Failure to Report and Intervene on Escalating Resident Behaviors Leading to Resident-to-Resident Injury
Summary
Facility staff failed to report resident-to-resident verbal abuse and escalating behaviors by a resident with known behavioral issues (Resident B) toward his roommate (Resident C) to administration or appropriate supervisory staff. Resident B had multiple diagnoses including vascular dementia with behaviors, delusional and psychotic disorders, anxiety, and intellectual disabilities, and his most recent Annual MDS showed physical, verbal, and other behaviors that significantly interfered with care and activities and posed significant risk of physical injury and disruption to others. His care plan called for monitoring and documenting target behaviors such as violence or aggression toward others and separating him from others as needed when behaviors were disruptive. In early December, medication administration notes documented that Resident B was yelling at his roommate on at least two occasions and was given PRN lorazepam for agitation and anxiety. On 12/11/25, a behavior note documented that staff heard Resident B yelling, found him standing and hovering over Resident C while yelling, and assisted him back to bed, again administering PRN lorazepam. Despite this, there were no new interventions implemented, no change in room assignment, and no documented notifications to the DON, Administrator, charge nurse, Memory Care Director, or other responsible leadership regarding these behaviors. Staff later reported that Resident B “yelled all the time” and that the nurse on duty did not report the incident of hovering over the roommate to anyone, and key staff including the Memory Care Director, Nurse Consultant, and primary day-shift RN were unaware of the 12/11/25 incident. Both residents remained in the same room, and on 12/28/25 an incident note documented that Resident B and Resident C were involved in a physical altercation. The residents were separated and assessed; Resident B had no injuries, but Resident C was sent to the hospital and diagnosed with a depressed fracture of the anterior wall of the left maxilla with associated maxillary hemorrhage. The facility’s behavior management policy in effect at the time required staff who witnessed behaviors to report them to the resident’s care staff and document accordingly, and to temporarily separate residents if behaviors were disruptive to others. The failure to report and act on the earlier verbal and threatening behaviors, including the hovering and yelling over the roommate, led to a lack of interventions to prevent the later physical altercation that caused injury.
Removal Plan
- Implemented a plan of correction and held a quality assurance meeting with department heads
- Inserviced all staff on the different types of abuse and reporting abuse
- Inserviced staff on the behavior management program for residents with new or worsening behaviors, including when and who to report those behaviors
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A resident exited the building through a bedroom window, walked off the property, and was observed and redirected by staff with assistance from law enforcement, who encountered the resident down the road and helped escort the resident back. The facility’s internal documentation lacked staff or witness statements and characterized the event as the resident remaining on facility grounds without injury. Despite the resident’s account, a police report, and a maintenance staff report confirming that the resident left the premises and that law enforcement responded, the DON did not report the incident to required state and federal agencies, even though the DON acknowledged that any incident involving law enforcement response must be reported.
Failure to timely report alleged verbal abuse: A volunteer reported that an activities staff member yelled at a resident during bingo, told the resident to stop interrupting, and also yelled at the volunteer when she intervened. The resident later described the staff member as rude and said the comment made him/her angry. Survey review found no evidence the allegation was reported, and the RCD confirmed the facility had no evidence of reporting despite policy requiring immediate reporting of abuse allegations.
The facility failed to ensure that alleged abuse and serious injuries were reported to the State Survey Agency as required, instead either reporting only to a state patient safety system or not reporting at all. One resident with severe cognitive impairment sustained bilateral femur fractures after a fall, another cognitively impaired resident with Parkinson’s disease was later found to have a femur fracture after being discovered on the floor, and a third cognitively impaired resident required ORIF surgery for fractures following a fall; none of these incidents were reported through the State Survey Agency’s incident reporting website, per the ADM. In addition, an allegation that a resident with dementia and sensory impairments may have been molested was documented in the abuse binder but not in the medical record, and the ADM did not report the allegation to agencies or law enforcement after deeming it not credible, despite interviewing the resident and family. These actions and omissions resulted in multiple unreported events that met criteria for immediate reporting of alleged abuse and injuries of unknown source.
