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
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Failure to Investigate Possible Resident-to-Resident Sexual Abuse: Two residents with severe cognitive impairment were repeatedly found unclothed together, but the facility did not assess either resident’s capacity to consent or complete a formal abuse investigation. The record also showed bruising and a report of bloody vaginal discharge for one resident, and staff, including the DON, stated no assessments or investigations were completed and the encounters were assumed to be consensual based on the residents’ behavior.
A CNA reported that another CNA forcibly grabbed a resident, pushed the resident into a wheelchair, blocked the resident with a table, and used profanities toward the resident. The RN supervisor and DON did not initiate an immediate abuse investigation, did not complete a resident assessment or incident documentation, did not notify the provider, and did not remove the accused CNA from access to the resident. The resident had dementia with moderately impaired cognition and a care plan noting potential for abuse related to resistance of care, verbal aggression, and physical aggression.
Failure to investigate and document an allegation of neglect: an RN received a Nursing Student’s report that a CNA was not providing cares and residents were left soaking wet and unchanged, and the complaint/grievance form was texted to the former ADM, DON, and SSD. The facility did not make its initial report to the SA until weeks later, the original grievance form could not be located, and no written investigation record was produced even though policy required prompt interviews of residents and staff and a written record.
Incomplete Investigation of Alleged Abuse: The facility did not have evidence that an allegation that a resident was pinched by staff was thoroughly investigated. The resident had moderate cognitive impairment and bruising to the L forearm. The provider investigation report lacked an identified perpetrator, documentation of who was contacted, and witness statements. The ADM and DON interviewed the resident and completed safe surveys, but no written staff statements were available and the investigation documentation was incomplete.
A facility failed to timely investigate allegations that nurses were taking insulin from one resident and giving it to another when insulin syringes were reportedly unavailable. Residents and LPNs described sharing insulin pens and vials between residents, and one resident reported missing insulin on at least one occasion. The DON was notified of the concern but initially only checked supply availability rather than interviewing residents or staff about whether insulin had been borrowed or misused.
A resident with stroke-related deficits, impaired cognition, and extensive care needs reported that an LPN inserted his finger into her anus during bowel care and continued despite her crying and asking him to stop. The family also reported the procedure was painful and distressing. The facility’s response was incomplete: the DON was not aware of an earlier progress note about the family’s complaint, no immediate rectal assessment was done, the initial body audit did not include the peri-rectal area, and resident interviews were delayed and limited to only a small sample of residents.
Failure to Investigate Possible Resident-to-Resident Sexual Abuse
Penalty
Summary
The facility failed to investigate potential resident-to-resident sexual abuse involving two residents with significant cognitive impairment, R58 and R61. R58’s annual MDS identified severe cognitive impairment, and diagnoses included Alzheimer’s disease, neurocognitive disorder with Lewy bodies, and dementia; R61’s quarterly MDS also identified severe cognitive impairment, with diagnoses including Alzheimer’s disease and dementia with psychotic disturbance. Both residents were identified in care plans as vulnerable adults, and staff were directed to report and investigate any allegations or suspected abuse, neglect, or exploitation. The record documented repeated incidents in which the residents were found together in bed unclothed or undressed, including on 10/3/25, 11/19/25, and 5/7/26. The record failed to show that the facility assessed either resident’s capacity to consent to sexual activity after any of the incidents, and the facility did not complete a formal abuse investigation to determine whether the encounters were consensual. The record also documented bruising on R58’s forearms, right anterior thigh, and inner thigh, as well as a report of bloody vaginal discharge, but there was no evidence these findings were investigated in relation to the known sexual activity. RN-A stated she did not know whether assessments or investigations had been completed, LPN-A stated she documented the 5/7/26 incident but did not complete assessments or investigations, and the DON stated no assessments had been conducted to evaluate injury or capacity to consent and that the facility did not complete a formal investigation because staff believed the encounters were consensual.
