Failure to Investigate Multiple Allegations of Sexual Abuse by a Nurse Aide
Summary
The deficiency involves the facility’s failure to conduct thorough investigations into multiple resident allegations of sexual abuse by a nurse aide, and failure to follow its own abuse policy requiring immediate removal of the accused staff from resident contact pending investigation. The facility’s policy on abuse, neglect, exploitation or misappropriation, dated August 21, 2025, required that all allegations be thoroughly investigated and that any employee accused of resident abuse be placed on leave with no resident contact until the investigation was complete. Despite this, the personnel file for Nurse Aide 1 showed only scattered, non-consecutive suspension days for an incident involving one resident and no documented discipline for another resident’s allegation, and there was no evidence that he was removed from resident care while allegations were being reviewed. The Nursing Home Administrator and acting Director of Nursing acknowledged that they did not conduct investigations into the allegations because they did not believe abuse had occurred and instead treated at least one allegation as a grievance. One cognitively intact resident (Resident 14), who was always continent of urine and required minimal help with daily care, reported in a grievance that around 5:00 a.m. a male nurse aide entered her room while she was sleeping and put his hand inside her pants to see if she was wet, without explanation, even though she had no history of incontinence. She stated in interview that he touched her inappropriately, that she felt violated, and that she immediately requested to speak to a nurse but was not seen until about 7:30 a.m., at which time she reported the incident to an LPN. She further stated that the Director of Nursing did not take her seriously and that she felt her complaint was dismissed. There was no documented evidence that the facility obtained statements from this resident or involved staff, or that a thorough investigation was completed to rule out sexual abuse. Another cognitively intact resident (Resident 6), who required assistance for ADLs and was usually incontinent of urine and bowel, filed a grievance stating that during incontinence care the same nurse aide left her naked on her bed twice with the door and curtain open while he left the room to gather supplies. She reported that he commented that she was not allowed to defecate, remarked on her soiling, asked if she slept in the nude, and told her he liked looking at naked women, including another woman there who did not like him doing it either. She also reported that he told her he had been accused of touching another nurse aide, that his suspension days were split so they did not affect his paycheck because staffing was short, and that other residents had complained about his care and comments. In interview, she confirmed feeling exposed and stated she feared for residents who could not speak for themselves. There was no documentation of interviews with her or staff, or of a comprehensive investigation into her allegations. A third cognitively intact resident (Resident 7), who required help to get in and out of the bathroom and was always incontinent of urine and bowel, stated in interview that she did not want this nurse aide to provide care because he startled her awake by sticking his hand inside her brief to see if she was wet, instead of asking her as other staff did. She reported that she did not like him putting his hand in her brief and did not want him back in her room. There was no documented evidence that the facility obtained statements from her or staff or conducted a thorough investigation into her allegation to rule out sexual abuse. A fourth cognitively intact resident (Resident 1), who required observation for ambulation and was frequently incontinent of urine and bowel, was the subject of a grievance initiated by her family member and Power of Attorney. The family member reported that the resident called her at about 1:00 a.m. crying, stating that the male nurse aide had put his hand inside her brief while she was sleeping and that his fingers penetrated her vagina, and that he had done this two or three other times; the resident reportedly expressed fear that she would be raped. The family member stated she informed the Director of Social Services that the resident said the aide had stuck his hand in her crotch, and that the resident later believed the aide had been fired when he had not. Staff interviews corroborated that the resident told a nurse aide and an LPN that the male aide had put his hand in her pants and digitally penetrated her, and that this was reported up the chain to an RN, who then reported it to the Director of Social Services and the Assistant DON. Another RN reported asking the Nursing Home Administrator if the aide would be replaced on night shift because a resident said he had fingered her, and the Administrator was not aware of the allegation at that time. Despite these reports, the Nursing Home Administrator and acting Director of Nursing stated that they did not consider the allegation regarding Resident 1 to be abuse and documented it only as a grievance. The acting DON stated she was not aware of any sexual abuse allegations, and the Director of Social Services emphatically denied that any abuse occurred, stating she knew there was no abuse and denying that she had been told about digital penetration or inappropriate touching, contrary to other staff accounts. The aide denied touching any residents inappropriately and claimed he could determine wetness by looking at the brief. Across all four residents’ cases, there was no documented evidence that the facility obtained written statements from the residents, from the staff who received the reports, or from staff who interviewed the residents, and no evidence of a thorough investigation including interviews with all pertinent staff to rule out that sexual abuse may have occurred, in violation of facility policy and state regulatory requirements.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Failure to Investigate Allegation of Misappropriation: A resident with COPD, anxiety, and PTSD reported $1,600 missing and believed another resident had taken the money, but the SSD told him it was too late to investigate. The grievance record and reporting portal contained no misappropriation report for the resident, and the CNO recalled hearing about missing funds from a family member but did not follow up, while the CEO stated the allegation should have been reported and investigated.
