Failure to Provide Ordered 1:1 Observation for Resident with Dementia
Summary
A resident with diagnoses of dementia, anxiety, and psychosis was admitted to the facility and exhibited severe cognitive impairment, as indicated by a BIMS score of 3. The resident displayed behavioral symptoms that interfered with activities, intruded on the privacy of others, and disrupted the living environment, including hypersexual behaviors and significant wandering. Due to these behaviors, a physician's order was in place for 1:1 observation every shift, and the care plan included this intervention to address the resident's needs. Despite the physician's order and care plan, the facility failed to provide 1:1 observation for the resident during the night shifts from 6:00 p.m. to 6:00 a.m. on multiple occasions. Staff interviews confirmed that the required 1:1 observation was not consistently implemented during these hours. This lapse in following the ordered intervention resulted in the resident not receiving the appropriate treatment and services necessary to attain or maintain their highest practicable physical, mental, and psychosocial well-being.
Penalty
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Failure to maintain dignity for a resident with severe cognitive impairment and dementia. The resident had a history of wandering into other residents’ rooms and exposing himself in common areas, including an incident where he exposed himself to a female resident in the dining room and asked if she wanted to touch him. Staff were unaware of any new assessment or ongoing behavior interventions, and observations showed the resident in the dining room, day room, courtyard, and near the entrance without staff present.
A resident with severe cognitive impairment, dementia, and ongoing mouth pain repeatedly hollered loudly for long periods in common areas and during meals, despite multiple interventions such as pain meds, ice, an oral soothing device, essential oils, repositioning, and staff reassurance. Staff described the behavior as the resident’s norm and did not consistently assess the underlying cause or incorporate the observed effective interventions into an individualized approach. Another resident with PTSD and loud-noise triggers was repeatedly distressed by the noise, yelled shut up from behind a closed door, and complained that the hollering was nonstop, day and night, but staff did not consistently intervene or redirect either resident.
A resident with advanced dementia was admitted after a hip fracture hospitalization that documented confusion, agitation, impulsivity, device removal attempts, and elopement risk, but the facility’s admission assessment did not identify fall or elopement risk and the care plan had no resident-specific dementia interventions. Soon after admission, the resident was confused, refused care, wandered, became physically aggressive, punched staff, and required 1:1 monitoring, yet continued to exit through an unsecured therapy door and fell outside. The DON stated the admission assessment was inaccurate and should have reflected the hospital-recorded behaviors and need for a resident-specific dementia care plan.
Failure to manage dementia-related aggression and roommate conflict: A resident with dementia, depression, mood disorder, anxiety, and a history of physical aggression was identified as possessive over belongings and intolerant of others in his space, yet he continued to be roomed with another cognitively impaired resident. After a documented verbal threat that was not escalated to the Abuse Coordinator, the resident struck his roommate in the eye during a dispute over the shared bathroom, causing bruising and discoloration. The roommate’s care plan also identified risk for injury from others in the secure unit, but the residents remained together despite repeated conflict.
Failure to protect a cognitively impaired resident from potential abuse. The resident had dementia, Pick's disease, mild ID, and schizoaffective disorder, with assessments showing moderate cognitive impairment and high abuse risk. Staff reported the resident had a mark on her neck after being seen kissing and hugging a male resident, and multiple staff noted she wandered the facility, sought attention from male residents, and needed redirection. The care plan had no interventions for wandering into other residents' rooms or seeking attention from male peers.
A resident with severe cognitive impairment and dementia was given incontinent care in a way that did not account for her condition or resistance. CNA A began by cranking the bed up without explaining what was happening, which startled the resident, and staff continued care while she repeatedly said stop, grabbed at staff, and kicked. RN C tried to calm her, but the care continued despite the resident’s ongoing distress and refusal.
