NANTICOKE, PA - Federal inspectors cited Lakewood Rehabilitation & Healthcare Center for failing to properly report multiple instances of verbal and mental abuse perpetrated by a resident with severe dementia against other residents and staff members.
Pattern of Unreported Abuse Incidents
The July 2024 inspection revealed that facility administrators failed to notify state authorities about a series of escalating incidents involving a male resident with Alzheimer's disease who repeatedly targeted female residents and staff with sexually inappropriate comments, racial slurs, and threatening behavior.
The resident, identified as having a Brief Interview for Mental Status score of 2 indicating severe cognitive impairment, engaged in a pattern of abusive behavior that began in early June 2024. Documentation shows the resident made sexually inappropriate comments to staff on June 8, with the behavior continuing and escalating over the following weeks.
On June 19, nursing staff documented that the resident made "inappropriate sexual comments, as well as derogatory comments regarding a nurse aide's ethnicity" while being assisted with showering. The facility responded by prescribing anti-anxiety medication, but the behavioral interventions proved insufficient.
Escalation to Physical Threats
The situation reached a critical point on July 3, 2024, when the resident threatened another vulnerable resident, stating "Wait till I get you alone later. The things I'm going to do to you." The female resident who was targeted became fearful and began crying, prompting staff to call police for intervention.
Later that same evening, the resident continued his threatening behavior, telling the same female resident "I'm looking forward to seeing you later when no-one is around" while winking at her. The targeted resident, who had moderate cognitive impairment herself, "began to cry, shake and tremble" according to nursing documentation.
Police and emergency medical services were called to remove the resident from the facility temporarily. However, he returned the following day, and the abusive behavior continued.
Medical Consequences of Psychological Abuse
Verbal and mental abuse in nursing home settings can have severe psychological and physical consequences for elderly residents, particularly those with cognitive impairments. When residents experience fear, humiliation, and intimidation, their stress response can trigger a cascade of health problems including elevated blood pressure, disrupted sleep patterns, and accelerated cognitive decline.
The targeted female resident's documented physical response - crying, shaking, and trembling - indicates acute psychological distress that can worsen existing medical conditions. Chronic stress from ongoing abuse can suppress immune function, making elderly residents more susceptible to infections and slower to heal from injuries.
Facility's Response Inadequate
Despite prescribing additional medications including Depakote for behavioral control, the facility's interventions failed to protect other residents. On July 7, nursing staff documented that the resident continued inappropriate sexual behaviors, telling a female resident "the things I would do to you" and later stating to staff "You can't tell me not to touch her" when attempting to reach for another resident's arm.
The facility eventually implemented one-on-one supervision after the resident was hospitalized for behavioral evaluation, but this occurred only after weeks of documented incidents affecting multiple residents and staff members.
Regulatory Violations and Reporting Requirements
Federal nursing home regulations require facilities to immediately report suspected abuse, neglect, or exploitation to the State Survey Agency and local Area Agency on Aging. The facility's abuse prohibition policy, reviewed in May 2024, clearly defined verbal abuse as "any use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents."
According to federal guidelines, mental and verbal abuse includes conduct that causes residents to experience "humiliation, intimidation, fear, shame, agitation, or degradation." The documented incidents clearly met these criteria, yet facility administrators acknowledged during the inspection that they had not filed required reports with state authorities.
Impact on Vulnerable Population
The incidents particularly affected residents with cognitive impairments who were unable to effectively advocate for themselves or remove themselves from threatening situations. The targeted female resident was documented to have moderate cognitive impairment, making her especially vulnerable to psychological harm from the ongoing abuse.
Multiple unnamed female residents complained to staff that the abusive resident "will not leave them alone" and that they disliked his conversation. Staff documented residents shouting at the abusive resident, with one telling him "You're a pain in the a*s you know that. You just won't shut up."
Standard of Care Requirements
Nursing homes are required to maintain environments free from abuse, neglect, and exploitation. When residents exhibit behaviors that threaten others, facilities must implement immediate protective measures while developing comprehensive behavioral intervention plans.
Proper protocols should include immediate separation of the aggressor from potential victims, psychiatric evaluation, medication adjustments when appropriate, structured supervision, and therapeutic interventions. Most importantly, facilities must report incidents to protect residents and allow proper investigation.
Ongoing Safety Concerns
The inspection revealed that even after implementing various interventions, the resident continued making derogatory comments about other residents' appearances and attempting to enter other residents' rooms without permission. When staff redirected him, he became "aggressive" and "defensive."
The facility's failure to report these incidents prevented external oversight and support that could have helped develop more effective interventions to protect vulnerable residents while ensuring appropriate care for the resident exhibiting problematic behaviors.
The inspection findings highlight the critical importance of proper incident reporting in maintaining resident safety and ensuring accountability in nursing home care. Federal regulators continue to monitor the facility's corrective actions to prevent similar failures in protecting vulnerable residents from abuse.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Guardian Healthcare and Rehabilitation Center from 2024-07-21 including all violations, facility responses, and corrective action plans.
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