The facility failed to complete a thorough investigation after a resident sustained a 7 cm penile laceration associated with a condom catheter. The resident had a stroke, contractures, cognitive communication deficit, and non-healing pressure ulcers, and the incident record lacked a full investigation or staff statements to determine the root cause and rule out abuse or neglect.
Incomplete Abuse Investigation: The DON investigated an allegation that a resident with dementia, depression, and a prior femur fracture was treated roughly during a shower, but only interviewed one CNA named on the abuse report. Another CNA was also assigned to the resident and documented providing the shower, yet was not interviewed, and no other residents cared for by either CNA were interviewed. The facility's abuse policy required thorough investigation, including staff and resident interviews, and the DON stated the policy was not followed.
Incomplete Investigation of Alleged Staff-to-Resident Sexual Abuse: The facility failed to thoroughly investigate an allegation that a CNA raped a resident during incontinence care. The resident, who had intact cognition and significant medical diagnoses, reported genital and anal touching and later said embarrassment affected how they described the event. The record lacked a written or recorded resident statement, and the facility concluded abuse did not occur based on conflicting accounts rather than documenting a comprehensive investigation of all evidence.
The facility failed to thoroughly investigate two resident abuse allegations. In one case, an altercation with a scratch injury was recorded as an accident/incident, but the final report had no abuse conclusion and the Abuse Coordinator did not interview the residents, observe the injury, or document staff witness statements. In another case, the final report also lacked a conclusion, interview notes could not be produced, and CNAs who were present or witnessed the altercation were not interviewed despite progress notes showing CNA presence.
Failure to Thoroughly Investigate Allegations of Neglect and Possible Abuse: A resident with significant care needs alleged a CNA left her on a bedpan too long, spilled urine/feces in bed, and performed an unsafe hoyer transfer, while another resident was heard screaming during a one-person hoyer transfer. The facility did not complete a thorough abuse/neglect investigation because it did not interview the second resident, other potentially affected residents, or assess non-interviewable residents.
Failure to Investigate Allegation of Misappropriation
Penalty
Summary
The facility failed to ensure an allegation of misappropriation was investigated as required for Resident #23, who was admitted with diagnoses including COPD, anxiety, and PTSD. Resident #23 stated that approximately two months earlier he reported $1,600.00 missing to the SSD and told the SSD he believed another resident had taken the money. He reported that when he explained the incident had occurred about one and a half months earlier, the SSD told him it had been too long ago to investigate. Review of the facility grievance records from February 2026 through June 2026 showed no documented allegation of misappropriation involving Resident #23, and review of the Long-Term Care Reporting Portal showed no report of misappropriation involving him. The CNO stated she recalled a family member mentioning Resident #23's missing funds but did not ask further questions, and the CEO stated the allegation should have been reported and investigated for potential misappropriation.
Incomplete Investigation of Penile Laceration
Penalty
Summary
The facility failed to conduct a thorough investigation to rule out the potential for abuse or neglect for one resident after a penile laceration was identified in connection with a condom catheter. The resident had diagnoses including stroke, contractures, cognitive communication deficit, and non-healing pressure ulcers of the buttocks and coccyx, and the condom catheter had been used to decrease moisture and help prevent worsening of the coccyx/buttocks wound healing. During review of the incident, the resident was found to have a 7 cm laceration of the penis from the condom catheter. The catheter had become dislodged during an assessment when the nurse aide noted low urine output, and the nurse supervisor later had an LPN reapply a new condom catheter. The facility’s incident documentation did not include a full investigation or staff statements to identify the root cause of the laceration and rule out abuse or neglect, and the Nursing Home Administrator confirmed that the investigation was not completed thoroughly.
Incomplete Abuse Investigation
Penalty
Summary
The facility failed to thoroughly investigate an allegation of abuse involving one resident who was admitted with diagnoses including a right femur fracture, difficulty walking, dementia, and depression. The resident reported that a CNA who assisted with her shower was "very rough," had "pushed me around," and became "nasty" when questioned. The allegation was documented in the facility's incident report and reported on the SOC 341 as suspected dependent adult/elder abuse. The DON stated she investigated the allegation and interviewed only CNA 1 because CNA 1 was named on the SOC 341 report and was believed to be involved based on staffing. However, the record showed CNA 2 was also assigned to the resident and documented that she showered the resident on the date of the alleged incident. CNA 2 was not interviewed, and no other residents cared for by CNA 1 or CNA 2 on that date were interviewed. The facility's policy required all allegations to be thoroughly investigated, including interviews with staff on all shifts who had contact with the resident and interviews with other residents cared for by the accused employee, and the DON stated the policy was not followed.