The facility failed to report an allegation of abuse after a resident with a history of cerebral infarction, moderate cognitive impairment, and wheelchair use told an LPN that another resident hit him and showed a bruise on his arm. The resident later described being punched by another resident in the hallway, stating that a CNA and another staff member witnessed the incident. The Administrator and DON focused on investigating the bruise as resulting from the resident bumping into a door frame or another resident’s wheelchair and, based on that conclusion, did not report the allegation to authorities, despite the facility’s abuse policy requiring immediate protection of residents and prompt investigation of all possible abuse reports.
A resident with paraplegia, reduced mobility, and dependence on staff for transfers developed new swelling and edema of the right lower leg, initially denying any known trauma. Nursing staff notified the physician, applied ACE wraps, and later sent the resident to the ED when swelling and vascular concerns worsened, where imaging revealed acute fractures of the right tibia and fibula. Although the injury’s origin was initially unknown and no clear root cause was established, facility leadership did not submit an incident report to the State Agency, relying instead on later documentation suggesting the leg was accidentally hit by a wheelchair.
A resident with a known history of attempting to leave the facility exited through the front door in the early morning, triggering both the door alarm and an elopement prevention device. The DON shut off the main alarm, looked outside but did not immediately exit the front door or make an overhead announcement, leading to confusion among staff about which door had alarmed and whether anyone was missing. CNAs searched the grounds, and an LPN used a car to search nearby streets, eventually locating the resident walking with a walker near a gas station, cold and without a coat, in freezing temperatures along a main highway. An RN then assisted in persuading the resident to return, with the total time away exceeding 25 minutes. The incident, which posed a risk to the resident’s health and safety, was not reported to the State Agency as required by the facility’s abuse, neglect, and exploitation reporting policy.
Failure to Report Elopement Incident Involving Law Enforcement
Penalty
Summary
The deficiency involves the facility’s failure to report an elopement incident to required state and federal agencies as mandated by 42 CFR 483.12(c). On the referenced date, Resident #5 exited the building through his bedroom window around 12:15 PM and walked across the facility property toward the perimeter fence. A CNA observed the resident outside and called for assistance, after which staff redirected and escorted the resident back into the building and placed him on one-to-one supervision. The facility’s internal incident documentation noted the window exit and subsequent maintenance inspection of the window seals but did not include any staff or witness statements. The DON later stated that the resident never left facility grounds and was returned without injury, and therefore the incident was not considered reportable. However, interviews and external records showed that the resident did leave the facility premises and that law enforcement was involved. Resident #5 recalled being outside the facility, being brought back by staff and a “police man,” and being told by the officer not to leave again. A police report from the local police department confirmed an encounter with the resident outside the facility and that an officer assisted staff in escorting him back. Maintenance staff (Staff G) also reported that the resident climbed out the window, left the facility property, and was stopped “down the road,” then redirected back with law enforcement assistance. In interviews, the DON initially denied that law enforcement had been notified or involved, then later acknowledged that law enforcement had responded but asserted they did not come into the facility. The DON also confirmed awareness that any incident in which law enforcement investigates or responds is required to be reported, yet the elopement and law enforcement involvement were not reported to the State Survey Agency or other required officials within the required time frames.
Failure to Timely Report Alleged Verbal Abuse
Penalty
Summary
The facility failed to ensure an allegation of verbal abuse was reported timely for resident #55. A volunteer submitted a grievance stating that during bingo on 2/14/26, activities staff member #1 yelled at resident #55 after the resident called out bingo and told the resident to stop interrupting while she was talking. The volunteer reported that the staff member continued yelling for a couple of minutes, and when the volunteer intervened and told the staff member to stop yelling at the resident, the staff member yelled at the volunteer as well. The grievance also stated that two residents, including resident #55 and resident #66, reported that the activities staff member yells at them all the time and speaks to them the same way every time they play bingo. Resident #55 later stated that the issue involved the activities staff member being rude during bingo and saying, in a smart-ass way, "weren't you paying attention?" The resident said the comment made him/her angry and that [he/she] called the staff member names. The volunteer confirmed hearing the staff member speak loudly and rudely to the resident and then yell at the volunteer before storming off. Review of the state survey agency incident database showed no evidence the allegation was reported, and the regional clinical director confirmed the facility had no evidence the verbal abuse allegation was reported. The facility policy required alleged abuse to be reported to the Administrator, state agency, adult protective services, and other required agencies within specified timeframes, immediately but no later than 2 hours when the allegation involved abuse or serious bodily injury.
