Failure to Implement Abuse Policy and Investigate Resident Wrist Injuries
Summary
The deficiency involves the facility’s failure to implement its abuse policy and to ensure a resident’s safety following an injury sustained during ADL care by a CNA, and the failure to investigate to rule out abuse. The resident, identified as R94, was admitted with diagnoses including altered mental status and had a BIMS score of 11/15, indicating moderately impaired cognition. Her preferred language was Korean. Her care plan, initiated months before the incident, addressed discoloration but was not updated after she sustained injuries to her wrist on 03/20/25. The facility did not report the incident to the state survey agency, and the CEO confirmed there was no investigation for the 03/20/25 incident, only a grievance form. On 03/20/25, an incident report documented that CNA2 informed RN1 that the resident developed discoloration and swelling of both wrists during ADL care when changing clothes, while the resident was resisting care. The report stated that the resident bumped her wrists against the wheelchair during transfer, and that CNA2 was removed from the assignment and educated to stop providing care if a resident resists. Employee witness statements from RN1 and CNA2 described the resident resisting care and bumping or hitting her wrists on the wheelchair, with RN1 noting that the resident was unable to communicate coherent English when questioned. CNA3’s statement only indicated that she was asked to assist, found the resident agitated, and that the nurse assessed and notified others. A nurse’s note by RN1 documented bilateral wrist discoloration and swelling after an “accident” during clothes changing while the resident was resisting, and that ice was applied. In a later interview, CNA2 stated he attempted to transfer the resident from the wheelchair to bed after toileting, that she resisted by lifting her arms, and that he did not know how the injury occurred. He confirmed the injury was not present before he attempted the transfer and that he remained assigned to the resident for the rest of the shift. The resident’s family member reported that the resident, who did not speak English, told her that during the 03/20/25 incident she refused to be changed into a nightgown and staff grabbed her hand and tried to force her, describing the staff as a big Black man. The family member also reported a second, similar wrist injury incident with a big Black male staff member and stated she reported these to facility staff and APS. The Social Service Director acknowledged that she did not interview the resident or other residents or complete a trauma assessment regarding the 03/20/25 allegation, despite stating that such steps were part of the usual abuse investigation process. The Administrator, who was the DON at the time, stated that the incident was not reported as abuse or injury of unknown origin because CNA2 self-reported that the injury occurred during care and denied abuse, and that only CNA2 and RN1 were interviewed. This was inconsistent with the facility’s written abuse policy, which required immediate investigation, interviews of all involved persons including the alleged victim and witnesses, and measures to protect residents from harm during and after the investigation. The facility’s abuse, neglect, and exploitation policy required an immediate investigation when there was suspicion or reports of abuse, including identifying and interviewing the alleged victim, alleged perpetrator, witnesses, and others with knowledge, and ensuring residents were protected from physical and psychosocial harm during and after the investigation. Examples in the policy included responding immediately to protect the alleged victim, examining the alleged victim for signs of injury, and making room or staffing changes if necessary to protect residents from the alleged perpetrator. Despite this, the Social Service Director did not conduct resident or collateral interviews or trauma assessments, and the Administrator confirmed that the facility limited its inquiry to CNA2 and RN1 and did not treat the event as an injury of unknown origin or an abuse allegation. The failure to follow these procedures and to ensure the resident’s protection and a thorough investigation led to the cited deficiency under 42 CFR §483.12 Freedom from Abuse, Neglect, and Exploitation, with Immediate Jeopardy identified at a scope and severity level J.
Penalty
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The facility failed to follow its abuse and electronic monitoring policies by not properly identifying, documenting, or investigating multiple allegations of abuse, neglect, and misappropriation involving a resident with dementia and chronic respiratory failure. Over several weeks, the resident’s daughter reported that an LPN intimidated the resident, administered Tramadol doses too close together, failed to provide ordered medications, ignored incontinence care requests, and publicly disparaged the resident, while a CNA and another aide allegedly yelled at the resident, disrespected her belongings, and spoke to her in a demeaning manner. The daughter also reported missing personal items, including socks, a camera, and an SD card that she said contained video of staff screaming at the resident. Despite these detailed complaints, facility leadership denied knowledge of the allegations, the concern log contained no entries for the resident, and the only self-reported incident was a vague mistreatment report that lacked specific interviews with the daughter, relied on a generic questionnaire for the resident, and did not include any documented attempt to obtain or review camera footage.
