Failure to Thoroughly Investigate Resident‑to‑Resident Abuse and Address Behavioral Triggers
Summary
The deficiency involves the facility’s failure to thoroughly investigate two resident‑to‑resident physical abuse incidents and to identify and address contributing behavioral factors. In the first incident on 12/25/25, a resident with anxiety was seated in a wheelchair in the dining room when another resident with traumatic brain injury, PTSD, bipolar disorder, and Alzheimer’s dementia approached and attempted to pull the wheelchair backward. When the seated resident told him to stop, he struck her in the face without apparent provocation, causing a laceration to her upper inner lip and pain that she reported lasted a long time. The injured resident later stated she would feel afraid and unsafe if the aggressor were on the unit because of his violent nature, and she was told by staff that he was no longer in the facility. Interviews and record review showed that the aggressive resident had known behavioral triggers, including becoming agitated when other residents went into his room or closet or were around the meal carts, and believing he was a licensed nurse who should control access to the food carts. The ADON and DSD stated that these triggers were known and that residents with unmanaged behaviors could have altercations and incidents of abuse. However, the IDT note dated 12/26/25 for the 12/25/25 altercation did not identify these behavioral triggers as contributing factors, and the resident’s care plan did not include these specific triggers or related interventions. The ADON acknowledged that after a prior incident on 11/14/25, when the same resident pushed another resident away from the food carts causing a fall, his behavior and triggers were still not identified and care planned, and that the investigation into the 12/25/25 incident did not result in corrective action to prevent further abuse. The ADON also confirmed there was no documentation that the injured resident was informed of how she would be protected from the aggressor. In the second incident on 12/30/25, another resident with unspecified dementia and schizophrenia, who was documented as going into other residents’ rooms and slamming doors and being hard to redirect, wandered into the aggressive resident’s room and put on his clothing. Staff, including a CNA, reported that this confused resident frequently wandered into other residents’ rooms, that he had been in the aggressor’s room most of the day and refused redirection, and that this behavior would have triggered the aggressor’s aggression. The altercation occurred when the aggressive resident approached the confused resident in the hallway, yelled at him, and grabbed his arm, leading the confused resident to swing and strike him in the face, causing him to fall. Despite this pattern, the IDT note dated 12/31/25 for the 12/30/25 altercation did not identify the confused resident’s wandering into other residents’ rooms as a contributing factor, and his care plan did not address this wandering behavior with resident‑specific interventions. The ADON and administrator, who served as the abuse preventionist, acknowledged that the investigations into both incidents did not identify the behavioral triggers and wandering as contributing factors and did not include corrective actions, and that the investigative summaries did not clearly verify the incidents or specify what corrective action was taken, contrary to the facility’s policy requiring thorough investigations and follow‑up reports with sufficient information and corrective actions when allegations are verified. The facility’s own policy on Abuse, Neglect, Exploitation or Misappropriation‑Reporting and Investigating, revised September 2022, required that all allegations be thoroughly investigated and that follow‑up investigation reports provide sufficient information to describe the results of the investigation and indicate any corrective actions taken if the allegation was verified. The policy also required that the follow‑up report provide as much information as possible and that the resident and/or representative be notified of the outcome immediately upon conclusion of the investigation. In these two incidents, the administrator and ADON acknowledged that the investigations were not thorough enough, did not identify key contributing behaviors such as the aggressor’s triggers and the other resident’s wandering, did not include corrective actions, and did not document communication to the abused resident about how she would be kept safe, leading to the cited deficiency for failure to thoroughly investigate alleged abuse and respond appropriately.
Penalty
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Failure to Investigate Allegation of Verbal Abuse: A volunteer reported that an activities staff member yelled at a resident during bingo and then yelled at the volunteer when she intervened. Interviews with the resident and volunteer confirmed the staff member spoke rudely and loudly to the resident, and the regional clinical director confirmed there was no evidence the verbal abuse allegation was reported or investigated.
Staff failed to remove alleged perpetrators from duty and fully investigate verbal abuse during two separate abuse allegations involving a resident and two CNAs. In the first event, a resident reported being intentionally pushed into a siderail during in-bed care, while multiple other residents described the same CNA as rough and having a bad attitude; despite this, the CNA completed the shift and worked additional days while the abuse investigation was open. In the second event, the same resident alleged that another CNA pushed his leg and made a profane, threatening statement, but the facility’s investigation did not address the verbal abuse allegation, and that CNA was also allowed to finish the shift and work subsequent days during the investigation. Timecard records and interviews with the administrator and DON confirmed that alleged perpetrators continued working with unrestricted access to residents while abuse allegations were under investigation, leading surveyors to identify immediate jeopardy and substandard quality of care.
