Failure to Investigate Alleged Abuse Between Cognitively Impaired Residents
Penalty
Summary
The facility failed to investigate an allegation of abuse involving two residents with cognitive impairment in the memory care unit. In June 2025, a CNA discovered one resident in another resident's room and bed, with both residents present but clothed. The CNA immediately separated them and reported the incident to the nurse, who then informed the Administrator. However, the Administrator instructed the nurse not to document the incident in the residents' charts and indicated that Social Services would handle the situation. There was no evidence of a formal investigation, and no abuse investigation was initiated or documented for this incident. Interviews with staff and review of records revealed that key personnel, including the current Administrator and previous Social Services staff, were either unaware of the full details or could not recall the specifics of the event. The residents involved had diagnoses of dementia and demonstrated severe to moderate cognitive impairment, with one resident unable to consent for herself. The facility's policy required immediate investigation and thorough documentation of any suspected abuse, neglect, or exploitation, but this was not followed in this case.