Failure to Investigate Abuse Allegation and Protect Resident
Penalty
Summary
The facility failed to investigate an allegation of abuse involving one resident and failed to implement immediate protective actions after a CNA reported observing another CNA forcibly grab the resident, push the resident into a wheelchair, and use a dining room table as a barrier to keep the resident from getting out of the wheelchair. The reporting CNA also stated they heard repeated profanities directed at the resident. The resident had diagnoses including dementia, depression, and anemia, and the admission MDS documented moderately impaired cognition. The resident’s psychosocial care plan identified a potential for abuse related to resistance of care, verbal aggression, and physical aggression. After the allegation was reported to an LPN and an RN supervisor, the RN supervisor did not initiate an immediate investigation at the time of discovery. The resident was not assessed for physical injury or psychosocial harm, no incident report or abuse investigation was documented, and the medical provider was not notified. The resident’s representative was not contacted until later, and there was no documented psychiatric consultation. The staff member accused of abuse was not removed from access to the resident or other residents, and the resident continued to be assigned to that staff member on subsequent shifts. Statements obtained from staff reflected conflicting accounts of the interaction in the dining/dayroom area of the locked memory care unit. One CNA reported seeing the resident being pushed and blocked in by a table, while the accused CNA stated the resident was yelling, cursing, and being redirected, and denied pinning the resident against a wall or blocking the resident with a table. The RN supervisor acknowledged that no accident and incident report, investigative summary, body assessment, resident assessment, or abuse investigation was completed on the day the allegation was reported, and that the accused CNA remained on the unit. The DON and administrator also stated the allegation was not reported as abuse because it was not believed abuse had occurred.
Failure to Investigate and Document Allegation of Neglect
Penalty
Summary
The facility failed to ensure an allegation of neglect was thoroughly investigated and documented after a Nursing Student reported that a CNA had not provided cares to residents on her unit. The allegation was first made to an RN, who described neglect as delayed care, staff isolation of residents, not giving medications, or not implementing interventions. The RN stated she notified the former Administrator, instructed the Nursing Student to complete a complaint/grievance form, took a picture of it, and texted it to the former Administrator. The RN also stated she later spoke with him by phone and relayed what had been reported, but she did not receive any status updates on the outcome of the investigation. The facility’s records showed the allegation was initially made on March 27, 2026, but the facility did not make its initial report of neglect to the State Agency until April 17, 2026, about 21 days later, and then initiated an investigation. Review of the State Agency complaint portal found no other self-report or 5-day investigation report for the alleged timeframe. The SSD stated that suspected neglect is reported to her as the abuse coordinator, that the grievance form was completed and sent by text to her, the DON, and the former Administrator, but she was unable to locate the specific form in the binder and said she was not assigned to investigate because the former Administrator said he would conduct the investigation. The DON acknowledged receiving the texted grievance form stating that residents were soaking wet all day and remained unchanged. She recalled speaking with the former Administrator and said he assumed responsibility for follow-up, but when asked to produce the original complaint/grievance form, it was missing. The former Administrator denied being notified of the allegation and denied receiving the texted form, though he acknowledged he was the abuse coordinator and expected to be available while traveling. A senior corporate clinical leader stated the former Administrator said he investigated by speaking with residents and staff, but no documentation of that investigation was provided. The facility policy required suspected neglect to be investigated as soon as practicable by interviewing residents and staff and maintaining a written record of the investigation.
Incomplete Investigation of Alleged Abuse
Penalty
Summary
The facility failed to have evidence that an allegation of abuse involving a resident’s report that a staff member pinched her was thoroughly investigated. Resident #4 was an older female admitted to the facility with a diagnosis of cerebral infarction and a BIMS score of 08, indicating moderate cognitive impairment. Her care plan noted two bruises to the left forearm and included interventions related to monitoring and documenting bruising and skin condition. According to the provider investigation report, on 05/15/2026 Resident #4 told the ADON that she believed a staff member had pinched her during care. The report did not identify an alleged perpetrator, did not document who was contacted about the allegation, and did not include witness statements. The report reflected that safe surveys were completed and abuse and neglect in-services were provided, but it did not contain documentation showing a complete investigative process. During interviews, the ADM stated he interviewed Resident #4, who could not recall a specific date or time of the incident, could not describe the staff member, and could not identify the color of the staff member’s scrubs. The ADM stated he instructed the DON to call staff who worked the relevant night shifts, start in-services, and conduct safe surveys. The DON stated she called staff who worked those shifts and that no staff knew anything about the bruises, but no written statements were available. The DON also stated she believed the bruises may have been caused by the lid of the bedside commode, and staff reported that Resident #4 often transferred herself to the commode despite requiring one-person assistance. The facility policy stated that all reports of abuse, including injuries of unknown origin, are to be thoroughly investigated and that findings of all investigations are to be documented and reported.
