Failure to Prevent Neglect Due to Inadequate Staffing and Improper Transfers
Summary
The deficiency involves the facility’s failure to protect multiple residents from neglect by not providing sufficient, qualified staff and by allowing untrained aides to perform transfers and incontinence care alone, contrary to the facility assessment, policies, and care plans. Timecard review showed that on 34 of 84 shifts between early January and mid-February, only one direct care staff member was on duty, despite the facility assessment requiring at least two direct care staff and one nurse per shift when residents required mechanical lifts or two-person transfers. The AIT and ADON both acknowledged ongoing staffing shortages, frequent no-shows, and that resident care suffered because the facility was short staffed. The AIT stated it was not safe to have only one aide working on the floor and that policies requiring two staff for transfers and incontinent care were not always followed. One resident with dementia, severe cognitive impairment, and a care plan requiring two staff and a mechanical lift for transfers was dropped during a mechanical lift transfer performed by a single aide who was not certified and had no documented training or abuse/neglect education. The resident reported being dropped to the floor, then pulled back into the wheelchair and told not to report the fall; her roommate, who had moderate cognitive impairment, stated she saw the aide alone with the lift, heard the aide exclaim, and observed the resident and lift on the floor. The resident was later found dragging her leg, reported pain, and was hospitalized with a distal femur fracture requiring surgery. The aide later stated she had not been trained on mechanical lift use and denied transferring the resident alone, while another aide and a nurse gave conflicting accounts and denied assisting with the transfer. Another resident with severe cognitive impairment and a care plan requiring two-person mechanical lift transfers was observed being transferred by a single aide using a stand-and-pivot method without a mechanical lift. The aide admitted she was the only aide working, knew the resident required a mechanical lift and two staff, and stated she routinely transferred the resident this way because no help was available. A third resident, with moderate cognitive impairment and high fall risk, required prompt response to call lights and assistance with transfers and toileting. She activated her call light to request help to the restroom, but no staff were present in the hall or at the nurses’ station; after waiting, she attempted to go alone, urinated on herself, slipped, and was found on the floor by a hospice aide while the call light was still engaged. The AIT confirmed that only one aide was on duty that shift, that staff no-shows were common, and did not explain why she and the ADON, who were in the office, did not answer call lights. A fourth resident with moderate cognitive impairment, colon cancer, muscle weakness, and a high fall risk had multiple falls over several weeks, including two falls on the same day that resulted in rib fractures, pleural effusion, and hospitalization, and another fall causing a forehead injury. Progress notes documented repeated falls related to attempts to transfer or reach items independently, and the resident’s representative reported the resident was anxious and tried to get up on her own. The care plan for falls had not been updated with new interventions since several months prior, despite the series of falls. Timecards showed that during at least two of the resident’s falls, only one direct care staff member was on duty. A fifth resident with severe cognitive impairment, depression, anxiety, mixed bladder incontinence, and a care plan requiring staff assistance for toileting and checks/changes every two hours was left in wet clothing for approximately two hours after requesting help. She first asked the only aide on duty, who told her she was too busy. The resident was later observed crying in the hall and then sitting in the dining room with visibly wet pants. When she asked an RN to change her, the RN looked at her but did not acknowledge the request. The resident became upset and attempted to remove her wet clothes in the dining room, after which the ADON reprimanded her and told her to go to her room. She was not assisted with changing until about two hours after her initial request. The aide later stated she was working alone, was very busy, and acknowledged that being short staffed could lead to residents not getting the care they needed and could be considered neglect. Personnel file reviews showed that aides designated as nurse aides were not certified and lacked documented training, including mechanical lift training and, in at least one case, abuse/neglect training. The facility’s policies required two staff for mechanical lift transfers and prohibited aides from performing transfers and incontinent care alone, and the facility’s abuse and neglect policy defined neglect as failure to provide necessary goods and services to avoid physical harm, pain, mental anguish, or emotional distress. The MD stated his expectation that residents be free from abuse and neglect, that policies be followed, and that residents’ needs be met by staff with the knowledge and skills to provide necessary care, and he confirmed that being dropped from a mechanical lift could cause the type of femur fracture sustained by one resident and that not following transfer policies could have led to injury for another resident. An Immediate Jeopardy situation was identified related to these failures.
Removal Plan
- Ensure there are two direct care staff on the floor at all times in addition to one LVN/RN charge nurse; if there are any mechanical lift residents, ensure a total of one LVN/RN and two direct care staff are in the building at all times; assess staffing requirements weekly based on census and resident needs; maintain two direct care staff if the facility has any residents that use a mechanical lift or are a two-person transfer.
