Failure to Prevent Abuse and Neglect and to Investigate Allegations Involving Two Residents
Summary
The deficiency involves the facility’s failure to protect residents from abuse and neglect, including failure to provide timely incontinent care and repositioning, failure to protect a resident from verbal abuse by a CNA, and an allegation of physical abuse by the ADON. One cognitively intact female resident with dementia, anxiety, depression, diabetes mellitus, and atrial fibrillation was care planned as needing staff assistance for ADLs, including one-person assistance for bathing, two-person assistance with a mechanical lift for transfers, and staff supervision for toileting, bed mobility, dressing, and eating. She was also care planned for bladder incontinence and impaired mobility, with interventions including application of barrier cream after incontinent episodes. A later care plan entry documented a potential psychosocial well-being problem related to an allegation of verbal abuse. Video evidence from one date showed this resident lying in bed on her back, not turned, repositioned, or provided incontinent care from 1:56 PM until 7:55 PM. On another date, a time-lapse video from 5:45 AM to 11:45 AM showed no staff entering the room to check, change, or reposition her for six hours. In interviews, the resident’s family member reported calling the facility and requesting incontinent care because no staff had checked on the resident since before 6 AM when night shift staff last checked her. A nursing assistant assigned to the resident on one of the dates stated she had not been in the room to provide care because she had not had time and acknowledged she was new and found it difficult to care for all assigned residents, adding that residents should be checked every two hours and that not doing so could be considered neglect. Another CNA who cared for the resident on the earlier date recalled arriving around mid-afternoon, possibly entering the room only to provide fresh ice and asking the resident if she needed changing, then not changing her until about 8 PM after a family call, and could not recall changing her at any other time that shift. This CNA stated she should have made rounds on every resident every two hours to check and clean them and acknowledged that failing to do so placed the resident at risk for neglect. The DON and Administrator both stated their expectation that CNAs check residents at least every two hours and recognized that extended periods without checks placed residents at risk for neglect. The same cognitively intact resident was also subjected to degrading verbal interactions by a CNA during incontinent care, captured on video with audio. The video showed the resident lying in bed on her back when the CNA entered, snatched gloves from the wall box, and responded condescendingly when the resident said she needed to be changed, telling her there was a line and that there were no “first privileges.” When the resident commented that the CNA did not like her job, the CNA replied hatefully that she liked her job but not when people could not wait in line, and further stated that the resident thought she was privileged and kept hitting her call light. The resident remarked that someone must have “peed in [the CNA’s] cheerios,” and the CNA responded that she had been doing this too long to “deal for people like this” and that she would not hold her tongue for anyone. While providing care, the CNA continued to interject instructions in a rude manner, pointing and telling the resident to roll. The resident later told surveyors that a staff member had talked mean to her when she asked to be changed, that the staff member must have had a bad day, and that she did not want that staff member back in her room. The resident’s family member reported bringing the video of the verbal interaction to the ADON and asking her to watch it, and requested that the CNA not be allowed back in the resident’s room because of how she talked to and treated the resident. The family member stated the ADON declined to watch the video, said she did not need to see it and would retrain the aide, and then walked away to move tables in the dining hall, leaving the family member standing there. In her interview, the ADON acknowledged declining to watch the video when it was offered, stating that the family member told her the CNA had provided all care perfectly but needed to talk to the resident when providing care. She said she did not retrain the CNA, did not initiate any reporting or investigation because she believed everything was done correctly, and told the CNA only to do the required care and get out of the resident’s room. The ADON stated she did not consider it important to talk to residents while providing care and said she did not receive a request from the family to keep the CNA out of the room. She also stated that if allegations of abuse were not reported and investigated properly, residents were placed at risk of abuse. A second resident, an elderly female with senile degeneration of the brain, dementia, and atherosclerotic heart disease, had a quarterly MDS showing she was usually understood and usually understood others, but with a BIMS score of 5 indicating severely impaired cognition and disorganized thinking. She required supervision or touching assistance with eating and was dependent on staff for toileting and transfers, and was incontinent of bowel and bladder. Her care plan documented an ADL self-care performance deficit related to impaired mobility, cognition, weakness, and reliance on staff for ADL assistance. An anonymous staff person reported that about three months prior, this resident was in the dining room hollering “Help! Help!” when the ADON walked by; the resident reached out to grab the ADON to stop her, and the ADON hit the resident on the hand and told her to leave her alone and not touch her. The anonymous reporter stated they then went to assist the resident, that another staff member also witnessed the incident, and that they were tired of injustices residents experienced. They reported that the ADON often refused to assist residents and that they had reported this to the DON, who did nothing, which was why they had not reported the hand-hitting incident earlier. The anonymous reporter further stated that many employees had witnessed the ADON’s mistreatment of residents and reported it to the DON but would not report it further due to fear of being fired. Another staff member named as a witness denied seeing the ADON abuse or mistreat residents and denied seeing the ADON hit this resident. The Administrator reported that the ADON was suspended related to the allegation of hitting this resident. When interviewed, the resident, who was confused, stated she did not remember any staff hitting or mistreating her and said everyone treated her well, but her confusion was evident when she answered her ringing cell phone by picking up her drink and saying hello. The DON stated that abuse should be reported immediately to the abuse coordinator and that if staff would not report to her, they should go to the Administrator, and that failure to report abuse and neglect immediately placed residents at risk of not being protected from abuse. The Administrator stated she expected staff to follow the abuse and neglect policy and report abuse and neglect immediately, that she was not aware of any abuse allegations involving this resident, and that abuse not being reported placed residents at risk of further abuse. The facility’s undated Abuse and Neglect policy stated that residents have the right to be free from abuse, neglect, misappropriation of resident property, and exploitation, and that residents should not be subjected to abuse by anyone, including facility staff, other residents, consultants, volunteers, staff of other agencies, family members, friends, or others. The policy defined abuse to include deprivation of goods or services necessary to attain or maintain physical, mental, and psychosocial well-being, and specified that instances of abuse cause physical harm, pain, or mental anguish, including verbal, sexual, physical, and mental abuse. Physical abuse was defined to include hitting, and mental abuse to include humiliation and harassment. Neglect was defined as the failure of the facility, its employees, or service providers to provide goods and services necessary to avoid physical harm, pain, mental anguish, or emotional distress. The policy required that all reports or suspicions of abuse, neglect, or potentially criminal behavior be investigated per facility protocol, reviewed by the Administrator and/or Abuse Preventionist within 24 hours, and reported to state authorities within specified time frames. It also required any employee with reasonable cause to believe an elderly or incapacitated adult was suffering from abuse, neglect, or exploitation to make an immediate verbal report to the Abuse Preventionist or designee and to the Administrator, with mandated reporting to state and/or adult protective services.
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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