Systemic Failure in Abuse/Neglect Training, Screening, and Licensing Leading to Resident Neglect
Summary
The deficiency involves the facility’s failure to implement its own policies and procedures to prevent abuse, neglect, and mistreatment, specifically through required screening and training of staff. The facility’s written Abuse, Neglect, & Mistreatment policy stated that all potential employees would be screened for a history of abuse, neglect, or mistreatment through inquiries to state licensing authorities or nurse aide registries and criminal background checks, and that abuse, neglect, and misappropriation education would be completed upon hire and at least annually for all employees. Despite this, review of employee files showed that one LPN had no documentation of a pre-employment background check, and an out-of-state scheduler had only a state background check with no evidence of the required FBI background check. Further review revealed that 26 facility employees had no pre-employment background check documented in their files until checks were completed later. The facility also failed to ensure that staff held current, valid licenses and that these were verified prior to and during employment. File reviews showed that multiple staff members, including two NAs, two RNs, and the DON, had expired licenses or no license on file. Additional audits identified two NAs who had been working with expired licenses. The NHA acknowledged not knowing the process for checking expired licenses. These lapses occurred despite the policy requirement that screening include inquiries into state licensing authorities and nurse aide registries to identify any disciplinary actions. In addition, the facility did not provide required annual abuse and neglect prevention training to its staff. Review of training records and staff files showed that five of seven staff members later identified as alleged perpetrators in a reported neglect incident had no documentation of annual abuse and neglect education for the current year. A broader review confirmed that none of the 90 current facility employees had documentation of annual abuse and neglect training for a 12‑month period. The Human Resources Director stated that no annual education had been completed from January through the date she started working at the facility, and the list of 2025 education topics did not include abuse and neglect. Staff interviews corroborated that while some employees had recently received abuse and neglect education, several indicated it had been a long time since they received such training at this facility or that they received it only at other jobs. These combined failures in training, background checks, and license verification resulted in an Immediate Jeopardy determination for all residents. The neglect incident that triggered identification of alleged perpetrators involved 12 residents on the second floor who did not receive any morning care because no staff were assigned to rooms 209-A through 217-B. A NA reported that these residents had not received morning care, and surveyors informed the NHA and DON twice during the same day that the 12 residents still had not received any morning care. The NHA confirmed that seven staff members, including NAs, an LPN, RNs, the DON, and the NHA, were identified as alleged perpetrators of neglect related to this incident. The facility’s own policy defined neglect as failure to provide goods and services necessary to avoid physical harm, pain, mental anguish, or emotional distress, including when staff are aware or should be aware of residents’ care needs but do not meet them due to factors such as lack of training, insufficient staffing, lack of supplies, or lack of knowledge of resident needs. The survey findings linked the lack of required abuse/neglect training, incomplete background checks, and unverified or expired licenses to this neglect event and the resulting Immediate Jeopardy for all residents. Surveyors confirmed through interviews with successive NHAs that the facility failed to ensure annual abuse and neglect prevention training for the majority of staff, failed to complete required pre-employment criminal background checks for multiple employees, failed to conduct an FBI background check for an out-of-state employee, and failed to verify current, valid licenses and any disciplinary actions prior to employment for several staff members. These findings were cited under Pennsylvania regulatory provisions related to the responsibility of the licensee, management, and personnel policies and procedures. The Immediate Jeopardy was based on these systemic failures in screening, training, and oversight, combined with the documented incident in which 12 residents did not receive morning care due to lack of staff assignment.
Removal Plan
- Facility has reviewed current policy on abuse and neglect.
- All current facility staff including agency will receive training on current facility policy for abuse and neglect.
- Those who do not complete education will not be permitted to work until education is completed.
- All current facility employee files, including agency, will be reviewed to ensure that they have education on facility policy for abuse and neglect, a current and active license on file, and a background check present in their file.
- Missing items that are identified in audit will be immediately corrected.
- Facility will audit all new hire and all new agency staff files to ensure that files contain evidence of abuse education, a current and active license, and a background check.