A resident with MS, quadriplegia, depression risk, incontinence, and documented rejection-of-care behaviors was involved in an incident where video showed a CNA entering the room without knocking, roughly repositioning the resident during incontinence care, striking him multiple times, throwing and forcefully holding a pillow over his face, and continuing care while the resident appeared to react. The CNA later reported that the resident had been verbally aggressive and spitting at her during care, and an RN confirmed the resident became verbally aggressive and refused care later that night. Despite these reports and facility policies requiring assessment and monitoring of residents with behaviors that might lead to conflict or neglect, and immediate interventions when behaviors could harm others, the RN did not assess or formally report the resident’s aggressive behaviors, resulting in a failure to assess the resident following reported aggressive behaviors in the setting of a substantiated abuse incident.
The facility failed to implement its abuse policy after a cognitively impaired, fully dependent resident was allegedly subjected to physical and verbal abuse by a CNA and verbal abuse by an RN during a nighttime transfer. A witness CNA reported that the CNA yelled and cursed at the resident, forcefully grabbed his arm, shoved him from an unlocked wheelchair, and aggressively threw him into bed while the resident cried and asked her to stop, and that the RN later entered and repeatedly yelled at the crying, non-combative resident. The DON was not promptly notified, the accused CNA remained on the unit until shift end, and there was no documented immediate assessment, no physician or representative notification, no nursing note describing the incident and assessment findings, and no investigation completed within the timeframe required by the facility’s abuse policy.
A resident with multiple comorbidities, impaired cognition, and a history of fractures reported arm pain and stated she had been in a fight with a CNA after receiving care. The CNA informed an agency nurse, who assessed the resident and noted no findings, but the CNA did not report the allegation to the DON or other supervisory staff as required by the facility’s abuse policy. The next day, an RN was informed the resident was complaining of left arm pain and had reported a fight with a CNA; on assessment, the RN found bruising and swelling, notified the DON and physician, and the resident was sent to the ED, where a left forearm fracture was diagnosed. The DON confirmed that the CNA failed to follow the abuse reporting policy requiring immediate reporting of all abuse allegations.
The facility failed to follow its abuse policy by not reporting multiple resident‑to‑resident physical altercations as abuse allegations to the State Agency. In several events, a cognitively impaired resident with documented aggressive behaviors pushed and struck other cognitively impaired residents in common areas and in a room, including hitting another resident in the abdomen and head and punching a resident in the face, while another incident involved a resident hitting a severely impaired resident in the chest, who reported that it hurt. Staff separated residents, assessed them, and documented no visible injuries, and internal incident reports were completed. However, leadership, including the Administrator, DON, and other clinical leaders, stated they did not submit self‑reported incidents because they believed there were no injuries and that the residents lacked the ability to intend harm or cause mental anguish, despite facility policies defining physical abuse as hitting or punching and requiring immediate reporting of alleged abuse and use of the reasonable person concept.
A resident with ADHD and other psychiatric and neurologic conditions was ordered Adderall 20 mg twice daily, but narcotic count sheets showed multiple instances where the count decreased by two pills when only one was ordered, all signed out by an LPN. The DON identified inaccurate counts tied to this LPN, who later stated she did not know why the count was wrong and claimed to have wasted a pill without a witness. The LPN refused an in-facility urine drug screen and did not appear for the initially scheduled independent test, yet was allowed to return to work despite a written Drug Free Safety Policy stating that refusal or failure to comply with required testing constitutes a refusal to test and results in termination.