- Ensure DON and ADON verify that all agency or temporary direct care staff have documented training/credentials prior to working a shift (including checking the agency portal and obtaining CNA credentials from the sister facility) and ongoing.
- Assess Residents #5, #3, #2, and #16 for any further injury, pain, or emotional distress.
- Report Resident #1's fall to the state agency per reporting requirements.
- Assess and monitor Resident #1 for negative outcomes.
- Remove NA-A from resident care pending investigation.
- Complete investigation of the incident by AIT.
- Terminate NA-A as disciplinary action.
- Create an informational handout for incident reporting and mechanical lift use and review it.
- Provide an instructional mechanical lift demonstration for all staff by the facility's COTA.
- Review incidents within the last 30 days to identify other residents at risk.
- Re-educate all direct care nursing staff on shift on abuse/neglect policy (including safe transfer procedures and supervision expectations) with a signature sheet; require review for all direct care staff before start of first shift.
- Provide abuse/neglect and related education at an in-service with a signature page.
- Ensure the agency and sister facility only send CNAs.
- Require the charge nurse to verbally educate any agency and sister facility staff on call lights, mechanical lift, and abuse/neglect during shift report prior to the aide starting the shift; require verbal return instruction to determine competency.
- Re-educate all residents about their rights, abuse, neglect, and reporting.
- Review abuse, neglect, transfers, and reporting upon hire; provide monthly review at mandatory in-service; provide one-on-one education annually at staff hire anniversary; enforce that any violations of policy will result in termination.
- Require the charge nurse to initial, date, and log the name of each agency and sister facility staff member educated.
- Complete a mandatory all-staff in-service reviewing falls and fall prevention, reporting incidents, mechanical lift transfers, and abuse and neglect.
- Reinforce expectation that violations of abuse/neglect, mechanical lift, and reporting policies will result in disciplinary action up to and including immediate termination.
- Train all staff on falls and call light usage via phone calls with return instruction to ensure retention of information; prevent staff who do not answer the phone from returning to work until retrained; maintain a DON log of staff contacted and educated.
- Have DON/designee review all incidents daily for 30 days to establish a risk-of-incident analysis based on patterns of staffing and incidents.
- Conduct a monthly abuse/neglect audit for direct care staff and incidents and report to QAPI for 3 months.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A facility failed to protect two residents with severe cognitive impairment from sexual abuse by not completing a comprehensive assessment of each resident’s capacity to consent after repeated sexual encounters were discovered. Staff found the residents together in bed or in the bathroom, often unclothed, and allowed privacy based on their behavior without documenting a structured consent assessment. The facility also did not fully investigate unexplained bruising and reported vaginal bleeding for one resident in the setting of the known relationship, and the MD was not notified of the incidents or injuries.
Failure to protect a resident from resident-to-resident physical abuse: one resident entered another resident’s area, got into her belongings, and then grabbed, hit, and scratched her left wrist/hand, causing a skin tear, bruise, swelling, and pain. The injured resident said she was afraid of the other resident, while staff heard yelling, found both residents in the room, separated them, and documented the wound and bruising. The other resident had dementia with behavioral disturbance and used a walker and wheelchair.
Failure to protect a resident from resident-to-resident abuse: a resident with PTSD and a long history of physical and sexual abuse reported another resident repeatedly entered their room at night, then later exposed himself, blocked the resident from leaving, and used meth in front of them. The record lacked an investigation, trauma assessment, psychosocial monitoring, and documented behavior-based monitoring for the other resident, and staff interviews confirmed the concerns were not fully addressed in the chart.
A resident with dementia, CKD, HF, and severe cognitive impairment was involved in a physical abuse allegation when a CNA struck or batted his arm/hand during care after he grabbed at staff. A witness reported that the CNA hit the resident hard and yelled at him, while the CNA said she only tapped his hand away and did not consider it abusive. The resident could not answer questions about the event, and the facility’s records showed the allegation was not promptly escalated through the abuse reporting chain.
A resident with impaired cognition, stroke-related deficits, and constipation was subjected to manual stool removal by an LPN after a suppository did not work. Staff interviews and the resident’s statements indicated she said stop and begged the LPN to stop while he continued the procedure, and she later described the care as painful, violating, and demeaning. The LPN said he manually removed the stool in the bathroom, did not complete an abdominal assessment, and did not contact the provider for further direction.
A resident with CKD, CHF, ESRD, DM, and multiple foot wounds did not receive ordered daily wound care, and the TAR and progress notes lacked documentation that the treatments were completed on multiple occasions. The resident was later hospitalized for worsening wound infection, with purulent drainage and concern for osteomyelitis; the wound care provider also reported concerns that ordered dressing changes were not being done and noted worsening skin breakdown to the buttocks.
