Failure to Identify and Investigate Allegations of Abuse
Penalty
Summary
The facility failed to identify and investigate allegations of abuse for 14 out of 14 residents who reported grievances that included potential abuse or neglect. Multiple residents and their family members submitted grievances describing incidents where staff told them to use the bathroom in their briefs or diapers due to lack of time, denied assistance with toileting, or made dismissive and inappropriate remarks. In several cases, residents reported being humiliated, embarrassed, or feeling like they were not cared for, and some described being forced to self-transfer or forego showers and personal care due to staff inaction. Despite these grievances, the facility did not recognize the complaints as potential abuse or neglect, and no formal investigations were conducted. Instead, the facility treated these reports as customer service or staffing issues, providing staff education or reassigning staff without initiating abuse protocols. In some cases, there was no documented resolution at all. The administrator and DON both confirmed in interviews that they did not consider these grievances as allegations of abuse, even when residents described psychosocial harm or direct statements from staff instructing them to soil themselves due to lack of assistance. The affected residents included individuals who were cognitively intact and able to articulate their needs and experiences, as well as those who required assistance with activities of daily living. Several residents expressed emotional distress, humiliation, and a loss of dignity as a result of staff actions and the facility's failure to respond appropriately. The lack of investigation into these allegations represents a failure to protect residents from potential abuse and to comply with regulatory requirements for reporting and investigating such incidents.