Failure to Honor Resident Care Preferences and Prevent Alleged Staff Abuse
Summary
The deficiency involves the facility’s failure to follow its abuse prevention and rules of conduct policies by assigning a CNA to provide care to residents who had requested not to receive care from that CNA, and by not honoring a resident’s expressed objection at the time of care. Resident 4, who has intact cognition and decision-making capacity and requires assistance with multiple ADLs due to hemiplegia, lack of coordination, and other medical conditions, had previously reported negative interactions with CNA4, including an incident where CNA4 forced a glove into the resident’s hand, applied A&D ointment to the glove, and told the resident to apply it herself. Resident 4 also reported that on a later night shift, CNA4 gave her a towel to clean herself, and when the towel fell to the floor and was picked up, CNA4 told her that next time it would be worse for her and stated, “I am from [NAME]; we do not play that in [NAME],” making the resident feel less than the staff. On the night in question, Resident 4 told LVN2 at the beginning of the 11 p.m.–7 a.m. shift that she did not want CNA4 assigned to her. Despite this, LVN2 completed the staff assignment including CNA4, stating her understanding was that the only resident CNA4 could not be assigned to was Resident 5, who had previously requested not to have CNA4. RN1 confirmed that one staff member had called in sick and that CNA4 was assigned to Resident 4; RN1 acknowledged that Resident 4 did not want CNA4, but he asked Resident 4 to give CNA4 a chance, and both agreed to work together. CNA4 stated that LVN2 knew she could not work with Resident 4 but told her the assignment could not be changed, and that RN2, who usually made assignments and did not assign CNA4 to Resident 4, was on vacation. During incontinent care for Resident 4 on that shift, an altercation occurred between Resident 4 and CNA4. CNA4 reported that Resident 4 requested another CNA, but LVN3 told the resident that due to short staffing she must allow CNA4 to change her. CNA4 stated that Resident 4 dried herself and then threw the dirty washcloth at CNA4, hitting her in the abdomen, and that Resident 4 kicked her in the stomach without provocation. Resident 4, however, told LVN3 and the Social Services Director that after she dried herself and gave the towel to CNA4, CNA4 became upset, accused her of throwing the towel, and then grabbed the same towel and threw it at Resident 4’s face, causing Resident 4 to feel abused and to kick CNA4 in self-defense. LVN3 corroborated that when she entered the room, Resident 4 and CNA4 were arguing, Resident 4 alleged that CNA4 hit her in the face with a towel, and CNA4 denied throwing the towel but stated that Resident 4 had hit her. The Administrator and SSD both acknowledged that Resident 4 reported CNA4 throwing the towel at her face and that there was a prior history between them. The deficiency also involves the facility’s handling of Resident 5’s complaints about CNA4. Resident 5, who has severely impaired cognition and multiple medical conditions including non-Hodgkin lymphoma, osteoarthritis, and polyneuropathy, requires extensive assistance with ADLs and mobility. Resident 5 told CNA5 that he wanted to speak to a supervisor to report abuse, and CNA5 reported this to the charge nurse, supervisor, and Administrator. Resident 5 later stated that CNA4 grabbed his left arm, swung him to the left side, and was rude, and that he did not like how CNA4 turned him and that CNA4 did not communicate what she was going to do. The Administrator confirmed that Resident 5 stated he did not like the care he received from CNA4 and requested that CNA4 no longer be assigned to him, and that CNA4 was barred from caring for Resident 5 based on his preference. Despite this, LVN2 and other staff referenced confusion or incomplete awareness about which residents CNA4 could not be assigned to, and CNA4 herself stated that Resident 5 did not want her to care for him and that she was aware she was not allowed to have Resident 5. These events demonstrate that the facility did not consistently ensure that staff assignments and care practices honored residents’ expressed preferences and protected them from alleged abusive or disrespectful interactions, as required by the facility’s abuse prevention and rules of conduct policies. In addition, multiple staff interviews revealed inconsistent understanding and communication regarding restrictions on CNA4’s assignments. LVN2 believed only Resident 5 could not be assigned to CNA4, while RN1 later learned from CNA4 that she was not supposed to be assigned to Resident 4. LVN3 stated she was unaware that CNA4 could not be assigned to Resident 4 until after the altercation, and also stated that CNA4 was not allowed to have Resident 5. The Social Services Director knew that CNA4 had been removed from caring for Resident 5 but did not know the reason or how Resident 5 developed bruising on his arm and fingers. The Administrator stated that if a resident does not want a staff member to care for them, staff should honor the resident’s request, and expressed concern about CNA4’s code of conduct and its effect on other residents. These facts collectively show that the facility failed to ensure that CNA4 was not assigned to residents who had requested not to receive care from her and failed to prevent situations that escalated into loud arguments and possible physical altercations, contrary to the facility’s abuse prevention and conduct policies.
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.
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