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F0600
D

Failure to Protect Residents from Verbal and Physical Abuse

Woodburn, Kentucky Survey Completed on 05-15-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to protect residents from verbal and physical abuse in two separate incidents involving two residents. In the first incident, a resident with a history of anxiety disorder, hypertension, and psychosis, and who was assessed as cognitively intact, reported that a Kentucky Medication Aide (KMA) spoke to her in a demeaning manner, pointed a finger in her face, and used aggressive language. This event was corroborated by a staff member who witnessed the KMA being verbally aggressive and cussing at the resident. The KMA's behavior was later substantiated as verbal abuse following an internal investigation. In a second incident, another resident, also assessed as cognitively intact, was physically struck on the head by a fellow resident who had severe cognitive impairment and diagnoses including dementia with agitation, schizophrenia, and Alzheimer's disease. The physical contact was witnessed by a State Registered Nursing Assistant (SRNA), who immediately separated the two residents. The resident who committed the act had a history of behavioral issues and was known to require increased supervision due to frequent emotional outbursts and episodes of aggression. Both incidents were verified through review of medical records, staff and resident interviews, and facility investigation reports. The facility's policies required residents to be free from all forms of abuse, including verbal and physical abuse, but these policies were not effectively implemented in these cases, resulting in residents being subjected to abuse by both staff and another resident.

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