Failure to Supervise Aggressive Resident Leads to Multiple Altercations and Harm
Summary
The deficiency involves the facility’s failure to maintain an accident‑hazard‑free environment and to provide adequate supervision of a resident with known aggressive and sexually inappropriate behaviors, which led to multiple resident‑to‑resident altercations and harm. Resident #14 (R14), who had vascular dementia with psychotic disturbance, anxiety, insomnia, restlessness, agitation, and severe cognitive impairment on MDS, was repeatedly allowed to move freely throughout the Memory Care Unit despite a documented history of wandering into other residents’ rooms, aggression, and sexual ideation. The facility’s own incident synopses and staff statements show that R14 entered other residents’ rooms or was involved in altercations on multiple occasions, while care plans and supervision levels did not consistently reflect or control these risks. On 3/20/24, Resident #17 (R17), who had Lewy body dementia with agitation, frontotemporal neurocognitive disorder, and severe cognitive impairment, was involved in a physical altercation with R14. Staff reported hearing a scream and a hard fall and then found R17 on the floor near a food cart with R14 standing nearby. Both residents stated that R17 slapped R14 and that R14 pushed R17 to the floor. R17 was found to have a bump on the top/back of her head. Although R14’s care plan was revised to address a psychosocial well‑being problem related to an alleged physical abuse incident, the care plan did not reflect his potential for aggressive behaviors, despite his severe cognitive impairment and prior behaviors. On 12/18/24, Resident #16 (R16), who had dementia with agitation, major depressive disorder, psychotic disorder with delusions and hallucinations, and was unable to complete a cognitive assessment, was found in bed fully covered with blankets while R14 was lying fully clothed on top of the covers in the same bed. A CNA had previously redirected R14 from attempting to go into R16’s room and had laid him down in his own bed, but later another CNA overheard a nurse telling R14 to exit R16’s bed and then observed R16’s brief undone with her buttocks exposed. The facility’s final synopsis documented that neither resident could recall the incident and that no injuries were noted, but the event occurred in the context of R14’s known behaviors of sexual ideations, roaming into rooms, taking others’ belongings, and defecating on the floor, which were already care‑planned. The facility was aware of R14’s history of entering other residents’ rooms and had previously used 1:1 supervision and Q15‑minute checks, but he was transitioned off 1:1 and later off Q15‑minute checks. On 1/22/25, Resident #15 (R15), who had Alzheimer’s dementia with agitation, major depressive disorder, anxiety, and severe cognitive impairment, wandered into R14’s room and called him a racial slur, after which R14 hit R15 in the mouth. Staff observed R15 exiting R14’s room holding a bloody rag to his mouth and stating that the other resident had hit him. A progress note documented a small cut to the lower lip and an interim skin check identified a new laceration. At the time of this incident, R14 was on Q15‑minute checks due to prior behaviors, and his care plan included general behavioral interventions such as monitoring behaviors, assisting with coping, and intervening to protect others, but he continued to have direct access to other residents and their rooms. On 12/30/25, Resident #2 (R2), who had dementia without behavioral disturbance, PTSD, psychosis, depression, chronic pain, and was on Eliquis for prevention of recurrent DVT, was involved in an altercation with R14 that resulted in significant injury. Staff were alerted by another resident that R2 and R14 were fighting. When staff entered, they observed R14 standing in front of R2, both struggling over R2’s reacher/grabber tool. R2 stated that R14 had come into her room, she tried to ask him to leave, and he hit her in her left eye. A nurse documented swelling and bruising around R2’s left eye, and an interim skin check identified a new bruise. R2 was initially kept in the facility with neuro checks and Q15‑minute safety checks. By the next morning, staff noted that R2’s left eye was swollen shut with purplish‑reddish bruising, she was less responsive, and then became unresponsive with critically abnormal vital signs and oxygen saturation, leading to her transfer to the emergency department. Her responsible party later reported that the hospital physician said R2 had suffered a significant brain bleed from being hit in the eye while on a blood thinner and that she died on 1/1/26. Additional documentation shows that all of these incidents occurred on the Memory Care Unit and were perpetrated by R14. A nurse progress note dated 1/3/26 recorded R14 being observed in a female resident’s room attempting to get into bed with her while clothed and wearing a brief, and that he became physically aggressive, making grabbing motions and attempting to hit staff when redirected. A psychiatric nurse practitioner note dated 1/5/26 described escalating behavioral disturbances, including aggression, poor impulse control, and sexually inappropriate behavior, and stated that R14 posed risks to staff and peers due to aggressive and sexually inappropriate behaviors. Despite this, a nurse progress note on 1/5/26 documented that R14 was no longer on 1:1 supervision per physician order, and he remained a current resident permitted to ambulate freely on the unit with direct access to other residents. The facility’s own safety and supervision policy required individualized, resident‑centered analysis of accident hazards and adequate supervision, but the pattern of repeated incidents involving R14 and multiple cognitively impaired residents demonstrates that adequate supervision and an accident‑hazard‑free environment were not maintained.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Unsafe Cord Placement and Failure to Follow Fall Interventions: A resident with cognitive impairment and wheelchair use had a TV power cord stretched tightly across the closet doorway, blocking access and creating an environmental hazard when staff had to lift the cord to open the closet. Another resident with severe cognitive impairment and a fall-risk care plan repeatedly ran barefoot in the hallway while staff observed but did not consistently provide planned interventions such as gripper socks, footwear, ambulation assistance, or redirection.
