Failure to Protect Residents From Aggressive Resident Leading to Abuse and Fear
Summary
The deficiency involves the facility’s failure to protect residents from abuse and to implement appropriate care plan interventions for a resident with severe cognitive impairment and escalating aggressive behaviors, which resulted in a resident‑to‑resident physical altercation and fear among multiple residents. One resident with non‑Alzheimer’s dementia, severe cognitive impairment (BIMS scores of 2/15 and later 1/15), hallucinations, delusions, and documented physical and verbal aggression toward others repeatedly exhibited behaviors such as hitting, grabbing, scratching, threatening, wandering, entering other residents’ rooms, and attempting to elope. Despite a Significant Change MDS that identified these behaviors and documented that they significantly intruded on others, the resident’s plan of care contained focus areas for impaired cognition, elopement/wandering risk, and psychotropic medication use, but lacked behavior‑specific interventions addressing the aggressive and intrusive behaviors recorded on the MDS and in multiple behavior notes. Point of Care and nursing documentation throughout March detailed numerous episodes in which this cognitively impaired resident was physically and verbally aggressive toward staff and residents, including grabbing and hitting others, cursing, threatening to hurt people with objects, attempting to enter other residents’ rooms, and causing disruption in common areas. Notes described the resident as very difficult to redirect, verbally violent and threatening, talking about using a “2 by 4” to “woop” people, attempting to elope multiple times, trying to get into the kitchen and out fire doors, and waving a fork aggressively while threatening to hit staff. Staff documented that other residents did not want this resident near them due to her confusion, nonstop talking, physical closeness, and disruptive behaviors. A housekeeper and CNAs confirmed that the resident independently ambulated throughout the facility and displayed hitting, kicking, throwing items, and frequent verbal outbursts during meals and activities. On one occasion, this aggressive resident confronted two other residents in a hallway after misunderstanding their conversation. Staff attempted to separate them, but the aggressive resident slapped another resident on the left upper arm with an open hand while yelling and being combative with staff, causing a red mark and pain at the time of the incident. The assaulted resident, who had intact cognition and a history of anxiety, depression, and adjustment disorder, reported discomfort around loud and aggressive individuals and subsequently described increased anxiety about being around the aggressive resident, fear of being hit again, and a preference to stay in her room or wear headphones during meals to drown out the other resident’s outbursts. Documentation showed that after the incident, this resident spent more time isolated in her room, came out mainly for meals, avoided eye contact, cried due to fear, and had reduced nutritional intake compared to earlier in the month. Two additional cognitively intact residents also reported fear related to the aggressive resident’s behaviors. One resident stated she witnessed the hallway incident in which the aggressive resident hit another resident on the shoulder/upper arm and threatened to hit harder, and reported being scared and now only coming out for meals, no longer attending activities as before. She kept her room door open so she could see if the aggressive resident attempted to enter and stated she would chase her out if needed. Another resident reported being scared of the aggressive resident, describing that the aggressive resident would yell and scream during activities and meals and would “hit anyone,” leading her to avoid coming out for activities. Multiple CNAs and an LPN corroborated that these residents were fearful, cried in their rooms, came out only for meals or small groups, and declined activities due to fear of the aggressive resident. The facility’s abuse prevention policy stated that residents must not be subjected to abuse by anyone, including other residents, and defined physical abuse as hitting, slapping, and similar acts, yet the documented pattern of aggressive behavior and the lack of corresponding care plan interventions contributed to an environment in which one resident physically struck another and several residents experienced ongoing fear. A registered nurse acknowledged that the facility did not put interventions in place after the physical altercation and that the plan of care lacked interventions for the behaviors identified on the Significant Change MDS. The primary care physician for the assaulted resident later confirmed that they became aware of the incident through round‑table discussions and that the resident reported anxiety about going to the dining room and being around large groups following the event. Throughout this period, observations showed the fearful residents remaining in their rooms with doors closed or only briefly attending meals or limited activities, often wearing headphones and avoiding interaction, while the aggressive resident continued to ambulate freely, enter common areas, and assert that the facility belonged to her and that she would make others do what she said. These documented actions and omissions demonstrate that the facility did not ensure residents were free from abuse by other residents and did not adequately address known aggressive behaviors through individualized care planning and effective supervision. The facility’s own Abuse, Prevention, Reporting and Investigation Policy stated that residents must be free