Failure to Maintain Dignity for Resident with Dementia and Exposure Behaviors
Penalty
Summary
The facility failed to provide appropriate services to ensure a resident with severe cognitive impairment and dementia maintained his highest practicable psychosocial well-being, specifically dignity. The resident’s quarterly MDS showed severely impaired cognition, wheelchair use, partial assistance with toileting, dressing, and personal hygiene, and diagnoses including hypertension, obstructive uropathy, and dementia. His care plan noted altered mood and behavior related to UTI, malnutrition, and sepsis, and also documented a history of attempting to masturbate in common areas with the potential of exposing himself to others. The resident had a documented history of entering other residents’ rooms and exposing himself. A progress note from 11/2025 stated social services followed up with the resident’s daughter regarding these behaviors and recommended memory care, which the daughter agreed to at that time. On 7/28/26, the resident propelled his wheelchair up to a female resident in the dining room, exposed himself, and asked if she wanted to touch him; the female resident said no and reported the incident to staff. The facility’s investigation documented that the resident’s BIMS score was 4, indicating severe cognitive impairment, and that hourly checks were completed for 48 hours, with no patterns identified. Despite the resident’s known behaviors and the interventions listed in the care plan, staff interviews showed they were not aware of any new assessment, care plan changes, or ongoing interventions after the exposure incident. Multiple observations showed the resident seated in the dining room, day room, courtyard, and near the main entrance without staff present, including one instance where he went outside into a courtyard independently. Staff stated they were supposed to monitor him and chart behaviors, but he was not always in sight of staff, and several staff members were unsure what supervision or behavior interventions were currently required. The administrator stated no comprehensive investigation was done because the incident was not reportable and was unsure what was being done to maintain the resident’s dignity.
Failure to Individualize and Evaluate Dementia-Related Distress
Penalty
Summary
The facility failed to consistently implement and evaluate individualized interventions for a resident with severe cognitive impairment, Alzheimer’s disease, dementia, delusional disorder, and depression who had persistent yelling and other expressions of distress. The resident’s care plan identified behaviors of yelling out, grabbing at staff, and swearing, with interventions to approach calmly, divert attention, remove the resident to another location as needed, monitor behavior episodes, and leave the resident in a safe space and return later for care when verbal or physical behaviors occurred. The resident also had documented pain concerns, including facial expressions indicating possible pain and scheduled pain medications with non-medication interventions. During observation, the resident was repeatedly heard hollering loudly for prolonged periods in common areas and the dining room, including while seated in front of the TV and during meals. Staff acknowledged the resident was having mouth pain and that they were trying to figure out what to do, and the resident had already received pain medication. The resident continued hollering despite being given an oral soothing device, ice, an ice pack, essential oils, a nutritional shake, and repositioning. Staff repeatedly described the hollering as the resident’s norm and stated the resident hollered every day, all day, but the resident remained in shared spaces where the noise continued for extended periods. A second resident with a history of PTSD and loud-noise triggers was affected by the ongoing hollering. That resident’s trauma-informed care plan identified loud noises as a trigger and noted a preference for a private room and use of a TV or white noise machine to block neighboring sounds. During the observations, the second resident was heard yelling shut up from behind a closed door while the first resident continued hollering nearby, and the second resident stated the noise was nonstop, day and night, and asked why the first resident could not be moved somewhere else. Staff did not consistently approach either resident or redirect the situation, and the facility did not complete an assessment of the first resident’s persistent hollering to determine the underlying cause or contributing factors, including whether it was related to pain, dementia-related distress, fear of being alone, environmental factors, or a combination of factors.
Failure to Assess Dementia Behaviors and Create a Person-Centered Care Plan
Penalty
Summary
The facility failed to provide appropriate treatment and services to a resident with advanced dementia by not completing an accurate assessment or developing a resident-specific, person-centered care plan based on the resident’s behavioral needs. The resident was admitted after a fall at home and hospitalization for surgical repair of a hip fracture. The hospital discharge summary documented persistent confusion, episodes of agitation, restlessness, impulsivity, attempts to remove medical devices, and elopement risk, and noted the resident required three medications to manage behavior while hospitalized. On admission to the facility, the resident was alert but oriented only to name, required extensive assistance with all bed mobility, transfers, dressing, toileting, and personal hygiene, used a wheelchair for mobility, had difficulty sleeping, and was not prescribed medication for mood or behavior. The admission assessment did not identify the resident as being at risk for falls or elopement, and the admission care plan contained no resident-specific interventions to guide staff in responding to behaviors related to advanced dementia. Within the first 48 hours, the resident was documented as confused, refusing care, removing clothes, hitting staff, wandering in the wheelchair, and not being redirectable. Staff called the on-call provider and later obtained an order for medication for anxiety. Additional notes documented aggressive behavior toward therapy staff, punching a staff member in the face, repeated wandering into other residents’ rooms, attempts to get up from the wheelchair, and the need for one-to-one monitoring. The resident continued to display wandering and unsafe behaviors, and a roommate complained about the resident’s behavior, prompting a room change. The incident investigation showed the resident exited the facility through the therapy door without staff knowledge or supervision, stood from the wheelchair, walked outside, and fell to the ground. Staff documented that the resident had been restless, agitated, physically aggressive, wandering inside, and trying to leave the facility since admission. The DON later stated the admission nursing assessment was not accurate compared with the hospital records, that the admission nurse should have reviewed the hospital records, identified the dementia behaviors, implemented interventions to prevent falls and elopement, and created a resident-specific dementia care plan.
