Failure to Enforce Smoking Policy for Oxygen‑Dependent Smokers Resulting in Facial Burns and Immediate Jeopardy
Summary
The deficiency involves the facility’s failure to protect residents from neglect by not enforcing its Smoking/Vaping policy for residents who smoked, including those who were oxygen‑dependent. Four residents who smoked and used or lived with oxygen were allowed to keep cigarettes and lighters on their person or in their rooms, and two oxygen‑dependent residents repeatedly smoked in their rooms, including while oxygen was in use. Staff, including CNAs, an RN, and the DON, were aware of ongoing unsafe smoking behaviors but did not consistently confiscate smoking materials, did not ensure materials were stored in the designated locked cart, and did not provide adequate supervision or rounding to prevent in‑room smoking. During a tour, surveyors observed three residents entering and leaving the designated smoking area with their own cigarettes and lighters, returning to rooms marked with “Oxygen in Use/No Smoking” signs without surrendering smoking supplies. One oxygen‑dependent resident with COPD, alcohol abuse, noncompliance with treatment, anxiety, and mood disorder had a history of smoking in his room while on oxygen, documented in multiple nursing notes over several months. On one earlier occasion, staff found him smoking with his nasal cannula on and oxygen flowing, with multiple beer cans in the room; he refused to relinquish cigarettes and alcohol, became belligerent, and law enforcement was called, but there was no documentation that staff removed his smoking materials. Another note documented him smoking in his room with oxygen turned off, with education provided and the DON notified, but again no successful confiscation of supplies. Despite care plan interventions requiring supervision while smoking and immediate notification of nursing staff if policy violations were suspected, he continued to keep all smoking materials with him, admitted to smoking in his room and bathroom, and reported that staff rarely entered his room. On the night of the burn incident, this same resident smoked in his room while receiving continuous oxygen at 2 L/min via nasal cannula. A CNA observed his nasal cannula ignite while he was smoking, and staff found burning oxygen tubing, a cigarette on the floor, and smoke in the room, triggering a Code Red and emergency transfer. Hospital records documented superficial partial‑thickness facial burns, soot in the nares and oropharynx, concern for inhalation injury, and the need for intubation during transport. Another oxygen‑dependent smoker, his roommate, reported that this resident smoked in the room multiple times a day while wearing oxygen and that he himself had also smoked in his own room, keeping cigarettes and a lighter on his person and not informing staff after obtaining supplies on leave of absence. Two additional residents, one oxygen‑dependent and one non‑oxygen‑dependent, also admitted to keeping cigarettes and lighters on their person, refusing to surrender them due to fear of theft, and acknowledged they were violating the smoking policy. Staff interviews confirmed that residents routinely refused to relinquish smoking materials and that CNAs and nurses often did not attempt to confiscate cigarettes and lighters from residents known to be aggressive, instead only notifying the Unit Manager, ADON, or DON. One CNA supervising the smoking area stated that most smokers kept their supplies on their person or in their rooms, that leadership had long been aware of this, and that no effective corrective action had been taken. Another CNA reported seeing an oxygen‑dependent resident smoking in his bathroom on the morning of the survey and only notifying the Unit Manager, without attempting to remove the smoking materials due to prior threats of aggression. Residents and staff both reported that nursing rounds were infrequent, with some residents stating they saw staff only a few times per day, allowing residents to smoke inside their rooms and bathrooms without detection. Documentation in care plans and smoking evaluations showed that residents were repeatedly classified as safe smokers, often without supervision, and that there was no recorded evidence of noncompliance with the smoking policy for several residents despite their own admissions and staff observations of in‑room smoking and retention of smoking materials. The facility’s failure to implement its Smoking/Vaping policy as written, to enforce storage of smoking materials in a locked cart, to reassess and document unsafe smoking behaviors, and to provide sufficient supervision and rounding for oxygen‑dependent smokers resulted in an Immediate Jeopardy situation. This failure directly contributed to the event in which an oxygen‑dependent resident’s nasal cannula ignited while he smoked in his room, causing second‑degree facial burns and respiratory distress requiring emergency transfer and burn‑unit care. The ongoing practice of allowing residents, including oxygen‑dependent residents and roommates of oxygen‑dependent residents, to retain cigarettes and lighters and to smoke inside the building left all residents at continued risk for serious injury, harm, impairment, or death, as explicitly stated in the report.