from abuse, including physical abuse such as hitting and slapping, and that residents must not be subjected to abuse by other residents. Despite this, the aggressive resident’s repeated physical and verbal behaviors toward others, the lack of corresponding care plan interventions, and the subsequent physical striking of another resident in the hallway show a failure to protect residents from abuse. The resulting fear, anxiety, social withdrawal, and decreased participation in activities and meals among multiple residents were documented by residents, staff, and clinical notes, all occurring in the context of the facility’s failure to implement behavior‑specific interventions for a resident with a clearly documented pattern of aggression and intrusion on others. Staff interviews further supported that the aggressive resident’s behaviors had worsened over the prior months and that other residents were fearful and scared. Housekeeping and CNA staff described residents crying in their rooms, expressing that they did not feel able to leave due to fear of being hit, and altering their daily routines to avoid contact with the aggressive resident. Observations by surveyors of residents remaining in their rooms with doors closed, wearing headphones, and avoiding eye contact aligned with these reports. Collectively, the documented behaviors, the absence of care plan interventions addressing those behaviors, the physical altercation, and the resulting psychosocial impact on multiple residents form the basis of the deficiency related to failure to protect residents from abuse and to maintain an environment free from resident‑to‑resident physical aggression. The facility census at the time was 32 residents, and six residents were reviewed, with one resident identified as the aggressor and three residents identified as experiencing fear related to that resident’s behaviors. The aggressive resident’s MDS and behavior documentation clearly showed severe cognitive impairment, psychotic symptoms, and a pattern of physical and verbal aggression that significantly intruded on others, yet the plan of care did not reflect interventions to manage these behaviors. This gap, combined with ongoing documentation of aggressive incidents and staff acknowledgment that interventions were not implemented after the physical altercation, directly contributed to the deficiency in protecting residents from abuse as required by facility policy and regulatory standards.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
An agency NA forcefully pushed a wheelchair-bound resident through a doorway while the resident was caught in the frame, causing the resident’s foot to strike both shins and resulting in bruising, swelling, pain, and an acute right tibia fracture. The resident had dementia, muscle weakness, and required assistance with mobility and transfers. CCTV and the facility’s investigation showed the NA did not follow safety measures during the transfer.
A resident with dementia and a history of aggression assaulted another resident in a hallway, pushing him from a chair onto the floor and then attempting to strike him with a chair while a third resident was nearby. Staff on constant observation and another observer did not intervene until after the resident had already been pushed down, despite the resident being on enhanced supervision for prior resident-to-resident altercations. Both residents had severe cognitive impairment, and interviews showed the assigned aide did not understand the urgency of the constant observation role.
Delayed reporting of resident-on-resident sexual abuse allowed continued nonconsensual sexual contact. A resident with schizophrenia and moderate cognitive impairment reported that his roommate kissed, touched, and sexually assaulted him without consent, while the roommate admitted to sexual contact. A nurse aide heard the allegation but did not report it right away, and the unit manager later confirmed the delay.
Failure to respond appropriately to an alleged sexual abuse incident: a resident with intact cognition alleged a CNA raped them during incontinence care, but the resident remained in the facility for hours without a documented medical or psychosocial assessment. The CNA said they provided care and applied ointment to the resident’s groin and vaginal area, while video showed the CNA in the room for 36 minutes. The resident was later tearful, fearful, and distrustful of staff, and the DON and admin did not report the allegation to DOH because the resident later described rough handling.
Failure to Maintain Separation Between Residents With Known Aggression: A resident with a known hx of resident-to-resident physical aggression struck another resident in the head with a cane in the dining room, causing a bump, laceration, and bruising. The assaulted resident was non-ambulatory, dependent on staff for transfers, and had dementia, while the aggressive resident had intact cognition, used a cane, and had a care plan for prior physical altercations. Staff placed the residents in the same area with limited supervision, and the aggressive resident stated the other resident deserved it and that he would hit him again.
A resident with stroke-related diagnoses and cognitive intact status was transferred to the hospital for weakness, dizziness, pallor, and low K+. After the resident was stable for return, the DON and administrator went to the hospital and, along with the owner and corporate administrator on speaker phone, were reported by the resident and hospital staff to have yelled, been rude and aggressive, and told the resident the facility would not take the resident back because of behaviors and money owed. The resident stated feeling pressured, outnumbered, and insignificant.
