A cognitively intact resident with behavioral issues, including physical aggression and noncompliance with care, was in a secured unit and was observed tapping on the window/door. A dietary aide, despite being told by a CNA and an RN not to enter the secured unit and that the resident’s assigned aide could assist, went onto the unit and interacted with the resident, including offering to buy a soda after seeing money in the resident’s hand. The resident struck the aide in the face, and the aide responded by punching the resident in the face; a CNA reported hearing the aide say, “I will hit you again,” and then observed the resident bleeding. The resident was later found at the hospital to have an open mandibular fracture and non-restorable teeth requiring extraction, and the facility’s investigation and policy definitions led to the incident being substantiated as staff-to-resident physical abuse.
A cognitively impaired resident with dementia and behavioral symptoms became involved in a physical altercation with another resident and was then taken to the nurses’ station, where three CNAs forcefully seated him in a chair, held his arms down, and one CNA straddled his leg while others pulled up on his sweatpants. Video showed the resident being repeatedly pushed back into the chair and physically restrained by multiple CNAs, while cognitively intact residents and a CNA witness reported that staff were laughing, teasing him, and making demeaning comments as he tried to get up and walk away. The resident was later found to have a bruise and skin tear of unknown origin on his arm, exhibited increased agitation, and was placed on Depakote for behavioral management for two days before it was discontinued. The facility’s investigation, including review of video and witness statements, substantiated that the CNAs’ actions constituted physical abuse and a violation of the resident’s rights.
A cognitively impaired female resident with Alzheimer’s disease and a BIMS score of 0 was involved in two separate incidents of sexual contact with cognitively impaired male residents, both of whom also lacked documented assessments of capacity to consent to sexual activity. In one event, a CNA found her in a male resident’s bed with him on top of her and both of their pants down; in another, staff found her naked in another male resident’s bed while he had his fingers in her vaginal area and stated she wanted it. Despite facility policies requiring evaluation of consent capacity when there is concern a resident may not be able to consent, no such evaluations were documented for any of the involved residents, and staff later acknowledged they relied only on BIMS scores to judge consent capacity. One of the alleged sexual abuse incidents was not reported to the state agency as required, law enforcement was not contacted, and the guardian of one male resident was not documented as being consulted about police involvement. Although 15‑minute checks were added to the female resident’s care plan, multiple CNAs and an RN on the unit reported they were unaware of any special monitoring and described only routine checks, indicating the enhanced supervision was not effectively implemented.
A resident with a history of inappropriate behaviors and a recent conviction for a sexual offense, who was documented as needing behavioral monitoring and supervision, was able to wheel past another cognitively impaired resident seated in a hallway and pull at that resident’s pants and brief, placing a hand inside the brief and touching the resident’s private area. Staff and a CNA witness observed the non-consensual contact and intervened to separate the residents. The victim, who had severe intellectual disability and was rarely or never understood, was unable to provide a reliable account of the event, though assessments showed no physical injury at that time. The facility’s abuse prevention policy defined sexual abuse as non-consensual sexual contact and required assessment and supervision of residents with behaviors that may lead to abuse, but the incident occurred despite these requirements, and the facility’s investigation confirmed resident-to-resident sexual abuse.
A resident with significant cognitive and physical impairments, including post-stroke hemiplegia, aphasia, and dependence for ADLs, was transported by a facility staff member to an outside cancer treatment appointment. Witnesses at the clinic reported that the transporter arrived visibly upset, stated he was having a bad day with the patient, and was then seen within an inch of the resident’s face, flailing his arms and yelling, leaving the resident appearing upset. The incident was reported to the clinic’s office manager and then to the Ombudsman, who later informed facility leadership of the allegation. The facility’s abuse policy defines mental abuse as including humiliation and harassment and requires immediate investigation and protection, and surveyors determined the facility failed to ensure the resident was free from verbal abuse by staff.
The facility failed to protect a dependent, hemiplegic resident from a known aggressive roommate who had previously threatened to kill him over TV volume. Staff initially moved the aggressive resident to another room after he threatened to shoot his roommate, but, on direction from the DON and despite staff objections and the aggressor’s documented history of verbal and physical aggression, the two residents were placed back together without updating care plans or increasing monitoring. The aggressive resident later struck his roommate while he was in bed, causing bruising to the shoulder and arm and leading to fear, withdrawal, and self‑isolation. Documentation minimized the event as a verbal altercation, there was no timely evidence of physician or family notification, and the victim reported that no one followed up with him for a statement or investigation, contrary to the facility’s abuse policy requirements.
A resident with a history of CVA, depression, anxiety, and moderate cognitive impairment, whose care plan included emotional support and reassurance, was involved in an incident where an RN reacted to the resident’s loud swearing and use of religious profanity by stating she was consecrated to the Lord and then spraying holy water twice in the resident’s direction from a spritzer bottle the RN carried. The resident had not agreed to this, was visibly bothered, and later reported to an LPN that someone had sprayed her in the face with something. The RN admitted to the LPN that she sprayed holy water at the resident because of the resident’s use of the Lord’s name in vain, and the resident became very agitated and confrontational afterward, leading to a finding of staff-to-resident physical abuse and inappropriate treatment.
A cognitively intact but quadriplegic resident with MS, incontinence, and a history of behavioral symptoms was physically abused by a CNA during incontinence care. Video showed the CNA entering without knocking while the resident slept, roughly rolling him, striking his face and upper body multiple times, throwing and forcefully holding a pillow over his face, and continuing care in a rough manner. The next morning the resident reported being punched in the nose and handled "like a rag doll"; staff and police noted dried blood and nasal deviation, and hospital imaging confirmed multiple nasal fractures and a perforated nasal septum. The facility’s investigation, based on video review and interviews, substantiated that physical abuse had occurred.
A cognitively impaired resident with multiple neurological conditions who required total assistance for ADLs was subjected to verbal and physical mistreatment during care. A CNA shouted in the resident’s ear, cursed, and forcefully transferred the resident from an unlocked wheelchair to bed, causing the resident to cry and plead for the behavior to stop. After the resident was in bed and still crying, an RN entered, leaned over the resident, pointed a finger, and repeatedly yelled for the resident to stop, despite the resident not being combative. A witnessing CNA reported the conduct as abusive, and leadership later confirmed the incident as substantiated verbal abuse, with no subsequent abuse education or training provided to staff.
The facility failed to protect residents from resident-to-resident physical abuse and did not substantiate clear abuse incidents despite documented injuries and witness accounts. In one case, a cognitively intact resident with mood issues sustained a forehead abrasion after another resident with a history of anger, agitation, and substance abuse entered the room uninvited and threw a can of shaving cream at the resident’s head. In another case, a cognitively intact resident with schizoaffective disorder and mobility limitations reported being punched in the face by a peer who blocked the doorway; this peer had a documented history of aggression, destructive behaviors, sexually inappropriate conduct, and recent refusal of antipsychotic medications after a leave of absence. An LPN witnessed the punch and described the aggressor as verbally aggressive and irritable throughout the day, yet no new interventions were implemented, and the facility’s investigations concluded that both allegations were unsubstantiated, contrary to its own abuse policy defining willful infliction of injury and requiring ongoing assessment and care planning for residents with aggressive behaviors.
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