Penalty
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A cognitively intact resident with behavioral issues, including physical aggression and noncompliance with care, was in a secured unit and was observed tapping on the window/door. A dietary aide, despite being told by a CNA and an RN not to enter the secured unit and that the resident’s assigned aide could assist, went onto the unit and interacted with the resident, including offering to buy a soda after seeing money in the resident’s hand. The resident struck the aide in the face, and the aide responded by punching the resident in the face; a CNA reported hearing the aide say, “I will hit you again,” and then observed the resident bleeding. The resident was later found at the hospital to have an open mandibular fracture and non-restorable teeth requiring extraction, and the facility’s investigation and policy definitions led to the incident being substantiated as staff-to-resident physical abuse.
A cognitively impaired resident with dementia and behavioral symptoms became involved in a physical altercation with another resident and was then taken to the nurses’ station, where three CNAs forcefully seated him in a chair, held his arms down, and one CNA straddled his leg while others pulled up on his sweatpants. Video showed the resident being repeatedly pushed back into the chair and physically restrained by multiple CNAs, while cognitively intact residents and a CNA witness reported that staff were laughing, teasing him, and making demeaning comments as he tried to get up and walk away. The resident was later found to have a bruise and skin tear of unknown origin on his arm, exhibited increased agitation, and was placed on Depakote for behavioral management for two days before it was discontinued. The facility’s investigation, including review of video and witness statements, substantiated that the CNAs’ actions constituted physical abuse and a violation of the resident’s rights.
A cognitively impaired female resident with Alzheimer’s disease and a BIMS score of 0 was involved in two separate incidents of sexual contact with cognitively impaired male residents, both of whom also lacked documented assessments of capacity to consent to sexual activity. In one event, a CNA found her in a male resident’s bed with him on top of her and both of their pants down; in another, staff found her naked in another male resident’s bed while he had his fingers in her vaginal area and stated she wanted it. Despite facility policies requiring evaluation of consent capacity when there is concern a resident may not be able to consent, no such evaluations were documented for any of the involved residents, and staff later acknowledged they relied only on BIMS scores to judge consent capacity. One of the alleged sexual abuse incidents was not reported to the state agency as required, law enforcement was not contacted, and the guardian of one male resident was not documented as being consulted about police involvement. Although 15‑minute checks were added to the female resident’s care plan, multiple CNAs and an RN on the unit reported they were unaware of any special monitoring and described only routine checks, indicating the enhanced supervision was not effectively implemented.
A resident with a history of inappropriate behaviors and a recent conviction for a sexual offense, who was documented as needing behavioral monitoring and supervision, was able to wheel past another cognitively impaired resident seated in a hallway and pull at that resident’s pants and brief, placing a hand inside the brief and touching the resident’s private area. Staff and a CNA witness observed the non-consensual contact and intervened to separate the residents. The victim, who had severe intellectual disability and was rarely or never understood, was unable to provide a reliable account of the event, though assessments showed no physical injury at that time. The facility’s abuse prevention policy defined sexual abuse as non-consensual sexual contact and required assessment and supervision of residents with behaviors that may lead to abuse, but the incident occurred despite these requirements, and the facility’s investigation confirmed resident-to-resident sexual abuse.
A resident with significant cognitive and physical impairments, including post-stroke hemiplegia, aphasia, and dependence for ADLs, was transported by a facility staff member to an outside cancer treatment appointment. Witnesses at the clinic reported that the transporter arrived visibly upset, stated he was having a bad day with the patient, and was then seen within an inch of the resident’s face, flailing his arms and yelling, leaving the resident appearing upset. The incident was reported to the clinic’s office manager and then to the Ombudsman, who later informed facility leadership of the allegation. The facility’s abuse policy defines mental abuse as including humiliation and harassment and requires immediate investigation and protection, and surveyors determined the facility failed to ensure the resident was free from verbal abuse by staff.
