F0689

G

Failure to Address Aggressive Roommate Risk and Provide Adequate Supervision

Pensacola, Florida Survey Completed on 02-12-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure an environment free from accident hazards and to provide adequate supervision and precautions for a vulnerable resident when roomed with another resident who had a documented history of aggressive and violent behaviors. Resident #1 was a cognitively impaired, non-verbal, limited-mobility adult who sustained unwitnessed physical injuries on 01/30/2026, including lacerations that required transfer to a higher level of care, suturing, and diagnostic testing that revealed intracranial bleeding. Resident #6, who moved into Resident #1’s room on 12/23/2025, had a clinical record documenting aggressive and violent behaviors such as yelling and physically acting out toward other residents and staff. Despite this, Resident #1’s record contained no documentation of enhanced supervision or other specific precautions related to being roomed with Resident #6.

Staff interviews further described a pattern of concerning behavior by Resident #6 that was not fully assessed or incorporated into supervision plans for Resident #1. A hospice CNA reported witnessing Resident #6 verbally cursing at Resident #1 prior to the 01/30/2026 incident. Another CNA, who discovered Resident #1 with significant blood on the bed rail, in her mouth, and on the floor, recalled that Resident #6 had previously become upset when Resident #1 made noise, had threatened another resident who sat in her chair, was often verbally abusive to other residents, and was physically strong enough to move Resident #1, though she had not personally witnessed physical altercations between the two roommates. A RN reported she had requested a room change for Resident #1 after staff notified her of Resident #6’s violent behaviors and that she had multiple attempts to contact the Administrator about this request. The facility’s Risk Manager and Administrator stated that the initial belief was that Resident #1’s injuries were caused by contact with the bed rails and her own teeth, and the Administrator acknowledged that the investigation of the 01/30/2026 incident did not include Resident #6 as a possible source of the injuries, despite Resident #6’s documented aggressive history and the later acknowledgment that the puncture wounds on the outside of Resident #1’s cheek could not have been caused by her teeth.