Failure to manage dementia-related aggression and roommate conflict
Penalty
Summary
The facility failed to ensure residents with dementia received appropriate treatment and services to maintain their highest practicable well-being for two residents reviewed for dementia care. Resident #2 had diagnoses including dementia, depression, mood disorder, and anxiety disorder, and his care plan identified a potential for physical aggression related to dementia and poor impulse control, with triggers noted as others using or touching his personal belongings. The record also showed prior incidents in which Resident #2 was physically aggressive toward other residents and staff, including hitting a resident in the mouth and striking another resident while seated near him. Despite this history, Resident #2 continued to be placed with roommates. After a prior incident in which he threatened to beat up Resident #3, the two residents remained in the same room arrangement until the later altercation. On the day of the incident, Resident #2 pushed and hit Resident #3 in the left eye after becoming upset about the shared bathroom. The incident documentation stated that Resident #2 was possessive over his items and that the altercation occurred in the bedroom doorway, with Resident #2 having his fists ready to hit Resident #3. Resident #3 was described as confused, wandering, and having behaviors including urinating on the floor. Resident #3’s record showed diagnoses including schizoaffective disorder, dementia, delusional disorder, anxiety disorder, and cognitive communication deficit. His care plan identified that he was at risk for injury from others while residing in the secure unit and included interventions to anticipate behaviors, redirect him, and monitor for behavioral episodes and underlying causes. Following the altercation, Resident #3 developed bruising and blackened discoloration below the left eye. Staff interviews and record review showed that the verbal threat made by Resident #2 before the assault was documented in the clinical record but was not reported to the Administrator, who served as the facility’s Abuse Coordinator, because the charge nurse believed it was verbal only.
Failure to Protect Cognitively Impaired Resident From Potential Abuse
Penalty
Summary
The facility failed to have interventions in place to protect a cognitively impaired resident from potential abuse. The resident had diagnoses including dementia, Pick's disease, mild intellectual disability, and schizoaffective disorder bipolar type, and the facility assessment described moderate cognitive impairment with moderate assistance needed for activities of daily living. The social services assessment identified trauma factors such as dementia, poor insight, and poor communication skills, and the abuse/neglect screening dated 5/2/26 showed the resident was at high risk for abuse. A nursing progress note documented that the resident had a mark to her neck after an incident involving a male resident. Staff reported that the resident and the male resident were seen kissing and hugging in a dark activity room, and the resident then followed him toward his room. Multiple staff members stated the resident wandered the facility, sought attention from male residents, and needed redirection, while the physician described it as a gray area whether she could consent and said she should be closely monitored. The care plan contained no interventions for wandering into other residents' rooms or seeking attention from male peers, and an updated intervention added after the incident stated the resident was capable of consenting to a friendship with a male resident.
Incontinent Care Provided Without Appropriate Dementia Communication or Response to Resistance
Penalty
Summary
The facility failed to ensure a resident with dementia received appropriate treatment and services to maintain her highest practicable well-being when staff provided incontinent care in a manner that did not account for her cognitive impairment, resistance to care, and behavioral symptoms. The resident had diagnoses including dementia, anxiety disorder, schizoaffective disorder, bipolar type, major depressive disorder, and hypertension. Her quarterly MDS indicated severe cognitive impairment with a BIMS of 3, fluctuating inattention and disorganized thinking, frequent bladder incontinence, occasional bowel incontinence, and a need for substantial to maximal assistance with toileting hygiene. During the incontinent care episode, CNA A entered the room and began raising the bed by manually cranking it without verbal communication to the resident. The bed and resident were observed shaking significantly as the bed was raised. NA B then assisted with care. The resident repeatedly stated that staff were not going to take off her brief, crossed her legs, tried to grab the brief, and verbally resisted the care. As staff continued, she hollered, grabbed at staff, kicked, and cried out for her mother and father. RN C entered during the care and attempted to calm the resident, but the care continued while the resident remained agitated and resistant. The resident’s care plan identified dementia-related impaired cognition, physical behaviors toward others, and refusal of care, with interventions focused on simple structured activities, consistent routines, consistent caregivers, and giving choices and autonomy. The facility’s dementia policy stated that behavior may reflect unmet needs or discomfort and that individualized approaches and staff communication are important. Interviews with RN C, NA B, the ADON, and the ADM confirmed that staff should stop care when a resident is resistant or refusing care and return later, and that the resident should have been told what was happening before the bed was cranked up. The ADM stated the care was not how he would have wanted to be cared for and that the staff should have given the resident time to wake up and should have stopped when she became resistant.
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