Failure to Immediately Investigate and Report Resident’s Abuse Allegation
Summary
The deficiency involves the facility’s failure to immediately initiate an investigation and report an allegation of abuse made by a resident. The resident, identified as R44, had diagnoses including COPD with acute exacerbation, gait and mobility abnormalities, anxiety disorders, depressive disorders, psychoactive substance abuse, and hypertension. R44’s BIMS score was 12, indicating moderate cognitive impairment, and the care plan documented a history of suspected abuse/neglect and behavioral symptoms, including involvement in other residents’ care. On a Sunday afternoon, R44 wrote a letter addressed to the Administrator or Executive Director stating that a CNA delivering food was hostile to the roommate, yelled at the roommate about being changed, told R44 to “shut up and mind my own business,” blocked R44’s path, threatened to throw R44 out the window, and bumped R44 while passing. R44 reported feeling like a “nervous wreck,” shaking, and expressed fear related to heart problems. R44 later reiterated the allegation in an interview, stating that two days earlier a CNA working the 3–11 p.m. shift, described as African American, came to deliver dinner trays and deferred changing the roommate for a couple of hours. When R44 questioned this, the CNA allegedly told R44 to get out of her face, used profanity, blocked R44 from leaving the room, and threatened to throw R44 out the window, causing significant fear and shaking. R44 reported going to the nurse’s station, speaking with the nurse and two other people there, then going downstairs to the receptionist, who provided pen and paper so R44 could write a letter that was placed in the administrator’s mailbox. R44 also stated that the Executive Director and Social Worker were informed. The receptionist confirmed that R44 complained that someone threatened to push her out the window, recognized that this could be considered abuse, and acknowledged not following protocol and “dropping the ball” by treating it as a complaint rather than an abuse allegation. The Executive Director stated that R44 interrupted him the day after the incident while he was busy, and he took time to speak with R44, who reported a confrontation with a CNA who had dropped off food and was supposed to care for the roommate. The Executive Director checked the schedule and identified the CNA, later identified as V17, and acknowledged that R44 said the CNA threatened her. He admitted he considered it abuse and that he “probably should have reported it yesterday,” explaining that he initially thought R44 was having psychosis based on the care plan. The Social Worker reported that R44 came to her office and complained that a staff member had talked to her in an incorrect way, and the Social Worker immediately informed the Executive Director. The facility’s reportable form documented that the facility became aware of the incident on a later date and initially listed the alleged perpetrator as unknown, despite the earlier letter and conversations. The facility’s abuse policy required immediate steps to protect residents, immediate notification to authorities not exceeding two hours after the initial allegation, and suspension of accused employees pending investigation. In this case, the allegation made to the receptionist and then to the Executive Director was not immediately reported or investigated, and the CNA continued to work on the unit until the Executive Director later identified and suspended the CNA after the Social Worker’s report. Additional interviews provided conflicting accounts of the incident but further highlighted the delay in response. The CNA, V17, stated that while passing trays she saw the call light on, dropped off the meal tray, and asked the roommate if she wanted to be changed, with the roommate requesting to eat first. According to V17, R44 then accused her of breaching a contract, was told to mind her own business, and began hitting V17’s leg with a walker and threatening to have her fired. V17 denied threatening to throw R44 out the window or doing anything to R44. Another CNA, V20, reported hearing R44 tell V17 at the elevator that she was going to report and fire V17, and that V17 responded she had not done anything. Despite these differing accounts, the key deficiency centers on the facility’s failure to treat R44’s initial report and written letter as an abuse allegation requiring immediate reporting and investigation, as required by the facility’s own abuse and neglect policy and federal guidelines. The facility’s own documentation shows that the reportable form listed the date and time the facility became aware of the incident as a later date and time, even though R44 had already reported the threat to the receptionist and had written a letter that was placed in the administrator’s mailbox earlier. The receptionist acknowledged not contacting the administrator as required when an allegation or witness of abuse occurs. The Executive Director acknowledged that he did not submit an initial reportable or start an investigation when he first spoke with R44 and that he should have reported the abuse allegation the previous day. As a result, the alleged perpetrator continued to work on the unit until the Executive Director later identified the CNA and suspended her pending investigation. This sequence of events demonstrates that the facility did not respond appropriately and immediately to the alleged violation of abuse, contrary to its written policy requiring immediate protection of residents, prompt notification to authorities, and timely initiation of an investigation.
Penalty
Resources
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Failure to Investigate Allegation of Misappropriation: A resident with COPD, anxiety, and PTSD reported $1,600 missing and believed another resident had taken the money, but the SSD told him it was too late to investigate. The grievance record and reporting portal contained no misappropriation report for the resident, and the CNO recalled hearing about missing funds from a family member but did not follow up, while the CEO stated the allegation should have been reported and investigated.