Failure to Assess Consent and Investigate Injury With Resident Sexual Activity
Penalty
Summary
The facility failed to protect two cognitively impaired residents from sexual abuse by not completing a comprehensive assessment of each resident’s capacity to consent to sexual activity after becoming aware that they were engaging in sexual contact. One resident had diagnoses including Alzheimer’s disease, neurocognitive disorder with Lewy bodies, dementia, and anxiety, with documentation showing severe cognitive impairment, wandering, hallucinations, confusion, and inability to consistently orient to time or place. The other resident also had diagnoses including Alzheimer’s disease and dementia with psychotic disturbance, with repeated BIMS scores showing severe cognitive impairment and care plan documentation noting cognitive loss and a history of wandering and checking doors. The record showed repeated incidents in which the two residents were found together in bed or in the bathroom, often unclothed, and staff documented that they appeared calm or did not show obvious distress. Staff notes and interviews showed that the residents were allowed privacy and continued access to each other without documentation of a formal assessment of whether either resident understood the nature of the relationship or could knowingly and voluntarily consent. Staff interviews also reflected that they relied on the residents’ behavior, such as whether they pushed away or said no, rather than documenting a structured assessment of capacity after each incident. The facility also failed to investigate unexplained bruising and reported vaginal bleeding for one resident in the context of the known sexual activity. The record documented bruises on the forearms and thigh in various stages of healing, along with a report of bloody vaginal discharge, but there was no evidence of a physical assessment or investigation to determine whether the findings were related to abuse, coercion, trauma, or another cause. Interviews with the RN, LPN, DON, MD, and family showed that the physician had not been notified of the sexual incidents, the bruising, or the vaginal bleeding, and that staff had not documented a formal assessment after the incidents.
Failure to Protect Resident from Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect a resident from resident-to-resident physical abuse when one resident attacked another during the night, causing a skin tear to the left wrist, bruising to the left thumb, swelling, pain, and fear for safety. The injured resident was admitted with diagnoses including type 2 diabetes mellitus, unsteadiness on feet, need for assistance with personal care, and muscle weakness, and had a BIMS score of 15/15 indicating cognitive intactness. The other resident involved had diagnoses including type 2 diabetes mellitus, dementia with other behavioral disturbance, and essential hypertension, and used a walker and wheelchair for locomotion. According to the injured resident, she returned from the bathroom and found the other resident in her area getting into her refrigerator. When she told the other resident to get out of her things, the other resident became angry, grabbed her left wrist, hit her left hand, and scratched her, causing the injury. The injured resident stated she was afraid of the other resident and was glad the other resident had been moved to another unit so she could not hurt her again. At observation the next day, the resident’s left wrist/hand was bandaged, an observable bruise was present at the base of the left thumb, and the hand/wrist was slightly swollen and painful to touch. Facility documentation and staff statements confirmed that staff heard yelling from the room, found the residents in the room, and separated them. Nursing notes documented a skin tear with partial skin flap loss to the left wrist/forearm and bruising to the left thumb, with the wound cleansed and steri-strips applied. Staff statements described the other resident as being in the injured resident’s area and making unwanted contact, while the administrator stated the investigation was still ongoing and could not yet determine whether resident-to-resident abuse had occurred. The facility’s abuse prevention policy states residents are to be free from abuse by anyone, including other residents, and defines physical abuse as willful infliction of injury resulting in physical harm or pain.
Failure to Protect Resident from Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect residents from abuse and failed to provide adequate supervision and effective interventions when Resident 7 reported fear and unsafe interactions with another resident. Resident 7 was admitted with COPD and PTSD and had a documented history of childhood through adulthood abuse, including physical and sexual abuse, domestic violence, and trafficking. A trauma questionnaire showed Resident 7 had previously tried to avoid reminders of past events and reported that nothing made them feel worse at that time. In one incident, Resident 7 told staff they were afraid to go to sleep because another resident came to their room at night and shook them awake. The resident admitted going to the room and waking Resident 7, and staff educated that resident about safety and respect. The progress note did not appear in the incident log or grievance log, and the record did not show an investigation, monitoring for negative psychological social outcomes, a trauma assessment, or care plan interventions to promote a sense of security. Staff interviews confirmed the social service department was unaware of the situation and that a trauma assessment should have been completed. In a second incident, Resident 7 reported that the same resident blew methamphetamine smoke in their face in the smoking shed, blocked them from leaving with a wheelchair, and exposed and masturbated in front of them. Resident 7 stated the event triggered past childhood trauma and made them feel trapped. The facility investigation documented a separation plan and one-to-one supervision for Resident 7, while the other resident was placed on alert status with increased monitoring and behavior risk. However, the record did not show implementation of behavior-based monitoring for the other resident, and observations later showed Resident 7 without staff supervision.
