Failure to Implement Abuse-Prevention Policies for Aggressive Resident on Memory Care Unit
Summary
Facility staff failed to implement abuse-prevention policies and provide adequate supervision and protection from abuse, neglect, and theft for multiple cognitively impaired residents on the Memory Care Unit, particularly in relation to one resident with escalating aggressive and sexually inappropriate behaviors. The facility’s written policies require identification of hazards, individualized supervision based on assessed needs, and staff competency in recognizing and reporting accident hazards and abuse. Despite these policies, the same resident (Resident #14), who had severe cognitive impairment and behavioral disturbances, was repeatedly involved in resident-to-resident altercations that resulted in physical harm and potential sexual abuse of other residents with severe cognitive impairment. In one incident, a resident with Lewy body dementia, frontotemporal neurocognitive disorder, and severe cognitive impairment (Resident #17) was involved in a physical altercation with Resident #14. Staff heard a scream and a hard fall and then found the cognitively impaired resident on the floor near a food cart, with the other resident standing nearby. Both residents reported that the cognitively impaired resident slapped Resident #14 and that Resident #14 then pushed her to the floor. The injured resident was later documented to have a bump on the back of her head. This event occurred despite the facility’s policy that resident supervision and accident prevention are facility-wide priorities and that supervision should be adjusted based on individual risk and environmental hazards. In another incident, a severely cognitively impaired female resident (Resident #16), who could not complete a cognitive assessment, was found in bed fully covered with blankets while Resident #14 was lying on top of the covers, fully clothed, in the same bed. A CNA later observed that the female resident’s brief was deviated to the side with her buttocks exposed. Neither resident could recall the incident. The facility’s policies state that residents have the right to be free from abuse and that staff must identify and mitigate hazards, including through adequate supervision and individualized interventions, yet a male resident with known behavioral issues was able to enter and remain in a vulnerable female resident’s bed. A further incident involved a male resident with Alzheimer’s dementia and severe cognitive impairment (Resident #15), who wandered into Resident #14’s room and used a racial slur, after which Resident #14 struck him. Staff later observed the injured resident exiting the room with a bloody rag to his mouth, stating that he had been hit, and documentation confirmed a new laceration to his lower lip. In another serious event, a female resident with dementia, PTSD, psychosis, chronic pain, and on long-term anticoagulant therapy for deep vein thrombosis (Resident #2) was found in a struggle with Resident #14 over a reacher/grabber tool. She reported that he had hit her in the left eye, and staff documented swelling and bruising to that eye. Her condition subsequently deteriorated, with abnormal vital signs and decreased responsiveness, and she was transferred to the hospital, where her responsible party later reported being told that she had suffered a significant brain bleed related to being hit while on a blood thinner. These repeated incidents, all involving the same resident aggressor on the Memory Care Unit, occurred despite facility policies requiring a systems approach to safety, close supervision based on individual risk, and protection of residents’ rights to be free from abuse. Post-incident documentation for Resident #14 showed that, after the altercation resulting in the eye injury, he was again observed in a female resident’s room attempting to get into bed with her while clothed and wearing a brief, and he became physically aggressive when redirected, making grabbing motions and attempting to hit staff. A psychiatric nurse practitioner documented that staff reported increasing aggressive and sexually inappropriate behaviors, including entering a female resident’s room and attempting to get into bed with her, and that these behaviors placed him and others at risk. Despite this, he was noted as no longer being on one-to-one supervision per physician order, and surveyors later observed him ambulating freely throughout the Memory Care Unit hallways and common areas with direct access to other residents. The facility’s own leadership and social services staff acknowledged in interviews that resident-to-resident physical altercations and a male resident in bed with a cognitively impaired female resident who could not consent would constitute abuse, and that residents have the right to be free from abuse and to feel safe, yet the same resident continued to have unrestricted access to other vulnerable residents on the unit.
Penalty
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Below are regulatory guidelines relevant to this citation:
Failure to Report, Investigate, and Prevent Resident-to-Resident Abuse: A resident with schizoaffective disorder and aggressive behaviors threatened and spit on another resident, but staff did not recognize the conduct as abuse, did not report it to the Ombudsman, police, or CDPH, and did not complete the required monitoring documentation. The same resident was later placed in a room with a bedbound resident and allegedly struck that resident with an overhead table, causing a head laceration and hospital transfer. The DON and an LVN stated spitting was not abuse, while the record showed the facility’s policies required abuse identification, investigation, and reporting.
