Failure to Timely Report and Investigate Repeated Verbal Abuse Allegations
Summary
The facility failed to follow its abuse policy by not timely reporting allegations of verbal abuse to the state agency and by not reporting a subsequent allegation at all for two cognitively intact residents. One resident (R1), with multiple medical conditions including spinal stenosis, type 2 diabetes mellitus, morbid obesity, chronic venous insufficiency with a non‑pressure ulcer, lumbar radiculopathy, and other comorbidities, had a BIMS score of 15 indicating intact cognition. Another resident (R3), with end‑stage renal disease on dialysis, cerebral palsy, chronic kidney disease, sequelae of cerebral infarction, major depressive disorder, PTSD, ADHD, and other diagnoses, also had a BIMS score of 15. R1 reported that R3 had been verbally abusive for almost a year, including calling R1 the n‑word and other racial slurs, and stated that the facility was not preventing this behavior. On 10/10/2025, staff, including an RN (V4) and an LPN (V12), observed or were informed that R3 was verbally aggressive, yelling racial slurs at R1 and others passing R3’s room. The Social Services Director (V14) documented in R3’s progress note that R3 was being verbally abusive and making racial slurs toward another resident and completed a petition for involuntary/judicial admission citing increased agitation, aggression, and racial comments. R3 was sent to the hospital and returned the same day. The Administrator (V1), who is the facility’s abuse coordinator, acknowledged that the incident occurred on 10/10/2025 but reported it to the state agency on 10/11/2025 at 9:09 PM, more than 24 hours after the occurrence, despite the facility’s Abuse Prevention Program requiring that reports of suspected abuse be filed no later than 2 hours from suspicion. The facility’s incident report to the state agency characterized the event as R3 being verbally impolite to R1. V1 stated being unsure why the report was not submitted on the date of the incident. On 2/2/2026, R1 again reported ongoing verbal abuse by R3 to the RN (V4), including continued use of the n‑word, racial name‑calling, and offensive gestures while R3 sat in front of R1’s room. V4 documented R1’s concerns in R1’s progress note and reported them to Social Services and the Director of Nursing, and also went to the Administrator’s office to notify V1. V4 stated that V1 responded that V1 was aware of the issues and was already investigating. V14 reported that about a week before the survey (on or around 2/2/2026), a staff nurse informed V14 that R1 said R3 was verbally abusing R1 again; V14 spoke with R1 but was unsure if this was reported to V1 and had no documentation of this interaction. V1 acknowledged that a nurse spoke with V1 about R3 calling R1 racially derogatory names but assumed the nurse was referring to the prior October incident, did not speak with R1 or R3 about the new allegation, and did not report the new allegation to the state agency. R1 stated that no one followed up after the October incident, that R1 was not informed of any investigation conclusions, and that R1 did not deny the October incident occurred. Review of state reportables from 10/1/2025 to 2/10/2026 showed only the single verbal abuse report from October, confirming that the February allegation was never reported, contrary to the facility’s Abuse Prevention Program requirements for immediate reporting, documentation, and resident notification. The facility’s Abuse Prevention Program (for Illinois facilities) specifies that employees must immediately report any observed, heard about, or suspected incident to a supervisor or the Administrator, that an initial report of an accusation should be completed immediately, and that a written report must be sent to the state agency no later than 2 hours from suspicion. It also requires that the Administrator inform the resident that a report has been made and that an investigation has started, and later notify the resident of the conclusion of the investigation. In this case, the October 10 verbal abuse incident involving racial slurs was not reported to the state agency within the required 2‑hour timeframe, and the subsequent February allegation of ongoing verbal abuse was not reported at all. Additionally, R1 reported not being informed about the investigation or its conclusion and not being asked if R1 felt safe, despite the policy requiring resident notification and follow‑up. These actions and inactions by the Administrator and other staff led to the identified deficiency in timely reporting and handling of abuse allegations.
