Resident Neglect Due to Missed Medications, Oxygen, Supervision, and Meal Leading to Unresponsive Event
Summary
The deficiency involves the facility’s failure to protect a resident from neglect by not providing ordered medications, continuous oxygen, supervision, and meals during an evening shift. The resident had chronic obstructive pulmonary disease requiring continuous oxygen at 3 L/min via nasal cannula, diabetes mellitus, heart failure, and major depressive disorder, and was cognitively intact but required supervision/touching assistance with activities of daily living. The resident was assessed as high risk for falls, had a history of falls, and had a care plan that included hourly visual safety checks, anticipation of needs, ensuring the call light was within reach, and providing physical and emotional support for safety. Physician orders included multiple scheduled medications and inhalers for COPD, diabetes, depression, and other conditions, with doses due at 4:00 PM, 8:00 PM, and 9:00 PM on the evening shift. On the date of the incident, the Medication Administration Record showed no documented evidence that any of the resident’s scheduled medications or treatments were administered between 4:00 PM and 9:00 PM. The Task List for CNAs showed the resident was to receive hourly visual checks for safety, but there was no documentation of hourly monitoring from 2:45 PM to 9:40 PM. The nutritional intake form also showed no evidence that the resident was served a meal or snack between 2:45 PM and 9:40 PM, and the visitor log contained no record of any visitor for the resident during that time. Despite the resident’s order for continuous oxygen, when the resident was later found, staff observed that the resident was not connected to oxygen. Registered Nurse (RN) #1 reported arriving on the unit at 4:15 PM and not seeing the resident during rounds, stating they had been told the resident had a visitor, but they did not verify the resident’s whereabouts and continued working without locating the resident. RN #1 did not administer the resident’s scheduled medications and did not ensure the resident received continuous oxygen. RN #1 stated they began looking for the resident around 9:40 PM, briefly checked the room, did not see the resident, and at approximately 9:43 PM called the resident’s adult child to ask if the resident had left with them. RN #1 then contacted the nursing supervisor to report the resident could not be located and subsequently found the resident at 9:49 PM lying face down on the floor beside the bed, unresponsive, with no pulse and no breathing. Certified Nursing Assistant (CNA) #1, assigned to the resident from 3:00 PM to 11:00 PM, stated they saw the resident in the room sitting on the bed at about 3:30 PM and did not see any visitor present. CNA #1 acknowledged they did not perform the ordered hourly safety checks and that the second time they checked on the resident was around 8:30 PM, when the resident was in the room and stated they were okay. CNA #1 also stated they did not serve a dinner tray to the resident because they were serving residents on the other side of the unit, did not know if the resident ate, and did not ask another CNA whether the resident had received a meal, despite being responsible for checking and documenting meal intake. Supervisory and leadership staff, including the RN supervisors, Infection Control Director, Director of Nursing, Administrator, and Medical Director, later confirmed they were not initially informed that the resident had been considered missing for several hours, had not received scheduled medications, treatments, or a meal, and that these facts were not documented in the incident report, which instead concluded the event appeared related to a medical event and that there was no cause to believe neglect had occurred. At 9:49 PM, the resident was found unresponsive on the floor beside the bed with no measurable vital signs, and CPR was initiated until EMS arrived at 10:07 PM and assumed care. The nursing progress note documented that the resident was found unresponsive with no pulse and no breathing, a STAT call was made, oxygen via nonrebreather mask at 15 L/min was applied, 911 was called, and IV fluids were started. EMS pronounced the resident expired at 10:24 PM. The Accident/Incident Investigation form documented that the call bell was within reach but had not been activated, the bed was in the lowest and locked position, and the floor was clean and dry. It also documented that the interdisciplinary team determined there was no cause to believe abuse, mistreatment, or neglect had occurred, and omitted that the resident had been unaccounted for from 4:15 PM to 9:48 PM, had not received evening medications, was not on oxygen when found, and that the nursing supervisor and physician were not notified of these circumstances at the time of the incident. During postmortem care, staff observed a large skin tear on the resident’s right cheek, described by the adult child as skin peeled off that looked like a burned skin injury. The adult child reported being called by RN #1 at about 9:43 PM and told the resident was missing, and then receiving another call that the resident had been found unresponsive beside the bed. The adult child stated that when they arrived, they were told the resident had expired at 10:24 PM and that a nurse supervisor attributed the facial injury to EMS. RN Supervisor #1 and RN Supervisor #2 both confirmed they responded to a report that the resident could not be found, but by the time they reached the unit, the resident had already been located on the floor unresponsive, and one supervisor noted that the resident was not connected to oxygen. The facility’s own policies defined neglect as the failure to provide goods and services necessary to avoid physical harm, pain, mental anguish, or emotional distress, and required accident investigations and care plan revisions as needed, but the investigation documentation did not reflect the prolonged lack of monitoring, missed medications, missed meal, and absence of continuous oxygen that occurred prior to the resident being found unresponsive.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A CNA aggressively slapped and grabbed a resident’s wrist during lunch feeding assistance, then roughly pulled the resident’s hand off his shirt sleeve after she had grabbed it. The CNA had prior disciplinary actions, including a previous feeding incident in which a resident choked and required the Heimlich maneuver. A nurse later assessed the resident and found no bruises or cuts.