Failure to Protect Resident During Transfer Resulted in Right Tibia Fracture
Penalty
Summary
The facility failed to protect a resident from abuse and neglect when an agency nurse aide forcefully handled Resident R86 during wheelchair transport. CCTV review showed the aide pulling the resident as she was caught in a doorway, then attempting to push her through the doorway forcefully. During this event, the resident’s right foot became caught on the doorframe and struck her right shin, then her left shin, before she was pushed through the doorway. Resident R86 was admitted to the facility with diagnoses including hypertension, vascular dementia, muscle weakness, and cognitive communication deficit. The resident’s MDS indicated dependence for multiple mobility-related activities and use of a wheelchair. The care plan noted that the resident could move around the facility without supervision but could not exit without supervision, and later documented bruising to both lower extremities, swelling of the lower right extremity, and a right tibia fracture, with bed rest and Hoyer transfers for all transfers. After the incident, bruising was documented on the resident’s lower extremities, including dark purple/green bruising to the right shin and swelling and pain in the right leg. The resident was unable to tolerate range-of-motion assessment because of pain and agitation. X-rays later showed an acute mildly displaced spiral fracture below the level of the tibial prosthetic stem in the right tibia. The facility’s investigation concluded that the nursing aide neglected to follow facility safety measures.
Failure to Prevent Resident-to-Resident Abuse During Constant Observation
Penalty
Summary
The facility failed to protect a resident from abuse when a resident with severe cognitive impairment and a history of aggressive behavior assaulted another resident in the hallway. Resident #1 had diagnoses including unspecified dementia with behavioral disturbance, COPD, muscle weakness, and major depressive disorder, and his MDS coded him with a BIMS score of 3 out of 15. Resident #2 also had severe cognitive impairment, with diagnoses including Alzheimer’s disease with early onset, unspecified dementia without behavioral disturbance, hypertension, and muscle wasting and atrophy, and his MDS also coded a BIMS score of 3 out of 15. During the incident, staff heard a chair flip over and a thud, then found Resident #2 on the floor. A video reviewed by the facility showed Resident #1 standing in front of Resident #2 and pushing him out of a chair and onto the floor. The video also showed Resident #1 picking up a chair and attempting to strike Resident #2 with it while Resident #3 was in close proximity. An OSM sitting nearby observed the incident and did not intervene until after Resident #2 had been pushed to the floor, and the chair was only stopped when the OSM placed a hand on it. The record and interviews showed that Resident #1 had been on constant supervision because of prior aggressive behavior and resident-to-resident altercations. The care plan documented behaviors related to aggression during care and a history of pushing another resident. Staff interviews indicated that the Activities Aide assigned to constant observation was watching the incident but did not intervene quickly, and the aide stated she did not think the situation would become physical and did not know what the constant observation was for. The facility’s policy required staff on constant observation to remain within close proximity to intervene immediately if necessary, but that did not occur during the altercation.
Delayed Reporting of Resident-on-Resident Sexual Abuse
Penalty
Summary
The facility failed to ensure that a resident was free from abuse when continued nonconsensual sexual contact occurred between two roommates. Resident 1 had diagnoses including schizophrenia and a BIMS score of 9, indicating moderate cognitive impairment. Resident 2 had a BIMS score of 15, indicating normal cognitive function. According to the resident’s statement, Resident 2 kissed his body and engaged in sexual contact that Resident 1 did not consent to, including manual genital manipulation, kissing and licking of his body, and anal penetration. A nurse aide heard Resident 1 say that Resident 2 liked to kiss his body and later questioned him about whether Resident 2 asked him to do things he did not want to do. Resident 1 responded that Resident 2 “jerks me off” and said it happened often. The nurse aide stated that he or she was unsure what to do and did not feel comfortable talking to anyone except the unit manager. The unit manager’s statement indicated that the nurse aide reported the allegation four days after the initial disclosure. Resident 2 also acknowledged sexual contact, stating that he had kissed Resident 1 all over his body and touched his private area, and said the last contact occurred two nights before the interview. The resident was evaluated in the ED for sexual assault, and the facility later substantiated sexual abuse based on the delayed reporting by the nurse aide. The report identified that the delay in reporting allowed further nonconsensual sexual contact to occur before the allegation was acted upon.