Failure to Timely Investigate Insulin Misappropriation Allegations
Penalty
Summary
The facility failed to timely investigate allegations that nurses were taking and using insulin from one resident for another when insulin syringes were reportedly unavailable. The deficiency involved residents who were receiving insulin, including residents with diabetes, and the report identified four residents as affected by the misappropriation concern. Resident #32 was cognitively intact and on both basal and sliding-scale insulin; Resident #15 had severe cognitive impairment and was on insulin; Resident #12 was cognitively intact and on insulin; and Resident #16 reported missing insulin one day and receiving insulin from another resident on other days when syringes were unavailable. Resident and staff interviews described that for about a week the facility was out of insulin syringes, and nurses responded by borrowing insulin pens or vials from other residents and administering them to residents who needed insulin. Resident #32 stated she heard nurses discussing sharing insulin needles and was told by an LPN that they were sharing insulin pens between residents because the facility was out of syringes. LPNs stated they took insulin from other residents and gave it to others, with one LPN saying she had no choice and another acknowledging she knew it was wrong. One LPN stated she likely took Resident #32's insulin or gave her someone else's insulin, and another stated she took Resident #12's insulin vial and gave it to Resident #15 or vice versa. The DON was notified by the Ombudsman that there was concern about insulin syringes not being available, but she stated she only checked whether syringes were currently in the building and did not interview residents or nurses at that time to determine whether insulin had been missed or borrowed from other residents. The SRI later documented an allegation of misappropriation involving staff taking insulin from one resident and giving it to another without consent. The facility policy required residents to be free from misappropriation and required a thorough investigation of alleged violations, but the report states the facility did not timely investigate the allegations.
Failure to Thoroughly Investigate Alleged Sexual Abuse
Penalty
Summary
The facility failed to thoroughly investigate an allegation of staff-to-resident abuse and failed to protect residents during the investigation for a resident who reported sexual abuse during bowel care. The resident had a recent stroke, atrial fibrillation, hemiplegia/hemiparesis, adjustment disorder with mixed anxiety and depressed mood, moderately impaired cognition, and required extensive assistance with personal care, transfers, toileting, and dressing. She used a manual wheelchair and was frequently incontinent of bladder and occasionally incontinent of bowel with constipation. Her care plan identified her as at risk for abuse and/or neglect and directed staff to keep her safe and follow the facility vulnerable adult policy. The allegation arose after the resident received treatment for constipation that included a rectal suppository and manual stool removal. Progress notes documented that the resident’s daughter complained the procedure was painful and that the family was dissatisfied with the nurse who performed it. The resident later stated that the nurse inserted his finger into her anus, kept circling it, and continued despite her crying and asking him to stop. She reported that he smiled at her while she was being hurt and later described feeling embarrassed, vulnerable, and fearful that he might return and retaliate. The facility’s report to the State Agency identified the allegation as sexual abuse and stated the most recent occurrence was in the resident bathroom. The investigation documented interviews with the alleged perpetrator, two NAs, and six residents out of 60, but the record also showed gaps in the response. The DON stated she was not aware of the incident until the family voiced concerns on 5/18/26 and that she was not aware of the 5/17/26 progress note describing the family’s complaint until later. The DON also stated no physical exam was completed at the time of the allegation, the resident’s rectal area was not assessed in the initial body audit, and resident interviews were not started until 5/22/26. The DON and administrator stated that all residents who could be interviewed should have been interviewed, and that residents unable to speak for themselves should have been checked for signs of distress, but this was not done at the time of the allegation.
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