Failure to complete required background check before direct care: CNA 1 was hired and began providing direct resident care before the facility completed the required criminal background clearance. The DON stated background checks were supposed to be done before staff started work, but CNA 1 worked full time and provided direct care for months before the background check was requested and completed. The facility policy required employee background checks as part of its abuse prevention program.
Failure to Report and Investigate Abuse Allegations: The DON, ADON, and Administrator did not treat a resident’s reported fight with a CNA and a separate resident-to-resident assault as reportable abuse events. Records showed conflicting resident statements, visible injuries, and staff accounts describing physical aggression, yet the incidents were not promptly reported to State agencies under the facility’s abuse policy. The Administrator stated the events were not considered abuse because of the residents’ statements and lack of willful intent.
Failure to Investigate and Report Abuse-Related Allegations: The facility did not follow its abuse prevention policy for three residents with abuse-related concerns. One resident reported being called a racial slur by a roommate, another reported degrading and dismissive treatment by a CNA, and a third reported humiliating comments during wound care. Staff and leadership were aware of the concerns, but the facility did not document State reporting, complete abuse investigations, or show resident, staff, or witness interviews, record review, findings, or final decisions.
Abuse Allegation Not Thoroughly Investigated: A resident with moderate cognitive impairment and multiple medical conditions was involved in a transfer incident in which staff described her legs as rigid and locked. Witnesses and the resident reported that an LPN hit or smacked the resident’s leg while telling her to relax and bend her knees, and the resident became tearful and said she had been hit. The facility’s abuse investigation was inconsistent and incomplete, with omitted written witness statements and a conclusion that the allegation was unsubstantiated despite accounts describing physical contact.
Failure to Prevent Retaliation Against Staff: The facility failed to prohibit and prevent retaliation after staff attempted to speak with surveyors and report concerns. Although the handbook and posted notice included anti-retaliation language, five terminated employees had personnel files that did not support the reasons given for termination, and the NHA cited vague reasons such as professionalism, job abandonment, refusal to complete an admission, aggression, and alleged inciting of a verbal riot. Confidential interviews described management questioning staff about speaking with the surveyor, threats of immediate termination for calling the state, and a climate of fear related to complaints about staffing and resident care.
Failure to Report, Investigate, and Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to implement its Abuse Prevention Program and Resident-to-Resident Altercations policies when Resident 2, who had diagnoses including schizoaffective disorder and parkinsonism and was later placed on 72-hour monitoring for verbal aggression and spitting, was not adequately managed after an altercation with Resident 3. On 6/15/2026, Resident 2 was documented as being irritated, calling Resident 3 names, threatening to beat Resident 3 up, and spitting on Resident 3, with the spit landing on Resident 3’s shirt. The facility moved Resident 2 to another room, but the record showed the 72-hour monitoring documentation was incomplete, with no note covering the final 11 hours of the ordered monitoring period. The facility also failed to report and investigate the abuse allegations involving Resident 2 and Resident 3. During interview, the DON and LVN1 stated that spitting was not abuse and that there was no need to report the incident as abuse. The DON stated she did not report the incident to the Ombudsman, local police, or CDPH because spitting and name calling were not considered abuse. Later, LVN1 used a Google search and stated that spitting at another resident was considered physical abuse, and the DON stated the physical abuse between Resident 2 and Resident 3 should have been reported and investigated. The facility’s policy stated that all altercations, including those that may represent resident-to-resident abuse, were to be investigated and reported. The facility further failed to protect Resident 1, who was bedbound and dependent on staff for multiple activities of daily living, from physical abuse by Resident 2. On 6/18/2026, Resident 1 alleged that Resident 2 hit him on the head with an overhead table, causing a laceration and bleeding. Resident 1 was transferred by emergency services to a general acute care hospital and was diagnosed with blunt trauma, closed head injury, and scalp lacerations. The record also showed that Resident 2 had been moved into Resident 1’s room after the earlier altercation with Resident 3, and the DON did not respond when asked whether supervision had been provided to prevent Resident 2 from hitting Resident 1. The report also states that staff were not able to identify all types of abuse, and that Resident 1 and Resident 3 were not protected from abuse from Resident 2.
