Failure to Thoroughly Investigate and Protect Cognitively Impaired Resident From Repeated Sexual Abuse Allegations
Summary
The deficiency involves the facility’s failure to conduct thorough investigations into multiple allegations of sexual abuse and to protect a cognitively impaired resident from potential further abuse during and after those investigations. The resident, admitted with diagnoses including hypertension with heart failure, dementia, narcolepsy, chronic respiratory failure, and osteoarthritis, was documented as severely cognitively impaired and unable to consent to sexual advances. Hospital records and family statements indicated the resident had always been mentally slow and did not like to be touched. Despite this vulnerability, the facility did not implement protective measures after repeated staff reports of concerning interactions between the resident and a family member. The first allegation occurred when a CNA reported feeling uncomfortable after entering the resident’s room and observing the family member quickly moving his hands away from the resident’s lap/stomach area on two occasions. The written investigation from the Administrator and Social Services Director concluded no abuse occurred, relying largely on the family member’s explanation that he was startled and holding a computer, and did not document any protective interventions or assessment of the resident’s vulnerability. Later interview with the CNA revealed additional details not included in the investigation, including that the resident’s shirt was lifted exposing her breast, that the resident would not have been able to expose herself, and that the family member intervened quickly when staff attempted to adjust the resident’s clothing. No additional staff statements or corroborating documentation were included in the investigation. A second documented allegation involved staff observations of the same family member positioned very close over the resident, with the resident’s wheelchair reclined and the family member reacting abruptly when staff entered, including jumping up and requesting privacy. A dietary aide’s written statement indicated she saw the family member’s hands under the resident’s blanket and that he jumped up quickly when she entered, causing a pillow to fall. In interviews, staff described not being able to see the family member’s hands, the resident appearing shocked and jumpy, and reports that the resident cried after the family member’s visits and seemed not to want to be touched. These details, including the aide’s observation of the arm under the blanket, were not reflected in the facility’s written investigation, which the Administrator and Business Office Manager confirmed as complete. Additional allegations arose in December when a CNA reported entering the room and seeing the family member with one leg on a chair and the resident’s shirt pushed up below her breasts, with the family member stating they were playing cards and telling the CNA to leave. The CNA stated he wrote a report and left it at the nurse’s desk, and another CNA confirmed being told of this incident but did not report it herself. The Administrator and Business Office Manager acknowledged being told about the leg-on-chair incident and viewing video footage from the family’s personal camera on the family member’s cell phone, but they did not initiate a formal investigation, did not verify the date or time of the footage, and relied on the video and the family member’s denial to decide not to investigate further. Another CNA later reported seeing the family member with his leg up on the resident’s wheelchair, wearing nylon shorts, jumping back and pulling his pant leg down when she entered, and appearing very anxious; she reported this to the Business Office Manager. Throughout these events, the facility did not initiate thorough investigations, did not consistently collect and reconcile staff statements, did not verify or preserve objective evidence, and did not implement care plan interventions or protective measures to keep the resident safe from further potential abuse. The facility’s abuse policy required immediate reporting of suspected abuse to the Administrator and mandated that the Administrator or designee report abuse to the state agency per state and federal requirements, and that employees report reasonable suspicion of a crime against a resident to law enforcement. Despite this, the Administrator stated she did not begin a sexual abuse investigation when informed by the surveyor because she did not know who it involved, and acknowledged that the investigations from the earlier dates were the complete investigations. The resident’s care plan, updated shortly before the survey, addressed self-care deficits but did not include any potential for abuse or interventions to keep the resident safe. Law enforcement later indicated that a staff member reported seeing the family member drop his pants and have his penis in the resident’s face and stated that the facility needed to take action and remove the family member and find a new POA. The surveyors determined that Immediate Jeopardy began with the first allegation and that the facility failed to protect the resident from further allegations of abuse and failed to conduct thorough investigations into four separate sexual abuse allegations involving the same family member.
Removal Plan
- Issued a visitor restriction notice to V17 by the Social Services Director to ensure R42’s safety.
- Abuse Coordinating Team called V39 to inform her the visitor restriction was moved to indefinite and explained the reasons.
- Mailed the visitor restriction letter and emailed it to V17 and V39.
- Obtained email acknowledgement of receipt of the restriction.
- Informed V17 the restriction is indefinite and related to safety concerns regarding incidents.
- Administrator ordered a camera system for public areas (hallways) to aid staff/resident safety and monitor visitors.
- Implemented nursing rounds at the end of every shift to verify the resident has remained free of abuse.
- Social Services Director initiated visits with the resident twice weekly to monitor for psychosocial changes.
- Interviewed all residents and documented they reported feeling safe and free of abuse/neglect.
- Administration to round on every shift to monitor activities.
- Initiated a sexual abuse care plan for R42.
- Updated the physician (Dr. [NAME]).
- Initiated an Abuse Checklist to ensure compliance and document all required steps with abuse reporting.
- Completed all-staff in-services on the Abuse Checklist.
- Implemented a team-based approach for all investigations to ensure accuracy and completeness for each allegation received.
- Implemented the Abuse Checklist for Abuse Coordinators to use with all received documentation (including statements) to conduct thorough investigations including resident assessments and interviews.
- Re-inserviced all staff on the facility Abuse and Neglect Policy.
- Abuse Coordinators conducted random competency checks.
- Added the new Abuse Checklist to new staff onboarding.
- QAPI members to hold a monthly QAPI meeting to discuss abuse investigations, staff compliance, and staff understanding of facility policy.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release August 26, 2026) and official state health department websites — never guesswork.
In your survey window? See what surveyors are citing.
The Survey-Prep Report maps your facility's risk from 12 months of CMS and state citation data — what's being cited around you and what to check first. $129 one-time.