Failure to Protect Resident From Sexual Abuse and Inadequate Abuse Investigation
Summary
The deficiency involves the facility’s failure to protect a resident from sexual abuse by a CNA. The cognitively intact resident, who required staff assistance for most ADLs and used a wheelchair, reported that on a night shift the CNA who routinely put her to bed and provided incontinence care climbed into her bed around 9–10 PM, lay sideways on top of the comforter, rubbed the side of her breast through the blanket, and made sexually inappropriate comments including that she could be his girlfriend, “you know you want it,” and “come on honey.” The resident stated she repeatedly told him to stop, to get out, and to leave her room. She reported that the night before this incident the CNA had been “way too friendly,” which led her to anticipate further inappropriate behavior. The resident reported the incident to the Social Services Director at the end of February, telling him what had happened. The Social Services Director acknowledged that when the resident began to describe an issue involving her chest, he stopped her, focused only on the fact that it involved her breasts, and immediately contacted the Administrator, without listening to or retaining the full details of her report. The Administrator then spoke with the resident by phone; the Administrator’s documentation and interview reflect that the allegation was characterized as the CNA touching the resident’s breast during routine ADL/peri care while she was on the edge of the bed, and the facility’s written incident report framed the allegation as occurring during routine care and described the resident’s interview as “inconsistent.” The facility’s investigation concluded the allegation was unsubstantiated, and the CNA denied any inappropriate touching, stating he only repositioned the resident during care and asserting that she sometimes said things that were not true. Another cognitively intact resident reported that she was on the phone with the abused resident during the incident and heard the male CNA making sexual remarks such as “come on honey” while the resident repeatedly told him to quit, go away, and get out of her room; she stated no one from the facility had interviewed her about what she heard. The abused resident’s sister reported that the resident, whom she described as of sound mind and normally very talkative, became unusually quiet and withdrawn, and later disclosed that the CNA had “jumped into bed” with her and rubbed her breast, and that another person told her “don’t start anything, we will take care of it.” The sister stated the resident was embarrassed and fearful at night and that she had been told the CNA was moved to a memory floor. The resident’s husband confirmed that his wife told him a CNA had gotten into bed with her. Facility records showed that prior to the surveyor’s investigation, the resident’s care plan had been revised to describe her as having “socially inappropriate behavior” and a history of telling different stories to different staff, despite no documented history of false abuse allegations, and the facility’s abuse policy required immediate protection of residents and prompt, aggressive investigation of all abuse reports, including sexual abuse such as sexual harassment, coercion, or assault. Law enforcement later interviewed the resident and the phone witness; the deputy summarized that the resident reported the CNA jumped into bed with her, said she could be his girlfriend, and touched the sides of her breasts, while the other resident reported hearing the CNA fall into the bed, attempt to kiss the resident, and persist in making sexual remarks and pushing for relations while the resident said no. Staff familiar with the resident, including an RN and the Social Services Director, described her as alert, oriented, and without behaviors, and similarly described the phone witness as alert, oriented, and a reliable historian. Despite these consistent accounts and corroborating witness information, the facility’s internal documentation continued to characterize the allegation as unsubstantiated and did not reflect that the phone witness had been interviewed as part of the initial investigation. These actions and omissions resulted in the facility’s failure to protect the resident from sexual abuse by a staff member and to fully and accurately investigate and respond to the allegation in accordance with its abuse policy.
Removal Plan
- Perform full body check on resident; document findings.
- Perform full body checks on residents in the facility who are not interviewable; document findings.
- Notify family and physician.
- Update resident care plan pertaining to the alleged abuse.
- Immediately suspend the CNA pending an investigation.
- Review facility resources for stress management and the abuse policy related to the occurrence; revise as indicated.
- Educate staff on how to take an initial report of abuse and what should be included in the report.
- Educate the Social Service Director on how to take an initial report of abuse and what should be included in the report.
- Educate the Administrator on how to conduct a thorough investigation and how to determine if abuse occurred.
- Assess residents for any markings that could be related to physical contact and interview residents who are able to be interviewed; document findings.
- Conduct interviews with residents and document concerns.
- Re-educate all staff and managers on the facility abuse policy, abuse prevention, and stress management.
- Provide pop quizzes to staff about abuse.
- Review compliance using a Quality Assurance audit tool for abuse.
- Review results of abuse audits with the interdisciplinary team.
- Discuss the abuse policy and prevention with all new hires at new hire orientation.
- Audit all residents' abuse assessments and abuse care plans for accuracy; review audits by the QA committee, evaluate trends/patterns, and implement corrective actions as indicated.
- Hold an emergency QA meeting with the interdisciplinary care team and Medical Director to discuss the abuse allegation and plans of correction and obtain approval of the plan of correction.
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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