The resident, identified as R59, has cerebral palsy, autism, epilepsy and severe cognitive impairment with a mental status score of zero. According to inspection records, another nursing assistant reported in January that she had been told "another CNA was involved with a male resident in a sexual way."
The facility's own policy, revised in September 2022, requires that "all allegations are thoroughly investigated" with the administrator initiating investigations and obtaining written, signed and dated witness statements.
Instead, the Director of Nursing sent the accused nursing assistant home for the rest of the day and moved the reporting staff member to a different hall "because it was all rumors," she told inspectors.
The investigation that followed violated multiple facility policies. Of 20 staff interviews collected, nine lacked either a name or date. The Director of Nursing told inspectors she completed a skin assessment of the resident, but later admitted she had not actually performed the examination despite documenting it in nursing notes.
The Director of Nursing also claimed she notified the medical director by fax, but could not locate the fax log when inspectors asked to see it. She told inspectors she "thought she called the MD but was not sure what method she used to contact the MD."
Local police were never contacted about the allegations.
The accused nursing assistant, CNA MM, told inspectors she learned about the accusations from two different coworkers who said another staff member was "stating bad things about her regarding R59." She wrote a statement to the Director of Nursing requesting that the "accusing CNA stop disseminating vicious and false rumors about her in the facility regarding unusual relationship with resident R59."
CNA MM was suspended for one day with pay pending investigation, according to the Human Resource Director. But the Human Resource Director told inspectors she "did not participate in investigations" and confirmed "nothing was in employee files at the moment."
The facility's incident report, dated January 9, 2025, stated that a supervisor "received a note under my door from a Certified Nursing Assistant stating that she was told that another CNA was involved with a male resident in a sexual way."
A nurse's note from the same date, written by the Director of Nursing, documented that "it was reported to the DON a CNA may have been sexually inappropriate with this resident." The note stated that the administrator, ombudsman, medical director and resident's representative were all notified, and that a report was submitted to the state.
The note also claimed "a skin assessment was completed by the DON and male CNA" with "no rashes or other skin issues noted - genitalia (within normal limits) WNL." But the Director of Nursing later admitted to inspectors that she had not actually performed this assessment.
During questioning, the Director of Nursing told inspectors she "did not observe any injuries and thought the concerns were not true and just rumors."
The current administrator, who was not in charge when the incident occurred, told inspectors he expects staff to report abuse immediately. For severe cases of "abuse, neglect, or exploitation," he said his reporting expectation is one hour, with all other cases requiring reporting within two hours.
The administrator revealed that the previous administrator "was not having staff to contact law enforcement and has since had to do inservice with DON."
Federal regulations require nursing homes to immediately report allegations of abuse to the administrator and notify appropriate officials, including local law enforcement when warranted. Facilities must also ensure thorough investigations are completed with proper documentation.
The accused nursing assistant remained employed at the facility during the inspection, according to records. The Human Resource Director confirmed no disciplinary action had been documented in the employee's file as of the February inspection date.
The resident at the center of the allegations requires total care due to multiple disabilities. His Quarterly Minimum Data Set assessment revealed severe cognitive impairment and behavioral symptoms, making him particularly vulnerable to exploitation.
Hill Haven Nursing Home, located on Ridgeway Road in Commerce, received a citation for failing to respond appropriately to alleged violations. Inspectors classified the violation as causing minimal harm or potential for actual harm to residents.
The facility's investigation failures occurred despite having a written policy specifically addressing abuse, neglect and exploitation reporting and investigating procedures. The policy clearly states that witness statements must be obtained in writing, signed and dated, with either the witness writing the statement or the investigator obtaining one.
Nine of the 20 staff interviews collected during the facility's investigation lacked proper identification or dates, violating the facility's own documented procedures.
The case highlights ongoing challenges in nursing home oversight and protection of vulnerable residents. Residents with severe cognitive impairments like R59 are often unable to report abuse themselves, making them dependent on staff observations and proper investigation protocols when concerns arise.
The Director of Nursing's admission that she documented a skin assessment she never performed raises additional questions about the accuracy of other medical records and documentation practices at the facility.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Hill Haven Nursing Home from 2025-02-20 including all violations, facility responses, and corrective action plans.