A resident with impaired cognition, cancer, non-Alzheimer's dementia, extensive ADL needs, and a fall history was identified as a high fall risk with care plan interventions including removing a movable bedside table. After a fall, the resident was found using the table as a walker, yet observations showed the table still placed beside the bed on multiple occasions, including when staff were present. Staff interviews confirmed they were unaware of the current fall prevention interventions and that the table remained at bedside for meals despite the care plan.
Failure to complete a restraint assessment before using a wheelchair alarm for a resident with muscle weakness, difficulty walking, repeated falls, and dementia. The care plan included the alarm as an intervention, but the record lacked an initial Restraint Evaluation, and the CNO confirmed the assessment had not been completed before the alarm was placed.
A resident with cognitive deficits, dementia, Alzheimer's disease, fracture, and repeated falls was dependent for toileting and care planned for an EZ stand with 2-person assist. During observed transfers, staff placed the harness and straps correctly, but the resident only rose to about 135 degrees and never came to a full stand, while staff remained by the bathroom door during privacy periods and continued the transfer despite the resident not standing fully. An RN stated the resident was expected to stand straight up with the EZ stand and that staff should sit the resident back down and try again if not.
A resident with Alzheimer's disease and dementia was found wandering in the parking lot after leaving the building unsupervised. A family member visiting another resident saw her looking into car windows and alerted staff, who were not aware she had exited until the report. Staff interviews showed the resident had been seen earlier eating in the dining room, but no one was actively looking for her or knew she had left the facility.
A resident with parkinsonism and Alzheimer's disease, severe cognitive impairment, and a fall history was pushed in her wheelchair without foot pedals and was not assisted when she called out for help. Nursing notes and staff interviews showed a CNA propelled the resident multiple times without foot pedals, including one instance where her socked foot hit the floor, and staff acknowledged that foot pedals should be used when pushing a resident.
Unsafe Cord Placement and Failure to Follow Fall Interventions
Penalty
Summary
The facility failed to ensure a television power cord was properly secured and maintained so it did not create an environmental accident hazard for R46. R46’s quarterly MDS identified moderate cognitive impairment, maximum assistance needed for dressing, grooming, and toileting hygiene, moderate assistance with transfers, and wheelchair use. During observation, R46 was in his room with the television mounted on the wall between the bathroom and closet, and the power cord ran across the closet doors and across the upper drawer of the dresser to a surge protector on top of the dresser. When R46 tried to open the closet doors, the cord was stretched tightly across the doorway and prevented the doors from opening fully unless the cord was lifted away. A later observation showed NA-D had to lift the cord above the closet door to open it and retrieve clothing. NA-D stated the cord had been positioned that way for about one year and could be dangerous if R46 pulled on it, and maintenance staff stated they were only notified that day that the television needed to be fixed. The facility also failed to ensure fall interventions were followed for R13, who had severe cognitive impairment with disorganized thinking and inattention, verbal behaviors toward others, and dependence on staff for footwear and partial to moderate assistance with dressing. R13’s care plan identified her as at risk for falls and included interventions such as ambulating with the resident, encouraging gripper socks, obtaining slip-on shoes, reducing noise, offering snacks, assisting her back to her room when running in the hallway, offering a wheelchair, and redirecting her to slow down. During observations, R13 repeatedly exited her room barefoot and ran through the hallway, including multiple times over an extended period, while staff observed but did not provide gripper socks or shoes, walk with her, redirect her to slow down, or offer other care-planned interventions. Staff interviews indicated they had difficulty redirecting her because she became agitated, and the DON stated the care plan should be followed to ensure safety.
Failure to Follow Fall Prevention Care Plan
Penalty
Summary
The facility failed to implement care planned interventions to prevent further falls for one resident who was reviewed for falls. The resident had moderate impaired cognition, diagnoses including cancer and non-Alzheimer's dementia, required extensive assistance with ADLs including toileting, transfers, and locomotion, and had a history of falls. The resident's care plan identified the resident as a high fall risk related to de-conditioning, cognitive deficits, and prior falls, and included interventions such as anti-rollbacks on the wheelchair, appropriate footwear, keeping a wheelchair behind the resident when ambulating, and removing the mobile bedside table from beside the bed. After a fall in which the resident was found on the floor by the room doorway with the mobile bedside table in the hallway next to him, the resident stated he had been using the table as a walker. Despite the care plan and post-fall assessment identifying removal of the mobile bedside table as an intervention, observations showed the movable bedside table still placed alongside the bed on multiple occasions, including when staff were present in the room. Staff interviews confirmed they were unaware of the current fall prevention interventions, acknowledged the table was movable, and stated it remained at the bedside to facilitate meals. The DON confirmed the table had been at the bedside and was removed only after the surveyor discussed it with staff.
