Failure to Provide Adequate Behavioral Health Services and Supervision for Residents With Dementia and Sexual Behaviors
Summary
The deficiency involves the facility’s failure to ensure that residents with dementia and known histories of sexually inappropriate behaviors received adequate and effective behavioral health services, individualized interventions, monitoring, and supervision. One resident with moderately impaired cognition and a long history of sexually inappropriate behaviors had multiple documented incidents over several months, including oral sex with another resident, encouraging a male resident to rub her legs, kissing a male resident in her room, being observed with a male resident’s hands in her pants, repeatedly entering male residents’ rooms, and speaking in explicit sexual detail to her roommate. Her guardian repeatedly expressed concerns and requested increased safety measures, including a transfer to an all-female facility. The resident’s care plan included intermittent periods of one-to-one observation and every 15‑minute checks, but these heightened monitoring interventions were repeatedly started and then resolved, and the 15‑minute checks were discontinued in October without documented rationale or authorization from the psychiatric provider. Another resident with severely impaired cognition and dementia also had a documented history of sexually inappropriate behaviors. His care plan identified sexually inappropriate behavior after an encounter with another resident and included interventions such as behavioral health services, medication management, and one-to-one observation if sexually inappropriate behavior occurred. He was prescribed cimetidine (Tagamet) off-label to reduce sexual desire. Nursing notes documented multiple episodes of him touching himself inappropriately in common areas and being redirected to his room, as well as reports from his sister about sexually inappropriate behaviors at his offsite day program and concerns about the effectiveness of his medication. Despite these ongoing behaviors and concerns, after his room was changed to a secured unit due to inappropriate touching of a female resident, there was no documented evidence of increased monitoring, reassessment, or new interventions between the time of the move and the subsequent incident. The deficiency culminated when the resident with severely impaired cognition and the resident with moderately impaired cognition, both with known sexually inappropriate behaviors, were placed on the same secured unit without reassessment or revision of their behavioral health care plans related to monitoring and supervision. Direct care staff expressed concerns about moving the male resident with sexually inappropriate behaviors to a unit where residents were generally less cognitively aware and more vulnerable, but these concerns were either not communicated to management or not acted upon. No increased monitoring or individualized behavioral interventions were implemented for either resident after the room change. Several days later, staff discovered the two residents in the female resident’s bedroom with both residents partially undressed and engaged in sexual intercourse, confirming that the facility had not provided the necessary behavioral health services, individualized interventions, and supervision required by their conditions and histories. The facility’s own policies on dementia care and behavior assessment required the interdisciplinary team to identify resident-centered care plans, evaluate behavioral symptoms for safety risk, monitor for worsening symptoms, and adjust interventions based on changes in behavior and needs. However, the residents’ ongoing sexually inappropriate behaviors, repeated incidents, guardian concerns, and changes in placement were not accompanied by consistent reassessment, documentation, or adjustment of monitoring and supervision. The psychiatric mental health nurse practitioner reported she was not informed of continued sexually inappropriate behaviors after the male resident’s room change and did not authorize discontinuation of the female resident’s 15‑minute checks, indicating a breakdown in communication and failure to follow established behavioral health protocols that contributed directly to the incident.
Removal Plan
- The DON, Certified Nurse Practitioner (CNP) #900, and Resident #05's guardian were notified of the sexual incident with Resident #10; full body skin assessments were completed for Resident #05 and Resident #10.
- Resident #10's guardian was notified by the facility of the sexual incident with Resident #05; the facility requested permission to transfer Resident #10 out of the facility later that day.
- The facility submitted an initial SRI with an allegation of sexual abuse to the State Survey Agency regarding the incident between Resident #05 and Resident #10.
- Resident #05 and Resident #10 were visited and evaluated by Psychiatric Mental Health Nurse Practitioner (PMHNP) #905.
- Resident #05 was sent to the hospital for further medical evaluation and sexually transmitted disease and hepatitis screenings.
- Resident #10 was discharged to another facility.
- Resident #05 was discharged to another facility.
- MDS Nurse #273, ADON #339, and Wound Nurse #354 interviewed all residents with a BIMS score of 13 and above about inappropriate sexual encounters, reporting, and safety; all residents with a BIMS score of 12 and below had a skin assessment completed to identify any possible changes.
- MDS Nurse #273, ADON #339, and Wound Nurse #354 completed behavior assessments for all residents in the facility.
