State inspectors found the facility's investigation of three separate incidents involving residents was incomplete, putting residents at risk of continued abuse and harm. In each case, staff failed to interview witnesses who could have provided crucial details about what actually happened.
A nursing assistant kissed Resident 110 and tried to climb into their bed on December 24, 2024, according to the facility's own investigation that substantiated the allegation. Staff fired the CNA immediately. But their investigation stopped there.
Records show the dismissed employee had worked on seven of the facility's nine units between October and December. Management never interviewed other potential victims or witnesses on those units. Staff never checked if the CNA had harmed other residents during those two months of access throughout the building.
"Residents on the six other units should have been, but were not, interviewed to determine if they were witness to, or negatively impacted by Staff I's conduct," Administrator Staff A told inspectors. Staff A admitted the background check, unit assignments, and resident interviews should have been included in the investigation.
When inspectors interviewed Resident 110 on January 2, the resident immediately brought up the Christmas Eve incident without being asked. Resident 110 stated the caregiver kissed them and tried to climb into their bed. Records confirm the allegation was reported and the incident took place on December 24.
Staff T, an interim unit manager from a sister facility, completed the investigation. Director of Nursing Staff B signed off on it. But the investigation included only a phone interview with the accused CNA and a statement from the Social Services Director.
No other staff members were interviewed as potential witnesses. No residents were questioned except for five on Resident 110's unit, and two of those couldn't be interviewed due to advanced dementia.
Another incident the same day revealed similar investigation gaps. Resident 95 slipped on spilled liquid when trying to help Resident 124, who had a hot beverage thrown at them by another resident in the dining room. Resident 95 hit their head on a table edge during the fall.
Facility records classified this as a simple fall. Progress notes stated Resident 95 "tripped on themselves and bumped their head." But both residents told inspectors a different story about what really happened.
"I slipped on the spilled beverage," Resident 95 explained to inspectors, expressing frustration that the facility's wrong characterization could hurt their independence. Resident 124 confirmed the account, stating another resident threw hot liquid at them after they sat in that resident's favorite chair.
Staff U, the nurse on duty, witnessed the incident according to both residents. Yet the investigation never included any witness interviews from staff or other residents who were in the dining room at 4:30 PM on Christmas Eve.
Director of Nursing Staff B told inspectors witness interviews "would be helpful to determine what happened." Staff B acknowledged being ultimately responsible for making sure investigations were thorough.
A third incident on January 2 involved Resident 124 backing their wheelchair into another resident who cursed at them loudly. Staff investigated this one too, but again missed potential witnesses.
Four staff members worked on that investigation: the administrator, director of nursing, director of clinical operations, and the interim unit manager. None signed off on it as complete. No staff or residents in the dining room area were interviewed about what they saw or heard.
Staff B interviewed the nurse on duty by phone. Another nurse interviewed the resident who cursed, though that nurse wasn't present during the incident. Social Services Director Staff D interviewed Resident 124, who gave conflicting details about whether staff patted their head or shoulder for comfort.
Investigators ruled out abuse because the incident was witnessed and Resident 124 gave different versions. But they never talked to the actual witnesses to find out what really happened.
Administrator Staff A admitted to inspectors that witness statements from other staff and residents "should have included" in all three investigations.
Facility policy requires thorough investigations of suspected abuse allegations, including interviews with witnesses and documentation of event details. Policy states investigations must document details of occurrences in all affected residents' records, including immediate interventions taken.
None of the three investigations met those standards. Key witnesses went uninterviewed. Potential victims on multiple units were never contacted. Background checks weren't completed properly or included in findings.
Providence Mount St Vincent houses residents with various cognitive abilities and physical limitations. Resident 110 had intact memory and required help transferring from chairs to bed due to a fractured hip. Resident 95 had intact memory but impaired vision and used mobility aids. Resident 124 had moderate memory impairment but adequate speech and vision.
All three residents were able to provide detailed accounts of their experiences to state inspectors. Their stories revealed investigation failures that could have left other residents vulnerable to unreported incidents or ongoing problems.
State inspectors classified the violation as having minimal harm or potential for actual harm, affecting some residents. But the failure to thoroughly investigate placed residents at risk of continued verbal and mental abuse, psychosocial harm, and diminished quality of life.
Inspectors completed their review on January 10, 2025, finding the facility failed to meet federal requirements for responding appropriately to alleged violations involving resident safety and welfare.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Providence Mount St Vincent from 2025-01-10 including all violations, facility responses, and corrective action plans.