The facility failed to complete a thorough investigation after a resident sustained a 7 cm penile laceration associated with a condom catheter. The resident had a stroke, contractures, cognitive communication deficit, and non-healing pressure ulcers, and the incident record lacked a full investigation or staff statements to determine the root cause and rule out abuse or neglect.
Incomplete Abuse Investigation: The DON investigated an allegation that a resident with dementia, depression, and a prior femur fracture was treated roughly during a shower, but only interviewed one CNA named on the abuse report. Another CNA was also assigned to the resident and documented providing the shower, yet was not interviewed, and no other residents cared for by either CNA were interviewed. The facility's abuse policy required thorough investigation, including staff and resident interviews, and the DON stated the policy was not followed.
Incomplete Investigation of Alleged Staff-to-Resident Sexual Abuse: The facility failed to thoroughly investigate an allegation that a CNA raped a resident during incontinence care. The resident, who had intact cognition and significant medical diagnoses, reported genital and anal touching and later said embarrassment affected how they described the event. The record lacked a written or recorded resident statement, and the facility concluded abuse did not occur based on conflicting accounts rather than documenting a comprehensive investigation of all evidence.
The facility failed to thoroughly investigate two resident abuse allegations. In one case, an altercation with a scratch injury was recorded as an accident/incident, but the final report had no abuse conclusion and the Abuse Coordinator did not interview the residents, observe the injury, or document staff witness statements. In another case, the final report also lacked a conclusion, interview notes could not be produced, and CNAs who were present or witnessed the altercation were not interviewed despite progress notes showing CNA presence.
Failure to Thoroughly Investigate Allegations of Neglect and Possible Abuse: A resident with significant care needs alleged a CNA left her on a bedpan too long, spilled urine/feces in bed, and performed an unsafe hoyer transfer, while another resident was heard screaming during a one-person hoyer transfer. The facility did not complete a thorough abuse/neglect investigation because it did not interview the second resident, other potentially affected residents, or assess non-interviewable residents.
Failure to Investigate Allegation of Misappropriation
Penalty
Summary
The facility failed to ensure an allegation of misappropriation was investigated as required for Resident #23, who was admitted with diagnoses including COPD, anxiety, and PTSD. Resident #23 stated that approximately two months earlier he reported $1,600.00 missing to the SSD and told the SSD he believed another resident had taken the money. He reported that when he explained the incident had occurred about one and a half months earlier, the SSD told him it had been too long ago to investigate. Review of the facility grievance records from February 2026 through June 2026 showed no documented allegation of misappropriation involving Resident #23, and review of the Long-Term Care Reporting Portal showed no report of misappropriation involving him. The CNO stated she recalled a family member mentioning Resident #23's missing funds but did not ask further questions, and the CEO stated the allegation should have been reported and investigated for potential misappropriation.
Incomplete Investigation of Penile Laceration
Penalty
Summary
The facility failed to conduct a thorough investigation to rule out the potential for abuse or neglect for one resident after a penile laceration was identified in connection with a condom catheter. The resident had diagnoses including stroke, contractures, cognitive communication deficit, and non-healing pressure ulcers of the buttocks and coccyx, and the condom catheter had been used to decrease moisture and help prevent worsening of the coccyx/buttocks wound healing. During review of the incident, the resident was found to have a 7 cm laceration of the penis from the condom catheter. The catheter had become dislodged during an assessment when the nurse aide noted low urine output, and the nurse supervisor later had an LPN reapply a new condom catheter. The facility’s incident documentation did not include a full investigation or staff statements to identify the root cause of the laceration and rule out abuse or neglect, and the Nursing Home Administrator confirmed that the investigation was not completed thoroughly.
Incomplete Abuse Investigation
Penalty
Summary
The facility failed to thoroughly investigate an allegation of abuse involving one resident who was admitted with diagnoses including a right femur fracture, difficulty walking, dementia, and depression. The resident reported that a CNA who assisted with her shower was "very rough," had "pushed me around," and became "nasty" when questioned. The allegation was documented in the facility's incident report and reported on the SOC 341 as suspected dependent adult/elder abuse. The DON stated she investigated the allegation and interviewed only CNA 1 because CNA 1 was named on the SOC 341 report and was believed to be involved based on staffing. However, the record showed CNA 2 was also assigned to the resident and documented that she showered the resident on the date of the alleged incident. CNA 2 was not interviewed, and no other residents cared for by CNA 1 or CNA 2 on that date were interviewed. The facility's policy required all allegations to be thoroughly investigated, including interviews with staff on all shifts who had contact with the resident and interviews with other residents cared for by the accused employee, and the DON stated the policy was not followed.