The facility failed to protect a dependent, hemiplegic resident from a known aggressive roommate who had previously threatened to kill him over TV volume. Staff initially moved the aggressive resident to another room after he threatened to shoot his roommate, but, on direction from the DON and despite staff objections and the aggressor’s documented history of verbal and physical aggression, the two residents were placed back together without updating care plans or increasing monitoring. The aggressive resident later struck his roommate while he was in bed, causing bruising to the shoulder and arm and leading to fear, withdrawal, and self‑isolation. Documentation minimized the event as a verbal altercation, there was no timely evidence of physician or family notification, and the victim reported that no one followed up with him for a statement or investigation, contrary to the facility’s abuse policy requirements.
Staff-to-resident physical abuse resulting in jaw fracture and tooth loss
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from staff-to-resident physical abuse, resulting in serious injury. A dietary aide entered a secured unit where a cognitively intact resident with a history of behavioral issues, including physical aggression and noncompliance with care and medications, was located. The resident had been tapping or knocking on the window/door of the secured unit, drawing the attention of the dietary aide. Multiple staff, including a CNA and an RN, told the dietary aide not to go onto the secured unit, noting that the resident’s assigned aide could assist and that the resident had been agitated the previous day. Despite these instructions, the dietary aide went onto the secured unit. Witness statements and interviews indicate that upon entering the unit, the aide interacted with the resident, including offering to buy the resident a soda after seeing the resident holding money. According to staff statements and the aide’s own account, the resident then struck the aide in the face. The aide responded by punching the resident in the face. A CNA on the unit reported stepping between the two to attempt to deescalate the situation and then calling for the nurse due to the resident’s aggression. The CNA also reported hearing the aide tell the resident, “I will hit you again,” and then observed that the resident was bleeding. Following the punch, the resident was noted by staff to be bleeding from the nose and mouth. The resident was assessed by nursing and subsequently transported to the hospital. Hospital records documented that the resident sustained an open fracture of the right jaw, with a loose right lateral mandibular incisor and bleeding from the socket at the fracture site. The resident’s remaining 11 teeth were extracted because they could not be restored. A police report documented that staff reported the incident as an assault in which a staff member punched a resident after the resident had punched the staff member. The facility’s policy defined abuse as the willful infliction of injury resulting in physical harm, including physical abuse such as hitting and punching, and the facility substantiated that the dietary aide had physically abused the resident.
Abusive Physical Restraint and Humiliation of Cognitively Impaired Resident by CNAs
Penalty
Summary
The deficiency involves the facility’s failure to protect a cognitively impaired resident with vascular dementia and other psychiatric and neurologic diagnoses from physical and psychosocial abuse by three CNAs. The resident had severely impaired cognition, intermittent ability to make himself understood, and a history of some physical and verbal behaviors, but was not known to reject care and typically required only supervision or touching assistance for transfers and ambulation. On the evening in question, a nurse heard yelling and arguing from another resident’s room and found this resident standing by a female resident’s bed, with both residents hitting and smacking each other as he yelled at her to get out of his bed. After staff separated the residents, a CNA took the resident to the nurses’ station, where he continued to be described as physically abusive and verbally aggressive toward staff. Subsequently, multiple CNAs physically controlled and restrained the resident in a manner that was later substantiated by the facility as physical abuse. Video footage showed two CNAs each holding one of the resident’s arms as they directed him down the hall toward the nurses’ station and sat him in a chair. When the resident became agitated and attempted to stand, a third CNA joined them; the two original CNAs grabbed his arms while the third CNA grabbed the back of his sweatpants, pulling them up and back as he was forcefully placed back into the chair. The two CNAs then held his arms down against the chair armrests with closed hands over his wrists and lower forearms, and one CNA straddled his leg. At various points, different CNAs took turns holding his arms or hands while he was kept in the chair for several minutes before being allowed to get up and return to his room. Witness accounts from cognitively intact residents and staff further described the abusive nature of the interaction. One resident reported seeing two female staff hold the resident down in a chair while he only wanted to go to his