Failure to Complete Required Background Check Before Direct Care
Penalty
Summary
The facility failed to implement its abuse prevention program when CNA 1 did not have a completed background check before providing direct resident care. The DON stated CNA 1 was hired on January 30, 2026, began direct patient care on March 3, 2026, and graduated from the facility's CNA training program on March 31, 2026. The DON also stated that background checks were supposed to be completed before staff started work, but CNA 1's background check was not requested until June 19, 2026, and was not completed until July 7, 2026. During interview and record review, CNA 1's background check document, titled California Investigative Consumer Report, showed the delayed request and completion dates. The DON stated CNA 1 should have had the background check done in January 2026 and that a previous HR employee had been responsible for ensuring background checks were completed, but management identified that the employee was not doing them as required. A time card report showed CNA 1 worked 571.7 hours between March 3, 2026, and July 7, 2026, before the background check was completed. The facility policy stated it conducts employee background checks and will not knowingly employ individuals convicted of abusing, neglecting, or mistreating individuals.
Failure to Report and Investigate Abuse Allegations
Penalty
Summary
The facility failed to implement its abuse policy for allegations involving resident-to-staff and resident-to-resident abuse. The report states that the facility did not notify the appropriate State Agencies and did not thoroughly investigate allegations involving three residents. The deficiency was based on clinical record review, facility documentation, staff interviews, and policy review. For one resident, who had diagnoses including unspecified mood disorder, suicidal ideations, anxiety disorder, and depression, a nurse documented that the resident reported being in a physical altercation with a CNA and had visible scratches to the arms. The DON and NP were notified, and later documentation reflected conflicting accounts from the resident, including statements that the scratches were self-inflicted and that the resident had slapped and choked the CNA. The resident’s record showed a BIMS of 14 and behaviors including delusions, physical and verbal behavior, and rejection of care. Staff interviews reflected that the resident was known for making false accusations, and the Administrator stated the allegation was not considered reportable because the resident said she was the aggressor. The report also noted that the CNA involved continued to work shifts after the initial allegation and was not placed on administrative leave until several days later. For two other residents, one resident was found standing over the other while the other resident stated that the roommate had walked up and started hitting him. The record documented that the residents were separated, one resident was placed on 1:1, and the injured resident had a bruise and later a skin tear and discoloration on the left hand. The resident who was alleged to have caused the injury had diagnoses including anoxic brain damage, hydrocephalus, PTSD, major depressive disorder, unspecified dementia, and unspecified mood disorder, with a BIMS of 1 and documented physical behaviors and aggression. Staff interviews described the incident as resident-to-resident abuse, with one CNA stating the resident was over the other resident in bed and another stating the residents were fighting when staff arrived. However, the Administrator stated the event was not considered abuse because there was no willful intent and therefore was not reported. The facility policy required suspected abuse to be reported immediately to the administrator and other officials according to state law, with immediate defined as within 2 hours for allegations involving serious bodily injury or within 24 hours for allegations not involving serious bodily injury.
Failure to Investigate and Report Abuse-Related Allegations
Penalty
Summary
The facility failed to follow its abuse prevention policy for three residents with abuse-related concerns by not reporting, investigating, documenting, or following up on the allegations as required. The report states the facility had a policy prohibiting abuse, neglect, exploitation, mistreatment, and misappropriation of resident property, and that suspected abuse or mistreatment was to be immediately reported, residents protected from further possible abuse, and a prompt, thorough investigation completed and documented. For each of the three residents, the facility had knowledge of the concerns but did not provide documentation showing the allegations were reported to the State Agency, investigated, concluded, or reviewed for follow-up and corrective action. For one resident, staff reported that the resident had been called a racial slur by a roommate. The resident was moved to another room after administration became aware of the concern, but the record did not show the allegation was reported or investigated. The administrator and DON later confirmed the facility knew about the allegation and moved the resident, but also confirmed no abuse investigation was completed and the allegation was not reported to the State Agency. The facility did not provide documentation showing interviews, record review, protection measures, findings, a final decision, or action to prevent recurrence. For a second resident, concerns involved staff treatment, refusal or delay of help, dignity, and possible mistreatment. A CNA reported that the resident said another CNA called her lazy and that there were repeated arguments and issues with care. The resident stated the CNA was intimidating, argued with her, called her lazy, and made her feel bad about herself. The administrator stated he was aware of the situation and spoke with the CNA, but there was no investigation. The facility did not document that it reviewed the concern as possible mistreatment, neglect, retaliation, or degrading treatment, and did not document reporting determination, resident or staff interviews, witness interviews, record review, follow-up, findings, or a final decision. For a third resident, the allegation involved degrading staff conduct during wound care. A nurse reported that the resident was upset after a staff member said the bandages were gross and that she did not want to catch anything from the resident’s draining wounds. The resident stated the nurse had a disgusted look, sighed, and asked whether the wounds were contagious, which made the resident feel angry, degraded, awful, and fearful. The administrator stated there was no abuse investigation related to the incident. The facility did not provide documentation showing the allegation was reported to the State Agency, reviewed as possible abuse, neglect, or mistreatment, or investigated with resident, staff, or witness interviews, wound-care record review, follow-up, findings, or a final decision.