- Results of the audit will be reported to the Ad Hoc Quality Assurance Performance Improvement Committee.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A resident with moderately impaired cognition and limited English proficiency sustained bilateral wrist discoloration and swelling during ADL care provided by a CNA while resisting care. Staff documentation and witness statements described the resident bumping or hitting her wrists on a wheelchair during transfer, but the CNA later stated he did not know how the injury occurred. The resident’s family reported that the resident said a large male staff member grabbed and held her hands while trying to force a nightgown change, and also reported a second, similar wrist injury incident to facility staff and APS. Despite a written abuse policy requiring immediate investigation, interviews of the alleged victim, alleged perpetrator, and witnesses, and protective measures, the facility did not report the incident as abuse or injury of unknown origin, did not interview the resident or other residents, and limited its inquiry to two staff members, resulting in a cited Immediate Jeopardy deficiency for failure to prevent and investigate potential abuse.
The facility failed to follow its abuse, neglect, and exploitation policy by not ensuring that a CNA completed required annual abuse-prevention and related trainings. Although the CNA reported being current on all yearly training, a review of her transcript showed that assigned courses on cultural competence, abuse/neglect/exploitation, and abuse/neglect/exploitation with HIPAA content were overdue past their required completion date. The administrator confirmed that these were mandatory annual trainings. Review of the written policy showed that existing staff must receive annual education on preventing, identifying, recognizing, and reporting abuse, neglect, exploitation, and misappropriation of resident property, as well as on resident behaviors that may increase risk, but this requirement was not met for this CNA.
The facility failed to follow its abuse reporting policy when an allegation that a resident had been roughly handled by a third-shift CNA was not immediately reported to the Administrator/Abuse Coordinator. One resident told his roommate he had been treated roughly and mishandled with a urinal; the upset roommate then reported this to a CNA, who in turn informed an LPN. The CNA and LPN acknowledged awareness of a complaint involving third-shift staff but did not directly notify the Administrator, and Social Services was only told that the resident had a complaint, without mention of abuse. Social Services made unsuccessful attempts to speak with the resident and did not learn the concern involved abuse until the resident’s son later stated it was "elder abuse." The Administrator reported first learning of the allegation hours after staff initially became aware, and the resident stated no one from the facility had come to talk with him about what occurred.
The facility failed to follow its abuse prevention policy when a cognitively intact, independent resident alleged that a CNA struck her with a garbage bag after a dispute over dishes left in a shared bathroom, an event that was witnessed by another cognitively intact, independent resident with psychiatric diagnoses. The Administrator did not initially consider the event to meet the definition of abuse, did not promptly report it to the state agency, did not initiate a timely internal investigation, and allowed the CNA to continue working, despite a written policy requiring prompt reporting, investigation, and protection of residents during abuse investigations.
The facility failed to follow its abuse and electronic monitoring policies by not properly identifying, documenting, or investigating multiple allegations of abuse, neglect, and misappropriation involving a resident with dementia and chronic respiratory failure. Over several weeks, the resident’s daughter reported that an LPN intimidated the resident, administered Tramadol doses too close together, failed to provide ordered medications, ignored incontinence care requests, and publicly disparaged the resident, while a CNA and another aide allegedly yelled at the resident, disrespected her belongings, and spoke to her in a demeaning manner. The daughter also reported missing personal items, including socks, a camera, and an SD card that she said contained video of staff screaming at the resident. Despite these detailed complaints, facility leadership denied knowledge of the allegations, the concern log contained no entries for the resident, and the only self-reported incident was a vague mistreatment report that lacked specific interviews with the daughter, relied on a generic questionnaire for the resident, and did not include any documented attempt to obtain or review camera footage.
Facility staff did not complete required Criminal Background Checks (CBCs) for three CNAs before they began working with residents, despite policies requiring background and criminal conviction checks for all direct-access employees. Review of personnel files showed no documentation that CBCs were requested or obtained for these CNAs. The administrator reported relying on verification through the Family Care Safety Registry (FCSR) and, when not registered, on requests to an external association for background checks, and acknowledged not requesting CBCs from the state highway patrol since assuming responsibility for this process.
