Failure to Timely Report Witnessed Physical and Verbal Abuse by an LPN
Summary
The deficiency involves the facility’s failure to ensure that witnessed physical and verbal abuse of a resident was reported to the administrator/designee and the state agency within the required 2-hour timeframe. On 02/17/2026 at approximately 4:00 PM, an LPN physically and verbally abused Resident #1 by repeatedly hitting him on the face, head, and shoulders with a closed fist, placing her knee on his neck, grasping his shirt and attempting to drag him across the floor, and yelling profanities at him, including, “b***h, don’t hit me” and “b***h, I’m tired of you.” This abuse was witnessed by two CNAs (S5 and S6) and another resident (Resident #2). The LPN further stated to the two CNAs, in front of Resident #1, “leave that b***h on the floor, don’t help him up.” The immediate jeopardy situation continued when the two CNAs left Floor B for approximately 8 minutes, leaving Resident #1 and 20 other residents alone on the unit with the same LPN who had just committed the physical and verbal abuse. Later, at approximately 5:00 PM, the LPN instructed one of the CNAs, again in front of Resident #1, to “leave that b***h in his chair.” The CNA then left the LPN unmonitored and with access to all 21 residents on Floor B while she went in and out of rooms to complete her rounds. Despite witnessing the abuse and understanding that abuse should be reported immediately, the CNAs did not report the incident to the administrator or other administrative staff within 2 hours, and the LPN remained on duty until she clocked out at 11:20 PM. Multiple staff interviews confirmed that the abuse was not reported in a timely manner and that there was confusion or lack of knowledge among some staff about how to contact administrative staff when they were not physically present in the facility. S5CNA acknowledged she did not report the abuse to any administrative staff or nurses until the morning of 02/18/2026 and stated she did not know how to reach them at the time of the incident. S6CNA similarly indicated that the abuse should have been reported immediately but was not reported until the next day, and that she did not know who to report to at the time. Another CNA (S7) reported that S5CNA told her about the abuse on 02/17/2026, but she also did not report it, despite having the phone numbers of the administrator and DON. The administrator and DON both indicated that the CNAs who witnessed or knew of the abuse should have reported it immediately. The administrator acknowledged that the physical and verbal abuse should have been reported to the state agency within 2 hours, which did not occur. The facility’s abuse-related policies, including the Abuse Prevention policy, Abuse Recognition, Reporting, and Investigation policy, and Abuse Reporting and Investigation policy, required that any person who witnessed or suspected abuse immediately inform the house supervisor, who would notify the administrator or designee, and that the administrator or designee report all allegations of suspected or actual abuse through the state incident reporting system and to proper parties as required by state and federal law. Despite these policies, the witnessed abuse of Resident #1 by the LPN on 02/17/2026 was not reported to the administrator until approximately 10:30 AM on 02/18/2026, and thus was not reported to the state agency within the required 2-hour timeframe. This failure to follow established reporting procedures and to promptly notify the appropriate authorities constituted the cited deficiency.
Removal Plan
- S1Administrator verbally in-serviced S5CNA and S6CNA on immediately reporting abuse to S1Administrator.
- S1Administrator started an investigation into the allegation of physical and verbal abuse of Resident #1 by S4LPN and requested S5CNA and S6CNA give written statements of the abuse they had witnessed.
- S1Administrator immediately suspended S4LPN from working with residents and requested she give a written statement.
- S1Administrator had staff perform an assessment of Resident #1 for any injuries and/or pain.
- S1Administrator entered a report regarding the physical and verbal abuse in the State Incident Management System (SIMS).
- Resident #1's medical provider conducted a psychological evaluation on Resident #1.
- S1Administrator had staff do an audit of the other residents that resided on Floor b to determine if they have suffered any abuse.
- S1Administrator obtained a witness statement from Resident #2.
- S2DON and S8Director of Education started retraining staff to immediately report any abuse to S1Administrator.
- S1Administrator reported the physical and verbal abuse to the local police department.
- S1Administrator reported S4LPN's physical and verbal abuse of Resident #1 to the Louisiana State Board of Practical Nurse Examiners.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Failure to report an alleged misappropriation of resident funds. A resident with COPD, anxiety, and PTSD reported $1,600 missing and believed another resident took it, but the SSD reportedly said it was too long ago to investigate. The CNO recalled hearing about missing funds from a family member but did not pursue it, and the CEO stated the allegation should have been reported to the State Agency.