room, stating he was not fighting and that staff were teasing him; another resident reported staff laughing and teasing the resident, telling him they were holding him down and that he should not move, including calling him “stupid.” A CNA witness stated she did not like how the staff handled the situation and, when asked if she would consider it abuse if it were her family member, she answered yes. The physician later documented that the resident’s behaviors were being instigated by staff and that he was responding to how staff intervened, describing him as being in a protective mode. Following the incident, the resident was noted to have a skin tear and bruise of unknown origin on his arm, increased agitation, and was started on Depakote for behavioral management for two days before it was discontinued. The facility’s own investigation, initiated after reviewing video footage while following up on the earlier resident-to-resident altercation, concluded that physical abuse had occurred. The three CNAs involved were identified as the perpetrators, and their personnel files documented termination for violating residents’ rights, including abuse and failure to report to a supervisor. The facility’s abuse policy defined abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish, and specified that willful meant acting deliberately, not necessarily intending harm. The actions of the CNAs in forcefully seating the resident, holding his arms down, straddling his leg, and teasing and laughing at him were determined by the facility to meet this definition of abuse, resulting in actual harm to the resident, including bruising, a skin tear, increased agitation, and the need for additional psychotropic medication for behavioral control immediately following the incident.
Failure to Protect Cognitively Impaired Residents From Sexual Abuse and to Assess Consent Capacity
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from sexual abuse and to evaluate and document residents’ capacity to consent to sexual activity, as required by facility policy. One resident with Alzheimer’s disease and severe cognitive impairment, documented by a BIMS score of 0, had no assessment in the medical record regarding her capacity to consent to sexual activity. Her care plan addressed impaired cognition, impaired thought processes, tearful episodes, and crying out, but did not address capacity to consent to sexual activity. The Kardex for this resident included general behavior interventions but did not include information about sexual behaviors or the 15‑minute checks that were later added to the care plan. The same resident was involved in two separate incidents of sexual contact with male residents who also had cognitive impairment and no documented assessment of capacity to consent to sexual activity. In the first incident, a CNA found the cognitively impaired female resident in a male resident’s room, lying in his bed with him on top of her and both of their pants down. Witness statements and interviews confirmed that the male resident had dementia, a legal guardian, and a diagnosis including high‑risk heterosexual behavior, but there was no documentation that his capacity to consent to sexual activity had been evaluated. Facility staff, including the DON and ADON, later stated they relied solely on BIMS scores to determine consent capacity and believed both residents in this incident could not consent based on their scores. Despite this, there was no documentation of a formal capacity assessment for either resident. In the second incident, the same cognitively impaired female resident was found naked in another male resident’s bed, with her clothing and his clothing on the floor. Witness statements documented that the male resident had his fingers in her vaginal area while she lay with her legs open, and that he stated she wanted it. This male resident also had dementia and a low BIMS score, but again there was no documentation that his capacity to consent to sexual activity had been evaluated. The facility’s own policies on abuse and residents’ rights required that when there was reason to suspect a resident might lack capacity to consent to sexual activity, the facility would evaluate capacity and take steps to protect the resident from abuse. The survey found that such evaluations were not completed before or after either incident for any of the involved residents. The facility also failed to report one of the alleged sexual abuse incidents to the state survey agency as required by policy. Review of the state SRI database showed no self‑reported incident for the sexual encounter between the cognitively impaired female resident and the first male resident. Interviews with regional leadership and the ADON confirmed that the incident was not reported to the state agency and that law enforcement was not contacted, nor was there documentation that the male resident’s guardian was consulted about police involvement. Additionally, although the care plan for the female resident was updated to include 15‑minute checks after the second incident, multiple staff members working on the unit reported they were unaware of any residents on special monitoring, and they described only routine hourly checks, indicating that the enhanced monitoring interventions were not effectively communicated or implemented.