Penalty
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Failure to report allegations of abuse and verbal mistreatment involved two residents. One resident with cancer, PVD, and Alzheimer’s disease was reported by a family member to have been rough-handled by two male CNAs during care, left in a wheelchair overnight, and not fed breakfast, but the allegation was not documented or logged. Another resident with stroke and recent abdominal surgery reported that staff talked about them like they were not there and called them fat; the concern was not clearly recognized as a current facility allegation and was not reported or investigated as expected.
Failure to Report Alleged Abuse and Neglect: A resident with severe cognitive impairment and dementia sustained a deep gash/skin tear to a finger and bruising during incontinent care after becoming combative with a CNA. The RP accused staff of abuse and called law enforcement, but the DON and Administrator did not report the allegation to the State Survey Agency, stating the police investigation was sufficient.
Failure to Report Suspected Abuse and Unexplained Injury Staff found two cognitively impaired residents repeatedly in bed together without clothing, but the incidents were only documented in progress notes and not reported to the SA because the team believed the interactions were consensual. One resident also had unexplained bruising and reported bloody discharge, yet the bruises and possible injury of unknown source were not reported as required. Neither resident had a documented capacity-to-consent assessment, and both care plans called for monitoring of their interactions and reporting suspected abuse.
Failure to Report Resident Abuse Allegations: A resident with schizophrenia, MDD, and other behavioral symptoms alleged that a nurse placed hands around his neck and that another staff member showed him marijuana and inappropriate pictures. Staff discussed a witness statement with the resident, but the allegation was not reported to the State Agency, and contracted consultant staff did not share the resident’s abuse concerns with facility leadership. Facility admin later stated the incident should have been reported.
A resident exited the building through a bedroom window, walked off the property, and was observed and redirected by staff with assistance from law enforcement, who encountered the resident down the road and helped escort the resident back. The facility’s internal documentation lacked staff or witness statements and characterized the event as the resident remaining on facility grounds without injury. Despite the resident’s account, a police report, and a maintenance staff report confirming that the resident left the premises and that law enforcement responded, the DON did not report the incident to required state and federal agencies, even though the DON acknowledged that any incident involving law enforcement response must be reported.
Failure to Immediately Report Alleged Staff-to-Resident Abuse: A CNA was observed striking a resident’s arm during care, but the allegation was not promptly reported to the DON/abuse coordinator. The resident had severe cognitive impairment, dementia, CKD, HF, and required extensive ADL assistance. Staff communication broke down when the CNA told an LPN, who did not ensure direct reporting to administration, and the DON later learned of the allegation only after a delay.
Failure to Report Allegations of Abuse and Verbal Mistreatment
Penalty
Summary
The facility failed to ensure that allegations of potential abuse, neglect, or verbal abuse were identified and reported to the Administrator and/or the State Survey Agency for 2 of 7 sampled residents. The report cites WAC 388-97-0640(5)(a) and the facility’s Purple Book guidance stating that alleged violations involving mistreatment, neglect, or abuse must be reported immediately to the Administrator and to other officials in accordance with State law, including the State survey and certification agency. Resident 27 was re-admitted with diagnoses including cancer, peripheral vascular disease, and Alzheimer’s disease, and was sometimes able to make needs known. A family member reported that Resident 27 said two male nursing aides awakened them in the middle of the night or early morning and handled them roughly during care, and that the resident had been left in a wheelchair all night and had not eaten breakfast. The family member said they reported this to nursing staff, but there was no documentation of an abuse allegation in the EHR and no incident logged for the resident. Staff E stated they did not report it because they thought the nurse would follow up. Resident 7 was admitted with stroke with right side weakness and recent abdominal surgery and was able to make needs known. Resident 7 stated staff talked about them like they were not there and called them fat, and later clarified that the incident happened at the facility. Staff L, the speech therapist, stated the resident mentioned a concern but that the resident’s husband said it happened at the last facility, so it was not understood as a current facility issue. The Administrator and DNS stated it was their expectation that the concern be reported and investigated, and that this did not meet their expectations.