Failure to complete restraint assessment before wheelchair alarm use
Penalty
Summary
The facility failed to complete a restraint assessment before implementing a wheelchair alarm for Resident #18. Resident #18 was admitted with multiple diagnoses including muscle weakness, difficulty walking, repeated falls, and dementia. The care plan for impaired mobility and fall risk, dated 3/8/26, included a wheelchair alarm as an intervention. A Bed Safety and Transfer Device Evaluation dated 4/28/26 documented that the bed/chair alarm did not restrict mobility, but the record did not include an initial Restraint Evaluation dated on or around 3/8/26 to identify the comprehensive evaluation of the chair alarm. On 7/9/26, the CNO stated that a Restraint Evaluation had not been completed prior to the chair alarm being placed for Resident #18.
Inadequate Supervision During EZ Stand Transfers
Penalty
Summary
The facility failed to ensure adequate supervision and assistance for one resident during transfers with an EZ stand lift. The resident had cognitive deficits and was dependent for toileting, with diagnoses including Alzheimer's disease, dementia, fracture, and repeated falls. The care plan identified a moderate fall risk related to weakness and directed toileting with an EZ stand and 2-person assist. During observation, nursing assistants placed the harness, safety belt, straps, and loops appropriately and assisted the resident with the lift, but the resident stood only to approximately 135 degrees and never came to a full stand. On two observed transfers, staff remained by the bathroom door while the resident was given privacy, then re-entered to continue the transfer and complete care. In both observations, the resident never achieved a full standing position despite encouragement and repeated attempts. One nursing assistant stated the transfer was safe because two staff were assisting, while the RN case manager stated she expected the resident to stand straight up when transferred with the EZ stand and that staff should sit the resident back down and try again if the resident did not. The RN case manager was unaware of any concerns about the resident transferring safely with the EZ stand. Facility policy was requested but not provided.
Resident Left Unsupervised and Was Found Wandering in Parking Lot
Penalty
Summary
The facility failed to recognize that a cognitively impaired resident had left the building unsupervised and was wandering in the parking lot. The resident had diagnoses including Alzheimer's disease, dementia, and anxiety disorder, and records showed she had moderately impaired cognition, walked and transferred independently, and had no documented wandering behaviors during the MDS lookback period. Although an elopement evaluation had previously concluded she was not at risk for elopement, the care plan identified confusion, impaired cognition, and lack of awareness of safety needs. On the day of the event, a family member visiting another resident saw the resident outside in the parking lot looking into car windows and walking from car to car with a jacket and pocketbook on her arm. The family member stated the resident appeared to be looking for someone and was in the middle area of the parking lot before she reported it to staff. Nurse #3 was notified and went to check on the resident, who was then brought back inside the facility. Staff interviews showed they were not actively looking for the resident and did not know she had exited the facility unsupervised until the family member reported seeing her outside. Staff accounts indicated the resident had been seen earlier in the dining room eating, but no one was aware she had left the building. Nurse #2 and NA #1 both stated they were not aware the resident was missing until the report from the family member. The administrator stated the resident exited through the front entrance doors, but it was not known whether she pushed the button behind the receptionist desk or was let out by a visitor. The previous NP stated the resident needed someone with her if she was outside the facility and could have wandered away if left alone.
Failure to Respond to Help Requests and Use Foot Pedals During Wheelchair Transport
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards for R25 when staff did not respond to her requests for help and did not provide foot pedals while propelling her wheelchair. R25 had diagnoses of parkinsonism and Alzheimer's disease, and her records documented severely impaired cognition, including a BIMS score of four on a quarterly MDS. Her care plan stated she was independent with locomotion in her manual wheelchair, but other documentation reflected a history of falls and need for staff assistance with wheelchair mobility. The care plan also lacked documentation regarding foot pedals. Nursing notes and staff interviews showed multiple instances in which R25 was pushed in her wheelchair without foot pedals. On one occasion, a CNA propelled her out of the restroom and her socked foot hit the floor when the wheelchair was pushed. On another occasion, R25 was seated in her wheelchair, holding onto the back of a recliner and calling out for help, while the CNA walked by her. The CNA later propelled R25 down the hallway without foot pedals and at one point pushed the chair and let it go. Staff interviews confirmed that residents should have foot pedals when staff are pushing them, and the CNA stated she should not push R25 without foot pedals.
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