Failure to Prevent Resident-to-Resident Sexual Abuse in a Common Area
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from resident-to-resident sexual abuse. One resident with a known history of inappropriate behaviors and a recent conviction for gross sexual imposition engaged in non-consensual sexual contact with another resident. The facility’s own documentation indicated that this resident required behavioral monitoring, supervision, and intervention to ensure the safety of others, yet he was in a position to have direct, unsupervised access to a cognitively impaired resident in a hallway. The resident identified as the aggressor had multiple medical and psychosocial conditions, including type II diabetes mellitus, hypertension, history of cerebral infarction, altered mental status, muscle weakness, history of falls, and an adjustment disorder with mixed anxiety and depressed mood. Hospital paperwork also documented that he had been incarcerated multiple times and was recently convicted of gross sexual imposition. Despite this history and the documented need for supervision due to inappropriate behaviors, he was able to wheel himself past another resident seated in a wheelchair in the hallway and initiate inappropriate sexual contact. The resident identified as the victim had severe intellectual disabilities, muscle weakness, and intractable localization-related epilepsy with complex partial seizures, and was documented as rarely or never understood with severely impaired cognitive skills for daily decision making. Nursing notes and a self-reported incident described that the aggressor pulled at the elastic waistband of the victim’s pants and brief and placed his hand inside the brief, touching the victim’s private area. A CNA witness corroborated that upon exiting the elevator, he observed the aggressor pulling the victim’s pants and brief out and placing his hand inside to touch the victim’s private area. Staff then intervened and separated the residents. The facility’s abuse prevention policy defined sexual abuse as non-consensual sexual contact of any type and required assessment and supervision of residents with behaviors that may lead to abuse, but the incident occurred despite these policy requirements, resulting in confirmed resident-to-resident sexual abuse. The facility’s investigation, as confirmed by the Administrator and DON, verified that the aggressor was observed pulling at the victim’s pants and brief and inappropriately touching her private area. Nursing documentation indicated that when confronted, the aggressor acknowledged awareness that he was touching someone’s private area and proceeded to make sexually inappropriate and explicit comments to the nurse. The victim, due to baseline cognitive impairment, was unable to provide a reliable account of the incident, but assessments documented no physical signs of trauma and no voiced complaints of pain or discomfort at that time. The combination of the aggressor’s known history and behavioral risks, the victim’s severe cognitive impairment, and the occurrence of non-consensual sexual contact in a common area formed the basis of the cited deficiency for failure to ensure residents were free from abuse. The facility’s abuse prevention policy, dated 08/25/25, required staff to immediately report, investigate, and implement interventions to protect residents from abuse, and further required assessment and supervision of residents with behaviors that may lead to abuse. Despite these written requirements, the incident occurred when the resident with a documented history of inappropriate behaviors and a recent conviction for a sexual offense was able to access and inappropriately touch a cognitively impaired resident in the hallway. The facility’s confirmation of the allegation as resident-to-resident sexual abuse, supported by staff and witness statements and nursing documentation, demonstrates that the facility did not effectively prevent the abusive contact from occurring. This deficiency was cited as past non-compliance that had been corrected prior to the survey, but the underlying incident and investigation findings clearly established that the facility failed to ensure residents were free from resident-to-resident sexual abuse as required by its own policy and regulatory standards.