- RDO #490 and Corporate Quality Assurance Nurse (CQAN) #467 educated all staff on the facility dementia clinical protocol, resident routine checks, behavioral assessment, intervention, and monitoring, and the facility system change for sexually inappropriate residents (including pre-admission IDT review for sexual behaviors; care planning for residents with dementia or cognitively intact residents with sexual inappropriate behaviors; psychiatric follow-up; immediate notification to nursing management and psychiatric team; immediate placement on every 15-minute checks and/or one-to-one observation until deemed safe).
- ADON #339 and Regional Nurse #255 reviewed the last 72 hours of resident charting to identify documentation of sexual behaviors; five residents (#60, #61, #63, #64, and #65) were placed on every 15-minute checks for inappropriate comments to staff; orders and notifications were completed; direct care staff would complete observations with management completing checks if changes were needed; IDT/psychiatric/physician would determine discontinuation; at-risk residents would be reviewed weekly with changes prompting team discussion and plan of action.
- MDS Nurse #273 reviewed and confirmed all residents with sexual behaviors had care plans in place with appropriate interventions.
- An ad hoc QAPI meeting was held to review the system change for sexually inappropriate residents and education provided to staff (including Medical Director, Activities Director, HRD, Social Services Assistant, Regional Nurse, MDS Nurse, Receptionist, Wound Nurse, and CQAN).
- The facility created an audit tool to be reviewed weekly at standard of care meetings with the IDT to ensure residents were identified and interventions were in place; residents with a diagnosis of sexual behavior or any sexual behavior identified would be audited weekly; the system change would continue ongoing.
- The DON or designee would audit behavior documentation five times a week for four weeks to ensure interventions were in place.
- The medical records for Residents #60, #61, #63, #64, and #65 were reviewed and verified care plans were in place with acceptable interventions for inappropriate sexual behaviors and confirmed each resident was under the care of PMHNP #905.
- Direct staff members were observed providing adequate surveillance for Residents #60, #61, #63, #64, and #65 with no issues noted.
- Interviews with RN #191, LPN #504, and CNA #141 verified staff were educated regarding dementia clinical protocol, resident routine checks, and behavioral assessment/intervention/monitoring, and were knowledgeable of residents requiring increased surveillance and the procedure for resident checks.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A resident with dementia and repeated resident-to-resident altercations was not comprehensively reassessed after multiple incidents, and the record did not show identification of triggers or updated individualized interventions. Staff described ongoing pillow-taking, room changes, and aggression, but the care plan was not documented as revised. In addition, another resident with severe cognitive impairment and Huntington’s disease was observed repeatedly running barefoot and agitated while staff did not consistently follow the care plan’s interventions such as footwear, ambulation, redirection, snacks, or a calm environment.
Staff failed to appropriately respond to dementia-related behaviors for multiple residents. A resident on a locked memory care unit repeatedly exit-seeked and became aggressive when prevented from going outside, while staff relied on redirection and PRN meds after escalation. Another resident was loudly scolded in the dining room after taking silverware, and a third resident was moved to a med room after wandering into female rooms and undressing, with staff reportedly telling him not to hit them and escalating his behavior. Care plans and notes did not show consistent individualized behavioral management.
A resident with dementia, anxiety, restlessness, agitation, wandering, and nighttime sleep disturbance had trazodone reduced from 50 mg to 25 mg after a pharmacy review. Staff later documented increased anxiety, insomnia, wandering, and agitation, and psychiatry recommended increasing trazodone back to 50 mg or even 75 mg nightly, but no order was entered and the resident continued receiving 25 mg. Interviews confirmed the psychiatric recommendation was missed and not addressed.
A resident with Parkinson’s disease, dementia, and major depressive disorder did not have an individualized, person-centered dementia care plan included in the comprehensive care plan. The RNAC confirmed the dementia diagnosis and that the facility failed to develop and implement a dementia care plan for the resident.
A resident admitted with dementia had a care plan that listed only general interventions such as cueing, reorienting, reporting changes to the physician, and providing activities that accommodate needs. The record did not show an individualized person-centered care plan addressing the resident’s specific cognitive loss and dementia-related needs, and the findings were reviewed with the NHA and DON.
A resident with Parkinson’s disease and dementia had documented wandering risk and prior behaviors of entering other residents’ rooms and beds, but the facility did not have a care plan addressing those behaviors before the incident. Staff found the resident in another resident’s bed with his genitals exposed and the other resident’s breast exposed. Interviews showed the assigned 1:1 sitter did not know why supervision was needed, the nurse was unaware of prior behaviors, and the DON reported the IDT typically identifies triggers and interventions, but no documentation showed that this occurred before the event.