Failure to Respond to Alleged Sexual Abuse and Assess Resident Distress
Penalty
Summary
The facility failed to protect a resident from abuse, psychosocial harm, and to respond appropriately after an allegation of staff-to-resident sexual abuse. The resident had diagnoses including obstructive and reflux uropathy and hemiplegia and hemiparesis following cerebral infarction. The resident’s MDS documented a BIMS score of 15, indicating intact cognition, and the care plan included psychosocial well-being interventions such as orienting the resident to the environment, introducing compatible peers, and addressing concerns. During incontinence care, the resident alleged that a CNA raped them. The incident report documented that the resident told an LPN they were raped, and the LPN notified a supervisor. The supervisor assessed the resident and noted redness in the perineal area. A nursing progress note later documented that the resident complained of burning in the sacral and vaginal area after incontinence care and that the DON was aware. Video review showed the CNA in the resident’s room for 36 minutes. The CNA stated they provided incontinence care, applied A and D ointment to the resident’s pubis, groin crease, and vagina, and remained in the room because the resident had multiple bowel movements, although the bowel record did not document multiple bowel movements. The resident remained in the facility for about five and a half hours after the allegation without documentation of a medical or psychosocial assessment. Family members reported the resident was hysterically crying, contacted law enforcement, and requested hospital transfer. The resident later stated they felt something enter their anus and vagina, that they told the CNA to stop, and that they became distressed, tearful, fearful, and distrustful of facility staff. The facility concluded abuse did not occur because of conflicting statements, and the DON and administrator stated the allegation was not reported to the state because the resident later described rough handling. The PCP stated the facility should have called law enforcement and the Department of Health if the allegation was rape, and stated a psychosocial assessment should have been completed. The social worker stated they were aware of the incident after it occurred and did not know what interventions should be put in place.
Failure to Maintain Separation Between Residents With Known History of Aggression
Penalty
Summary
The facility failed to protect a resident from resident-to-resident abuse when one resident struck another resident in the head with a cane in the main dining room. The assaulted resident was non-ambulatory, dependent on staff for bed-to-chair transfers, used a Broda wheelchair, and had diagnoses including non-Alzheimer’s dementia and depression. He had a BIMS score of 12 out of 15 and was documented as having potential verbally aggressive behaviors toward other residents related to dementia. After the assault, he was found with a 5 cm bump and a 1 cm laceration to the left forehead, along with facial bruising, and he stated he felt unsafe around the other resident. The resident who struck him had a BIMS score of 13 out of 15, walked with a cane, transferred independently, and had diagnoses including stroke and depression. His care plan identified a history of resident-to-resident physical aggression and directed staff to monitor for agitation, assist him to a quiet area, and maintain separation from the other resident. Despite that history, he independently approached the other resident in the dining room and struck him multiple times with the cane. During the interview, he stated the other resident deserved it and said he would hit him again if he saw him, indicating the assault was intentional and unprovoked. The investigation also documented a prior resident-to-resident altercation between the same two residents in which the aggressive resident had struck the other resident in the face with his cane several times, causing bruising to the eye and cheek. Staff statements showed the two residents were placed in the same dining area with limited supervision, and staff were occupied with other residents when the assault occurred. Several staff members stated they believed the aggressive resident was simply walking back to his room and did not realize he would attack the other resident. The facility’s investigation concluded that previously identified supervision and separation interventions were not consistently maintained, allowing the aggressive resident to reach and assault the other resident again.
Verbal Abuse During Hospital Discharge Discussions
Penalty
Summary
The facility failed to ensure a resident was free from verbal abuse by facility staff. The resident had diagnoses including frontal lobe and executive function deficit, stroke, atrial fibrillation, cerebrovascular accident, and hemiparesis, and the record also documented the resident as cognitively intact. The resident had been admitted on 01/17/2025 and was transferred to the emergency department on 6/18/2026 for further evaluation and treatment related to possible infection, weakness, dizziness, pallor, and low potassium. After the hospital transfer, the resident stated that facility leaders told the resident the facility would not allow the resident to return because there were no available beds. The resident reported that the administrator and DON came to the hospital, that the administrator, DON, company owner, and corporate administrator were on speaker phone, and that the administrator and DON were verbally abusive, yelled at the resident, and said the resident had behavioral issues, owed the facility a lot of money, and was a bad person. The resident stated feeling pressured, outnumbered, and extremely insignificant, and said the resident never told staff not to return until being told the facility did not want the resident back. Hospital staff corroborated the resident’s account. The hospital social worker stated the facility refused to accept the resident back, that the DON was rude, unpleasant, and harassed the resident in the emergency department waiting room, and that the administrator and DON were aggressive and yelled at the resident during the discussion about returning to the facility. The hospital case manager stated the administrator and DON told the resident about problems the resident had caused for the facility and said the resident could return if the resident paid on the bill. The administrator later stated that staff had to yell because the resident was hard of hearing and acknowledged that the conversation involved reviewing the letter and bullet points about what led to the situation.
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