Incomplete Investigation of Alleged Staff-to-Resident Sexual Abuse
Penalty
Summary
The facility failed to conduct a thorough investigation of an allegation of staff-to-resident abuse for 1 of 1 residents reviewed for abuse. The resident, who had diagnoses including obstructive and reflux uropathy and hemiplegia and hemiparesis following cerebral infarction, was documented as having intact cognition. The allegation involved a CNA during incontinence care, and the resident reported that the CNA raped them and touched and rubbed their genital and anal area, causing them to feel unsafe in the facility. The facility’s investigative record did not include a written or recorded statement from the resident detailing the allegation, limiting the ability to objectively investigate the complaint. The facility’s accident/incident report documented that the resident told an LPN they had been raped, and an RN supervisor noted redness in the perineal area during assessment. However, the report also stated the facility concluded abuse did not occur because the resident gave conflicting statements, rather than documenting a comprehensive investigation of all available evidence. Additional statements in the record showed the resident later explained they felt embarrassed and ashamed when law enforcement and a male nursing supervisor were present, which affected how they described the event. The CNA stated they provided incontinence care and applied ointment, but denied doing anything beyond what was requested. The DON stated the facility obtained a statement from the resident, while the RN supervisor stated no statement was obtained or documented from the resident.
Incomplete Abuse Investigations and Missing Conclusions
Penalty
Summary
The facility failed to thoroughly investigate allegations of abuse involving two separate resident altercations. For one incident involving two residents, the final Facility Reported Incident classified the event as an accident/incident rather than resident abuse, even though the report documented an alleged altercation and that one resident sustained a scratch on the right cheek requiring first aid. The final form did not include a conclusion stating whether abuse or assault did or did not occur. During review of the investigation file, the Administrator, who was also the Abuse Coordinator, could provide only the initial and final reports submitted to the state survey agency and could not provide additional evidence such as staff interviews, witness statements, or documentation of observations after the alleged abuse. She stated she did not interview either resident, did not observe the injured resident’s scratch, and only spoke with the ADON and an RN, both of whom said they did not witness the altercation. She also did not attempt to interview a CNA she believed may have pulled the injured resident from the other resident’s room, and there was no documentation showing staff interviews were completed. The injured resident’s EHR also did not show documentation of the scratch assessment, appearance, treatment orders, or any documentation that the abuse with injury occurred. A second altercation between two other residents was also not thoroughly investigated. The Administrator and DON provided only the initial and final reports and resident face sheets, and the final report did not include an investigation conclusion. Although the Administrator stated she had completed all interviews before submitting the final report, she could not produce handwritten interview notes or other investigation documentation. One resident said he discussed the incident with staff present at the time, while another resident could not recall the altercation. A CNA stated she was present during the incident and was never interviewed, and another CNA stated he witnessed the incident and reported it to the ADON but was never interviewed by the Administrator. Progress notes for both residents documented CNA presence during the altercation, yet the Administrator stated she did not interview any CNAs because she was told none were present. The facility policy required prompt and aggressive investigation of all abuse allegations, including interviews of the reporter, anyone with direct knowledge, and the resident if interviewable, and required the final report to contain a conclusion based on known facts.
Failure to Thoroughly Investigate Allegations of Neglect and Possible Abuse
Penalty
Summary
The facility did not thoroughly investigate allegations of abuse and neglect involving two residents. One resident, who had complex regional pain syndrome, mononeuropathy, muscle wasting and atrophy, pruritus, and required assistance with personal care, submitted a written grievance stating that a CNA left her on a bedpan for over an hour, questioned her about re-wearing a soiled brief, spilled the bedpan in bed, attempted a hoyer transfer without ensuring the sling was properly secured, and did not clean her skin after she had lain on a wet pad. The resident and her representative described the event as neglect, and the facility’s self-report also documented the allegation as neglect. A second resident, who had rheumatoid arthritis, polyneuropathy, non-[NAME] lymphoma, osteoarthritis, and dependence on enabling machines and devices, was heard screaming from behind a closed bedroom door while a CNA was transferring her alone with a hoyer lift. Staff reported hearing the resident yell, "Help me" and "Oww," and when they entered the room they found the resident in the lift and sling, leaning to one side, while the CNA was unhooking her. The resident’s care plan required two staff for bed mobility, toileting, and hoyer transfers. The facility’s investigation did not include a statement or interview from the second resident, did not include interviews of other residents cared for by the CNA during the shift, and did not include skin assessments of non-interviewable residents who may also have been affected. Facility leadership later stated the investigation was not thorough and should have included those interviews and assessments. The acting administrator also stated that hearing a resident screaming behind a closed door would make her suspicious of abuse, and that the incident should have been investigated as an additional allegation involving the same CNA.
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