Failure to Implement Abuse Policy and Investigate Resident Wrist Injuries
Penalty
Summary
The deficiency involves the facility’s failure to implement its abuse policy and to ensure a resident’s safety following an injury sustained during ADL care by a CNA, and the failure to investigate to rule out abuse. The resident, identified as R94, was admitted with diagnoses including altered mental status and had a BIMS score of 11/15, indicating moderately impaired cognition. Her preferred language was Korean. Her care plan, initiated months before the incident, addressed discoloration but was not updated after she sustained injuries to her wrist on 03/20/25. The facility did not report the incident to the state survey agency, and the CEO confirmed there was no investigation for the 03/20/25 incident, only a grievance form. On 03/20/25, an incident report documented that CNA2 informed RN1 that the resident developed discoloration and swelling of both wrists during ADL care when changing clothes, while the resident was resisting care. The report stated that the resident bumped her wrists against the wheelchair during transfer, and that CNA2 was removed from the assignment and educated to stop providing care if a resident resists. Employee witness statements from RN1 and CNA2 described the resident resisting care and bumping or hitting her wrists on the wheelchair, with RN1 noting that the resident was unable to communicate coherent English when questioned. CNA3’s statement only indicated that she was asked to assist, found the resident agitated, and that the nurse assessed and notified others. A nurse’s note by RN1 documented bilateral wrist discoloration and swelling after an “accident” during clothes changing while the resident was resisting, and that ice was applied. In a later interview, CNA2 stated he attempted to transfer the resident from the wheelchair to bed after toileting, that she resisted by lifting her arms, and that he did not know how the injury occurred. He confirmed the injury was not present before he attempted the transfer and that he remained assigned to the resident for the rest of the shift. The resident’s family member reported that the resident, who did not speak English, told her that during the 03/20/25 incident she refused to be changed into a nightgown and staff grabbed her hand and tried to force her, describing the staff as a big Black man. The family member also reported a second, similar wrist injury incident with a big Black male staff member and stated she reported these to facility staff and APS. The Social Service Director acknowledged that she did not interview the resident or other residents or complete a trauma assessment regarding the 03/20/25 allegation, despite stating that such steps were part of the usual abuse investigation process. The Administrator, who was the DON at the time, stated that the incident was not reported as abuse or injury of unknown origin because CNA2 self-reported that the injury occurred during care and denied abuse, and that only CNA2 and RN1 were interviewed. This was inconsistent with the facility’s written abuse policy, which required immediate investigation, interviews of all involved persons including the alleged victim and witnesses, and measures to protect residents from harm during and after the investigation. The facility’s abuse, neglect, and exploitation policy required an immediate investigation when there was suspicion or reports of abuse, including identifying and interviewing the alleged victim, alleged perpetrator, witnesses, and others with knowledge, and ensuring residents were protected from physical and psychosocial harm during and after the investigation. Examples in the policy included responding immediately to protect the alleged victim, examining the alleged victim for signs of injury, and making room or staffing changes if necessary to protect residents from the alleged perpetrator. Despite this, the Social Service Director did not conduct resident or collateral interviews or trauma assessments, and the Administrator confirmed that the facility limited its inquiry to CNA2 and RN1 and did not treat the event as an injury of unknown origin or an abuse allegation. The failure to follow these procedures and to ensure the resident’s protection and a thorough investigation led to the cited deficiency under 42 CFR §483.12 Freedom from Abuse, Neglect, and Exploitation, with Immediate Jeopardy identified at a scope and severity level J.
Failure to Ensure Completion of Required Annual Abuse-Prevention Training
Penalty
Summary
The deficiency involves the facility’s failure to implement its abuse, neglect, and exploitation policy by not ensuring that one CNA received required annual abuse-related training. During an interview, CNA #3 stated that she was current on all required yearly training. However, a review of her annual training transcript showed that multiple assigned trainings, including "Cultural Competence Inservice," "Abuse, Neglect, and Exploitation," and "Abuse, Neglect, and Exploitation HIPAA for Long-Term Care Employees," were overdue. These trainings had been assigned on February 2, 2026, with a completion due date of February 28, 2026, but remained incomplete as of the survey date. The administrator confirmed that the records reviewed were the yearly training records and stated that employees were required to complete these courses annually and by the due date. A review of the facility’s written policy titled "Abuse, Neglect, and Exploitation" showed that new employees must be educated on abuse, neglect, exploitation, and misappropriation of resident property during orientation, and existing staff must receive annual education through planned in-services and as needed. The policy specified that training topics must include prohibiting and preventing all forms of abuse, neglect, exploitation, and misappropriation; identifying and recognizing signs and indicators of these issues; and understanding reporting processes and resident behavioral symptoms that may increase risk. In a meeting with the DON, administrator, and regional director of clinical services, the DON stated she was a new hire and that the training should have been completed, and no additional information was provided.
