Failure to Provide Appropriate Dementia‑Focused Care and Responses to Behavioral Incidents

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to provide adequate, necessary, and effective interventions for a resident with dementia and behavioral symptoms, as outlined in his care plan. The resident was admitted with vascular dementia, unspecified psychosis, depression, seizure disorder, cognitive communication deficit, unsteadiness on feet, and muscle weakness, and had a care plan addressing behaviors such as restlessness, anxiety, physical aggression, hallucinations, delusions, exit seeking, verbal aggression, and wandering. The care plan interventions included approaching the resident calmly, re-approaching later if he became agitated, attempting redirection, communicating care before tasks, providing non-judgmental support, keeping him safe during behavioral episodes, documenting behaviors, notifying the physician when behaviors persisted, and using non-pharmacological interventions and activities of interest to keep him engaged. On the evening of the incident, during a medication pass, an RN heard yelling and arguing from another resident’s room and found the cognitively impaired resident standing by a female resident’s bed while both residents were hitting and smacking each other. The resident was yelling at the female resident to get out of his bed. The RN attempted to separate the residents and diffuse the situation, and an unidentified CNA took the resident to the nurses’ station, where he continued to be physically abusive and verbally aggressive toward staff. The physician was notified and new orders were obtained for Haldol and Depakote, and the resident’s son consented to the new medications. The resident was later taken to bed and fell asleep, and the as-needed Haldol was not administered, but Depakote was started as a daily medication. The nursing progress note did not document specific details on how staff attempted to diffuse the situation or what non-pharmacological interventions were used in response to this behavioral episode. Subsequent documentation indicated that the resident had been reported to the physician as having increased agitation and aggressive behaviors with psychotic issues, and that Depakote had been started in response to the incident. The physician later documented that the resident was being treated inappropriately and that his behaviors were instigated by staff, describing the resident as being in a protective mode and stating that he had been told a CNA grabbed the resident. The physician stated that staff should have tried redirection without force, removal from the provoking area, and other calming strategies, and that holding down a cognitively impaired resident could elicit a retaliatory response. CNAs interviewed about the incident reported that they “arm to armed” the resident by wrapping their arms around his arms to move him from the other resident’s room to a chair near the nurses’ station, and that when he stood up and became argumentative or went toward a CNA, they again “arm to armed” him back into the chair. One CNA reported that additional staff from another floor came up and that this likely worsened the resident’s agitation and was overwhelming for him. Multiple CNAs stated they did not feel properly trained to deal with aggressive behaviors, reporting only limited or computer-based training and describing that management’s guidance was mainly to offer food or snacks during behaviors, which contrasted with the more comprehensive behavioral management approach described in the facility’s behavior management policy and the resident’s care plan. The facility’s behavior management policy required that residents exhibiting behaviors negatively affecting themselves or others be reviewed by a behavior management team, that root causes and target behaviors be identified, and that individualized plans of care and non-pharmacological interventions be used to minimize the need for medications or allow for the lowest possible dose. In this case, the record and interviews did not show that the non-pharmacological, de-escalation, and redirection strategies specified in the resident’s care plan and the facility’s policy were effectively implemented or documented during and after the behavioral episode. Instead, staff used physical control techniques (“arm to armed”) and obtained new psychotropic medication orders without clear evidence of prior, thorough use of individualized, non-pharmacological interventions as outlined in the care plan and policy. This failure to follow the resident’s behavior care plan and the facility’s behavior management program requirements led to the cited deficiency for not ensuring the resident received appropriate treatment and services for dementia-related behaviors.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to provide necessary dementia care and treatment to maintain the safety and well-being of residents on the secured dementia unit, particularly one resident with severe vascular dementia and significant behavioral symptoms. The resident was admitted with diagnoses including severe vascular dementia without behavioral disturbance, major depressive disorder, alcohol dependence with alcohol-induced persisting dementia, anxiety disorders, restlessness, and agitation. Physician orders over time included multiple psychotropic and mood-stabilizing medications (Depakote, Zyprexa, Ativan, Rexulti) and an order for placement on the secured unit. A quarterly MDS assessment documented that the resident was severely cognitively impaired, exhibited hallucinations, delusions, physical behaviors toward others, other behavioral symptoms, rejection