Failure to Prevent Neglect and Abuse Due to Inadequate Skin Management and Staff Conduct
Summary
The facility failed to develop and implement a comprehensive and individualized skin management program, resulting in neglect of two residents with significant medical needs. One resident, who was severely cognitively impaired and dependent on staff for care, developed a worsening wound on the left lateral foot. Despite care plan interventions for skin breakdown prevention, weekly wound reports documented the wound's decline without evidence of physician notification or wound treatments being implemented. The wound nurse only worked one day per week, did not notify the physician, and did not add treatment orders to the treatment administration record. The resident's wound deteriorated to the point of severe sepsis, requiring hospital transfer and resulting in the resident not returning to the facility. Another resident, with end stage renal disease, diabetes, and a history of amputation, developed a right heel ulcer that was first identified by the dialysis center. The dialysis center attempted to communicate the finding to the facility multiple times without success. Facility staff continued to document no new skin issues in weekly assessments, and the physician was not made aware of the ulcer. The ulcer progressed to wet gangrene and necrotizing infection, ultimately requiring an above-the-knee amputation after hospital transfer. Interviews revealed that nursing staff were unaware of the wound, had not performed or documented required skin assessments, and failed to communicate changes in the resident's condition. Additionally, the facility failed to protect two other residents from verbal abuse by staff. In one case, a CNA was verbally aggressive and threatened a resident during an argument, as corroborated by multiple witness statements. The facility's investigation into the incident was delayed, and staff failed to intervene appropriately during the altercation. These deficiencies affected four residents and were substantiated through medical record review, interviews, and facility policy review.
Removal Plan
- Resident #46 was transferred to the hospital and did not return to the facility.
- Resident #20 was transferred to the hospital for emergent treatment. The resident returned to the facility. Upon return, Resident #20 was re-assessed for pressure injury risk with a Braden scale, a skin assessment was completed, pressure reducing device were ordered and implemented and weekly skin assessments and wound care chart audits were implemented.
- The Director of Nursing (DON) and Assistant Director of Nursing (ADON) #504 completed assessments on all residents.
- Regional Nurse #566 educated the DON and ADON #504 on wound identification, staging and dressing changes.
- The facility initiated a plan for the DON/designee to audit 100% of skin assessments, weekly wound reports, and dialysis communication logs for eight weeks. Inaccurate findings would be reported to the facility Quality Assessment and Performance Improvement (QAPI) committee. Audits would be reviewed in monthly QAPI meetings to assess processes and performance of staff through proper identification and compliance.
- Regional Nurse #566, the DON and ADON #504 initiated education for all nurses on accurate wound documentation, wound documentation process and wound rounding expectations.
- ADON #504 contacted the dialysis center to verify processes for return communication for residents with wounds or new orders.
- The facility implemented a Monthly Dialysis Foot Check form. This form would be sent to the Dialysis Center monthly by the DON/designee for communication when they do monthly skin checks.
- Regional Nurse #566, the DON and ADON #504 completed additional education and competencies for all licensed nurses related to wound identification and staging.
- The DON and ADON #504 completed in-service education for Certified Nursing Assistant (CNA) staff on early reporting of skin changes.
- All full time and part time licensed nurses were evaluated for competencies and completed return demonstrations for wound assessment and documentation (for a simulated wound). Competencies were completed by the DON and ADON #504. Licensed staff off or who worked as needed (PRN) would have competencies evaluated before their next shift on the floor.
- The DON revised the facility Resident Return admission Checklist to include wound verification and order reconciliation for all returning residents. Education on the new form was provided to licensed nurses by the DON and ADON #504. The checklist would also be reviewed by the DON or ADON #504 upon admission. These would be monitored during any new admission or readmissions to facility. New staff would also be educated by the nurse training them on this form.
- The DON and ADON #504 provided education for all nursing and CNA staff on proper wound care and to alert nurse if a resident dressing had come off or needed replaced.
- The facility implemented staff training on the facility Abuse, Neglect & Misappropriation policy.
- The Administrator sent a message out to all staff on the definition of neglect. Receptionist #808 was calling each staff person to educate, offer time for questions and express understanding.
- The facility implemented a plan to randomly ask three staff members per week for four weeks about the definition of neglect.
- A root cause analysis was conducted related to the incidents of neglect. The facility identified the root cause of neglect for Resident #46 and Resident #20 was the facility's failure to provide ordered wound care and monitor wound status. There were no systems to verify treatment completion, escalate concerns, or ensure nursing accountability.
- The facility implemented a plan for the Administrator or designee to complete audits for three residents three times per week for four weeks then monthly for two months to identify potential areas of neglect to include showers, medication administration and wound care.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A CNA aggressively slapped and grabbed a resident’s wrist during lunch feeding assistance, then roughly pulled the resident’s hand off his shirt sleeve after she had grabbed it. The CNA had prior disciplinary actions, including a previous feeding incident in which a resident choked and required the Heimlich maneuver. A nurse later assessed the resident and found no bruises or cuts.
