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F0600
D

Failure to Protect Resident from Physical and Sexual Abuse by CNA

Warsaw, Missouri Survey Completed on 06-20-2025

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

Facility staff failed to protect a resident from physical and sexual abuse when a Certified Nursing Assistant (CNA) pinched and twisted the resident's chest. Two nursing assistants witnessed the incident, with one describing the action as physical abuse and the other considering it sexual abuse due to the intimate area involved. The incident occurred while the resident, who has severe cognitive impairment, traumatic brain injury, and behavioral symptoms such as inappropriate comments and sexual inappropriateness, was in bed and being assisted by staff. The CNA in question did not assist with care but instead engaged in the inappropriate conduct after the resident reportedly grabbed at the CNA. The facility's policy strictly prohibits abuse, including physical and sexual abuse, and defines such actions as willful infliction of injury or non-consensual sexual contact. The resident's care plan noted behaviors such as exposing the chest and sexual inappropriateness, with staff directed to use redirection and calm communication. Despite these measures, the CNA's actions violated the policy and resulted in the resident not being protected from abuse.

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