F0610

D

Failure to Investigate Abuse Allegations for Two Residents

Glasgow, Kentucky Survey Completed on 02-04-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to thoroughly investigate and respond to allegations of abuse for two residents, despite having a policy requiring immediate and comprehensive investigations of suspected or reported abuse, neglect, or exploitation. The facility’s abuse policy, reviewed in June 2025, required immediate investigation upon suspicion or report of abuse, including identifying and interviewing all involved persons (alleged victim, alleged perpetrator, witnesses, and others with knowledge) and providing complete documentation of the investigation. Interviews and record review showed that these steps were not carried out as required for the allegations involving two residents.

For one resident with severe cognitive impairment, dementia with behavioral disturbance, and a BIMS score of 1, the record showed an event report dated mid‑June 2025 describing the resident as being “assisted to floor due to behaviors” in the bathroom with no injuries noted. Progress notes over the next two days documented complaints of right hand and wrist pain, an x‑ray, and later a bruise on the right index finger attributed to a recent fall. In a later interview, the resident stated that a male staff member pushed him out of his wheelchair onto the bathroom floor, told him he was going to put him back in bed, and bent his arm back, hurting his hand and wrist. The resident reported telling multiple nurses and stated that the staff member no longer came into his room. Multiple staff interviews revealed that staff had heard about the incident, that it was widely discussed among staff, and that some believed it had been reported to the DON and administrator. One CNA who was orienting at the time stated she saw the CNA involved screaming at the resident, threatening to put him on the floor, and then putting him on the floor, and that she reported this to the DON. The former SSD stated the resident told her the CNA put him on the floor and threw him in bed, and that she reported this to the DON and administrator and was later told in a meeting that the resident had lowered himself to the floor. The former DON, however, stated she did not recall any abuse allegation being reported to her, and there was no documentation of a thorough abuse investigation as required by policy.

For another resident with Alzheimer’s disease, moderate cognitive impairment (BIMS 9), and a history of falls and muscle weakness, interviews indicated that the resident developed a black eye for which there was no corresponding documentation of bruising or discoloration in progress notes or skin assessments from August through October 2025. A CNA reported that the resident told her and another CNA that a male CNA had hit her in the eye, and that dayshift staff said it had been reported to the DON and administrator; HR allegedly told her to stay out of it. The resident later stated that a black male staff member hit her left eye with the back of his hand on purpose, causing a large bruise, and that no one came to ask her questions about it. An LPN reported hearing a scream, seeing the CNA in the hallway, then entering the resident’s room with the DON, where the resident was screaming that the CNA had hit her eye and a bruise was starting; the LPN stated the DON told her to chart that the bruise was from the resident rubbing her eye, which she refused to do, and that the incident was not investigated. Other staff reported hearing that the resident accused the CNA of hitting her and that explanations were given that she had been rubbing or scratching her eye. The former SSD recalled the resident telling her the CNA hit her in the eye and being later told by the DON that the resident had just been rubbing her eye. The current DON and administrator both stated they were not informed of these abuse allegations and described an abuse investigation process that was not implemented in these cases, and there was no evidence of the comprehensive interviews, assessments, or documentation required by the facility’s abuse policy for these allegations.