Failure to Investigate and Respond to Repeated Abuse, Neglect, and Misappropriation Allegations
Penalty
Summary
The deficiency involves the facility’s failure to follow its own policies for promptly identifying, reporting, and investigating allegations of abuse, neglect, and misappropriation involving a resident. The resident, who had dementia, anxiety disorder, chronic respiratory failure, and was assessed as having mild or no cognitive impairment, had no documented abuse or misappropriation allegations in her progress notes for 2026 despite multiple concerns raised externally. The Ohio Department of Health (ODH) website showed only one self-reported incident (SRI) related to this resident within the prior six months, dated 03/09/26, for alleged neglect and mistreatment by an LPN and a CNA, even though numerous additional allegations had been communicated by the resident’s daughter. Record review of emails from the resident’s daughter to facility staff and ODH showed repeated allegations over several weeks, including that an LPN administered Tramadol doses too close together, displayed animosity, intimidated the resident, failed to provide ordered medications, falsely documented refusals, and ignored calls for incontinence care after turning off the call light. Additional emails alleged that a CNA disrespected the resident’s belongings and spoke to her in a demeaning manner, that an unidentified aide yelled at the resident, and that personal items such as cabin socks were stolen. The daughter also reported a missing camera and SD card to the ombudsman, and later alleged that the SD card containing footage of staff screaming at the resident had been stolen. Despite these detailed complaints, the Administrator, DON, ADON, and Regional Nurse all denied knowledge of the abuse, neglect, and misappropriation allegations contained in the emails. The facility’s handling of the one documented SRI did not follow its abuse policy requirements for a focused investigation. The SRI described staff speaking to the resident in a loud, abrasive manner and referenced mistreatment concerns but lacked specifics, did not include an interview or attempted interview with the daughter, and documented only a generic questionnaire-style interview with the resident in which pre-written answers were circled indicating she felt safe and had no concerns. There was no documented attempt to obtain footage from the monitoring camera that had been in the resident’s room until it was removed by the facility. A call log later produced by the facility showed several calls to and from the daughter but contained no record of the content or results of those calls. The resident concern log for the past year contained no entries regarding this resident, and the Administrator stated that the resident did not know what he was talking about during the SRI interview and that the daughter did not respond to his attempts to reach her, further underscoring the lack of documented, policy-compliant investigation and response to the reported allegations.
Failure to Assess Resident After Reported Aggressive Behaviors in Context of Abuse Incident
Penalty
Summary
The deficiency involves the facility’s failure to assess a resident following reported aggressive behaviors, in the context of an abuse incident. The resident involved had multiple complex medical conditions, including multiple sclerosis, quadriplegia, muscle weakness, falls, failure to thrive, and dysphagia. His care plans documented hearing loss, risk for altered mood related to depression and medical diagnoses, incontinence of bowel and bladder, and self-care deficits requiring assistance with ADLs and mechanical lift transfers. A quarterly MDS assessment showed intact cognition, dependence for eating, toileting, bathing, and personal hygiene, incontinence of bowel and bladder, and behaviors that included rejection of care. On one evening, video footage showed a CNA entering the resident’s room without knocking while the resident was asleep, lowering the bed, removing sheets, and exposing and opening the resident’s incontinence brief while he remained asleep. The CNA was observed rolling the resident roughly, causing him to fall quickly onto the mattress, and then making a swift, swinging motion with both hands toward his face, with enough force that the resident’s body and mattress shook. The CNA then stood over the resident, pointed at him, appeared to touch his face with enough force to slightly shake his body, and continued to point at him while her mouth moved as if speaking. She slapped the resident with an open palm to his upper chest and/or face, again causing his body and pillow to shake, and used a closed fist to hit his right upper shoulder, chest, and/or face, though the exact area was obscured by the wall. The video further showed the CNA throwing a pillow at the resident’s upper chest and face, leaving it there while covering him and the pillow with a sheet, then striking him in the chest with the pillow and holding the pillow with force over his face for approximately two seconds before removing her hand but leaving the pillow on his face as she raised the head of the bed. Later, an RN approached and entered the room after the CNA had been seen wiping the resident’s face; the CNA pointed at or on the resident’s mouth and held up a cloth when it appeared the resident spit at her. The CNA’s written statement claimed she had provided routine care, denied treating the resident roughly or hitting him, and reported that the resident had used racial slurs, derogatory language, and spit at her during care at multiple times that night, including an instance when a nurse entered to help de-escalate and another when a nurse advised discontinuing care. The RN’s statement confirmed the resident was calm and cooperative earlier in the evening, and later verbally aggressive and refusing care, but documented that staff remained calm and professional. A progress note by the former DON documented that the resident had increased behaviors, including cursing at staff during care. In a subsequent telephone interview, the former DON stated that the RN should have assessed the resident for the aggressive behaviors reported by the CNA and should also have reported those behaviors accordingly. Facility policies on resident abuse and behavior management required assessment, care planning, and monitoring of residents with needs and behaviors that might lead to conflict or neglect, including those with a history of aggressive behaviors, and required immediate implementation of keep-safe interventions and provider notification when residents present with behaviors that will harm others. Despite the CNA’s reports of escalating verbal aggression and spitting, there was no documented assessment of the resident’s aggressive behaviors by the RN as expected under these policies, which constituted the failure cited in this deficiency. The facility’s self-reported incident documented that the resident’s family reported the CNA had handled the resident roughly and that he had been hit in the nose during care. Upon assessment, the resident was found with a small amount of blood under his nostril and an apparently deviated nose, and he was transported to the hospital where he was admitted with multiple facial fractures. The facility’s investigation, including review of video footage, led to a determination that abuse had occurred. The deficiency specifically addresses that, in the context of these events and the resident’s documented behavioral issues, the facility failed to ensure the resident was assessed following reported aggressive behaviors, contrary to its own abuse prevention and behavior management policies. This deficiency was investigated under Complaint Number 2806407 and was based on interview, record review, policy review, and video camera footage. The cited non-compliance centers on the lack of appropriate assessment and reporting of the resident’s aggressive behaviors after they were reported by staff, in a resident with known behavioral symptoms and complex medical and psychosocial needs, as required by the facility’s policies for prevention and identification of abuse and for behavior management.