Failure to Reassess Dementia Behaviors and Follow Care Plan Interventions
Penalty
Summary
The facility failed to provide appropriate dementia care treatment and services for a resident with moderate cognitive impairment, dementia, anxiety, insomnia, wandering, and rejection of care. The resident’s care plan identified repetitive questions, wandering into other residents’ rooms, and involvement in resident-to-resident altercations as a victim, with interventions such as psychology follow-up, monitoring and documenting mood and behavior, calm approach, removal from crowded areas, one-to-one visits, and introduction to residents with similar interests. The record also noted use of a different colored pillow for forgetfulness and reminders for staff to prompt the resident to carry the special pillow when seen with a white pillow. After repeated resident-to-resident altercations, including incidents in which the resident struck a roommate, fought with another resident over a pillow, slapped a resident in the dining room, and later kicked and hit another resident before being sent to the ER, the medical record did not show that staff reassessed the underlying causes of the behaviors, evaluated whether prior interventions were effective, identified behavioral triggers, or revised the care plan with new individualized interventions. Staff interviews described that the resident wandered with a pillow, took other residents’ pillows, and was moved from room to room after conflicts, but documentation of a comprehensive updated plan of care was not provided. The facility also failed to follow established dementia care interventions for another resident with severe cognitive impairment and Huntington’s disease who had verbal behaviors, agitation, running in the hallway, and physical aggression. The care plan and aide care sheet called for gripper socks or shoes, ambulation with the resident, a calm and quiet environment, reduced noise, snacks or food when agitated or running, wheelchair use when needed, and redirection. During observations, the resident repeatedly ran barefoot through the hallway and in and out of the room, while staff did not provide footwear, walk with the resident, redirect her to slow down, or consistently implement the planned interventions. The dining room television was also observed playing violent scenes at a volume loud enough to interfere with conversation despite the care plan calling for reduced environmental stimulation and a calm environment.
Staff Failed to Respond Appropriately to Dementia-Related Behaviors
Penalty
Summary
The facility failed to ensure staff knew how to appropriately respond to, assess, and address behavioral symptoms in residents diagnosed with dementia. The report identifies three residents with dementia-related behaviors who were managed primarily through staff redirection, verbal correction, or PRN medication, rather than through consistent individualized behavioral approaches described in their care plans and the facility’s dementia care policy. One resident, who had dementia and agoraphobia with panic disorder and lived on a locked memory care unit, repeatedly wandered and attempted to exit through doors leading to an enclosed outdoor area. When she became upset and aggressive after being prevented from going outside, multiple staff members responded, and a nurse sought PRN medication to calm her down. Staff statements indicated they usually did not let her go outside or walk with her even though the area was available, and that they relied on PRN medication when she became upset. Her progress notes documented repeated aggressive and exit-seeking behaviors, and her care plan listed wandering and verbal aggression interventions, but the observed response centered on containment, redirection, and medication after escalation. Another resident with dementia and anxiety was observed in the dining room taking silverware from the table and wrapping it in a napkin and placing it in his shirt. A nurse responded in a loud, stern voice, repeatedly telling him not to do it and stating that all new silverware was needed because of him. The resident’s progress notes did not document this behavior, and his care plan did not address the specific utensil-taking behavior. A DON later stated the resident needed to be spoken to calmly because otherwise it would work him up more. A third resident with dementia was reported by his sister and staff to be wandering into female residents’ rooms, trying to remove his clothes, and becoming aggressive. Staff moved him to the medication room and told him not to hit staff, which reportedly escalated his behavior. The sister stated staff seemed shocked by his wandering despite his dementia and believed they lacked training on how to handle the behavior. The resident’s progress notes documented wandering into female peers’ rooms, undressing, and becoming combative, while his care plan addressed general behavior issues with calm approach, diversion, and removal from the situation, but the events described showed staff responses that were loud, reactive, and not aligned with those approaches.