Failure to Immediately Report and Investigate Alleged Abuse
Penalty
Summary
The deficiency involves the facility’s failure to follow its Abuse Prohibition and Reporting policy by not immediately reporting an allegation of abuse involving one resident (R1) to the Abuse Coordinator/Administrator. The facility’s written policy requires any employee or agent who becomes aware of alleged abuse or neglect to immediately report the matter to the Administrator or designee, and specifies that staff must report whenever they hear the word "abuse" or suspect abuse. R1’s face sheet shows he was admitted with diagnoses including acute respiratory failure with hypoxia, peripheral vascular disease, generalized anxiety disorder, and benign prostatic hyperplasia. Despite this policy, multiple staff members became aware that R1 allegedly experienced rough handling by a third-shift CNA but did not promptly notify the Administrator as required. On the morning of 4/15/26, R2 reported to a CNA (V8) that he believed his roommate, R1, had been abused by a third-shift CNA, describing that there were two CNAs, one nice and one not, and that the rough CNA had been very rough with R1 and did something involving a urinal. V8 acknowledged that R2 appeared upset and that she understood this as a concern about possible abuse of R1 by third shift. V8 then reported the concern to an LPN (V6) and accompanied her to the residents’ room. V6 spoke briefly with R1, who stated he had a complaint about a third-shift CNA, and V6 told him she would get Social Services so he would not have to repeat himself. V8 stated she did not know who the Abuse Coordinator was and did not report the allegation to the Administrator. V6 stated she contacted Social Services (V5) only to report that R1 had a complaint, without specifying that it involved alleged abuse. Social Services (V5) reported being told only that R1 had a complaint and made two unsuccessful attempts to speak with him before R1’s son (V15) was brought to her office later that afternoon. V5 stated that the first time she became aware that the issue involved abuse was when V15 came in and stated, "This is Elder Abuse." V6 similarly stated she did not realize it was an abuse allegation until V15 used the term "elder abuse" when she took him to Social Services. The Administrator (V1), who is the Abuse Coordinator, reported that she did not become aware of the allegation until between 3:00 and 4:00 p.m. that day, despite the policy requiring immediate reporting to her when abuse is suspected. R1 stated that no one from the facility had come to talk to him about what occurred, although they had spoken with his son and his roommate. R1’s son also reported that he was not notified by the facility of the abuse allegation and instead learned of it from R1 and R2, and that when police later interviewed R1 and R2, R2 told the police he had reported the incident to the Administrator the morning it occurred. These interviews and record reviews demonstrate that the facility did not implement its abuse reporting procedures as written for this allegation involving R1.
Failure to Implement Abuse Reporting and Investigation Policy After Alleged Staff-to-Resident Abuse
Penalty
Summary
The facility failed to implement its abuse prevention program policy related to prohibiting and preventing abuse, investigating allegations, protecting residents during investigations, and reporting abuse. One cognitively intact resident (R4), who has diagnoses including depression, COPD, and GERD and is independent in daily activities, reported that after returning from dinner she was told by her roommate that a CNA (V26) had taken dishes she left on the shared bathroom sink. When R4 confronted the CNA, she stated the CNA hit her with a garbage bag. R4 reported that she called the police, who came to the facility, and that the next day the Administrator (V1) spoke with her but did not take action regarding the allegation. Another cognitively intact resident (R9), with diagnoses including bipolar disorder, schizophrenia, major depressive disorder, and anxiety disorder and who is also independent in activities of daily living, stated she witnessed the CNA hitting R4 with a garbage bag. Despite these allegations and the facility’s written Abuse Prevention Program policy, the Administrator/Abuse Coordinator (V1) acknowledged that he did not report the incident to the state agency at the time because he did not believe it met the facility’s definition of abuse. The incident was not reported to the Illinois Department of Public Health until months later, and no internal investigation was initiated at the time of the allegation. V1 further acknowledged that the CNA continued to work after the allegation. The DON (V2) and ADON (V3) later stated that the facility had overlooked the incident and that the abuse allegation should have been addressed in a timely manner. The facility’s policy, revised 01/2019, states that the facility will not tolerate incidents of abuse and that the policy defines how investigations of abuse allegations will be conducted and outlines the process of reporting, investigating, and reaching conclusions on allegations, which was not followed in this case.