Failure to Implement Abuse Policy After Alleged Staff Physical and Verbal Abuse
Penalty
Summary
The deficiency involves the facility’s failure to implement its abuse policy in response to substantiated allegations of staff-to-resident physical and verbal abuse. A male resident with neurocognitive disorder with Lewy bodies, dementia, Parkinson’s disease, major depressive disorder, cognitive communication deficit, gait and mobility abnormalities, and generalized muscle weakness was severely cognitively impaired per his most recent MDS, with both short- and long-term memory problems and severely impaired decision-making. He required assistance with all functional abilities, including hygiene, bathing, dressing, repositioning, transferring, toileting, and walking. Despite these vulnerabilities, there was no documentation in his medical record that he was assessed immediately after the alleged abuse incident, and no progress notes described the event. According to the facility’s substantiated Self-Reported Incident, at approximately 3:30 A.M. a CNA became aggravated with the resident, yelled and cursed in his ear, grabbed his arm forcefully, shoved him out of his wheelchair, and aggressively threw him into bed while continuing to shout at him. A witness CNA reported that the wheelchair was unlocked when the resident was shoved out, that the CNA slammed the wheelchair pedals shut aggressively, and that the resident cried and said “please stop” as his legs were thrown into bed. After the resident was in bed and crying, an RN entered the room, pointed a finger at the resident, and repeatedly yelled at him in an aggressive tone to “stop right now,” while the resident continued crying and was not combative. These events constituted verbal and physical abuse as documented in the SRI and witness statement. The facility did not follow its Abuse, Neglect, and/or Misappropriation of Resident Funds or Property Policy. The DON was not notified until approximately two hours and 24 minutes after the incident, and the CNA accused of physical abuse remained on the unit providing resident care until the end of her shift. There was no documentation that a nurse supervisor performed the required immediate assessment, including range of motion, full body assessment for signs of injury, and vital signs, and no documentation that the resident’s physician or representative were notified. The incident was not documented in the nurses’ notes with an accurate description of the event, assessment findings, notifications, or treatment. Additionally, the facility never conducted an investigation into the physical abuse by the CNA and verbal abuse by the RN, and therefore did not complete an investigation within the five working days required by its policy.
Failure to Follow Abuse Reporting Policy After Resident Allegation of Injury
Penalty
Summary
The deficiency involves the facility’s failure to implement and follow its abuse policy when a resident reported possible abuse associated with care. The resident, who had multiple medical conditions including a displaced fracture of the upper left humerus, pain related to an orthopedic prosthesis, unsteadiness, muscle weakness, osteoporosis, hypertensive heart disease, peripheral vascular disease, nutritional anemia, moderately impaired cognition (BIMS score of 7/15), and frequent incontinence, complained of a broken arm and pain after care provided by a CNA. The CNA reported this complaint only to an agency nurse, who performed an assessment on the same day and documented no findings. The CNA did not report the allegation to the DON or any other appropriate facility staff member as required by the abuse policy, which states that all allegations of abuse, neglect, and misappropriation must be reported immediately to designated supervisory personnel. On the following day, during evening shift change, an RN was notified that the resident was complaining of left arm pain and reported having been in a fight with a CNA. The RN immediately assessed the resident and observed bruising and swelling of the left arm, notified the DON and the physician, and the resident was sent to the ED, where a left forearm fracture was diagnosed and nonsurgical management with a sling was recommended. The DON confirmed that the CNA failed to follow the facility’s Abuse, Neglect, Misappropriation and Crime Reporting policy by not immediately reporting the resident’s allegation to appropriate supervisory staff, resulting in a delay in the facility’s recognition and response to the reported incident.