A facility failed to protect two residents from resident-to-resident physical abuse. In one incident, a resident with dementia and cognitive impairment was struck during a dispute over TV volume and responded by scratching the other resident. In another, a resident with dementia and physically aggressive behaviors scratched a roommate’s face, leaving superficial marks. Staff interviews and clinical records confirmed both altercations and the resulting injuries.
A resident with a left ankle fracture, muscle weakness, and total-assist transfer needs was supposed to receive 2-person assistance and remain NWB on the left leg. Instead, a nurse aide transferred the resident with only one staff member during a toilet-to-wheelchair transfer, and the resident heard a pop and developed increased pain. X-ray and hospital imaging confirmed fractures of the distal R tibia and fibula, and the facility substantiated neglect for not following the care plan.
Failure to Protect Resident from Repeated Room Intrusions: A cognitively intact resident with depression and hip OA was repeatedly frightened when another resident with dementia and wandering behaviors entered her room, took belongings, and could not be reliably redirected. Staff used a stop sign banner and other barriers, but the other resident continued to enter the room, and the resident became so fearful that she requested discharge before completing her therapy goals.
Failure to protect a resident from alleged physical abuse: A resident with COPD, speech disturbances, and dysphagia reported that an LPN pushed them in the chest during med pass after they refused meds, causing them to fall. The resident had no visible injuries, but the report was documented by nursing staff and the NP, and the resident later reiterated by writing/gestures that the LPN pushed them. The LPN denied pushing the resident and described the contact as accidental, while the facility concluded there was no evidence of abuse.
A resident-to-resident sexual abuse allegation was not thoroughly investigated, and the resident was not promptly protected or monitored after the allegation. In a separate issue, a handwritten sign with personal care instructions was posted above another resident's bed, and an RT, LPN, RN, and CNA all acknowledged it was a privacy and dignity concern and against facility policy.
Failure to Protect Resident from Abuse During Feeding Assistance
Penalty
Summary
The facility failed to ensure a resident’s right to be free from abuse during lunch assistive feeding. While standing about 3 feet from the lunch table, the surveyor heard a CNA aggressively slap Resident #56’s left wrist and observed the CNA grab the resident’s left wrist and roughly pull her hand off of his shirt sleeve after she had grabbed it. The surveyor then continued observing the meal and later reported the incident to the DON and Administrator. Resident #56 was assessed by a licensed nurse after the incident, and no bruises or cuts were found on her wrists. The CNA involved had been hired by the facility in 2024, had signed the facility’s Resident Abuse Procedural Summary, and had attended behavior training in 2026. The CNA also had three prior disciplinary actions, including a prior incident in which a resident choked after being given too large a bite during assistive feeding and required a Heimlich maneuver.
Failure to Protect Residents from Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to ensure two sampled residents were free from physical abuse by other residents. One resident with dementia, anxiety, chronic pain, visual hallucinations, and moderate cognitive impairment was involved in an altercation with a roommate after a disagreement about TV volume. The incident escalated when the roommate attempted to take the TV remote and struck the resident with an open hand, and the resident responded by scratching the roommate. The record also documented a new scratch on the resident’s left hand and later noted that the resident no longer wanted to share a room with the other resident. The other incident involved a resident with dementia and significant cognitive impairment who had a behavior care plan for impaired safety awareness and physically aggressive behaviors. The record stated that the resident clawed a roommate in the face, leaving superficial scratches and red marks on the roommate’s chin and cheek. The roommate’s record reflected ongoing monitoring for scratches to the chin and neck, and the roommate stated that the other resident reached up and ran fingernails across her face while they were getting up for breakfast. Facility documentation and staff interviews confirmed both resident-to-resident incidents. Staff described the first event as a physical altercation triggered by conflict over TV volume, and the second as an incident in which one resident scratched another resident’s face. The DON stated the facility investigated and reported the incidents, and also acknowledged that the documentation surrounding the second event was inconsistent and did not meet expectations or policy. The cited deficiency was based on the facility’s failure to ensure the residents were protected from physical abuse by other residents.
