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.
Multiple cognitively impaired residents with known behavioral or wandering histories physically assaulted other residents in separate incidents. In one case, a resident with an impulse disorder struck another resident who verbally intervened when staff attempted to redirect him from taking a meal tray. In another, a resident with a conduct disorder punched a wandering resident who entered his room and could not be redirected. A third incident occurred when a resident with severe dementia and wandering behaviors entered another resident’s room, took his blanket, and hit him when he tried to retrieve it. In the fourth incident, a severely cognitively impaired, wandering resident grabbed and yelled at another resident over a TV remote. These events occurred despite documented cognitive and behavioral issues and an abuse policy stating residents will be free from abuse and protected from harm.
Failure to Protect Resident from Verbal Abuse: A resident with intact cognition and a history of amputation-related care and anxiety reported that an RN yelled at him, blocked his wheelchair, and grabbed his arm while enforcing masking and room restriction after the resident’s girlfriend may have been ill. The resident said he felt traumatized and later complained of pain, while the RN documented that she only stopped the wheelchair and that the resident was verbally abusive toward her; staff interviews reflected conflicting accounts of the encounter.
A resident with a history of sexually inappropriate comments and touching, who was care planned to remain in staff line of sight and at least an arm’s length from female residents, was left unsupervised in a lounge with a nonverbal, severely cognitively impaired resident. The resident with known behaviors was observed with his hand on the other resident in a manner that appeared to involve her private area. An agency CNA later stated she believed the extra supervision applied only during meals, despite the documented requirement for continuous monitoring in common areas. This failure to follow the care plan and provide adequate supervision resulted in sexual abuse and was cited as an immediate jeopardy deficiency.
A resident with severe cognitive impairment and psychiatric diagnoses, known by staff to be verbally and physically aggressive toward staff and other residents, slapped another cognitively impaired resident when their wheelchairs became entangled in a hallway. A witnessing resident reported the incident to a CNA, who separated the residents and notified an LPN; the LPN performed only a brief visual check for injury, did not document the event, did not complete further assessment such as vital signs, and was unaware of any new interventions to prevent recurrence. The NHA acknowledged being told about the slap and that such incidents should be investigated, documented, and possibly reported to the state, but did not document the event, did not interview involved staff or other residents, and did not conduct a formal investigation, while other staff confirmed that no new behavioral or supervision interventions were added to care plans or CNA guides despite the aggressive resident’s ongoing history of combative behavior.
The facility failed to prevent physical abuse when a cognitively impaired resident with dementia and anxiety disorder twice assaulted other severely cognitively impaired residents. In one incident, an LPN observed the aggressive resident arguing with another resident and forcefully squeezing that resident's wrist, resulting in bruising to the victim's hand and wrist and a bruise and skin tear to the aggressor's hand. In a separate incident, staff saw the same resident extend a leg to trip a wheelchair-bound resident and forcibly grab that resident's hand and wrist, causing pain and two bruises. Both victims had dementia with severely impaired cognition, and staff documentation and interviews confirmed the resident-to-resident altercations and resulting injuries.
A resident with moderate cognitive impairment and a documented history of sexually inappropriate behavior toward other male residents had his supervision progressively reduced and ultimately discontinued despite prior incidents of non-consensual genital touching. Later, this resident was found in another cognitively intact resident’s room with his hand inside the other resident’s pants, touching his penis and upper thigh; the second resident reported the contact was not consensual. Staff interviews and records confirmed that the abusive resident was known to be sexually inappropriate, and that facility policies required prevention of abuse and monitoring of residents with behaviors that might lead to conflict, but supervision was not consistently maintained, leading to an Immediate Jeopardy finding related to failure to protect residents from sexual abuse.
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