Failure to Assess Sexual Consent Capacity and Implement Protective Monitoring After Repeated Sexual Incidents
Summary
The deficiency involves the facility’s failure to implement preventative measures to protect residents from sexual abuse, including failure to evaluate and document residents’ capacity to consent to sexual activity. One resident with Alzheimer’s disease, severe cognitive impairment (BIMS score of 0), and care plan problems for impaired cognition and tearful episodes was involved in two separate incidents of sexual contact with male residents. Her medical record did not contain any assessment of her capacity to consent to sexual activity, and her care plan did not address sexual consent capacity or sexually inappropriate behaviors. Despite her severe cognitive impairment and behaviors such as wandering and crying out, there was no documentation that anyone was making healthcare decisions for her, and facility leadership acknowledged that nobody was doing so at that time. The first incident occurred when a CNA, after noticing the cognitively impaired resident was not in the dining room, searched rooms and found her in a male resident’s bed with both residents’ pants down and the male resident on top of her. This male resident had dementia, a BIMS score of 11, a diagnosis including high-risk heterosexual behavior, and a court-appointed guardian, yet his record also lacked any evaluation of his capacity to consent to sexual activity and his care plan did not address sexual consent capacity. Witness statements from the CNA and LPN confirmed that the residents were found in this position and immediately separated. Facility leadership later verified that the male resident was on top of the cognitively impaired resident with both of their pants down and that the incident was not reported to the state agency, no self-reported incident was made, and the police were not contacted, nor was there documentation that the male resident’s guardian was consulted about police involvement. The second incident involved the same cognitively impaired female resident and another male resident with dementia, agitation, and a BIMS score of 3. His record also contained no evaluation of his capacity to consent to sexual activity. During rounds, CNAs could not find the female resident in her room and discovered her in this male resident’s room behind a pulled curtain. Witness statements and a nursing note documented that both residents were naked, their clothing was on the floor, and the male resident had several fingers in the female resident’s vaginal area while stating that she wanted it. Both residents were separated. A self-reported incident was completed for this event and later unsubstantiated by the facility. Interviews with multiple CNAs and an agency RN who routinely worked on the unit revealed they were unaware of any residents on special monitoring or 15-minute checks, despite the care plan for the cognitively impaired resident indicating such checks after the prior incident. Facility leadership and the DON acknowledged that no assessments of capacity to consent to sexual activity were completed for the involved residents, that they relied solely on BIMS scores for consent determinations, and that they were not aware of or did not implement a specific protocol for alleged sexual abuse as described in the facility’s own abuse policy, which required evaluation of capacity to consent and systemic actions to protect residents when abuse was suspected. The facility’s written policy on residents’ right to freedom from abuse, neglect, and exploitation stated that residents had the right to engage in consensual sexual activity, but that when there was reason to suspect a resident might lack capacity to consent, the facility would evaluate capacity and take steps to protect the resident from abuse. The policy also required the development of written procedures to determine whether the resident was protected, identify contributing risk factors, and determine the need for systemic actions and tracking of similar occurrences. Despite this policy, there was no documented evaluation of capacity to consent for any of the three involved residents, no documented implementation of the policy’s required procedures following the incidents, and no consistent implementation or communication of monitoring interventions such as 15-minute checks to staff on the unit. Interviews with the DON, ADON, and regional nurse confirmed the absence of a known protocol for alleged sexual abuse incidents and the lack of standardized monitoring measures following these events.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A resident with dementia and chronic respiratory failure, but assessed as having mild or no cognitive impairment, was the subject of multiple detailed email complaints from her daughter alleging that an LPN improperly administered Tramadol, intimidated the resident, failed to provide ordered meds and incontinence care, and used derogatory language, and that a CNA and another aide verbally mistreated the resident and disrespected her belongings, with an item reported stolen and video evidence referenced. Despite these repeated allegations sent to facility staff and the state agency, the only self-reported incident documented vague concerns of mistreatment, lacked specific details, did not include an interview or documented attempt to interview the daughter, relied on a generic questionnaire for the resident, and showed no effort to obtain camera footage. Facility leadership denied knowledge of the reported abuse, neglect, and misappropriation, the concern log contained no entries for this resident, and the call log lacked documentation of call outcomes, all contrary to the facility’s abuse policy requiring immediate, thorough investigation and reporting of all such allegations.
