F0609

D

Failure to Report Administrator’s Verbal and Mental Abuse of a Resident

Indianapolis, Indiana Survey Completed on 03-05-2026

Penalty

No penalty information released

Summary

Facility staff failed to immediately report an incident of alleged staff-to-resident verbal and mental abuse to facility management or the facility’s compliance hotline, as required by facility policy. On 2/19/26, the Administrator was in Resident B’s room and, according to Resident B’s later report and a video evidence summary, spoke to the resident in a mocking, undignified, degrading, and intimidating tone, including responding “Not my problem” when the resident asked where she should go. The Administrator’s behavior was determined by the facility’s investigation to have violated the resident’s rights and to meet the definition of abuse. Multiple staff members, including the DON, ADON, Staffing Coordinator, and Housekeeping Supervisor, were present in and out of the room and witnessed the Administrator’s verbal and mental abuse toward Resident B.

Despite witnessing the incident, the DON, ADON, Staffing Coordinator, and Housekeeping Supervisor did not intervene and did not report the alleged abuse to facility management or to the facility’s compliance hotline, as required by the facility’s Abuse and Incident Reporting Policy. That policy states that all alleged violations involving mistreatment and verbal abuse, which may be considered a type of mental abuse, must be reported immediately to the Administrator or other officials, and that if staff are aware of or witness any abuse, it must be reported. The abuse allegation was ultimately reported by Resident B to the local Ombudsman on 2/27/26, who then notified the CNO. The CNO confirmed through interview with Resident B that the Administrator had spoken in a mocking, undignified, and intimidating tone and that multiple staff had witnessed the incident but had not reported it.