Failure to Fully Investigate Resident-on-Resident Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to fully investigate an allegation of abuse between two residents and to follow its own abuse investigation policy. One resident reported that on the night of 12/28/25, another resident entered her room, held her arms above her head and down, attempted to get into bed with her, and repeatedly yelled, “You know who I am.” She stated she screamed for help for quite some time and no one came. She described trying to defend herself by hitting the other resident, throwing water at him, and wishing she could have used her cane, which was across the room. She also reported that the same resident had previously entered her room on two other occasions and used her toilet before leaving. The resident stated she was scared, upset, and fearful that the other resident would return at night and potentially harm or sexually assault her, and she was not aware that his room remained next door to hers. The facility’s written policy on abuse investigations, updated 10/22, required identification and interviews of involved persons, including the alleged victim, alleged perpetrator, witnesses, and others with knowledge of the allegations. However, during interviews, facility leadership acknowledged they did not initially have staff or resident interviews for the facility-reported incident involving the two residents. They later located some staff statements, including one from a CNA who documented returning from lunch to find the alleged perpetrator in another resident’s room, the alleged victim’s call light on, and the alleged victim yelling for help, very upset, and reporting that a man had tried to get into bed with her, that she had hit him, yelled for help, and thrown water at him, with water observed all over the room. Staff further stated they did not consider the incident to be abuse at the time, which contributed to the residents’ rooms remaining next to each other and to the lack of a complete investigation consistent with facility policy.
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