The facility failed to investigate multiple major injuries and an allegation of sexual abuse involving three residents with severe cognitive impairment and significant medical conditions. One resident, dependent for transfers, was found on the floor after attempting to get out of bed and was later found to have bilateral femur fractures. Another resident with Parkinson’s disease was found on the floor after a wheelchair alarm sounded and was later diagnosed with a femur fracture following complaints of leg pain. A third resident, described as very independent, triggered a bed alarm and was found kneeling by a recliner, later requiring ORIF for fractures of the right 4th and 5th metacarpals. In each case, the ADM acknowledged awareness of the fractures, stated there was no belief of neglect or abuse, and confirmed that no investigation into the cause of the injuries or the alleged abuse was initiated or documented.
A resident at risk for elopement exited the facility through a front door in the early morning, triggering both the door alarm and an elopement device alarm. The DON shut off the main alarm and looked outside but did not immediately exit the front door, while CNAs and an LPN searched the building and surrounding areas. The resident, wearing everyday clothes and no coat in freezing weather, was eventually located by an LPN walking with a walker near a gas station on a busy road, and a second nurse assisted in persuading the resident to return. The facility’s investigation failed to preserve or document key information from available video footage, did not record specific times, route, distance traveled, or weather conditions, and included incomplete and delayed risk management documentation with limited witness statements, contrary to facility policy requiring prompt incident reporting and medical record entries after an elopement event.
A resident with cognitive impairment and a history of cerebral infarction, identified as at risk for abuse, reported to an LPN that another resident punched them in the arm and showed a bruise, while other staff and the other resident described only a collision with a wheelchair and denied any hitting. The Administrator was unaware that an abuse allegation had been made, and the DON’s investigation focused on the bruise without obtaining statements from the reporting resident or the LPN, and without completing initial or final reports or determining the cause of the bruise or whether abuse occurred, in contrast to the facility’s abuse policy requiring prompt and thorough investigation of all abuse reports.
A resident with moderately impaired cognition and a preferred language other than English developed bilateral wrist discoloration and swelling during ADL care when a CNA reported the resident was resisting and bumped her wrists on a wheelchair. Documentation noted the injury, assessment, and treatment, but the care plan was not updated. A family member reported that the resident said staff grabbed her hand and tried to force care, and this was reported to nursing and administration. Despite this allegation, the facility did not conduct a full abuse investigation per its policy: the Social Service Director did not interview the resident or other cognitively intact residents or complete a trauma assessment, and the Administrator/DON confirmed that only the involved CNA and RN were interviewed before concluding no abuse occurred.
Failure to Investigate Allegation of Verbal Abuse
Penalty
Summary
The facility failed to ensure an allegation of verbal abuse was thoroughly investigated for resident #55. A complaint/grievance form documented that a volunteer reported activities staff member #1 yelled at resident #55 during bingo after the resident called out bingo, and the volunteer stated the staff member continued yelling at the resident and then yelled at the volunteer when she intervened. The grievance also noted that two residents reported the activities staff member yelled at them all the time and spoke to them the same way during bingo. Interviews confirmed the incident involved rude and loud comments by the activities staff member toward resident #55 during bingo, including telling the resident to stop interrupting and making a smart-ass remark. Resident #55 stated the interaction upset him/her and that the staff member was later terminated. A volunteer corroborated hearing the staff member speak loudly and rudely to the resident and then yell at the volunteer. Review of the state survey agency incident database showed no evidence the allegation was reported, and the regional clinical director confirmed the facility had no evidence the verbal abuse allegation was investigated.