Failure to Report Alleged Abuse and Serious Injuries to State Survey Agency
Penalty
Summary
The deficiency involves the facility’s failure to ensure that all alleged violations of abuse, including injuries of unknown source and incidents involving major injuries, were reported immediately to the State Survey Agency and other officials as required by state law. For four sampled residents, the Administrator acknowledged that incidents were reported only to the state’s patient safety website and not to the State Survey Agency’s incident reporting website. This omission meant that the State Survey Agency did not receive timely notice of serious events, including an allegation of sexual abuse and multiple incidents resulting in significant fractures and surgery. For one resident with severely impaired cognition and diagnoses including hemiplegia and hemiparesis, nursing notes documented that the resident was found on the floor after attempting to get out of bed, was sent to the ER, and returned with immobilizing braces on both legs due to bilateral femur fractures. The resident’s bones were not strong enough for surgery, and he was placed on comfort care. Despite the seriousness of the injuries and the requirement to treat such events as potential abuse or neglect until ruled out, the Administrator stated that this incident was reported only to the state’s patient safety website and not to the State Survey Agency’s incident reporting system. Another resident with Parkinson’s disease and severely impaired cognition was found on the floor after a wheelchair alarm sounded, initially with no visible injury and able to bear weight. A few days later, staff documented complaints of left leg pain, tenderness, and wincing with movement, leading to an order for x‑rays and transfer for imaging. X‑ray results revealed a femur fracture, and surgery was not pursued. The Administrator reported this incident to the state’s patient safety website but not to the State Survey Agency’s incident reporting website. A third resident with severe cognitive impairment experienced a fall with complaints of pain in the left knee, left elbow, and fingers, and later underwent ORIF surgery for fractures of the right fourth and fifth metacarpals; this incident also was not reported to the State Survey Agency’s incident reporting system, according to the Administrator. For another resident with dementia, adjustment disorder with anxiety, hearing and visual loss, and age‑related debility, a document in the facility’s abuse binder described a possible molestation allegation originating from a phone call by the resident’s nephew. The nephew reported that his mother, the resident’s sister and then‑POA, was emotionally unstable and had stated she felt the resident had reported being molested. The Administrator documented that the nephew did not believe the allegation was credible, that the sister had dementia and emotional issues, and that the Administrator considered the report “not a viable allegation.” The Administrator noted that he interviewed the resident, who denied being touched, and that the sister could not provide more details beyond stating that a man had groped the resident’s breast. The Administrator concluded the allegation was not credible and did not report it to any agencies or law enforcement. The incident was not documented in the resident’s medical record, and the Administrator confirmed in interview that he did not report this sexual abuse allegation to the State Survey Agency’s incident reporting website. Across these four residents, the common deficiency was the facility’s failure to treat serious injuries and a sexual abuse allegation as reportable events to the State Survey Agency, as required. Instead, the Administrator limited reporting to the state’s patient safety website or chose not to report at all when he personally judged an allegation as not credible. This pattern of inaction regarding mandated reporting requirements formed the basis of the cited deficiency.
Failure to Report Resident’s Allegation of Physical Abuse
Penalty
Summary
The facility failed to report an allegation of abuse involving one resident when the resident reported being hit by another resident and presented with a bruise. The resident, who had a history of cerebral infarction, was moderately cognitively impaired per the MDS and used a wheelchair, and was care planned as being at risk for abuse and neglect. The resident told an LPN that someone had hit him and showed a bruise on his left arm; the LPN notified the Administrator. The resident later stated he had been going down the hall, asked another resident to move, and that the other resident punched him in the arm, allegedly witnessed by a CNA and another staff member. The Administrator stated she was not aware of the abuse allegation and that they investigated the bruise as having resulted from the resident bumping into a door frame, and therefore it was not reported. The DON stated she conducted interviews regarding the bruise and concluded it was caused by the resident running into another resident’s wheelchair, and also did not report the allegation, despite the facility’s abuse policy requiring immediate protection of residents and prompt investigation of all reports and allegations of abuse. The deficiency centers on the facility’s failure to treat the resident’s statement that another resident hit him as a reportable allegation of abuse and to report it to the proper authorities, instead focusing only on determining an alternative cause for the bruise. This inaction occurred despite the resident’s documented risk for abuse and the facility’s written abuse policy that requires immediate protection and aggressive investigation of all possible abuse reports.
