Failure to Protect Resident from Physical Abuse by Another Resident: A cognitively intact resident reported that another resident with dementia repeatedly entered her room uninvited, called her names, and struck her hand with a cane when she tried to block a blow to her face. Records and staff interviews confirmed the other resident had a pattern of wandering into female residents’ rooms, verbal aggression, and threats involving his cane, while the care plan lacked documented interventions for his room-entry behavior.
Failure to Protect Residents From Abuse and Neglect: Multiple CNAs reported a pattern of rough handling, ignored call lights, refusal to provide toileting and hygiene care, and disrespectful treatment by a CNA. Witnesses described a resident being held down on a commode, another being denied requested clothing, a resident with contractures being forcefully positioned despite screaming in pain, and a resident being thrown onto a bed despite needing a mechanical lift. The facility substantiated elder neglect and mistreatment, but records did not show timely full-body injury checks or psychosocial assessments for the affected residents.
A resident who was alert and communicative alleged that an LPN wrapped hands around the resident’s neck, hit the resident, and threw the resident to the floor in the dining area. Witnesses reported seeing the LPN physically control the resident and tip or lift the wheelchair in a way that caused the resident to fall and hit the head, and one witness heard the LPN make a profane statement about the resident falling out of the chair. The resident had multiple chronic conditions, including depression and adjustment disorder, and the incident was later substantiated as abuse.
Failure to Protect a Resident from Verbal Abuse: A CNA used profanity and disrespectful language toward a resident during evening care, telling her to stay on her “f***ing side” while another CNA witnessed the interaction. Staff also reported prior incidents of the CNA yelling at residents and using aggressive behavior, and the DON confirmed that abuse concerns had not been promptly reported.
A CNA was found to have verbally abused and mistreated residents by speaking disrespectfully, using foul language, and handling a resident's soiled clothing in a demeaning way while changing care. One resident with heart disease, vascular dementia, and frequent incontinence reported being pushed in his wheelchair and having his pants held close to his face, while another resident with dementia was overheard being told, "Don't start that shit now" and "Get your ass up." Interviews, a police report, and facility records supported the allegations, and one resident's record lacked documentation of the verbal abuse or psychosocial follow-up.
Failure to Protect Residents from Physical Abuse During Resident-to-Resident Altercations: Two residents were involved in a physical incident after one resident repeatedly backed a wheelchair into another resident and was struck in the head, with video review substantiating physical contact. A later elevator altercation involved the same cognitively impaired resident and another resident, with witnesses describing grabbing, swinging, and punching that resulted in bruising, skin tears, and a fall. Staff and management acknowledged the physical contact, and the record showed prior concerns about the resident’s impulsive and aggressive behavior.
Failure to Protect Residents from Abuse and Physical Aggression: An LPN verbally abused a resident during a medication dispute, raising her voice and threatening to mark all meds refused after the resident questioned the pill. The report also described multiple resident-to-resident assaults involving residents with cognitive impairment and behavioral diagnoses, including punches to the face and eye, with staff and resident statements confirming the incidents and the facility acknowledging that physical altercations occurred.
A facility failed to protect residents from resident-to-resident abuse. In one incident, a cognitively intact resident with psychotic disorders and another resident exchanged racial slurs, and the second resident struck the first resident in the face, leaving redness. In another incident, a resident with dementia and severe cognitive impairment entered another resident’s room and hit her in the leg with a fist and a comb; the injured resident reported the intruding resident entered her room almost daily, and the facility did not identify the event as abuse or add lasting interventions.
A resident with dementia and Parkinsonism reported that a male CNA sexually assaulted her during the night, and staff interviews, voicemail messages, and camera footage showed the CNA entering her room and remaining inside with the door closed. The resident was fearful and anxious afterward, did not want the CNA around her, and the police report identified the CNA as the suspect for sexual penetration. Another resident also said the CNA made her feel uncomfortable and did not want him to provide care.
Failure to Protect a Resident from Resident-to-Resident Abuse: A resident with a history of aggression and verbal abuse repeatedly backed his wheelchair into another resident in a hallway until the resident fell, causing a head laceration and a hip fracture that required surgery. Surveillance video and the facility’s investigation substantiated resident-to-resident abuse, and records showed the aggressive resident had prior abusive incidents and a behavior care plan without added supervision interventions.
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