The facility failed to thoroughly investigate multiple allegations of misappropriation of resident funds involving several cognitively impaired and cognitively intact residents. Unauthorized online purchases were made for clothing, electronics, snacks, personal care items, and activity supplies using resident trust accounts without resident or representative consent, and documentation of these purchases was absent from medical records. Some items bought with resident funds were not received by the residents and were instead found in the activities department or could not be located. Former business office, activities, and social services staff, as well as facility leadership, had access to and approved these orders, yet not all potential perpetrators were investigated, and suspicions raised by a staff member were not promptly reported to administration or corporate leadership, contrary to facility policies requiring resident authorization and thorough investigation of misappropriation.
Facility staff failed to thoroughly investigate an allegation of neglect related to a resident’s death. A cognitively intact resident with multiple comorbidities and a full code status was found unresponsive and without vital signs by an LPN during morning med pass, with no prior documented change in condition or record of when the resident was last checked. Staff interviews indicated that an agency CNA assigned to the resident was frequently unavailable, did not consistently respond to call lights, and last checked the resident around midnight to 1:00 A.M., with no further checks before the resident was found unresponsive at 5:30 A.M., despite an expectation for at least q2h monitoring. The DON acknowledged that the resident was not checked in a timely manner, that such a lapse would be considered neglect, and that no investigation or required reporting of the alleged neglect and death had been completed in accordance with facility policy.
A resident with moderate cognitive impairment, multiple chronic conditions, and total dependence on staff for mobility and ADLs was found on the floor and subsequently had multiple negative x‑rays of the right arm, leg, and hip despite ongoing pain. A later hip x‑ray showed a cortical breach and recommended a CT, and a subsequent CT revealed a nondisplaced right intertrochanteric femur fracture of unknown origin. The DON could not determine whether the fracture was related to the fall or occurred during routine care and acknowledged that no Facility‑Reported Incident was completed, no investigation into the injury of unknown origin was conducted, and the event was not reported to the State Agency, despite facility policy requiring identification, investigation, and reporting of possible abuse, neglect, or mistreatment.
Two residents with a history of conflict over TV volume, one highly dependent with hemiplegia and bleeding risk and the other with documented aggressive behaviors, were placed together in a shared room despite prior threats by the more independent resident to shoot his roommate. The dependent resident later reported being punched or slapped while in bed, and the aggressive resident admitted to hitting him, with staff observing the dependent resident as scared and later noting bruising to his shoulder and arm. However, the DON’s late entry progress note minimized the event as a verbal dispute with no harm, no timely injury assessment or witness statements were obtained, CNAs were not asked for statements, and there was no documented, timely abuse investigation as required by the facility’s abuse policy, resulting in a failure to thoroughly investigate the abuse allegation.
The facility failed to thoroughly investigate an injury of unknown origin for a dependent, long‑term resident with multiple comorbidities and a history of falls. After routine night care involving repositioning by a CNA, the resident yelled out during care, later complained of left knee pain, and was sent to the ER at the POA’s request, where she was diagnosed with a distal femur fracture and UTI. The resident reported that her leg had been pulled back and believed it was broken, while the CNA reported the resident resisted and screamed during rolling. The facility’s SRI concluded the fracture was likely pathological with no trauma or fall, despite a hospital note describing an acute, impacted distal femoral metaphyseal fracture due to specific trauma and a physician note referencing a recent fall with a distal femur fracture. The DON could not explain how the fracture occurred or reconcile the conflicting documentation and was unable to provide further investigative documentation, contrary to the facility’s abuse/neglect investigation policy.
