F0600

D

Failure to Monitor and Manage Resident Behaviors Resulting in Resident-to-Resident Slap

Warsaw, Kentucky Survey Completed on 01-29-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to sufficiently monitor and manage resident behaviors that could provoke or result in resident-to-resident altercations, specifically cursing and physical slapping, for two residents. One resident, R118, had a medical history including Parkinson’s disease, schizoaffective disorder bipolar type, anxiety disorder, and borderline intellectual functioning, and was assessed with intact cognition and no documented behaviors on a recent MDS. However, the care plan identified significantly complex behavioral symptoms and noted that staff should firmly redirect the resident when demanding or aggressive behaviors occurred and redirect behaviors due to unawareness of social norms. Another resident, R78, had diagnoses including unspecified dementia with behavioral disturbances, unspecified mood disorder, and depression, and was assessed with moderate cognitive impairment. R78’s care plan noted the resident could be unpleasant and flat related to placement, with interventions for staff to report declines and behaviors to social services.

The incident occurred in the dining room when R118 approached R78 to ask if anyone was in the kitchen because she wanted a drink. According to the residents’ statements, R78 did not respond to repeated questions, which upset R118, who then called R78 an expletive. Both residents reported that, in response, R78 slapped R118 in the face with an open hand. There were no staff witnesses to the interaction leading up to the slap, and the activities assistant present in the dining room only heard R118 yell out and then learned from both residents that a slap had occurred. The social services director and LPN staff later obtained consistent statements from both residents that the slap followed the verbal insult.

Interviews with staff, including the LPN who led the investigation, the activities assistant, the social services director, the DON, and the administrator, confirmed that staff were not aware of any prior provocation history between the two residents and that no staff member directly observed the altercation. The facility’s own documentation and interviews established that R118 had known behavioral issues requiring redirection and unawareness of social norms, and that R78 had dementia with behavioral disturbances and could be unpleasant, yet the interaction between them in the dining room was not monitored closely enough to prevent or promptly intervene in the escalating exchange. The lack of staff presence and direct supervision at the time of the verbal and physical interaction, despite both residents’ identified behavioral risks, led to a resident-to-resident physical contact incident that constituted the abuse-related deficiency.