Failure to report alleged sexual abuse within required timeframe. A resident with intact cognition and significant ADL dependence alleged that a CNA raped them during incontinence care; the resident later described possible penetration and burning, while the CNA said they only provided brief care and applied ointment. The family member contacted law enforcement and requested hospital transfer, but facility leadership did not report the allegation to DOH within 2 hours, stating they believed the allegation had changed to rough handling and did not meet the reporting threshold.
Failure to Immediately Report Abuse Allegations and Injury of Unknown Origin: Staff did not immediately report two resident-to-resident sexual abuse incidents involving one resident touching two others, and staff also did not immediately report bruising of unknown origin on another resident. A CNA redirected the resident during the abuse incidents but did not notify the charge nurse, DON, or Administrator, and an RN and LPN did not escalate the bruising after assessing it and hearing it described as handprint-like. The delayed reporting prevented timely initiation of the abuse investigation process and resident assessment.
Failure to Report Alleged Physical Abuse: A resident alleged that two CNAs were rough while repositioning them in bed and that the resident’s head was bumped into the headboard, causing pain. One CNA confirmed the head bump occurred during care, and the administrator stated the abuse allegation and failure to report were substantiated because the staff did not report the incident immediately.
Failure to Timely Report Allegation of Abuse: A nurse witnessed one resident touch another resident inappropriately, but the incident was not reported within the required timeframe. The LPN separated the residents and addressed boundaries with the resident involved, but did not report the event because she believed the RN would notify the DON. The DON and Administrator later stated the incident had not been reported immediately as required.
Failure to Immediately Report Verbal Abuse Allegation: A CNA was heard using foul and disrespectful language toward a cognitively impaired resident during care, but the allegation was not reported immediately to the DON/Administrator. The witness delayed reporting for several hours, and the DON, ADON, and Administrator confirmed the report was not made until later that morning. The resident had severe cognitive impairment, was dependent on staff for care, and received nutrition via GT.
Failure to Report Alleged Misappropriation
Penalty
Summary
The facility failed to ensure an allegation of misappropriation was reported to the State Agency as required for Resident #23, who was admitted with diagnoses including COPD, anxiety, and PTSD. Resident #23 stated that approximately two months before the survey, he reported $1,600.00 missing to the Social Services Director and believed another resident had taken the money. He reported that the SSD asked how long ago it happened, and when he said about one and a half months earlier, he was told it had been too long ago to investigate. During the survey, the SSD did not respond to a call for interview, the CNO stated she recalled a family member mentioning the missing funds but did not ask further questions, and the CNO said the allegation was never made directly to her or facility staff. The CEO stated the allegation should have been reported to the State Agency.
Failure to Report Alleged Sexual Abuse Within Required Timeframe
Penalty
Summary
The facility failed to ensure that an alleged incident of abuse was reported to the New York State Department of Health and local law enforcement within two hours of the allegation. The deficiency involved one resident who had diagnoses including obstructive and reflux uropathy, hemiplegia, and hemiparesis following cerebral infarction. The resident’s MDS documented a BIMS score of 15, indicating intact cognition, and the care plan showed the resident required assistance with ADLs, including two staff members for transfers and toileting and extensive assistance for dressing, bathing, grooming, and bed mobility. According to the facility’s incident report, the resident told an LPN that they had been raped by a CNA while receiving care. The resident later described that the CNA entered the room to change a wet brief, applied cream to the hip and then to the anus and vaginal area, and that they felt something enter the anus and vagina while asking the CNA to stop. The CNA stated they provided incontinence care and applied A and D ointment to the perianal area, and the video review showed the CNA entered the room at 4:43 AM and exited at 5:19 AM. The resident’s family member reported that the resident called them, said to come immediately, and later stated that a staff member had raped them. The family member contacted law enforcement and requested hospital transfer. Facility leadership acknowledged awareness of the allegation but did not report the alleged rape to the Department of Health, stating they believed the allegation changed to rough handling and did not meet the reporting threshold. The DON, Administrator, and Social Worker each described differing understandings of the allegation and reporting status, and the report states there was no documented evidence that the allegation was reported to local law enforcement or the Department of Health within two hours as required.