Failure to Investigate Allegations of Abuse, Neglect, and Misappropriation
Penalty
Summary
The deficiency involves the facility’s failure to thoroughly investigate multiple allegations of abuse, neglect, and misappropriation involving one resident. The resident was admitted with dementia, anxiety disorder, and chronic respiratory failure, but her MDS assessment indicated mild or no cognitive impairment. Progress notes for the year contained no documentation of abuse or misappropriation allegations, and the resident concern log for the past year showed no concerns regarding this resident, despite numerous detailed complaints made by her daughter via email to facility staff and the state agency. Emails from the resident’s daughter alleged that an LPN administered Tramadol doses too close together, spoke with animosity and hatred, and made disparaging remarks about the resident and her daughter; that the LPN intimidated the resident, who was afraid to be alone with her; that the LPN failed to administer medications as ordered, falsely documented refusals, and failed to respond to calls for incontinence care for several hours after turning off the call light. Additional emails alleged that a CNA disrespected the resident’s personal belongings and spoke to her like a three-year-old, that an unidentified aide verbally abused the resident by continually yelling at her, and that a set of cabin socks was stolen. The daughter also reported that the LPN publicly called the resident a derogatory name, that the resident was terrified of the alleged perpetrators, and that her repeated reports were being ignored. The only self-reported incident involving this resident in the prior six months was one SRI alleging staff spoke to her in a loud, abrasive manner, which documented only general concerns of mistreatment without specifics. The SRI contained no interview or attempted interview with the daughter, and the only interview with the resident was a generic questionnaire with pre-circled answers indicating she felt safe and had no concerns. There was no documented attempt to obtain video footage from a monitoring camera that had been in the resident’s room until it was removed, despite progress notes and the daughter’s email referencing video evidence. Facility leadership, including the Administrator, DON, ADON, and Regional Nurse, denied knowledge of the various allegations described in the emails and interview, and a call log produced by the facility showed calls to the daughter without any documentation of the content or results of those calls. These actions and omissions were inconsistent with the facility’s abuse policy, which required immediate, focused investigations of all reports of abuse, neglect, or exploitation, including interviews of all involved persons and timely reporting to the state agency.
Failure to Thoroughly Investigate Misappropriation of Resident Funds
Penalty
Summary
The deficiency involves the facility’s failure to thoroughly investigate multiple allegations of misappropriation of resident funds, including failure to investigate all alleged perpetrators. For one resident with CHF, Alzheimer’s disease, and aphasia who was severely cognitively impaired and dependent for ADLs, quarterly fund statements showed unauthorized debits to an online retailer, including purchases of clothing and snack items. The resident’s representative did not authorize these purchases, and there was no progress note documentation by the former Business Office Manager (BOM), former Activities Director (AD), or former Social Services (SS) staff regarding these transactions. Online retailer receipts showed that the former AD made several purchases under the resident’s name, and the Administrator later confirmed that items such as a cowboy outfit and other clothing could not all be verified as having been provided to the resident. Another cognitively intact resident with diabetes, PTSD, and osteoarthritis had large online purchases made in her name for a tablet, tablet keyboard, clothing, personal care items, and nutritional products. The quarterly fund statement reflected significant activity, and receipts showed that the former SS used the resident’s funds for these items without authorization from the resident or her representative. The resident reported that a cart of items was brought to her, that she had not requested them, and that she sent them back, including a tablet when she already had one. The Administrator confirmed that the former SS placed a large order under this resident’s name without authorization and that the purchase was made with the intent that the cost be withdrawn from the resident’s account. A moderately cognitively impaired resident with diabetes, pulmonary hypertension, and generalized anxiety disorder had unauthorized online retailer debits for hearing aids and a television, with no documentation in progress notes by the former BOM, former AD, or former SS. Receipts showed the former AD purchased hearing aids and the former BOM purchased a television using the resident’s funds, and the Administrator confirmed these purchases were unauthorized and that the television’s location was unknown. Another severely cognitively impaired resident with epilepsy, ESRD, and aphasia had unauthorized debits for clothing and personal items, with no documentation of purchases in the medical record. Receipts showed the former BOM and former AD purchased multiple clothing items and labels using the resident’s funds without authorization, and some items could not be found in the resident’s room. A further severely cognitively impaired resident with Alzheimer’s disease, CHF, and diabetes had multiple unauthorized online purchases for televisions, snacks, clothing, activity items, and other goods, with no documentation by the former BOM, former AD, or former SS. Receipts showed the former BOM and former AD used this resident’s funds for numerous items, some of which were later found stored in the activities department rather than with the resident. Interviews with former and current staff revealed that the former BOM, former AD, and former SS were involved in directing and placing orders using resident funds, including for residents on Medicaid who were over the $2000 resource limit, and that some items purchased with resident funds were used by the activities department. The former BOM stated that the Administrator was aware of and approved all online orders, and the former AD stated he ordered items as directed by the Administrator and former BOM. The current AD reported that the former AD told her he would order items for one resident using another resident’s funds and that numerous snack and activity items ordered under resident fund accounts were kept in the activities room and never delivered to residents; she discussed her suspicions with other staff but did not report them to the Administrator, DON, or corporate office. The Administrator acknowledged that self-reported incidents (SRIs) for several residents were not reported in a timely manner because the AD did not report her suspicions, and leadership interviews confirmed that the Administrator and a corporate clinical operations leader had access to and approved online orders but were not fully investigated as potential perpetrators. The facility’s own policies required resident or designee signatures for fund disbursements and mandated thorough investigation and timely reporting of misappropriation, which did not occur in these cases.