A facility failed to protect two residents from resident-to-resident physical abuse. In one incident, a resident with dementia and cognitive impairment was struck during a dispute over TV volume and responded by scratching the other resident. In another, a resident with dementia and physically aggressive behaviors scratched a roommate’s face, leaving superficial marks. Staff interviews and clinical records confirmed both altercations and the resulting injuries.
A resident with a left ankle fracture, muscle weakness, and total-assist transfer needs was supposed to receive 2-person assistance and remain NWB on the left leg. Instead, a nurse aide transferred the resident with only one staff member during a toilet-to-wheelchair transfer, and the resident heard a pop and developed increased pain. X-ray and hospital imaging confirmed fractures of the distal R tibia and fibula, and the facility substantiated neglect for not following the care plan.
Failure to Protect Resident from Repeated Room Intrusions: A cognitively intact resident with depression and hip OA was repeatedly frightened when another resident with dementia and wandering behaviors entered her room, took belongings, and could not be reliably redirected. Staff used a stop sign banner and other barriers, but the other resident continued to enter the room, and the resident became so fearful that she requested discharge before completing her therapy goals.
Failure to protect a resident from alleged physical abuse: A resident with COPD, speech disturbances, and dysphagia reported that an LPN pushed them in the chest during med pass after they refused meds, causing them to fall. The resident had no visible injuries, but the report was documented by nursing staff and the NP, and the resident later reiterated by writing/gestures that the LPN pushed them. The LPN denied pushing the resident and described the contact as accidental, while the facility concluded there was no evidence of abuse.
A resident-to-resident sexual abuse allegation was not thoroughly investigated, and the resident was not promptly protected or monitored after the allegation. In a separate issue, a handwritten sign with personal care instructions was posted above another resident's bed, and an RT, LPN, RN, and CNA all acknowledged it was a privacy and dignity concern and against facility policy.
Failure to Protect Resident from Abuse During Feeding Assistance
Penalty
Summary
The facility failed to ensure a resident’s right to be free from abuse during lunch assistive feeding. While standing about 3 feet from the lunch table, the surveyor heard a CNA aggressively slap Resident #56’s left wrist and observed the CNA grab the resident’s left wrist and roughly pull her hand off of his shirt sleeve after she had grabbed it. The surveyor then continued observing the meal and later reported the incident to the DON and Administrator. Resident #56 was assessed by a licensed nurse after the incident, and no bruises or cuts were found on her wrists. The CNA involved had been hired by the facility in 2024, had signed the facility’s Resident Abuse Procedural Summary, and had attended behavior training in 2026. The CNA also had three prior disciplinary actions, including a prior incident in which a resident choked after being given too large a bite during assistive feeding and required a Heimlich maneuver.
Failure to Protect Residents from Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to ensure two sampled residents were free from physical abuse by other residents. One resident with dementia, anxiety, chronic pain, visual hallucinations, and moderate cognitive impairment was involved in an altercation with a roommate after a disagreement about TV volume. The incident escalated when the roommate attempted to take the TV remote and struck the resident with an open hand, and the resident responded by scratching the roommate. The record also documented a new scratch on the resident’s left hand and later noted that the resident no longer wanted to share a room with the other resident. The other incident involved a resident with dementia and significant cognitive impairment who had a behavior care plan for impaired safety awareness and physically aggressive behaviors. The record stated that the resident clawed a roommate in the face, leaving superficial scratches and red marks on the roommate’s chin and cheek. The roommate’s record reflected ongoing monitoring for scratches to the chin and neck, and the roommate stated that the other resident reached up and ran fingernails across her face while they were getting up for breakfast. Facility documentation and staff interviews confirmed both resident-to-resident incidents. Staff described the first event as a physical altercation triggered by conflict over TV volume, and the second as an incident in which one resident scratched another resident’s face. The DON stated the facility investigated and reported the incidents, and also acknowledged that the documentation surrounding the second event was inconsistent and did not meet expectations or policy. The cited deficiency was based on the facility’s failure to ensure the residents were protected from physical abuse by other residents.
Failure to Follow Two-Person Transfer Plan Resulted in Resident Fractures
Penalty
Summary
The facility failed to protect a resident from neglect when staff did not follow the resident’s individualized transfer plan requiring assistance from two staff members. The resident was admitted with a left lower leg trimalleolar fracture, polyosteoarthritis, and muscle weakness, and the MDS indicated the resident was cognitively intact but required total assistance for transfers and toileting. The comprehensive care plan and physician orders both directed staff to provide two-person assistance for transfers and to maintain non-weight-bearing status on the left lower extremity. During a transfer from the toilet to a wheelchair, one nurse aide assisted the resident without a second staff member. According to the documentation, the resident stood without difficulty, but during the pivot transfer the resident’s right foot turned inward and both the resident and the aide heard a loud pop. The resident immediately reported increased pain. Later that day, x-ray findings identified an acute fracture of the right tibia, and the resident was transferred to the hospital emergency department for further evaluation and treatment. Hospital imaging confirmed fractures of the distal right tibia and fibula, and the resident was scheduled for surgical repair. The facility’s investigation determined that the aide transferred the resident with only one staff member despite the care plan and physician order requiring two staff members, and that this failure directly resulted in the resident sustaining the fractures. The facility substantiated caregiver neglect and terminated the employee following the investigation.