Failure to Report Alleged Abuse and Neglect
Penalty
Summary
The facility failed to ensure that an allegation of abuse and neglect involving a resident with severe cognitive impairment was reported to the State Survey Agency within the required timeframe. Resident #30 was an elderly female with diagnoses including type 2 diabetes, anxiety disorder, adult failure to thrive, and vascular dementia. Her quarterly MDS reflected a BIMS score of 04, indicating severe cognitive impairment, and she was documented as requiring dependent assistance to supervision or touching assistance for functional abilities. On 05/19/2026, Resident #30 was involved in an incident during incontinent care in which staff reported that she became combative and pulled a CNA's hair. During the incident, blood was observed on her fingers, and she sustained a deep gash/skin tear to her right ring finger along with bruising on her hands and arms. The resident's representative later reported the injury to the DON and Social Worker and stated she was told the resident had become aggressive with the CNA. The representative also stated she did not receive follow-up after requesting information about what occurred. The record and interviews showed that the representative accused staff of abusing Resident #30 and called law enforcement to the facility. Law enforcement responded and investigated the matter, and the facility later stated the allegations were not substantiated. However, the DON and Administrator stated the incident was not reported to the State Agency because law enforcement had investigated it. The Administrator acknowledged she was the Abuse Coordinator, that allegations of abuse and neglect were to be reported to the State Agency within 2 hours after being reported to her, and that she did not investigate the incident further or report it to the State Agency.
Failure to Report Suspected Abuse and Unexplained Injury
Penalty
Summary
The facility failed to report allegations and suspicions of resident-to-resident sexual abuse to the State Agency for two residents with significant cognitive impairment, and it also failed to report a potential injury of unknown source for one of those residents who had unexplained bruising and vaginal bleeding. Both residents had diagnoses including dementia and Alzheimer’s disease, and both care plans identified them as vulnerable adults who required supportive monitoring of their interactions with peers. Neither resident’s medical record contained an assessment identifying capacity to consent to a sexual relationship. R58’s record showed severe cognitive impairment, wandering, and need for assistance with dressing, grooming, and bathing. Her care plan noted cognitive loss, confusion, wandering, intrusive behavior, hallucinations or delusions, and a relationship with a male peer that required supportive monitoring to ensure interactions were safe and appropriate. R61’s record showed severe cognitive impairment, a history of wandering and checking doors, and a relationship with a female peer that also required supportive monitoring to ensure interactions were safe and appropriate. Staff were directed in both care plans to monitor interactions, observe for distress or behavioral changes, and report suspected abuse, neglect, or exploitation. Progress notes documented repeated incidents in which the two residents were found together in bed, unclothed, and asking staff to leave them alone. On one occasion, R58 had scattered bruises on both forearms in various stages of healing and stated she occasionally bumped into things and bruised easily. On another occasion, staff reported R58 had bloody discharge, but there was no further documentation. Additional notes documented bruising on R58’s thigh and another incident in which R58 and R61 were found in bed without clothing. Staff interviews showed the incidents were documented in progress notes and discussed with the team, but no event report or State Agency report was completed because the incidents were believed to be consensual and not abuse. The DON also stated the bruises were not reported because staff assumed they were caused by bumping into things and aspirin use, despite the facility policy requiring reporting of bruises of unknown origin and reporting suspected abuse within the required timeframe.