Failure to Immediately Report Abuse Allegations and Injury of Unknown Origin
Penalty
Summary
The facility failed to ensure staff immediately reported allegations of abuse to administration for two separate resident-to-resident sexual abuse incidents involving three residents. One CNA witnessed Resident #3 inappropriately touch Resident #1’s breasts while Resident #1 was asleep, and later saw Resident #3 reach under Resident #2’s blanket while Resident #2 pushed the hands away and told Resident #3 to stop. The CNA redirected Resident #3 during both incidents but did not immediately notify the charge nurse, DON, or Administrator. The incidents were later identified by the DON through electronic medical record alerts, and the DON and Administrator stated they were not notified when the events occurred. The facility also failed to ensure staff immediately reported an injury of unknown origin for Resident #4. Two CNAs observed multiple bruises, including bruises resembling handprints, while providing care and notified an RN and LPN. The RN assessed the resident and documented bruising of unknown origin, but neither the RN nor the LPN notified the DON or Administrator at that time. The LPN stated the CNAs were discussing the bruises with the RN and therefore did not contact higher management, while the RN did not believe the bruising was concerning because the resident had fragile skin and was on a blood thinner. Because the allegations were not immediately escalated, the facility’s abuse investigation process was delayed, including resident assessment and collection of investigative information. For Resident #4, the DON stated the resident had already been transferred to the hospital before the facility initiated an abuse investigation and could not be assessed as part of the initial investigation. The Administrator acknowledged that facility protocol requiring immediate reporting of abuse allegations was not followed in both events.
Failure to Report Alleged Physical Abuse
Penalty
Summary
The facility failed to ensure an allegation of physical abuse was reported for one resident. A written statement from the resident said that a night shift CNA and the CNA’s helper slid the resident up in bed and rammed the resident’s head into the headboard, causing the resident to holler out in pain. The resident later stated that the staff had hurt them by being rough. An email statement from one CNA said that the resident’s head bumped the headboard while the resident was being pulled up in bed after a change, and that the CNA apologized and asked several times if the resident was okay. Employee counseling records showed two CNAs were terminated for failure to report an allegation of abuse. The administrator stated the abuse allegation and failure to report were substantiated after the facility investigation, and stated the staff should have reported the incident immediately when the resident said they were hurt.
Failure to Timely Report Allegation of Abuse
Penalty
Summary
The facility failed to report an allegation of abuse within the regulated timeframe for 2 of 27 residents reviewed for abuse. The facility policy stated that suspected abuse, neglect, exploitation, misappropriation of resident property, or injury of unknown source must be reported immediately, defined as within 2 hours for allegations involving abuse or serious bodily injury, or within 24 hours for allegations that do not involve abuse or serious bodily injury. R15 was admitted with diagnoses including dementia, essential hypertension, depression, and pure hyperglyceridemia, and R14 was admitted with diagnoses including hypertension, left above-the-knee amputation, anxiety disorder, neurogenic bladder, and COPD. Staff interviews and record review showed that a nurse witnessed R14 touch R15 inappropriately in the dining room on 06/22/26, with the Social Services Director later stating the incident was reported to her on 06/24/26. The LPN stated she was told by an RN that R14 touched R15 inappropriately, separated the residents, discussed boundaries with R14, and did not report it because she thought the RN would report it to the DON. The DON stated she was made aware on 06/24/26 of an incident that had occurred a couple of nights earlier, and the Administrator stated the nurse assigned to the residents did not report the incident immediately.
Failure to Immediately Report Verbal Abuse Allegation
Penalty
Summary
The facility failed to ensure that an allegation of verbal abuse was reported immediately to the Administrator when a CNA was witnessed using foul language at the bedside within earshot of a resident. The deficiency involved one resident reviewed for abuse/neglect and was based on interviews and record review showing that the allegation was not reported right away, but instead was brought to the DON hours later the same morning. The resident involved was a female with multiple serious diagnoses, including respiratory failure, a stage 2 sacral pressure ulcer, encephalopathy, anemia, diabetes, malnutrition, non-Alzheimer's dementia, depression, hypertension, severe chronic kidney disease, difficulty walking, failure to thrive, leukemia in remission, and a bone marrow transplant history. Her quarterly MDS showed a BIMS score of 07, indicating severe cognitive impairment, with delusions and inattentiveness. She was dependent on staff for personal hygiene, dressing, toileting, positioning, and transfers, was always incontinent of bowel and bladder, and received nutrition through a feeding tube. A CNA reported that while assisting the resident with care, another CNA repeatedly used disrespectful language toward the resident, including calling her a derogatory name while the resident was in the room and within hearing distance. The witness said she did not report the allegation immediately because she was thinking about it and did not want to jeopardize the other CNA's job, and she ultimately reported it later that morning to the DON. The DON and ADON confirmed the allegation was not brought to the Administrator until hours after it occurred, and the Administrator stated she was unaware of the behavior until the report was made. The facility records also showed policies requiring immediate reporting of suspected abuse and defining verbal abuse as communication within hearing distance that can cause humiliation, intimidation, fear, shame, agitation, or degradation.
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