Failure to Investigate Alleged Neglect Following Resident Death
Penalty
Summary
Facility staff failed to thoroughly investigate a concern of possible neglect related to a resident’s death. The resident had diagnoses including nonalcoholic steatohepatitis (NASH), diabetes, ascites, and obesity, and an MDS BIMS score of 15 indicating intact cognition. The resident’s care plan documented a full code status with interventions to call 911, initiate CPR, provide oxygen or ambu-bag breaths if not breathing, and notify the physician and family if the resident stopped breathing or her heart stopped. The care plan also identified risk for impaired skin integrity related to diabetes, incontinence, mobility problems, and long-term steroid use, with an intervention to turn and reposition the resident every two hours. On the date of death, a progress note by an LPN documented that during morning medication pass at 5:30 A.M., the resident was found nonresponsive, cool to the touch, and without measurable blood pressure, pulse, or respirations. A second nurse verified the absence of heartbeat and breath sounds. The record contained no documentation of any change in condition prior to death, nor any notation of the last time the resident was checked, seen, or cared for before being found unresponsive. The DON later stated that the nurse reported last seeing the resident alive around midnight, and that it was unknown when the assigned CNA had last provided care. Interviews with staff revealed concerns about the assigned agency CNA’s lack of timely care and monitoring. A CNA and a hospitality aide reported that the agency CNA was frequently sitting at the desk, difficult to locate, and not tending to residents’ needs or following up on care requests. The agency CNA stated he assumed care at 11:00 P.M., that the resident had been using the call light for incontinence care, drinks, and repositioning, and that he last checked on her between midnight and 1:00 A.M. when she appeared to be sleeping; he did not check on her again before she was found unresponsive at 5:30 A.M. The DON acknowledged that residents were expected to be checked at least every two hours, that the resident was not checked in a timely manner, that not checking on a resident for an extended period would be considered neglect, and that no investigation or self-reported incident had been completed regarding the resident’s death or the allegation of neglect, contrary to the facility’s abuse/neglect policy requiring thorough investigation and reporting of all such allegations.
Failure to Investigate and Report Injury of Unknown Origin
Penalty
Summary
The deficiency involves the facility’s failure to investigate an injury of unknown origin for one resident who was dependent on staff for toilet hygiene, bed mobility, transfers, and bathing, and who had moderate cognitive impairment and multiple medical diagnoses including COPD, anxiety, diabetes, hypertension, and unspecified hemiplegia. The resident was found on the bedroom floor with her back on the floor and head against the bedside stand, and the family, CNP, and DON were notified, with x‑rays ordered. Initial x‑rays of the right arm, leg, and hip were negative for fracture, and a subsequent hip x‑ray also showed no fracture. A later x‑ray of the right hip with unilateral pelvis showed a cortical breach with a small step deformity of the femoral neck and recommended a CT scan for further evaluation. A CT scan of the right hip later revealed a nondisplaced right intertrochanteric femur fracture. The DON stated that multiple x‑rays were done after the fall because of continued complaints of pain and that all were negative for fractures until the later imaging, and also stated that the resident refused the initially scheduled CT scan and it was rescheduled. The DON reported that the facility did not believe the fracture occurred from the original fall but could not identify what caused the fracture, acknowledged that the resident was dependent on staff for all transfers, toileting, and bed mobility, and could not say if the fracture was caused during routine care. The DON confirmed that, despite the fracture being identified and its cause being unknown, the facility did not complete a Facility‑Reported Incident, did not conduct an investigation into the injury of unknown origin, and did not report the injury of unknown origin to the State Agency, contrary to the facility’s abuse, neglect, and exploitation policy requiring identification, investigation, and reporting of all possible incidents within required timeframes.