Failure to Protect Resident from Repeated Room Intrusions
Penalty
Summary
The facility failed to protect a cognitively intact resident with osteoarthritis of the right hip and major depressive disorder from mental abuse by another resident. The resident was admitted as a vulnerable adult and her care plan identified a goal of being free from abuse, neglect, or financial exploitation, but it did not include interventions to protect her from abuse. The resident later reported that another resident repeatedly entered her room, scared her, and took belongings, and she asked staff to contact her lawyer. She also began using a stop sign banner across her door and later barricaded her room with a walker, closet door, and bedside table because she was afraid of the other resident. The other resident had moderate cognitive impairment, vascular dementia with agitation, and Alzheimer’s disease, and his care plan documented restlessness, agitation, sundowning, wandering into other residents’ rooms, and urinating in public. Progress notes showed repeated episodes of wandering into other residents’ rooms, difficulty with redirection, aggression toward staff, and disruptive behavior in resident rooms. Notes also documented that he entered the affected resident’s room on multiple occasions, and staff observed that he could move barriers out of the way and continue entering the room despite attempts to block access. Staff interviews confirmed that the resident was very scared of the other resident and that the repeated room intrusions continued over several days. Staff stated that stop sign banners did not stop him, closed doors did not stop him, and that it often took two or more staff to remove him from rooms. The resident requested discharge from the facility and left before reaching her maximal level with therapy services. Therapy documentation stated she was improving but still needed higher-level therapy before discharge, and the therapy director stated her early discharge was because she could not remain in the facility due to the other resident coming into her room. Facility records also showed staffing levels that were below the facility assessment on several shifts, and the assignment sheets did not identify a staff member assigned to 1:1 observation for the wandering resident.
Failure to Protect Resident from Alleged Physical Abuse
Penalty
Summary
The facility failed to ensure that a resident was free from physical abuse when a nurse allegedly made physical contact with the resident during medication administration. Resident #7, who had diagnoses including COPD, speech disturbances, and dysphagia, had intact cognition on the MDS dated 03/18/2026 and was care planned as at risk for misappropriation, neglect, abuse, and/or exploitation. On 04/08/2026, the resident reported to the RN supervisor that an LPN pushed them in the chest after they refused medications, causing them to fall to the floor. The resident was assessed and no visible injuries were noted. The resident’s report was documented in nursing and medical progress notes, and the facility’s investigation recorded that the resident was visibly upset while describing the incident. The LPN denied the allegation and stated that any contact was accidental, describing that the resident was close behind them as they left the room and that the resident’s chest contacted their back or shoulder. The RN supervisor, DON, and NP each documented interviews and assessments in which no bruising, swelling, or visible injury was found, and the resident later communicated by writing and gestures that they had told the LPN to leave the room and that the LPN pushed them in the chest and they fell. The facility concluded there was no evidence of abuse, neglect, exploitation, or mistreatment, despite the resident’s allegation and the conflicting accounts from the LPN and resident. The RN supervisor stated law enforcement was notified and police interviewed the resident and the LPN, but no report was filed. The DON later stated the contact was accidental and that the resident’s reporting was inconsistent regarding whether a fall occurred.
Failure to Protect Resident from Abuse and Maintain Privacy
Penalty
Summary
The facility failed to ensure a resident was free from abuse when a resident-to-resident sexual abuse allegation was not thoroughly investigated and the resident was not promptly protected or monitored after the allegation. The report states this involved 1 of 52 sampled residents, Resident 45, and that the deficient practice had the potential to place the resident at risk for continued abuse, emotional distress, fear, anxiety, a diminished sense of safety, and delayed implementation of interventions necessary to protect the resident from further abuse. The facility also failed to protect the privacy and confidentiality of Resident 58. Resident 58 was admitted with diagnoses including chronic obstructive pulmonary disease. During observation, a handwritten sign reading, "Attention please no briefs chucks only!!" was posted above the resident's bed and remained there on a later observation. Staff members including a Respiratory Therapist, LPN, RN, and CNA each acknowledged the sign was visible above the bed and stated it was a privacy, dignity, and policy issue. A facility Residents Rights policy stated residents have the right to privacy and confidentiality with personal care and medical records, and that resident medical and personal care information is private and staff are required to respect and uphold resident privacy at all times.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release October 8, 2026) and official state health department websites — never guesswork.
In your survey window? See what surveyors are citing.
The Survey-Prep Report maps your facility's risk from 12 months of CMS and state citation data — what's being cited around you and what to check first. $129 one-time.