Failure to Report Resident Abuse Allegations
Penalty
Summary
The facility failed to report allegations of abuse involving a resident with schizophrenia, major depressive disorder, adverse effect of methamphetamines, and adjustment disorder with anxiety to the State Agency as required. The resident’s EMR and MDS documented intact cognition with a BIMS of 15, daily wandering, verbal and other behavioral symptoms, and independence with ADLs. The resident’s behavioral CAA noted refusal of care including medications, rare participation in activities, behavior that interfered with others, and that some behavior was provoked but most was unprovoked. The care plan identified a potential for aggressive behavior, both physical and verbal, related to schizoaffective and bipolar disorder and directed staff to de-escalate and keep the situation calm when aggressive behavior occurred. A progress note documented staff met with the resident after a reported incident in which the resident stated a charge nurse had placed her hands on his neck. Staff offered a written witness statement so the allegation could be formally submitted to the appropriate state agency, but the resident declined to pursue it further at that time and gave no additional details. A later therapy note from the mental health consultant documented the resident reported that a facility nurse had put her hands around his neck and another staff member had shown him marijuana and inappropriate pictures during a smoke break. Consultant staff stated the documentation of these concerns had not been shared with the facility and would be brought to the survey team. Facility administrative staff later stated the named nurse had not been employed there, that the state agency should have been notified, and that they had not received notes from the contracted company reporting the resident’s allegations. The facility policy required all employees to immediately report actual or potential abuse, neglect, or misappropriation to the team leader, Administrator, or State Agency Complaint Hotline.
Failure to Report Elopement Incident Involving Law Enforcement
Penalty
Summary
The deficiency involves the facility’s failure to report an elopement incident to required state and federal agencies as mandated by 42 CFR 483.12(c). On the referenced date, Resident #5 exited the building through his bedroom window around 12:15 PM and walked across the facility property toward the perimeter fence. A CNA observed the resident outside and called for assistance, after which staff redirected and escorted the resident back into the building and placed him on one-to-one supervision. The facility’s internal incident documentation noted the window exit and subsequent maintenance inspection of the window seals but did not include any staff or witness statements. The DON later stated that the resident never left facility grounds and was returned without injury, and therefore the incident was not considered reportable. However, interviews and external records showed that the resident did leave the facility premises and that law enforcement was involved. Resident #5 recalled being outside the facility, being brought back by staff and a “police man,” and being told by the officer not to leave again. A police report from the local police department confirmed an encounter with the resident outside the facility and that an officer assisted staff in escorting him back. Maintenance staff (Staff G) also reported that the resident climbed out the window, left the facility property, and was stopped “down the road,” then redirected back with law enforcement assistance. In interviews, the DON initially denied that law enforcement had been notified or involved, then later acknowledged that law enforcement had responded but asserted they did not come into the facility. The DON also confirmed awareness that any incident in which law enforcement investigates or responds is required to be reported, yet the elopement and law enforcement involvement were not reported to the State Survey Agency or other required officials within the required time frames.
Failure to Immediately Report Alleged Staff-to-Resident Abuse
Penalty
Summary
The facility failed to ensure that an allegation of staff-to-resident abuse was immediately reported to the Administrator/abuse coordinator, but not later than 2 hours after the allegation was made. The allegation involved a CNA striking a resident on the arm during care on 5/10/26 at approximately 6:00 p.m., but the Administrator stated he was not notified until the morning of 5/12/26. The facility’s investigation summary and provider report both reflected that the allegation was not reported to the abuse coordinator until 5/12/26, well after the incident occurred. Resident #1 was a male resident with diagnoses including dementia without behavioral disturbance, chronic kidney disease, and heart failure. His quarterly MDS indicated severely impaired cognition with a BIMS score of 2, limited ability to respond to simple direct communication, extensive assistance needs for most ADLs, and bowel and bladder incontinence. His care plan identified potential physical aggression due to poor impulse control and resistive behavior during care, with interventions to calm and redirect him when agitated or resistive. According to the incident documentation, CNA C reported that during shift change rounds CNA B hit Resident #1’s hand when he grabbed CNA B, and CNA B then yelled at the resident. CNA C stated she told LVN D about the incident, and LVN D told her the DON would be contacted. The DON later stated she never received a text from LVN D and first learned of the allegation on 5/12/26 after a group text from another nurse. The Administrator stated staff were expected to immediately report allegations of abuse to the abuse coordinator, and the facility’s policy required employees to report allegations to the administrator, who would then report to HHSC. The report also states CNA C was counseled for not following the proper abuse reporting procedure.
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