F0689

J

Failure to Supervise Aggressive Wanderer Leading to Repeated Resident Distress and Assaults

Baltimore, Maryland Survey Completed on 02-24-2026

Penalty

Fine: $55,890

Summary

The deficiency involves the facility’s failure to provide adequate supervision and prevent accident hazards related to a resident with dementia, wandering, and aggressive behaviors. Resident #10 had documented diagnoses of unspecified dementia with agitation and vascular dementia with behavioral disturbances, including wandering, physical aggression, noncompliance with treatment, irritability, and poor insight. Psychiatric evaluations in December and January documented ongoing confusion, disorientation, unpredictable agitation, noncompliance with rules about staying out of other residents’ rooms, disorganized speech, and poor insight, yet no new interventions were recommended beyond continued monitoring. Despite multiple resident complaints about ongoing room entries and inappropriate behaviors since an assault on 12/6/25, there were no documented changes in the plan of care or additional interventions implemented after 12/10/25.

On 2/18/26, GNA staff #2 reported being struck in the face by Resident #10 while cleaning the resident’s room after a messy bowel movement. She stated that the resident had been notably agitated when brought back and left in the room by the DON, and that while she was focused on cleaning, Resident #10 got up, was agitated, and she ended up with a black eye. GNA #2 indicated that similar incidents with Resident #10 occurred about once a month and reported that the resident had punched Resident #5 in December. However, a change in condition note entered by the DON documented that the black eye occurred when the GNA attempted to catch the resident from falling, which did not match GNA #2’s account of being hit. The DON stated that staff were familiar with the resident and redirected him/her as needed, and that referrals had been sent out, but did not identify additional specific interventions in response to the repeated incidents and grievances involving other residents.

Multiple cognitively intact residents on the same floor reported ongoing fear and distress due to Resident #10’s behaviors and repeated entry into their rooms. Resident #5, with a BIMS score of 15 and wheelchair dependence, reported that on 12/6/25 Resident #10 entered the room, grabbed both hands, then punched the resident in the face about five times, leading to police being called and a brief two-day one-to-one. Resident #5 stated that in the week of 2/9/26 the same resident continued to walk in and out of the room, causing fear and difficulty sleeping, and reported never being offered another room or having a STOP sign banner placed; a surveyor confirmed on 2/19/26 that no STOP banner was in use. Resident #8, also cognitively intact with depression, anxiety, and wheelchair use, reported that Resident #10 frequently entered the room despite a STOP banner, grabbed items, and on one occasion went to the roommate’s side of the bed, pulled pants down, and was about to pull down a pull-up, prompting both roommates to yell and one to hit Resident #10 with a grabber. Resident #7, with a BIMS of 15 and reliance on a power wheelchair, reported that Resident #10 entered the room when the roommate was absent, causing stress and fear due to limited ability to defend against an intruder, and stated that staff had been repeatedly informed of these concerns.

Resident #1, bedbound and cognitively intact with a BIMS score of 15, reported that Resident #10 would come into the room at night, pull pants off, and stand at the bedside, and expressed fear of being hit, noting that the resident had already hit a friend and staff. During a surveyor observation on 2/19/26, Resident #10 was seen walking up and down the hallway, stopping at each doorway while residents inside their rooms, many eating, yelled for the resident to stay out or leave. Staff were present at the nurses’ station or walking around the unit, but no staff intervened to redirect Resident #10 during this observation. The Maryland Office of Health Care Quality determined that these concerns met the federal definition of Immediate Jeopardy related to lack of supervision, with a resident inappropriately wandering into multiple rooms and verbally or physically assaulting residents, and noted there were no documented interventions in place after 12/10/25 to address these ongoing behaviors.

The facility’s initial and revised plans of removal were submitted and reviewed on 2/19/26, and the Immediate Jeopardy was not removed until 2/24/26 after verification that the accepted plan of correction had been implemented.

Removal Plan

• Have the identified resident evaluated by the medical director
• Prescribe antianxiety medication for the identified resident
• Place the identified resident on a 1:1 assignment until further notice
• Assess the residents with the identified concerns by the social worker
• Hold an ad hoc quality assurance meeting with the interdisciplinary team
• Complete education with facility staff on the Dementia protocol and Unmanageable Residents