Psychiatric trazodone recommendation not implemented for resident with dementia and wandering
Penalty
Summary
The facility failed to address psychiatric NP recommendations to increase trazodone for a resident with dementia, anxiety, restlessness, agitation, wandering, and nighttime sleep disturbance. The resident was admitted with diagnoses that included dementia, anxiety, restlessness, and agitation, and had a documented pattern of exit-seeking, wandering, refusing medications, and requiring 1:1 supervision. Trazodone had initially been ordered at 50 mg at bedtime, then reduced to 25 mg after a pharmacy recommendation for gradual dose reduction was accepted by the NP. After the dose was reduced, an NP progress note documented that staff reported increased anxiety and insomnia and that the resident had failed the dose reduction, but the order remained at 25 mg at bedtime. The record showed no new order to increase trazodone back to 50 mg at that time. Nursing notes later documented ongoing wandering throughout the night, the resident entering another resident’s room, being found in another resident’s bed, and becoming agitated and combative when redirected. The care plan continued to identify behavioral symptoms including restlessness, anxiety, agitation, wandering, and exit-seeking. A psychiatric assessment noted significant cognitive and behavioral challenges, agitation, suspicious behavior, and a history of violent behavior, and indicated medication management services were needed. A psychiatric follow-up later recommended increasing trazodone to 50 mg or 75 mg nightly for sleep and restlessness, but the MAR showed the resident continued to receive 25 mg nightly and no corresponding order was found. Interviews with the Clinical Coordinator, NP, Psychiatric NP, and DON confirmed that the psychiatric recommendation to increase trazodone was missed and not addressed, and the NP stated it was her error and that she thought the medication had been discontinued completely.
Missing Dementia Care Plan
Penalty
Summary
Facility staff failed to develop and implement an individualized, person-centered care plan to address dementia for Resident R20. The facility policy on comprehensive care plans stated that each care plan should include measurable objectives and time frames to meet the resident’s medical, nursing, mental, and psychosocial needs identified in the comprehensive assessment, and should describe the services and care to be furnished to attain the resident’s highest practicable physical, mental, and psychosocial well-being. Resident R20 was admitted to the facility and the MDS indicated diagnoses of Parkinson’s disease, dementia, and major depressive disorder. Review of the clinical record showed that the resident’s care plans did not include a care plan for dementia. During interviews, the RNAC confirmed that Resident R20 had a diagnosis of dementia and that a dementia care plan was not included in the comprehensive care plans, and also confirmed that the facility failed to develop and implement an individualized person-centered care plan to address dementia for this resident.
Failure to Individualize Dementia Care Plan
Penalty
Summary
Failure to provide appropriate treatment and services for dementia was identified for Resident 11, who was admitted on April 3, 2026 with a diagnosis including dementia, described as loss of memory, language, problem-solving, and other thinking abilities that interfere with daily life. Review of the resident’s current care plan for impaired cognitive function/dementia or impaired thought processes related to dementia showed only general interventions such as cueing and reorienting, reporting changes to the physician, and providing activities that accommodate needs. The record did not show that the facility had implemented an individualized person-centered care plan to address the resident’s specific dementia and cognitive loss needs. The findings were reviewed with the NHA and DON on June 17, 2026 at 12:10 PM.
Failure to Address Dementia-Related Wandering and Inappropriate Bed Entry
Penalty
Summary
The facility failed to implement effective interventions for a resident with dementia-related behaviors in a timely manner. The resident, who had diagnoses including Parkinson’s disease and dementia, was documented as being at risk for wandering on wandering risk assessments, and prior progress notes described him urinating in his hat and garbage can, sitting in another resident’s bed, and becoming agitated when redirected from another resident’s room. Despite these documented behaviors and collateral information noting a history of wandering and searching behaviors related to his deceased spouse, there was no care plan addressing the resident’s known wandering risk until after the incident in which he was found in another resident’s bed. On the day of the incident, staff found the resident in another resident’s bed under the covers with the other resident. The resident was undressed from the waist down, his genitals were exposed, and the other resident’s breast was exposed. The resident stated he did not know what happened and did not remember, and when asked why he took off his brief, he said it was dirty. The record also showed that the resident had been moved to a new room on the second floor, but there was no documentation explaining why the room change was made. Interviews with staff showed that the CNA who was assigned as a 1:1 sitter did not know why the resident required that supervision and believed it may have been because he wandered into other residents’ rooms. The nurse assigned to the resident reported being unaware of prior wandering or sexual behaviors, although she had heard reports that he wandered into other residents’ rooms. The DON stated the resident was placed on the second floor and that the IDT typically identified triggers and interventions for wandering behaviors, but no documentation was found showing the IDT monitored the resident’s wandering pattern or identified triggers before the incident. The facility’s behavioral management policy stated that the IDT would identify causes of behavior changes, document and track behaviors, and address behaviors and interventions in the care plan.
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