Physical abuse allegation involving a resident during care
Penalty
Summary
The facility failed to ensure a resident was free from physical abuse when a CNA slapped the resident’s arm during care. The resident was a male with dementia without behavioral disturbance, chronic kidney disease, and heart failure. His care plan identified that he could be physically aggressive due to poor impulse control and resistive to care because of impaired cognition, and his quarterly MDS showed severely impaired cognition with a BIMS score of 2, extensive assistance needs for most ADLs, and bowel and bladder incontinence. According to the incident documentation, the event occurred in the resident’s room during care when one CNA reported that another CNA hit the resident’s hand after the resident grabbed her. A written statement from the witnessing CNA said the CNA hit the resident hard on the arm and then yelled at him. The resident was unable to answer questions about the event because of his stroke and cognitive impairment, and the incident report noted that he had a history of hitting staff. The CNA involved stated that the resident struck her arm and that she tapped his hand gently, comparing her action to what one would do with a child. The facility’s investigation summary described the contact as the CNA batting the resident’s hand away, while the witness described it as striking the resident on the arm. The report also showed that the allegation was not immediately escalated through the facility’s abuse reporting process, as the witness said she reported it to an LVN and was told the DON had been notified, but the abuse coordinator did not receive the information until later. The facility’s records also reflected that the incident was ultimately treated as an unsubstantiated allegation of abuse.
Abuse During Manual Stool Removal
Penalty
Summary
The facility failed to ensure a resident was free from abuse during bowel care when an LPN performed manual removal of impacted stool from the rectum without consent and continued after the resident asked him to stop. The resident had moderately impaired cognition, was dependent on staff for transfers and toileting hygiene, and had a history of constipation. Her diagnoses included stroke, atrial fibrillation, hemiplegia/hemiparesis, adjustment disorder, and mixed anxiety and depressed mood. Her care plan identified limited physical mobility and the need for two staff with a stand lift for transfers. On the day of the incident, the resident had not had a bowel movement for several days and had received constipation medications and a rectal suppository. Progress notes documented that a rectal check found hard stool and that manual evacuation was performed with removal of large amounts of stool. Staff interviews described that the resident cried, said stop, and begged the LPN to stop while he continued the manual removal for additional time. The resident later reported that the procedure was painful, that she felt violated, embarrassed, and demeaned, and that she believed the nurse was smiling and laughing at her during the care. Multiple staff interviews confirmed that the resident was distressed during the procedure and that the LPN did not stop when she requested it. Staff also stated the procedure was invasive and should have been stopped when the resident expressed pain. The LPN stated he manually removed the stool in the bathroom, did not complete an abdominal assessment, did not administer an enema before manual removal, and did not contact the provider for further direction. The report also states the facility failed to ensure the resident was free from abuse during cares, and the immediate jeopardy was identified based on this event.
Failure to Complete Ordered Wound Care
Penalty
Summary
The facility failed to provide wound care services as ordered by the physician for one resident with multiple chronic conditions, including CKD, CHF, HTN, ESRD, muscle wasting/atrophy, anemia, and diabetes-related foot wounds. The resident’s records showed a BIMS score of 15, indicating cognitive intactness, and documented multiple wounds, including ulcers on both feet, a diabetic foot ulcer, and a wound infection. Physician orders required daily wound care to the left calcaneus, right calcaneus, right plantar foot, right medial foot, and daily povidone-iodine application to the right foot, but the TAR did not document completion of these treatments on multiple dates in May 2026, and the progress notes also lacked documentation that the treatments were completed. The resident was hospitalized on 5/26/26 with worsening wound infection. The hospital history and physical documented ESRD on daily dialysis, CHF, COPD, DM, depression, HTN, prior MI with stenting, oxygen use, chronic wound status, and ulcers of both feet with necrosis of muscle. The hospital record stated the resident reported the nursing home should have been changing wound dressings daily but said that was not done. The wound care provider stated the right foot wound had purulent drainage, she was concerned about osteomyelitis, and she sent the resident to the emergency room. She also stated she had concerns that the facility was not completing the ordered dressing changes and that the resident had worsening buttocks skin breakdown, while the DON stated treatments should be completed as ordered and documented on the TAR or in progress notes.
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