Failure to Prevent Resident Abuse by Staff
Penalty
Summary
The facility failed to protect residents from verbal and physical abuse, as evidenced by multiple incidents involving a certified nurse aide (CNA). One resident with severe cognitive impairment and multiple diagnoses, including dementia and depression, was subjected to deliberate agitation by a CNA during a shower, resulting in the resident spitting at the CNA, who then retaliated by throwing a towel at the resident's face and head. This incident was substantiated through staff witness reports and facility investigation. Additional incidents involved the same CNA exhaling vapor from a nicotine vaping pen into the face of another severely cognitively impaired resident during incontinence care, and verbally abusing a third resident by telling them to "go find a bridge to jump off of" when the resident expressed confusion in the hallway. These actions were reported by another CNA and confirmed through interviews and investigation. The facility's policy prohibits abuse, neglect, and exploitation, but these events demonstrated a failure to ensure residents were free from such mistreatment.