Failure to Remove Alleged Abusive Staff Member From Resident Care
Penalty
Summary
Facility staff failed to ensure that a staff member observed verbally abusing a resident was immediately removed from access to vulnerable residents. Record review showed that Resident #6 had dementia and was severely cognitively impaired per an MDS with an assessment reference date of 12/18/25. The facility’s investigation file for a reported incident indicated that on 1/20/26 during the evening shift, GNA #3 verbally abused Resident #6 while GNA #3 and GNA #4 were putting the resident back to bed, stating, “Do not fucking hit me.” Staff did not recognize this as abuse at the time, and it was not reported to the DON until 1/21/26 at 9:32 AM. Staff assignment sheets and time punches confirmed that GNA #3 worked the evening shift starting at 2:30 PM on 1/20/26 and continued working until 6:30 AM on 1/21/26, resulting in approximately 10 hours of continued work with vulnerable residents after the verbal abuse occurred. A CMA who was present confirmed the time frame of the incident as between 8:00 PM and 8:30 PM on 1/20/26. These findings show that the facility did not promptly remove the alleged perpetrator from resident care or immediately report the abuse to appropriate leadership after it occurred.
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