A resident was subjected to verbal abuse when a staff member used abusive language while attempting to bring the resident inside from a smoking area. Witnesses reported that the staff member told the resident to come inside, sit down, and shut up, and the staff member later confirmed having a verbal exchange with the resident and telling the resident to shut up. The facility’s internal investigation verified that this interaction constituted verbal abuse.
Two roommates became involved in a verbal dispute over clothing placement that escalated into a physical altercation in which each punched the other, resulting in one resident sustaining facial swelling, a forehead laceration, and documented intracranial bleeding and eye injury. A GNA, alerted by calls for help while passing breakfast trays, found one resident bleeding from the forehead, removed the other resident from the room, and notified nursing staff. An RN Supervisor assessed the injured resident and obtained a history that the roommate had struck the resident in the face after an argument about clothes. Records showed that one of the residents had a prior history of aggressive behavior and a previous fight, and psychiatry notes described this as a second patient‑to‑patient altercation, confirming that the facility failed to protect residents from abuse.
A resident with dementia and PTSD, who had moderate cognitive impairment, was involved in an altercation with the facility Administrator during a smoking break. Witnesses, including staff and cognitively intact residents, reported that the Administrator blocked the door to prevent the resident from re-entering the building due to a cigarette, pushed the resident in the chest multiple times, and used a racial slur. The resident stated the Administrator was hitting them and calling racial slurs while they tried to return inside, leading the resident to choke the Administrator to get past her. These actions constituted physical and verbal abuse by the Administrator, in violation of the facility’s abuse policy and the resident’s right to be free from abuse, and were cited at an Immediate Jeopardy level under 42 CFR 483.12.
A resident urgently requested assistance to use the toilet, stating they had been asking for help for a long time and feared wetting themselves, but the assigned GNA told the resident to go ahead and wet the bed because they were serving breakfast trays and would clean the resident later, then left without providing the requested care. When another GNA later returned to collect breakfast trays, the resident again reported needing to use the bathroom and believed they had started to wet themselves. Other residents reported that the same GNA frequently delayed or failed to return to provide promised baths and incontinence care, stated they did not have time to change residents, expressed hating their job when asked for help, and made residents feel afraid to request assistance, including during painful bathing. The coworker GNA confirmed their account, and the facility’s investigation verified the allegation of verbal abuse and neglect.
A resident reported that an agency GNA provided rough and rude care while repositioning them in bed, including being roughly pulled by the neck and arm. During the facility’s investigation of the incident, two other residents also reported that the same agency GNA was rude and provided rough care. The NHA concluded that the agency GNA had abused the resident.
A cognitively impaired resident who depended on staff for most ADLs was being transferred with a mechanical lift when a GNA reported being hit by the resident and responded by cursing at and verbally degrading the resident, including making offensive remarks and threatening to withhold treats. Another staff member nearby overheard the GNA loudly say, “Don’t fucking hit me,” but did not report the incident because she believed the comment was directed at another staff member rather than the resident, resulting in unreported verbal abuse.
A resident alleged that no staff provided care during an overnight (11p–7a) shift, and the facility’s follow-up investigation confirmed that the assigned GNA did not enter the room to provide care. Review of GNA task documentation for that shift showed no entries for bathing, bed mobility, oral hygiene, toileting, barrier cream after incontinence care, bowel and urinary incontinence care, or use of foam ankle boots in bed as tolerated. The DON stated that all care, including refusals, must be documented and that blank spaces indicate a lack of support that care was completed.
A resident at the nursing station became upset about delayed laundry and began yelling and cursing at a GNA after being told the dryer was down. The resident then threw an iPad and a heavy metal snack tray toward the GNA and two LPNs seated at the nurses’ station. The GNA caught the tray and slammed it down on the desk, striking the resident’s hand, which was resting on the desk, and causing a broken fingernail. This incident reflects a failure to ensure the resident was free from abuse.
Staff failed to protect a cognitively intact resident from verbal abuse when a GNA, while assisting with care and responding to complaints about the facility, told the resident to "calm down and shut up." The incident was not reported at the time it occurred, and the GNA did not notify a nurse or supervisor about the resident’s concerns or the exchange. In subsequent interviews, the resident confirmed the statement and described another GNA in the room who witnessed it, while the involved GNA acknowledged making the remark and having prior abuse training, and the DON later characterized the situation as a cultural misunderstanding despite incomplete documentation of all witnesses in the investigation.
A resident who was alert and oriented reported that a nurse repeatedly entered the room despite the resident’s request to keep the door closed and to stop coming in. A GNA accompanied the resident back to the room and informed an LPN of the resident’s wishes, but the LPN stated he did not care and entered anyway to give meds to the roommate. The resident continued to ask the LPN to leave, the situation escalated into yelling, and both the resident and the LPN used expletive language. The LPN told the resident to hit him, stated the resident would not do anything, and threatened to beat the resident, which was witnessed and later confirmed as verbal abuse by supervisory staff and the administrator.
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