Failure to Investigate and Respond to Repeated Abuse, Neglect, and Misappropriation Allegations
Penalty
Summary
The deficiency involves the facility’s failure to follow its own policies for promptly identifying, reporting, and investigating allegations of abuse, neglect, and misappropriation involving a resident. The resident, who had dementia, anxiety disorder, chronic respiratory failure, and was assessed as having mild or no cognitive impairment, had no documented abuse or misappropriation allegations in her progress notes for 2026 despite multiple concerns raised externally. The Ohio Department of Health (ODH) website showed only one self-reported incident (SRI) related to this resident within the prior six months, dated 03/09/26, for alleged neglect and mistreatment by an LPN and a CNA, even though numerous additional allegations had been communicated by the resident’s daughter. Record review of emails from the resident’s daughter to facility staff and ODH showed repeated allegations over several weeks, including that an LPN administered Tramadol doses too close together, displayed animosity, intimidated the resident, failed to provide ordered medications, falsely documented refusals, and ignored calls for incontinence care after turning off the call light. Additional emails alleged that a CNA disrespected the resident’s belongings and spoke to her in a demeaning manner, that an unidentified aide yelled at the resident, and that personal items such as cabin socks were stolen. The daughter also reported a missing camera and SD card to the ombudsman, and later alleged that the SD card containing footage of staff screaming at the resident had been stolen. Despite these detailed complaints, the Administrator, DON, ADON, and Regional Nurse all denied knowledge of the abuse, neglect, and misappropriation allegations contained in the emails. The facility’s handling of the one documented SRI did not follow its abuse policy requirements for a focused investigation. The SRI described staff speaking to the resident in a loud, abrasive manner and referenced mistreatment concerns but lacked specifics, did not include an interview or attempted interview with the daughter, and documented only a generic questionnaire-style interview with the resident in which pre-written answers were circled indicating she felt safe and had no concerns. There was no documented attempt to obtain footage from the monitoring camera that had been in the resident’s room until it was removed by the facility. A call log later produced by the facility showed several calls to and from the daughter but contained no record of the content or results of those calls. The resident concern log for the past year contained no entries regarding this resident, and the Administrator stated that the resident did not know what he was talking about during the SRI interview and that the daughter did not respond to his attempts to reach her, further underscoring the lack of documented, policy-compliant investigation and response to the reported allegations.
Failure to Complete Required Criminal Background Checks for Direct-Care Staff
Penalty
Summary
Facility staff failed to complete required Criminal Background Checks (CBCs) for three CNAs prior to their employment, contrary to Missouri DHSS requirements and the facility’s own policies. Record review showed that the Abuse, Neglect and Exploitation policy required screening potential employees for a history of abuse, neglect, exploitation, or misappropriation of resident property, with documentation maintained as proof of screening. The Background Screening Investigations policy further required that background and criminal conviction checks, including fingerprinting as required by state law, be initiated within two days of an employment offer and completed prior to employment for all applicants with direct access to residents. Review of personnel files revealed that CNA A, CNA B, and CNA C, each hired on different dates, had no documentation that a CBC was requested or received. During an interview, the administrator stated he/she was responsible for requesting CBCs on all potential staff prior to hire and explained that he/she typically verified whether applicants were registered with the Family Care Safety Registry (FCSR). If applicants were registered with the FCSR, the administrator did not request a CBC, and if they were not, he/she sent a request to the Missouri Association of Nursing Home Administrators (MANHA) for a background check. The administrator also stated that he/she had not requested a CBC from the Missouri State Highway Patrol (MSHP) since assuming responsibility for employee CBCs in April 2025.
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