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:
A CNA aggressively slapped and grabbed a resident’s wrist during lunch feeding assistance, then roughly pulled the resident’s hand off his shirt sleeve after she had grabbed it. The CNA had prior disciplinary actions, including a previous feeding incident in which a resident choked and required the Heimlich maneuver. A nurse later assessed the resident and found no bruises or cuts.
A facility failed to protect two residents from resident-to-resident physical abuse. In one incident, a resident with dementia and cognitive impairment was struck during a dispute over TV volume and responded by scratching the other resident. In another, a resident with dementia and physically aggressive behaviors scratched a roommate’s face, leaving superficial marks. Staff interviews and clinical records confirmed both altercations and the resulting injuries.
A resident with a left ankle fracture, muscle weakness, and total-assist transfer needs was supposed to receive 2-person assistance and remain NWB on the left leg. Instead, a nurse aide transferred the resident with only one staff member during a toilet-to-wheelchair transfer, and the resident heard a pop and developed increased pain. X-ray and hospital imaging confirmed fractures of the distal R tibia and fibula, and the facility substantiated neglect for not following the care plan.
Failure to Protect Resident from Repeated Room Intrusions: A cognitively intact resident with depression and hip OA was repeatedly frightened when another resident with dementia and wandering behaviors entered her room, took belongings, and could not be reliably redirected. Staff used a stop sign banner and other barriers, but the other resident continued to enter the room, and the resident became so fearful that she requested discharge before completing her therapy goals.
Failure to protect a resident from alleged physical abuse: A resident with COPD, speech disturbances, and dysphagia reported that an LPN pushed them in the chest during med pass after they refused meds, causing them to fall. The resident had no visible injuries, but the report was documented by nursing staff and the NP, and the resident later reiterated by writing/gestures that the LPN pushed them. The LPN denied pushing the resident and described the contact as accidental, while the facility concluded there was no evidence of abuse.
A resident-to-resident sexual abuse allegation was not thoroughly investigated, and the resident was not promptly protected or monitored after the allegation. In a separate issue, a handwritten sign with personal care instructions was posted above another resident's bed, and an RT, LPN, RN, and CNA all acknowledged it was a privacy and dignity concern and against facility policy.
Failure to Protect Resident from Abuse During Feeding Assistance
Penalty
Summary
The facility failed to ensure a resident’s right to be free from abuse during lunch assistive feeding. While standing about 3 feet from the lunch table, the surveyor heard a CNA aggressively slap Resident #56’s left wrist and observed the CNA grab the resident’s left wrist and roughly pull her hand off of his shirt sleeve after she had grabbed it. The surveyor then continued observing the meal and later reported the incident to the DON and Administrator. Resident #56 was assessed by a licensed nurse after the incident, and no bruises or cuts were found on her wrists. The CNA involved had been hired by the facility in 2024, had signed the facility’s Resident Abuse Procedural Summary, and had attended behavior training in 2026. The CNA also had three prior disciplinary actions, including a prior incident in which a resident choked after being given too large a bite during assistive feeding and required a Heimlich maneuver.
Failure to Protect Residents from Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to ensure two sampled residents were free from physical abuse by other residents. One resident with dementia, anxiety, chronic pain, visual hallucinations, and moderate cognitive impairment was involved in an altercation with a roommate after a disagreement about TV volume. The incident escalated when the roommate attempted to take the TV remote and struck the resident with an open hand, and the resident responded by scratching the roommate. The record also documented a new scratch on the resident’s left hand and later noted that the resident no longer wanted to share a room with the other resident. The other incident involved a resident with dementia and significant cognitive impairment who had a behavior care plan for impaired safety awareness and physically aggressive behaviors. The record stated that the resident clawed a roommate in the face, leaving superficial scratches and red marks on the roommate’s chin and cheek. The roommate’s record reflected ongoing monitoring for scratches to the chin and neck, and the roommate stated that the other resident reached up and ran fingernails across her face while they were getting up for breakfast. Facility documentation and staff interviews confirmed both resident-to-resident incidents. Staff described the first event as a physical altercation triggered by conflict over TV volume, and the second as an incident in which one resident scratched another resident’s face. The DON stated the facility investigated and reported the incidents, and also acknowledged that the documentation surrounding the second event was inconsistent and did not meet expectations or policy. The cited deficiency was based on the facility’s failure to ensure the residents were protected from physical abuse by other residents.
