse, including sexual and physical aggression. Any noncompliance identified will be addressed by the Administrator assistant and/or [NAME] by written education, and incidents identified will be reported following the HFRD reporting protocol.
- The DON, Financial Controller, and Nurse Managers notified all current non-interviewable resident representatives via written notification on Abuse & Neglect Prevention Policy, and the Elder Justice Act and reporting.
- An ADHOC QAPI meeting was held with the Medical Director, center leadership, and Governing Body to notify of the deficiencies cited and the interventions implemented to ensure that the deficient practices do not reoccur. The Abuse Policy was reviewed with no needed revisions needed.
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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