Incomplete Investigation of Alleged Staff-to-Resident Sexual Abuse
Penalty
Summary
The facility failed to conduct a thorough investigation of an allegation of staff-to-resident abuse for 1 of 1 residents reviewed for abuse. The resident, who had diagnoses including obstructive and reflux uropathy and hemiplegia and hemiparesis following cerebral infarction, was documented as having intact cognition. The allegation involved a CNA during incontinence care, and the resident reported that the CNA raped them and touched and rubbed their genital and anal area, causing them to feel unsafe in the facility. The facility’s investigative record did not include a written or recorded statement from the resident detailing the allegation, limiting the ability to objectively investigate the complaint. The facility’s accident/incident report documented that the resident told an LPN they had been raped, and an RN supervisor noted redness in the perineal area during assessment. However, the report also stated the facility concluded abuse did not occur because the resident gave conflicting statements, rather than documenting a comprehensive investigation of all available evidence. Additional statements in the record showed the resident later explained they felt embarrassed and ashamed when law enforcement and a male nursing supervisor were present, which affected how they described the event. The CNA stated they provided incontinence care and applied ointment, but denied doing anything beyond what was requested. The DON stated the facility obtained a statement from the resident, while the RN supervisor stated no statement was obtained or documented from the resident.
Incomplete Abuse Investigations and Missing Conclusions
Penalty
Summary
The facility failed to thoroughly investigate allegations of abuse involving two separate resident altercations. For one incident involving two residents, the final Facility Reported Incident classified the event as an accident/incident rather than resident abuse, even though the report documented an alleged altercation and that one resident sustained a scratch on the right cheek requiring first aid. The final form did not include a conclusion stating whether abuse or assault did or did not occur. During review of the investigation file, the Administrator, who was also the Abuse Coordinator, could provide only the initial and final reports submitted to the state survey agency and could not provide additional evidence such as staff interviews, witness statements, or documentation of observations after the alleged abuse. She stated she did not interview either resident, did not observe the injured resident’s scratch, and only spoke with the ADON and an RN, both of whom said they did not witness the altercation. She also did not attempt to interview a CNA she believed may have pulled the injured resident from the other resident’s room, and there was no documentation showing staff interviews were completed. The injured resident’s EHR also did not show documentation of the scratch assessment, appearance, treatment orders, or any documentation that the abuse with injury occurred. A second altercation between two other residents was also not thoroughly investigated. The Administrator and DON provided only the initial and final reports and resident face sheets, and the final report did not include an investigation conclusion. Although the Administrator stated she had completed all interviews before submitting the final report, she could not produce handwritten interview notes or other investigation documentation. One resident said he discussed the incident with staff present at the time, while another resident could not recall the altercation. A CNA stated she was present during the incident and was never interviewed, and another CNA stated he witnessed the incident and reported it to the ADON but was never interviewed by the Administrator. Progress notes for both residents documented CNA presence during the altercation, yet the Administrator stated she did not interview any CNAs because she was told none were present. The facility policy required prompt and aggressive investigation of all abuse allegations, including interviews of the reporter, anyone with direct knowledge, and the resident if interviewable, and required the final report to contain a conclusion based on known facts.
Failure to Thoroughly Investigate Allegations of Neglect and Possible Abuse
Penalty
Summary
The facility did not thoroughly investigate allegations of abuse and neglect involving two residents. One resident, who had complex regional pain syndrome, mononeuropathy, muscle wasting and atrophy, pruritus, and required assistance with personal care, submitted a written grievance stating that a CNA left her on a bedpan for over an hour, questioned her about re-wearing a soiled brief, spilled the bedpan in bed, attempted a hoyer transfer without ensuring the sling was properly secured, and did not clean her skin after she had lain on a wet pad. The resident and her representative described the event as neglect, and the facility’s self-report also documented the allegation as neglect. A second resident, who had rheumatoid arthritis, polyneuropathy, non-[NAME] lymphoma, osteoarthritis, and dependence on enabling machines and devices, was heard screaming from behind a closed bedroom door while a CNA was transferring her alone with a hoyer lift. Staff reported hearing the resident yell, "Help me" and "Oww," and when they entered the room they found the resident in the lift and sling, leaning to one side, while the CNA was unhooking her. The resident’s care plan required two staff for bed mobility, toileting, and hoyer transfers. The facility’s investigation did not include a statement or interview from the second resident, did not include interviews of other residents cared for by the CNA during the shift, and did not include skin assessments of non-interviewable residents who may also have been affected. Facility leadership later stated the investigation was not thorough and should have included those interviews and assessments. The acting administrator also stated that hearing a resident screaming behind a closed door would make her suspicious of abuse, and that the incident should have been investigated as an additional allegation involving the same CNA.
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