Failure to Protect Resident From Alleged Verbal Abuse by Transport Staff
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from verbal abuse by a staff member responsible for transportation. The resident was admitted with multiple significant diagnoses, including cerebral infarction with right-sided hemiplegia and hemiparesis, unspecified psychosis, anxiety disorder, colon cancer, altered mental status, hypertension, type 2 diabetes, aphasia, and dependence on staff for emotional, intellectual, physical, and social needs. The care plan documented that the resident required extensive assistance with bed mobility, was dependent for bathing and toileting, required a mechanical lift for transfers, and had no documented hearing impairment. The resident’s MDS showed dependence for toileting, bathing, personal hygiene, bed mobility, and transfers, and that the resident was non-ambulatory. On the date in question, the resident was transported by a facility transporter to an outside appointment at a comprehensive cancer treatment center. Written and verbal statements from the cancer center’s office manager and secretary indicated that the transporter arrived at the center appearing upset and stated he was having a bad day with the patient. The secretary reported that after the transporter went back out to the van to get the resident, he was observed within an inch of the resident’s face, flailing his arms up and down and yelling at the resident, who had an upset look on his face. The secretary stated she had her hand on the phone ready to call the police and reported the incident to the office manager. The office manager reported that the transporter was observed yelling at the resident and that this concern was reported to the Ombudsman. The transporter later denied yelling at the resident and provided no further comments. The Ombudsman reported that she had been informed by the cancer center staff that they witnessed the transporter yelling at the resident and that they were concerned for the resident, prompting them to report it. The Ombudsman also stated she informed facility leadership during a video conference of the allegations that the transporter had been observed yelling at the resident. The facility’s abuse, neglect, and exploitation policy defines abuse as the willful infliction of injury, intimidation, or punishment resulting in physical harm, pain, or mental anguish, including staff-to-resident abuse, and specifies that mental abuse includes humiliation and harassment. The policy requires immediate investigation and protection of residents from physical and psychological harm when suspicions of abuse occur. The surveyors concluded that the facility failed to ensure the resident was free from verbal abuse by a staff member.
Failure to Protect Resident From Known Aggressive Roommate Resulting in Physical Abuse
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from abuse by not implementing appropriate interventions after clear threats and known aggressive behavior, which led to a resident‑to‑resident physical assault. One resident with left‑sided hemiplegia, significant dependence on staff for ADLs, and a care plan goal to remain free from bruising and injury was verbally threatened by his roommate, who stated he would kill or shoot him over TV volume. Staff, including a CNA and the Social Services Designee (SSD), were aware of the threat, and the aggressive resident was initially moved to a private room. Despite this, the DON later directed that the aggressive resident be returned to the same room, without documented assessment of the threatened resident’s feelings of safety, without documented room‑change orders, and without updating either resident’s care plan or instituting increased monitoring or other protective interventions. Multiple staff interviews confirmed that the aggressive resident had a history of verbal and physical aggression, including prior physical assault of staff and specific threats to choke, shoot, or kill his roommate. Staff voiced concerns to management that returning the aggressive resident to the same room was unsafe, particularly because the threatened resident was physically dependent and unable to defend himself. Nonetheless, the residents were placed back together. On the night of the incident, staff reported that the aggressive resident punched or slapped his roommate while he was lying in bed, with his affected left side toward the aggressor. The victim later described being hit in the left shoulder while dozing, and the aggressor admitted to hitting him in the head or shoulder after becoming angry about language used by the roommate. Following the altercation, the victim reported pain and later exhibited a yellow‑green bruise on the left bicep and a quarter‑sized bruise on the left shoulder, which he attributed to the assault and which a CNA verified. Progress notes and interviews showed that the DON, who was not present at the time of the incident, authored a late entry describing only a verbal altercation and initially reported to the Administrator that there had been no physical contact. There was no timely documentation of family or physician notification regarding the victim being hit, and the victim stated that no one followed up with him for a statement and that he was unaware of any investigation. Staff also reported that they were not asked to provide statements at the time of the incident. The facility’s own abuse policy required immediate protection of residents, reporting to the Administrator and state agency, thorough investigation, documentation, and care plan review and revision, but the report shows that these steps were not carried out in connection with the threats and subsequent physical assault between these two residents. The aggressive resident’s record documented a care plan for inappropriate behaviors, including verbal and physical aggression and delusions, with goals of no injury to self or others and interventions such as documenting behaviors and redirecting him. A progress note documented that he had threatened to shoot his roommate over TV volume, and the on‑call physician ordered medication and increased checks. However, there is no evidence that this known risk was translated into sustained environmental or supervision interventions to prevent further conflict, nor that the threatened resident’s vulnerability and bleeding risk were incorporated into protective planning. Staff accounts consistently indicated that the decision to reunite the residents in the same room, despite prior threats and staff objections, directly preceded the physical assault that caused bruising and psychosocial harm, including fear, withdrawal, and self‑isolation in the victim.
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