Failure to Remove Alleged Abusers and Investigate Verbal Abuse During Abuse Allegations
Penalty
Summary
Facility staff failed to protect residents during investigations of two separate abuse allegations made by one resident against two CNAs and failed to investigate an allegation of verbal abuse. In the first incident, the resident alleged that a CNA pushed him over "so the fuxx hard" while cleaning him on the evening shift that his head hit the siderail and that it was done on purpose. The resident contacted 911 the evening of the incident and police responded to the facility, indicating staff were aware of the allegation that same evening. The DON assessed the resident with no injury noted. Staff interviews documented that the resident became verbally and physically abusive during care, scratched staff, and that his head "tapped" the rail but not hard or on purpose. The resident, however, told another CNA that the aide had rolled him too hard, his eye hit the rail, and his legs came out of the bed, and he repeated similar details to the DON, stating the aide came in with an attitude and rolled him extra hard. As part of the facility’s internal investigation of the first incident, 12 residents were interviewed about the CNA’s care. Several residents reported that the CNA was rough, pulled them over hard, almost threw them on the floor when turning them in bed, had a bad attitude, and one resident did not want the CNA in her room. Despite these concerns and the resident’s allegation of being intentionally pushed, the CNA was allowed to complete her shift and to work subsequent scheduled shifts while the investigation was ongoing. Timecard records showed that the CNA worked the night of the incident and additional shifts on the following days and was paid for those hours. Although a suspension notice was later dated and an involuntary termination recorded, the contemporaneous documentation and time records demonstrated that the CNA remained in the building and had access to residents during the open abuse investigation. In the second incident, the same resident alleged that another CNA verbally and physically abused him during ADL care. The resident reported that the CNA pushed his leg down harder and stated, "I want to fuck with you now," and he called 911 to report that a staff member pushed his leg. Four staff members present in the room provided statements that no one harmed him, describing that his leg was lifted to remove a pillow and dirty sheets and then set down softly, after which he began yelling, accusing the CNA of cracking his leg and hip, cursing staff, and digging his fingernails into a staff member’s arm. Police interviewed staff and concluded that no harm was done to the resident. The facility’s investigation included resident safety interviews, one of which noted a resident did not feel safe on certain shifts due to staff. However, the verbal abuse allegation (the reported statement "I want to fuck with you now") was not addressed in the facility’s investigation, and the CNA involved was allowed to complete her shift and work additional scheduled days while the investigation was in progress. The administrator later acknowledged that she did not instruct the CNA to go home and that everyone "stayed kinda together" during the investigation. These actions and inactions resulted in surveyors identifying immediate jeopardy and substandard quality of care due to residents not being protected from alleged perpetrators during abuse investigations.
Failure to Investigate Major Injuries and Alleged Abuse
Penalty
Summary
The deficiency involves the facility’s failure to initiate and document investigations into multiple major injuries and an allegation of sexual abuse, as required for all alleged violations involving abuse and injuries of unknown source. For one resident with hemiplegia, hemiparesis, and severely impaired cognition (BIMS score of 6), nursing notes documented that his roommate activated the call bell after the resident fell while attempting to get out of bed by himself. He was found on the floor between his bed and the window, reported knee pain with a popping sensation, and was sent to the ER. On return from the hospital, he was noted to have bilateral femur fractures, immobilizing braces on both legs, and was placed on comfort care due to bones not being strong enough for surgery. The Administrator acknowledged awareness of the bilateral femur fractures, stated he did not believe neglect or abuse caused the injury, and confirmed he did not investigate the cause of this major injury. Another resident with Parkinson’s disease and a BIMS score of 0 (rarely/never understood) was documented in an incident note as sitting in a wheelchair in the dining room when his alarm sounded; he was found supine on the floor, denied hitting his head or injury, and was assisted back into the chair with no signs of injury noted. Several days later, nursing notes recorded that CNAs reported the resident complaining of left leg pain when getting him out of bed. On assessment, he had tenderness and wincing with movement of the left leg but was able to bear weight. The MD was notified, an x-ray was ordered, and the resident was transported for imaging, which revealed a femur fracture for which surgery was not pursued. The Administrator stated he was aware of the femur fracture, did not feel neglect or abuse caused the major injury, and did not investigate the cause of the injury. A third resident with COPD, scoliosis, and severely impaired cognition (BIMS score of 7) had an incident note documenting that her bed alarm sounded and staff found her in a kneeling position leaning into her recliner after she attempted to get up from bed to go to the bathroom, stating her walker “didn't go where she was going.” She complained of left knee, left elbow, and right pinky pain, with no visible injury except an abrasion on the right ring finger. A later nursing note documented that she underwent ORIF of fractures of the right fourth and fifth metacarpals at a hospital and returned from surgery the same day. The Administrator reported being aware of the fractures, described the resident as very independent and wanting to wander the facility, stated he did not feel neglect or abuse caused the major injury, and confirmed he did not investigate the cause of the injury. Across these three residents, the facility did not initiate or document investigations into the causes of the major injuries or the related allegation of sexual abuse, nor did it determine causation or responsible parties as required.