Failure to Timely Report Injury of Unknown Origin Involving Lower Extremity Fractures
Penalty
Summary
The deficiency involves the facility’s failure to timely report an injury of unknown origin to the State Agency within the required two-hour timeframe for one resident with fractures of the right tibia and fibula. The resident had paraplegia, reduced mobility, weakness, adult failure to thrive, neuralgia, neuritis, and a history of right tibia and fibula fractures with routine healing. The resident required staff assistance with dressing, turning, and transfers using a mechanical lift, and used a wheelchair for mobility. On the morning of 4/14, the night nurse reported new edema of the resident’s right lower leg; the resident denied hitting his leg on anything. The physician was notified and ordered ACE wraps and observation, with an x-ray to be obtained if the condition did not improve. Later that night, due to increased swelling, +3 pitting edema, and poor capillary refill, the on-call physician was notified and the resident was sent to the emergency department for suspected fracture. In the emergency department, imaging showed an acute oblique longitudinal fracture of the distal tibial shaft with a lateral cortical step-off and a mildly displaced distal fibular shaft fracture. The ED documentation noted that swelling had started one to two days earlier, there were no recent falls or notable injury, and it was reported that the resident accidentally hit his right lower leg in a wheelchair. The resident returned to the facility with a diagnosis of closed fractures of the right tibia and fibula, and the DON was notified. No incident report related to these fractures was submitted to the State Agency. During interview, the DON acknowledged that the incident was not reported and that, prior to hospital transfer, the resident did not know how the injury occurred. The admissions director stated that, because hospital paperwork later attributed the injury to the wheelchair, they determined it did not meet criteria for reporting, even though the origin of the injury was initially unknown and a definitive root cause could not be established.
Failure to Report Resident Elopement in Freezing Conditions
Penalty
Summary
The deficiency involves the facility’s failure to report an elopement incident to the State Agency (SA) as required by its abuse, neglect, and exploitation policy. A resident identified as R10, who was known by staff to have previously attempted to leave the facility and was considered an elopement risk, exited the building through the front door in the early morning hours. When R10 left, both the front door alarm and the elopement prevention device alarm were activated. The DON was in the building, went to the front door, shut off the main alarm, and realized the elopement prevention device was sounding. The DON looked outside but did not exit through the front door, and there was no immediate overhead announcement identifying which door had alarmed or whether a resident was missing, which created confusion among staff. Following the alarm, CNAs went outside to look in the parking lot and surrounding areas around the building, and another CNA spoke with the DON at the door. A head count was then called, and an LPN determined that R10 could not be found in the building. The LPN got into her car and drove to the main street to search for the resident. During this time, the service drive was described as snowed in with no footprints in the snow, and staff did not initially know which door had alarmed. The LPN eventually located R10 walking near a gas station but reported that the resident refused to get into the car, prompting an RN to drive to the location to assist. The RN later stated that it took about 20 minutes to find R10 and additional time to pick her up and convince her to get into the car. The facility’s investigation confirmed that R10 left the building at approximately 5:15 AM and was gone for over 25 minutes, walking with a walker outdoors. Historical weather data reviewed by the surveyor showed temperatures between 22 and 29 degrees Fahrenheit on the day of the incident, and the resident was described as cold and freezing, without a coat, while walking on a sidewalk next to the main highway. The surveyor determined that this situation represented a risk to the resident’s health and safety, and it was further found that the elopement incident was not reported to the SA, despite the facility’s policy requiring reporting of such events within specified timeframes.
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