Abuse Allegation Not Thoroughly Investigated
Penalty
Summary
The facility failed to implement its abuse policy after an incident involving a staff member and Resident #96. Resident #96 was admitted with multiple diagnoses including palliative care, muscle spasms, atherosclerotic heart disease, cervical cancer, type 2 diabetes, hypertension, urinary incontinence, a sacral pressure ulcer, polyneuropathy, and generalized anxiety disorder. A Medicare 5-Day MDS showed a BIMS score of 11, indicating moderate cognitive impairment. During the incident, the resident was found slipping from her wheelchair with both knees locked and her body rigid while staff attempted to reposition her. The resident was repeatedly instructed to relax and bend her knees, and she was later assisted to bed for safety. The clinical record and investigation documents showed conflicting accounts of what occurred during the transfer. One staff witness reported that the LPN tapped or smacked the resident’s leg to get her to bend her knees, while the resident later told staff that the nurse hit her leg until it relaxed. Another staff member documented that the resident said the nurse was yelling and hitting her legs, and the resident became tearful and stated that the incident made her feel like no one cared about her and that she was not wanted at the facility. The resident’s family members also reported that they were told the nurse had hit or jabbed the resident’s leg during the transfer. The facility’s investigation was incomplete and inconsistent with its own policy. The investigation was initially determined to be unsubstantiated, with the conclusion that no policies were broken, despite witness statements and resident interviews describing physical contact to the resident’s leg during the transfer. The investigation also omitted written witness statements that were later requested and obtained, including statements from staff who reported that the resident said she had been hit and that the nurse had struck or smacked her leg. The facility policy required all allegations of abuse to be thoroughly investigated, including interviews with staff who had contact with the resident, witnesses, the reporting person, and the resident or representative, and required written, signed, and dated witness statements.
Failure to Prevent Retaliation Against Staff
Penalty
Summary
The facility failed to prohibit and prevent retaliation against employees after staff members made complaints and attempted to speak with the State Survey Agency. Review of the facility handbook showed anti-retaliation language and disciplinary procedures, and a posting in the staff lounge stated that an LTC facility cannot punish or retaliate against an employee for lawfully reporting a crime. Despite those policies, survey interviews and employee file review identified five terminated employees whose terminations were described by the Nursing Home Administrator as being for "professionalism," with additional explanations such as refusal to complete an admission, aggression toward the NHA, alleged inciting of a verbal riot, and job abandonment. The personnel records reviewed for the terminated employees did not contain documentation supporting the reasons given for the terminations. One employee had no disciplinary actions in the prior 12-month rolling calendar and a performance evaluation showing meets or exceeds expectations. Another had one attendance-related disciplinary action and performance evaluations showing meets or exceeds expectations. Two employees had no performance reviews or disciplinary actions documented, and another had no disciplinary actions with performance evaluations showing meets or exceeds expectations. The NHA confirmed that the files did not contain documentation of the behaviors cited as the basis for termination. During confidential staff interviews, multiple employees reported unsafe staffing, residents not receiving timely care, and fear of retaliation for speaking with surveyors or reporting concerns. One staff member stated the Interim DON called to ask why the staff member wanted to speak to the surveyor, and the staff member later reported being terminated by voicemail. Other staff reported being told that if they called the state they would be immediately terminated, that management knew who was calling the state, and that employees were being told to keep their mouths shut. On survey, the facility administration was made aware that the facility failed to prohibit and prevent retaliation for five of fifteen staff members.
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