Failure to Thoroughly and Timely Investigate Resident Elopement
Penalty
Summary
The deficiency involves the facility’s failure to conduct a complete, thorough, and timely investigation of an elopement involving one resident. A complaint to the State Agency alleged that the resident left the facility in the early morning hours in freezing temperatures, walking several blocks on a highway with a walker and without a jacket, and that staff discovered the resident missing only after some time had passed. The complaint further alleged that the DON shut off the main door alarm that alerts staff when residents wearing an elopement prevention device leave the facility, did not immediately initiate a headcount, and returned to other tasks, while another nurse later determined that an elopement‑risk resident was not in the building and initiated a search. The resident was reportedly found 15–20 minutes later about a half mile away on a busy road and returned to the facility uninjured. The facility’s written investigation, presented nearly four weeks after the event, described that the resident exited the front door, triggering both the door alarm and the elopement device alarm. The DON responded to the alarm, shut off the main alarm, and looked outside but did not go out the front door, while CNAs searched the parking lot and surrounding areas and another CNA spoke with the DON. A headcount was called, and an LPN reported she could not find the resident, then drove her car to the main street, located the resident walking near a gas station, and reported that the resident initially refused to get into the car. A second nurse drove to the location, and together they persuaded the resident to return. The facility’s own summary of concerns noted that the resident was able to leave the building, that the DON did not go out the front door, that other staff exited through the back door, and that no one went immediately out the front door, and also noted that the resident had been triggered earlier and had previously attempted to leave the facility. The investigation was incomplete and inaccurate in multiple respects. The facility had camera footage of the exit door used by the resident, but the NHA reported that the footage was not saved because they did not know how to preserve it, and it was taped over. The Maintenance Director stated he viewed the video and could see the resident exit in everyday clothes and later re‑enter, but he did not record the times, and those times were not included in the investigation. The investigation did not document the time the resident exited, who went out the door, when the resident was found, or when she re‑entered the building. It did not address the route taken, did not measure the distance traveled, and did not document the weather conditions, even though historical data showed temperatures between 22–29°F and there was snow that might have shown the resident’s path. The risk management report, authored by the DON, contained an internal inconsistency in timing (stated as written before the alarm response time), included written witness statements from only a limited number of involved staff, omitted the second nurse who assisted in returning the resident, and the DON’s witness statement was linked to a late entry progress note written over two weeks after the event. A regional RN stated she would have expected the risk management report and documentation to be completed as part of the investigation as soon as possible and certainly sooner than two weeks later, and the facility’s own elopement policy required completion and filing of an incident report and appropriate medical record entries upon the resident’s return, which was not timely or thoroughly done in this case.
Failure to Thoroughly Investigate Resident’s Abuse Allegation and Unexplained Bruise
Penalty
Summary
The deficiency involves the facility’s failure to thoroughly investigate an allegation of abuse related to a resident with a history of cerebral infarction who was moderately cognitively impaired and used a wheelchair. The resident’s care plan identified them as being at risk for abuse and neglect. The resident reported to an LPN that another resident had punched them in the arm while they were going down the hall, and showed the LPN a light purple circular bruise on the back of the left arm, approximately two inches in diameter. The LPN notified the Administrator of the resident’s report. Other staff and the alleged perpetrator resident provided written and verbal statements describing an interaction in which the resident in question ran into the other resident’s wheelchair, and they denied seeing or performing any hitting. Despite the allegation of being hit and the presence of a bruise, the facility’s investigation did not include a statement from the resident who alleged the abuse or from the LPN who initially received the report. The Administrator stated she was not aware that the resident had made an abuse allegation and believed they were only investigating a bruise. The DON stated that she conducted interviews regarding the bruise but did not obtain a statement from the resident and acknowledged she probably should have. The investigation file lacked initial or final reports, did not determine the cause of the bruise, and did not reach a conclusion about whether the alleged abuse occurred, contrary to the facility’s abuse policy that requires immediate protection of residents and prompt, aggressive investigation of all reports and allegations of abuse.
Failure to Investigate Allegation of Abuse After Resident Wrist Injury
Penalty
Summary
The facility failed to investigate an allegation of potential abuse after a resident sustained bilateral wrist injuries during ADL care by a CNA. The resident, who had moderately impaired cognition with a BIMS score of 11 and whose preferred language was Korean, was admitted with altered mental status. On the date of the incident, an incident report documented that the CNA informed an RN that the resident developed discoloration and swelling of both wrists during clothing changes when the resident was resisting care and bumped her wrists against the wheelchair during transfer. A nurse’s note recorded similar information, stating that the resident developed bilateral wrist discoloration and swelling after an accident during clothing changes while the resident was resisting, and that ice was applied and an x-ray was ordered to rule out fracture. The resident’s care plan, which addressed discoloration, was not updated after the wrist injuries occurred. The facility did not conduct a comprehensive abuse investigation as required by its policy. The CEO acknowledged there was no investigation for the incident and only produced a grievance document. A family member reported that the resident told her staff grabbed her hand and tried to force her when she refused to be changed, and that this allegation was reported to a nurse and the prior Administrator. The Social Service Director stated that, in abuse investigations, she typically interviews the resident and five other cognitively intact residents and completes a trauma assessment, but she did not interview this resident, did not interview other residents, and did not complete a trauma assessment related to this incident. She reported that the facility held a meeting and determined abuse did not occur but was unsure how that conclusion was reached. The Administrator, who was the DON at the time, stated that after allegations of abuse they immediately start an investigation, but in this case they only interviewed the involved CNA and RN and relied on the CNA’s denial of abuse and explanation that the injury occurred during ADL care, without interviewing the resident, witnesses, or others as required by the facility’s abuse, neglect, and exploitation policy.
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