Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
The facility failed to protect residents from abuse and neglect by not properly investigating grievances and ensuring timely care. One resident with quadriplegia and total dependence on staff for activities of daily living reported being left in a wet brief for four hours after requesting incontinence care. The resident also reported that a CNA repeatedly turned off his call light and failed to return in a timely manner, with similar incidents occurring in the past. Staff interviews confirmed the delay in care, and facility leadership acknowledged the incident should have been investigated as neglect. Another resident with severe cognitive impairment was the subject of a grievance after a CNA was heard yelling and making condescending remarks, such as telling the resident to go to her room and accusing her of seeking attention. Multiple staff reported the CNA used a stern or loud tone, which was disruptive and could be perceived as scolding, though the facility's investigation did not substantiate abuse. Additionally, a third resident with cognitive and physical impairments was left in a stool-filled brief for an extended period after unsuccessfully seeking assistance from a CNA. The facility did not determine why the resident was not changed as requested, and the resident expressed increased sadness and frustration related to care provided.