Failure to Secure Residents During Van Transport Results in Neglect
Summary
The facility failed to protect two residents from neglect during transportation to medical appointments in the facility van. One resident, a male with diabetes, flaccid hemiplegia, and moderate cognitive impairment, was not secured with a seatbelt while being transported in his wheelchair. Despite requesting the seatbelt, the transport aide did not secure him, stating she did not like the seatbelt. During the trip, the aide had to brake suddenly due to traffic, causing the resident to fall out of his wheelchair onto the floor of the van. The resident remained on the floor for approximately 30 minutes until returning to the facility, where it took four staff members to assist him out of the van. The resident reported feeling unsafe and stated the aide was aware of his need for a seatbelt but failed to provide it. Another resident, a female with cerebral infarction, bilateral above-knee amputation, diabetes, and end-stage renal disease, was also transported without being secured by a seatbelt. She reported asking the transport aide to use the seatbelt, but the aide claimed it did not work. During the trip, the aide braked suddenly, and the resident had to brace herself to avoid falling out of her wheelchair. The resident expressed feeling unsafe and unwilling to be transported by the same aide in the future. Both incidents involved the same transport aide, who had received training and return demonstrations on securing residents and using seatbelts but failed to follow procedures during actual transports. Interviews with facility staff and review of training records revealed that the transport aide had been trained and checked off on competencies related to securing wheelchairs and using seatbelts. However, the aide stated she was unsure how to secure residents with seatbelts and did not feel properly trained, despite documentation of completed training and return demonstrations. The facility's policies required staff to ensure residents were safely secured during transport, but these procedures were not followed, resulting in residents being placed at risk of injury. The facility identified these failures as neglect, as defined in their policy, due to the lack of necessary services to prevent physical harm and emotional distress.
Removal Plan
- Resident #10 was assessed by the charge nurse for injuries, physician was notified, orders for x-rays were obtained, and responsible party was notified.
- Residents with appointments requiring wheelchair transport were identified as affected by use of the current van.
- Safe Surveys were conducted with other residents transported by facility staff in wheelchairs and those not in wheelchairs.
- Van driver was retrained on facility safety procedures for strapping residents into the wheelchair using tie downs and seatbelts by another staff member.
- Nursing Home Administrator observed retraining of van driver by a more senior staff member with van experience.
- Facility van was removed from service for transporting residents in wheelchairs.
- Van will not be put back in service until the complete restraint system, including seatbelts for wheelchairs, is replaced.
- Facility purchased a new van; residents requiring wheelchair transport will be transported by sister facilities until all staff are checked off for operations of the new van.
- Administrator, surveyor, and two facility-approved drivers observed sister facility driver demonstrate wheelchair tie downs and seat belting prior to transporting a resident.
- One of the facility's van drivers accompanied the resident and the driver on the appointment.
- Administrator reviewed van driver competencies completed on the vehicle.
- Residents will not be transported in the existing van in a wheelchair until after the restraint system is updated and all drivers are checked off on securing the wheelchair with tie downs and seatbelt system.
- Both van drivers have been in-serviced not to use the wheelchair van until the system for securing wheelchairs is replaced and competencies with return demonstration are completed by the NHA/designee.
- Van driver was suspended pending investigation.
- Van was inspected by a company specializing in wheelchair transport vehicles; technician stated system is functioning but old and needs updating.
- NHA called and emailed to request the inspection report.
- NHA/designee in-serviced all staff on state provider letter regarding Abuse, Neglect, Exploitation, Misappropriation of resident property, and other incidents.
- All staff, including new hires and agency, are required to complete the in-service prior to starting their next scheduled shift.
- NHA/designee in-serviced all staff that drive the van on safety and emergency procedures with a post-test; staff who fail the post-test will be retrained and retested.
- Staff will not be allowed to operate the facility van until they have successfully passed the post-test.
- NHA/designee performed competencies and return demonstration on emergency procedures, operating the wheelchair lift, test driving, and reviewing a YouTube video for strapping the wheelchair and buckling the person in the wheelchair for all transport staff.
- Staff will be suspended from driving until competencies are passed; competencies with return demonstration will be completed on hire, annually, and as needed.
- NHA and Regional Nurse Consultant reviewed the Van Driver Orientation List and added instructions for emergency procedures, including procedures for if a resident falls out of seat or chair (pull over, call 911, notify NHA).
- NHA/designee will conduct audits with observation for proper securement of wheelchair and seatbelt use.
- NHA/designee will interview residents transported by facility staff using a set of safety-related questions.
- Ad-Hoc QAPI held with Medical Director, NHA, DON, ADON, Regional Nurse Consultant to review the alleged deficiency, policy and procedure, and the plan of removal of immediacy.
- NHA will be responsible for ensuring the plan is completed.
- RDO/designee will provide oversight by observation and record reviews to ensure the plan of removal items are reviewed and completed, continuing monitoring.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A resident with a history of CVA, depression, anxiety, and moderate cognitive impairment, whose care plan included emotional support and reassurance, was involved in an incident where an RN reacted to the resident’s loud swearing and use of religious profanity by stating she was consecrated to the Lord and then spraying holy water twice in the resident’s direction from a spritzer bottle the RN carried. The resident had not agreed to this, was visibly bothered, and later reported to an LPN that someone had sprayed her in the face with something. The RN admitted to the LPN that she sprayed holy water at the resident because of the resident’s use of the Lord’s name in vain, and the resident became very agitated and confrontational afterward, leading to a finding of staff-to-resident physical abuse and inappropriate treatment.
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.
Staff-to-Resident Abuse Involving Spraying Holy Water Without Consent
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from staff-to-resident physical abuse when an RN attempted to spray holy water on the resident without consent. The resident had been admitted with diagnoses including hemiplegia, hemiparesis, aphasia following cerebral infarction, major depressive disorder, anxiety disorder, and a need for assistance with personal care. The resident’s care plan addressed depression with interventions such as reassurance, diversional activities, decreased stimuli, and allowing the resident to vent feelings, and also addressed emotional issues related to a prior CVA. A quarterly MDS assessment documented moderate cognitive impairment and no physical or verbal behaviors. The incident occurred when the resident was conversing with another resident, during which they were swearing, using curse words, and laughing. According to the RN’s own statement, the two residents were swearing loudly and using an explicit word alongside the name of Jesus. The RN reported that she reminded them to be quieter because it was late. When the resident began to “insult the Lord,” the RN told the resident that this hurt her because she was consecrated to the Lord and then stated she had holy water that might help the resident be nicer. The RN had a spritzer bottle of holy water on her person that she used on herself and then spritzed it twice in the direction of the resident from about six feet away. The resident did not agree to this action and was visibly bothered by it. The resident subsequently reported to an LPN that someone had sprayed her in the face with something. The LPN then approached the RN at the nurse’s station, and the RN admitted she had sprayed the resident with holy water due to the resident using the Lord’s name in vain. The RN further reported that the resident became very agitated, red-faced, pointing, swearing, and continued to threaten the RN’s safety after the spraying. The facility determined that the RN did not provide appropriate behavioral intervention and that the conduct constituted inappropriate treatment and physical abuse related to the imposition of religious beliefs and spraying holy water toward the resident without consent.
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.
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