Failure to Follow Two-Person Transfer Plan Resulted in Resident Fractures
Penalty
Summary
The facility failed to protect a resident from neglect when staff did not follow the resident’s individualized transfer plan requiring assistance from two staff members. The resident was admitted with a left lower leg trimalleolar fracture, polyosteoarthritis, and muscle weakness, and the MDS indicated the resident was cognitively intact but required total assistance for transfers and toileting. The comprehensive care plan and physician orders both directed staff to provide two-person assistance for transfers and to maintain non-weight-bearing status on the left lower extremity. During a transfer from the toilet to a wheelchair, one nurse aide assisted the resident without a second staff member. According to the documentation, the resident stood without difficulty, but during the pivot transfer the resident’s right foot turned inward and both the resident and the aide heard a loud pop. The resident immediately reported increased pain. Later that day, x-ray findings identified an acute fracture of the right tibia, and the resident was transferred to the hospital emergency department for further evaluation and treatment. Hospital imaging confirmed fractures of the distal right tibia and fibula, and the resident was scheduled for surgical repair. The facility’s investigation determined that the aide transferred the resident with only one staff member despite the care plan and physician order requiring two staff members, and that this failure directly resulted in the resident sustaining the fractures. The facility substantiated caregiver neglect and terminated the employee following the investigation.
Failure to Protect Resident from Repeated Room Intrusions
Penalty
Summary
The facility failed to protect a cognitively intact resident with osteoarthritis of the right hip and major depressive disorder from mental abuse by another resident. The resident was admitted as a vulnerable adult and her care plan identified a goal of being free from abuse, neglect, or financial exploitation, but it did not include interventions to protect her from abuse. The resident later reported that another resident repeatedly entered her room, scared her, and took belongings, and she asked staff to contact her lawyer. She also began using a stop sign banner across her door and later barricaded her room with a walker, closet door, and bedside table because she was afraid of the other resident. The other resident had moderate cognitive impairment, vascular dementia with agitation, and Alzheimer’s disease, and his care plan documented restlessness, agitation, sundowning, wandering into other residents’ rooms, and urinating in public. Progress notes showed repeated episodes of wandering into other residents’ rooms, difficulty with redirection, aggression toward staff, and disruptive behavior in resident rooms. Notes also documented that he entered the affected resident’s room on multiple occasions, and staff observed that he could move barriers out of the way and continue entering the room despite attempts to block access. Staff interviews confirmed that the resident was very scared of the other resident and that the repeated room intrusions continued over several days. Staff stated that stop sign banners did not stop him, closed doors did not stop him, and that it often took two or more staff to remove him from rooms. The resident requested discharge from the facility and left before reaching her maximal level with therapy services. Therapy documentation stated she was improving but still needed higher-level therapy before discharge, and the therapy director stated her early discharge was because she could not remain in the facility due to the other resident coming into her room. Facility records also showed staffing levels that were below the facility assessment on several shifts, and the assignment sheets did not identify a staff member assigned to 1:1 observation for the wandering resident.
Failure to Protect Resident from Alleged Physical Abuse
Penalty
Summary
The facility failed to ensure that a resident was free from physical abuse when a nurse allegedly made physical contact with the resident during medication administration. Resident #7, who had diagnoses including COPD, speech disturbances, and dysphagia, had intact cognition on the MDS dated 03/18/2026 and was care planned as at risk for misappropriation, neglect, abuse, and/or exploitation. On 04/08/2026, the resident reported to the RN supervisor that an LPN pushed them in the chest after they refused medications, causing them to fall to the floor. The resident was assessed and no visible injuries were noted. The resident’s report was documented in nursing and medical progress notes, and the facility’s investigation recorded that the resident was visibly upset while describing the incident. The LPN denied the allegation and stated that any contact was accidental, describing that the resident was close behind them as they left the room and that the resident’s chest contacted their back or shoulder. The RN supervisor, DON, and NP each documented interviews and assessments in which no bruising, swelling, or visible injury was found, and the resident later communicated by writing and gestures that they had told the LPN to leave the room and that the LPN pushed them in the chest and they fell. The facility concluded there was no evidence of abuse, neglect, exploitation, or mistreatment, despite the resident’s allegation and the conflicting accounts from the LPN and resident. The RN supervisor stated law enforcement was notified and police interviewed the resident and the LPN, but no report was filed. The DON later stated the contact was accidental and that the resident’s reporting was inconsistent regarding whether a fall occurred.
Failure to Protect Resident from Abuse and Maintain Privacy
Penalty
Summary
The facility failed to ensure a resident was free from abuse when a resident-to-resident sexual abuse allegation was not thoroughly investigated and the resident was not promptly protected or monitored after the allegation. The report states this involved 1 of 52 sampled residents, Resident 45, and that the deficient practice had the potential to place the resident at risk for continued abuse, emotional distress, fear, anxiety, a diminished sense of safety, and delayed implementation of interventions necessary to protect the resident from further abuse. The facility also failed to protect the privacy and confidentiality of Resident 58. Resident 58 was admitted with diagnoses including chronic obstructive pulmonary disease. During observation, a handwritten sign reading, "Attention please no briefs chucks only!!" was posted above the resident's bed and remained there on a later observation. Staff members including a Respiratory Therapist, LPN, RN, and CNA each acknowledged the sign was visible above the bed and stated it was a privacy, dignity, and policy issue. A facility Residents Rights policy stated residents have the right to privacy and confidentiality with personal care and medical records, and that resident medical and personal care information is private and staff are required to respect and uphold resident privacy at all times.
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