F0689

K

Failure to Adequately Supervise Aggressive and High Fall-Risk Residents

Front Royal, Virginia Survey Completed on 01-12-2026

Penalty

Fine: $34,230

Summary

The deficiency involves the facility’s failure to ensure an environment free from accident hazards and to provide adequate supervision and care to prevent accidents for residents with known behavioral and fall risks. One resident with non-Alzheimer’s dementia, depression, severe cognitive impairment, and a long history of physical aggression toward others repeatedly assaulted other cognitively impaired residents on the memory care unit. Despite documented episodes of hitting, grabbing, throwing objects, wandering into other residents’ rooms, and striking residents with fists and objects, the resident continued to wander and interact with others on the unit without consistently implemented, sustained close supervision. Facility documentation showed multiple resident-to-resident altercations over many months, including incidents where the resident struck others in the face and head, sometimes causing visible injuries such as redness to an eye and bruising on the bridge of the nose.

Clinical records, change-in-condition notes, and psychiatry progress notes described this resident as having recurrent, sometimes unprovoked, violent outbursts triggered by perceived threats to possessions, food, or personal space, and as being unpredictable and increasingly aggressive toward both staff and residents. Staff statements indicated that the resident could ambulate independently but required someone to walk with them due to fall risk, and that the resident had a history of hitting other residents. However, supervision practices on the memory care unit were described as having staff stationed in the common area and CNAs rounding on rooms every couple of hours, rather than continuous or 1:1 supervision for this resident despite the pattern of aggression. Nursing staff acknowledged that repeated resident-to-resident assaults constituted abuse and that repeated incidents indicated residents were not being adequately supervised.

A second deficiency involved another resident with dementia, severe cognitive impairment, poor standing balance, and high fall risk who sustained a fall with serious injury. This resident’s MDS, therapy evaluations, and fall risk assessments documented substantial to maximal assistance needs for sit-to-stand and transfers, poor standing balance, impulsivity when standing, and a fall risk score above the facility’s threshold for being at risk. The resident’s care plan included an intervention instructing staff not to leave the resident alone in the room. On the night of the incident, a CNA assisted the resident onto the toilet in the resident’s bathroom, then left the resident alone on the toilet with the bathroom door closed while physically redirecting the roommate to another bathroom. When the CNA returned after this brief absence, the resident was found on the bathroom floor complaining of right hip and elbow pain, with contusions noted to the right elbow and side of the head. Hospital evaluation confirmed a right hip fracture and intracranial hemorrhage. This sequence of events demonstrates that the resident was left unsupervised during a high-risk toileting transfer despite known fall risk and documented need for close assistance, resulting in a fall and serious injury.

Removal Plan

• Place Resident #99 on 1 on 1 supervision until the resident is discharged or a significant change in condition limits the resident's physical ability to come in contact with another resident.
• Conduct an audit of Point of Care behavior documentation to ensure that residents identified with aggressive behaviors have interventions and care plans in place to provide adequate supervision.
• Reeducate all staff of the facility/agency on the HVHC Safety and Supervision of Residents Policy.
• Require all staff to complete mandatory education prior to the start of their next shift.
• Do not allow any staff member to return to work until the mandatory education has been completed.
• Include this training in new hire orientation as part of the new hire process.
• Require all agency staff to complete this education prior to starting work in the facility.