Failure to Follow Two-Person Transfer Plan Resulted in Resident Fractures
Penalty
Summary
The facility failed to protect a resident from neglect when staff did not follow the resident’s individualized transfer plan requiring assistance from two staff members. The resident was admitted with a left lower leg trimalleolar fracture, polyosteoarthritis, and muscle weakness, and the MDS indicated the resident was cognitively intact but required total assistance for transfers and toileting. The comprehensive care plan and physician orders both directed staff to provide two-person assistance for transfers and to maintain non-weight-bearing status on the left lower extremity. During a transfer from the toilet to a wheelchair, one nurse aide assisted the resident without a second staff member. According to the documentation, the resident stood without difficulty, but during the pivot transfer the resident’s right foot turned inward and both the resident and the aide heard a loud pop. The resident immediately reported increased pain. Later that day, x-ray findings identified an acute fracture of the right tibia, and the resident was transferred to the hospital emergency department for further evaluation and treatment. Hospital imaging confirmed fractures of the distal right tibia and fibula, and the resident was scheduled for surgical repair. The facility’s investigation determined that the aide transferred the resident with only one staff member despite the care plan and physician order requiring two staff members, and that this failure directly resulted in the resident sustaining the fractures. The facility substantiated caregiver neglect and terminated the employee following the investigation.
Failure to Protect Resident from Repeated Room Intrusions
Penalty
Summary
The facility failed to protect a cognitively intact resident with osteoarthritis of the right hip and major depressive disorder from mental abuse by another resident. The resident was admitted as a vulnerable adult and her care plan identified a goal of being free from abuse, neglect, or financial exploitation, but it did not include interventions to protect her from abuse. The resident later reported that another resident repeatedly entered her room, scared her, and took belongings, and she asked staff to contact her lawyer. She also began using a stop sign banner across her door and later barricaded her room with a walker, closet door, and bedside table because she was afraid of the other resident. The other resident had moderate cognitive impairment, vascular dementia with agitation, and Alzheimer’s disease, and his care plan documented restlessness, agitation, sundowning, wandering into other residents’ rooms, and urinating in public. Progress notes showed repeated episodes of wandering into other residents’ rooms, difficulty with redirection, aggression toward staff, and disruptive behavior in resident rooms. Notes also documented that he entered the affected resident’s room on multiple occasions, and staff observed that he could move barriers out of the way and continue entering the room despite attempts to block access. Staff interviews confirmed that the resident was very scared of the other resident and that the repeated room intrusions continued over several days. Staff stated that stop sign banners did not stop him, closed doors did not stop him, and that it often took two or more staff to remove him from rooms. The resident requested discharge from the facility and left before reaching her maximal level with therapy services. Therapy documentation stated she was improving but still needed higher-level therapy before discharge, and the therapy director stated her early discharge was because she could not remain in the facility due to the other resident coming into her room. Facility records also showed staffing levels that were below the facility assessment on several shifts, and the assignment sheets did not identify a staff member assigned to 1:1 observation for the wandering resident.
Failure to Protect Resident from Alleged Physical Abuse
Penalty
Summary
The facility failed to ensure that a resident was free from physical abuse when a nurse allegedly made physical contact with the resident during medication administration. Resident #7, who had diagnoses including COPD, speech disturbances, and dysphagia, had intact cognition on the MDS dated 03/18/2026 and was care planned as at risk for misappropriation, neglect, abuse, and/or exploitation. On 04/08/2026, the resident reported to the RN supervisor that an LPN pushed them in the chest after they refused medications, causing them to fall to the floor. The resident was assessed and no visible injuries were noted. The resident’s report was documented in nursing and medical progress notes, and the facility’s investigation recorded that the resident was visibly upset while describing the incident. The LPN denied the allegation and stated that any contact was accidental, describing that the resident was close behind them as they left the room and that the resident’s chest contacted their back or shoulder. The RN supervisor, DON, and NP each documented interviews and assessments in which no bruising, swelling, or visible injury was found, and the resident later communicated by writing and gestures that they had told the LPN to leave the room and that the LPN pushed them in the chest and they fell. The facility concluded there was no evidence of abuse, neglect, exploitation, or mistreatment, despite the resident’s allegation and the conflicting accounts from the LPN and resident. The RN supervisor stated law enforcement was notified and police interviewed the resident and the LPN, but no report was filed. The DON later stated the contact was accidental and that the resident’s reporting was inconsistent regarding whether a fall occurred.
Failure to Protect Resident from Abuse and Maintain Privacy
Penalty
Summary
The facility failed to ensure a resident was free from abuse when a resident-to-resident sexual abuse allegation was not thoroughly investigated and the resident was not promptly protected or monitored after the allegation. The report states this involved 1 of 52 sampled residents, Resident 45, and that the deficient practice had the potential to place the resident at risk for continued abuse, emotional distress, fear, anxiety, a diminished sense of safety, and delayed implementation of interventions necessary to protect the resident from further abuse. The facility also failed to protect the privacy and confidentiality of Resident 58. Resident 58 was admitted with diagnoses including chronic obstructive pulmonary disease. During observation, a handwritten sign reading, "Attention please no briefs chucks only!!" was posted above the resident's bed and remained there on a later observation. Staff members including a Respiratory Therapist, LPN, RN, and CNA each acknowledged the sign was visible above the bed and stated it was a privacy, dignity, and policy issue. A facility Residents Rights policy stated residents have the right to privacy and confidentiality with personal care and medical records, and that resident medical and personal care information is private and staff are required to respect and uphold resident privacy at all times.
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