Failure to Thoroughly Investigate Resident-to-Resident Abuse Allegations
Penalty
Summary
The deficiency involves the facility’s failure to thoroughly investigate allegations of resident-to-resident abuse involving two residents. One resident with left-sided hemiplegia, chronic pain, anemia with aspirin therapy, and significant dependence on staff for ADLs reported that his roommate came through the closed curtain and punched him in the left shoulder while he was lying in bed dozing. His care plan included interventions to assist with transfers and mobility and to observe for bruising due to bleeding risk, and his MDS documented moderate cognitive impairment and extensive physical assistance needs. Despite this, the initial documentation by the DON, entered as a late entry, characterized the incident only as a disagreement over TV volume with no harm to the resident, and there was no contemporaneous documentation of a physical assault, assessment for injury, or immediate investigation. Multiple interviews and records later confirmed that a physical altercation had occurred and that the facility did not conduct a timely, thorough investigation as required by its abuse policy. The resident who reported being hit stated that he told a nurse about the incident but could not recall which nurse, and he reported that no one followed up with him or obtained a statement. The SSD learned of the incident days later, interviewed both residents, and documented that the dependent resident described being struck in the shoulder and having a “knot” on his shoulder, which the SSD did not verify. The alleged aggressor resident, who had a care plan for inappropriate behaviors including verbal/physical aggression and delusions, admitted in interviews and on a grievance form that he slapped or hit his roommate in the head or shoulder after being angered by the use of profanity. Staff interviews revealed that CNAs were aware of the physical assault, observed the dependent resident as scared and terrified, and were never asked to provide statements. Additional documentation showed that prior to the physical assault, the aggressive resident had threatened to shoot his roommate over TV volume, resulting in a temporary room change, and that staff questioned why the two residents were later placed back in the same room given ongoing issues. On observation weeks after the incident, the dependent resident had yellow-green bruising on the left bicep and a quarter-sized bruise on the left shoulder in various stages of healing, which he attributed to the altercation; this was verified by a CNA. The facility’s abuse policy required that all alleged violations of abuse, including resident-to-resident incidents, be investigated within five working days, with interviews of the resident, the accused, and all witnesses, collection of written statements, review of medical records, documentation of the investigation, and revision of care plans as needed. The Administrator and VPO confirmed there were no witness statements and no documented investigation by the DON, and the Administrator acknowledged that the investigation was not thorough, demonstrating noncompliance with the facility’s own abuse investigation policy. The second resident involved, who was more independent and had diagnoses including anxiety, hypertension, heart failure, and pulmonary embolism, had a care plan for inappropriate and aggressive behaviors with goals to prevent injury to self or others. Progress notes documented that he had previously threatened to shoot his roommate over TV volume, leading to physician notification and temporary relocation. Despite this history and staff concerns, the residents were returned to the same room, and when the subsequent physical assault occurred, the facility failed to promptly recognize, document, and investigate it as abuse. The lack of timely assessment, failure to obtain and document statements from involved staff and residents, and absence of a complete investigative record as required by policy formed the basis of the cited deficiency.
Failure to Thoroughly Investigate Injury of Unknown Origin
Penalty
Summary
The deficiency involves the facility’s failure to thoroughly investigate an injury of unknown origin for one resident. The resident was a long‑term resident with heart failure, pulmonary fibrosis, dysphagia, memory problems, and dependence on staff for ADLs. Her care plan identified her as at risk for falls due to a history of falls, with interventions including family involvement and assistance with ADLs. Physician orders required use of a two‑person mechanical lift for transfers and turning/repositioning every two hours as tolerated. On the evening in question, after routine night care in which a CNA rolled the resident for check and change, the resident began complaining of left knee pain approximately 20 minutes later and contacted her POA, who requested transfer to the ER. The roommate reported that during the check and change the resident was yelling out, and CNA #902 reported that the resident resisted, pushed back, and screamed while being rolled, after which she was placed on her back and later complained of knee pain. The resident was sent to the hospital and diagnosed with a distal fracture of the femur and a UTI. The facility’s SRI documented this as an injury of unknown origin and concluded the fracture was most likely secondary to underlying chronic disease processes rather than acute trauma, with no reported history of falls or physical injury, even though the resident reported that her leg had been pulled back and she believed it was broken. Despite these differing accounts and clinical information, the facility’s investigation, as reflected in the SRI and email correspondence, concluded that no incident or trauma occurred and that the fracture was pathological in nature. A hospital note described the fracture as an acute, impacted distal femoral metaphyseal fracture indicating a recently broken bone due to a specific trauma or injury, and a follow‑up note by the medical director referenced a recent fall with a distal left femur fracture. The DON stated she was unaware how the fracture occurred, acknowledged there was no known fall before the resident was sent out, and attributed the event in part to the resident pushing against the bed during care. When questioned about the discrepancy between the hospital documentation of an acute fracture and the facility’s conclusion of a pathological fracture, as well as the medical director’s note referencing a fall, the DON was unable to provide additional documentation to clarify the SRI findings, the documented fall, or the ambiguity between an acute versus pathological fracture, despite a facility policy requiring all allegations to be thoroughly investigated.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
