A resident who required extensive assist of two staff for transfers reported that an aide hurt her leg when she was put to bed. She later had ongoing pain, was sent out for evaluation, and was found to have a blood clot and then a fracture of the fibula and tibia. The facility did not complete staff education on transfers after the substantiated incident at the time of review.
The facility failed to complete thorough investigations of alleged resident-to-resident abuse and neglect. A resident’s finger was twisted by another resident at the dining table, but the investigation lacked witness statements, psychosocial follow-up, and additional documented steps. In another event, a resident on a chopped diet was found with blue lips during a choking episode, EMS removed food from the airway, and the resident was pronounced deceased, yet the Administrator disputed the choking event and no FRI was completed.
Abuse investigations were not correctly interpreted, and residents were not protected while the investigations were pending. One resident was observed inappropriately with another resident, but the ordered 1:1 supervision did not begin until later that evening. Other incidents involved a resident reporting verbal abuse, another resident alleging a unit manager hit her while separating residents, and investigations that were incorrectly labeled inconclusive or unsubstantiated despite staff-witnessed contact and a resident kicking and attempting to punch another resident.
Failure to properly substantiate neglect allegations: A resident reported being left wet overnight, and three other residents on the same assignment reported delayed call light response and missed or late incontinence/ADL care. The IDT unsubstantiated the allegation based on no skin impairments and residents denying distress, even though resident statements described delayed care and being left wet.
Failure to investigate and report neglect and diet-order errors: A resident reported being left overnight in a soiled brief with diarrhea, with staff describing raw, red skin and excoriation, yet the event was not reported or thoroughly investigated. A second resident’s daughter reported the resident was found in the same soaked brief from the prior evening and that the DON did not classify it as neglect, while another resident was served grilled cheese despite a mechanical soft diet order, coughed after eating it, and the incident was not reported.
Two residents reported and staff observed sexually inappropriate behavior by a male resident, including entering a resident’s room uninvited while naked from the waist down and pulling on her in bed, and placing his hands under another resident’s blanket and rubbing near and on her private area. Both residents described the contact as unwanted, and one was documented as cognitively intact with capacity. Despite staff corroboration and resident statements to clinical providers, the facility’s investigations concluded that sexual abuse was not substantiated, citing lack of physical harm and inconsistent statements, and failed to adequately assess or address whether the residents felt safe or to alleviate their expressed anxiety.
The facility failed to fully implement staff education following a fall in which a resident sustained a hematoma to the scalp, complained of knee pain, and was later found to have fractures of the shoulder/collarbone and scapula after ER evaluation. Although the investigation identified the injuries and the need for safe resident handling education, only two CNAs received training, and no additional staff were educated, indicating the facility did not use the investigation results to ensure comprehensive staff education.
Failure to Report and Thoroughly Investigate Alleged Neglect: A resident alleged that after wetting the bed, he was not cleaned up for several hours and that staff turned off his call light and left. The grievance investigation was inconclusive and relied on typed aide statements and a skin assessment, but the allegation was not reported to the appropriate state agencies as required by the facility’s grievance policy.
Failure to investigate allegations of abuse: A surveyor found a typed statement in an investigation file describing repeated verbal abuse and unprofessional conduct by two NAs toward residents, including name-calling, rude comments during care, and shutting off call lights. The writer of the statement was not identified, and the Administrator stated the allegations in the statement had not been previously investigated.
A resident reported unknown charges on her debit card and alleged that a former roommate had used the card without permission, estimating losses of several hundred dollars. The facility documented initial steps such as notifying external agencies, involving law enforcement, cancelling the card, separating the roommates, and assisting the resident in obtaining bank statements. However, the facility did not maintain or retain key documentation, including copies of bank statements, the total amount of funds involved, or clear follow‑up on the status and outcome of the allegation. The resident reported not receiving updates, and the BOM acknowledged that the facility lacked the resident’s financial records because they had been turned over to law enforcement and were not requested or reviewed by facility staff until shortly before the survey, resulting in an incomplete internal investigation record of the alleged misappropriation.
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