A resident with dementia and bipolar disorder, who had severely impaired cognition but could communicate and understand others, was verbally abused by a CNA who yelled, got in the resident’s face, and used harsh language when the resident asked to be put to bed. Witness statements described repeated yelling, refusal to help with the transfer, and dismissive comments such as saying the resident was “just playing games.” The DON’s investigation found the CNA did not treat the resident with kindness and respect, and the record showed an LPN present during the event was not interviewed.
A resident with Parkinson’s disease, dementia, and severe cognitive impairment was slapped in the face by his representative while she was assisting him with a meal in the dining room. A CNA heard the representative yell that she was being hurt, saw the resident holding her wrist, and observed the slap but did not intervene at the time. The LPN later assessed the resident and found no visible injury, and the DON and Administrator acknowledged the slap was abuse and that staff should have intervened immediately.
Verbal and Physical Abuse During Resident Care: Staff used profanity and threatening language toward a resident with dementia during bathing and reportedly sprayed the resident with the shower head after the resident became resistive. In a separate incident, a CNA allegedly cursed at a severely cognitively impaired resident, handled the resident roughly during bed care and a lift transfer, and swatted the resident's hand. Both residents had care plans calling for calm, direct, individualized approaches during care.
A facility failed to protect two residents from sexual abuse when one resident was found performing oral sex on another resident. Both residents had moderate cognitive impairment, but the facility had no documentation that either had been assessed for capacity to consent before the event. Staff later stated they were unaware of any sexual relationship, did not know whether the residents could consent, and the DON said the facility did not fully investigate the incident or report it to the State Agency.
A facility failed to protect two cognitively impaired spouses from resident-to-resident abuse. One resident repeatedly yelled at and threatened the other, and the spouse later struck the resident on the head and face multiple times. Surveyors found incomplete behavior monitoring, missing documentation, and confusion among staff about reporting and protective interventions while the couple continued to argue and act aggressively toward each other.
Failure to Protect Residents From Sexual Abuse: Two cognitively impaired residents with documented inappropriate sexual behaviors were found together in bed and later in each other’s rooms, including one resident touching the other’s penis. An LPN did not report the first incident to management, and the resident’s POA was not notified. Staff interviews and the facility’s investigation confirmed repeated resident-to-resident sexual contact and inadequate supervision before the incidents were stopped.
Two residents were physically abused by peers when the facility failed to prevent resident-to-resident altercations. In one case, a cognitively intact wheelchair user was grabbed by another cognitively intact wheelchair user and flipped backward out of his chair after a verbal dispute, as observed by an LPN who heard a commotion and then saw the resident on the floor. In another case, a cognitively impaired resident with a history of physical assault and a care plan calling for separation from aggressors and staff presence during activities was struck in the face multiple times by a peer with known impulsive and aggressive behaviors during a supervised group activity, resulting in swelling and redness to the head and face. These events occurred despite existing care plans and a facility policy intended to prohibit and prevent abuse.
Two moderately cognitively impaired residents with multiple comorbidities, including alcohol abuse, COPD, age-related cognitive decline, and cancer, were involved in a dining room incident where one resident loudly yelled at and threatened the other to “shut up,” during which the threatened resident experienced an unwitnessed fall. Staff, including a CNA, an LPN, the SSD, the DON, and the NHA, acknowledged awareness of the yelling and the fall, but there was no documentation in either resident’s record of the altercation, no formal abuse investigation, and no behavior or separation interventions care planned for the resident making threats, despite facility policies requiring prompt reporting, documentation, and investigation of suspected abuse and federal guidance treating resident-to-resident altercations as potential abuse.
The facility failed to protect cognitively impaired residents from sexual abuse by other residents with known histories of hypersexual and inappropriate behaviors. In one case, a CNA observed a resident crying in the dining area and later saw another resident, previously documented as sexually inappropriate with staff, with a hand inside the crying resident’s shirt grabbing the breast; the CNA had to physically remove the hand. Despite known wandering, tearfulness, and a reported history of past sexual trauma, the affected resident’s care plan was not updated with new safety measures, and behavior tracking for the aggressor was frequently incomplete, with missing entries and unclear 1:1 supervision documentation. In another case, a resident with vascular dementia, traumatic brain injury, and documented hypersexual behavior was seen in a cognitively impaired resident’s room touching the inner thigh near the pubic area, after staff had repeatedly noted this resident’s pattern of targeting and attempting to enter that same resident’s room. The care plan did not reflect the targeting behavior, and behavior monitoring for this resident was also largely incomplete, contributing to inadequate supervision and failure to prevent further inappropriate contact.
A resident with multiple chronic conditions, including neuropathy, DM2, COPD, and heart failure, who was cognitively intact and frequently incontinent, reported that a CNA refused or failed to provide requested toileting and incontinence care for an entire day shift, leaving the resident in urine‑soaked linens until the next shift. The resident described feeling like garbage, useless, and severely abused, and was found by a second‑shift CNA in a soaked brief and bed, requiring a full bed bath, linen change, and cleaning of the mattress. Multiple staff, including a CNA, the ADON, and a social worker, were informed of the allegation, but there was no contemporaneous documentation in progress notes, no entry on the grievance log initially provided, no self‑report to the state, and the NHA was not notified. A handwritten grievance later produced described the same events but contained no documented investigation, follow‑up, or resolution, demonstrating a failure to provide timely incontinence care and to recognize, report, and investigate an allegation of neglect as required by facility policy.
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