Failure to Report Resident‑to‑Resident Physical Altercations as Abuse Allegations
Penalty
Summary
The deficiency involves the facility’s failure to implement its abuse policy by timely reporting multiple resident‑to‑resident physical altercations as allegations of abuse to the State Agency. In one series of incidents, a resident with Alzheimer’s disease, dementia with mood disturbance, bipolar disorder, anxiety, depression, obesity, and documented behavioral symptoms including verbal and physical aggression, wandering, rummaging, and taking others’ belongings was involved in a physical altercation with another resident who also had Alzheimer’s disease, dementia with agitation, depression, anxiety, and wandering and aggressive behaviors. Nursing notes and internal risk reports documented that one resident slammed a dining room chair into a table, the other resident pushed him in the abdomen, and the first resident then struck the other on the back of the head. Staff separated the residents, assessed them, and documented no injuries, and internal incident reports were completed. However, the Administrator and DON confirmed that no self‑reported incident was filed because there was no observed injury and they believed the residents lacked the ability to intend harm or cause mental anguish, despite the facility’s policy and abuse flow sheet referencing the reasonable person concept and the need to report resident‑to‑resident physical altercations that could cause injury, pain, or mental anguish. In a separate incident involving the same aggressive resident, staff responded to another resident’s room after hearing a verbal outburst and found the cognitively impaired, wandering resident sitting in his wheelchair eating dinner while the aggressive resident was on the bed. The resident in the wheelchair reported that the other resident had come into his room, gotten onto his bed, and punched him in the face. Nursing documentation and an internal risk report confirmed that the residents were immediately separated, no injuries were observed, and notifications within the facility were made. The resident who reported being punched had Alzheimer’s disease with late onset, unspecified psychosis, vascular dementia, personality disorder, anxiety disorder, and wandering and aggressive behaviors documented on the MDS and care plan. Despite the allegation of being punched in the face and the facility’s written policy defining physical abuse to include hitting and punching and requiring immediate reporting of alleged violations involving abuse, the Administrator and DON again confirmed that no self‑reported incident was filed because there was no observed injury and they believed the residents involved could not intend to harm or cause mental anguish. Another incident involved a resident with dementia, delusions, severe cognitive impairment, and extensive behavioral symptoms such as exit seeking, physical aggression toward staff, verbal aggression, wandering into other residents’ rooms, grabbing, kicking, hitting, pushing, cursing, anger, and agitation, who struck another severely cognitively impaired resident with multiple medical conditions including vascular dementia, COPD, heart disease, chronic kidney disease, malnutrition, and pain. An incident audit report and a physical aggression form documented that a CNA witnessed the aggressive resident hit the other resident in the left side of her chest with her hand in a common area, immediately redirected the aggressor, and notified the nurse. The nurse assessed the struck resident, documented no redness or bruising, obtained vital signs, and recorded that the resident stated it hurt but did not know why she had been hit. The physician and family were notified and monitoring was ordered. The DON stated that a self‑reported incident was not completed because she did not believe the resident sustained an injury requiring reporting, despite the facility’s abuse policy defining physical abuse to include hitting and requiring reporting of alleged violations involving abuse to the State Agency within specified timeframes. Across these events, the facility conducted internal investigations and documentation but did not treat the resident‑to‑resident physical altercations as reportable abuse allegations under its own policies and procedures.
Failure to Enforce Misappropriation and Drug-Free Workplace Policies for Controlled Medication
Penalty
Summary
The deficiency involves the facility’s failure to implement its own policies related to misappropriation and drug-free workplace requirements in connection with a resident’s controlled medication. One resident, admitted with multiple diagnoses including ADHD, bipolar disorder, seizure disorder, and Tourette’s Disorder, had an order for Adderall 20 mg twice daily at 8:00 A.M. and 3:00 P.M. The resident’s MDS showed the resident was cognitively intact and independent with ADLs. Review of the resident’s Adderall narcotic count sheets showed that on specific dates, the pill count decreased by two tablets at times when only one tablet was ordered to be administered, indicating that two pills were signed out instead of one on multiple occasions. The facility’s SRI documented that the DON became aware that the Adderall count for this resident was inaccurate and identified that an LPN had signed out the medication at the times when the count decreased by two instead of one. During an interview, the LPN stated she did not know why the count was incorrect and claimed there was a day she punched out two capsules and wasted one but could not find another nurse to witness the waste. The DON reported that the LPN refused to complete an in-facility urine drug screen and did not appear for the initially scheduled independent drug test, despite facility policy stating that refusal or failure to comply with testing requirements constitutes a refusal to test and is subject to immediate termination. The DON acknowledged that, contrary to the written Drug Free Safety Policy, the LPN was allowed to return to work after refusing and missing the drug test, even though the policy specified that refusal to submit to required testing would result in termination.
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