of care, and wandering, and required maximum assistance for all personal care except eating. From admission through discharge, nursing progress notes documented escalating and persistent behaviors, including wandering into other residents’ rooms, placing clothes and items in toilets, exit-seeking, and increasing agitation and aggression. Early in the stay, staff documented incidents such as the resident exposing himself and urinating on the floor and wall, with staff providing redirection and cleaning. Over time, the resident was repeatedly found in female residents’ rooms, sometimes naked, engaging in inappropriate sexual behavior on their beds, defecating in hallways, and attempting to rub feces on other residents. The resident was transferred for psychiatric evaluation when the psychiatric practitioner indicated the facility was unable to manage his behaviors, and upon readmission he was placed on one-to-one supervision and moved between unsecured and secured units due to a COVID-19 outbreak. Despite these measures, his behaviors of wandering into female residents’ rooms, insisting they were his wife, inappropriate elimination, and physical aggression toward staff and residents continued. Care plan review showed that a behavior care plan and a mood/behavior care plan were initiated early in the stay, with generic interventions such as encouraging social activities, explaining things in a way the resident could understand, administering medications as ordered, monitoring labs, charting behaviors, observing for early warning signs, and consulting psychiatric services. The behavior care plan was last revised on a date that did not reflect the later, more severe behaviors, and the mood/behavior care plan was never revised during the resident’s stay. The care plans did not address specific risks or interventions related to the resident entering female residents’ rooms naked, insisting they were his wife, attempting to get into bed with them, or the use of one-to-one supervision upon readmission. Referral information from the prior facility indicated that the same types of behaviors had been present before admission. Staff and administrator interviews revealed that female residents were afraid of the resident, some were barricading their doors, and that the administrator did not initially consider the resident’s naked entry into female residents’ rooms and attempts to get into bed with them as sexually inappropriate behavior. A documented incident described the resident in the hallway with genitals exposed, refusing redirection, becoming physically aggressive with an LPN, and then entering a female resident’s room naked, claiming she was his wife, and forcefully attempting to get into her bed, leading to the female resident falling out of bed while trying to get away. These events occurred despite the facility’s written dementia care policy, which described person-centered, individualized approaches and staff training for managing dementia-related behaviors, and led surveyors to determine that the facility failed to provide necessary dementia care and treatment for this resident, with the potential to affect all residents on the secured unit. Interviews with staff and leadership further detailed the actions and inactions contributing to the deficiency. An anonymous employee reported that staff concerns about the resident’s behaviors, including entering rooms naked and frightening female residents, were repeatedly brushed off by the administrator until after a female resident fell and subsequently did not walk as before. The administrator acknowledged being aware that the resident had a history of behaviors at the prior facility, including inappropriate urination, wandering, and minimal sleep, and that he believed female residents were his wife. The administrator also stated she did not conduct an on-site review before admission based on advice from the former admissions/marketer director and was initially hesitant to accept the resident. Despite a prior transfer for psychiatric evaluation due to the facility’s inability to manage his behaviors, the administrator decided to readmit him, believing the secured unit could handle his needs. The administrator reported receiving emails from families requesting the resident’s discharge and was unaware that female residents were barricading their doors because staff did not inform her. The combination of inadequate behavior-specific care planning, failure to adjust interventions in response to ongoing and escalating behaviors, and leadership’s handling of staff and resident concerns led to the determination that the facility did not provide appropriate dementia care and services to ensure the safety and well-being of residents on the secured unit.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to develop and implement comprehensive, individualized, and effective behavioral health treatment plans and services, including non‑pharmacological interventions, for residents with dementia and behavioral disturbances, which resulted in resident‑to‑resident altercations and actual harm. Two residents with dementia and significant behavioral histories repeatedly wandered, entered other residents’ rooms, and displayed agitation and aggression without evidence of effective monitoring or individualized non‑pharmacological strategies to manage these behaviors or prevent altercations. The facility relied heavily on psychotropic medication adjustments and brief periods of increased supervision, without documenting or care‑planning specific behavioral interventions tailored to each resident’s needs. One resident had vascular dementia with behavioral disturbance, agitation, anxiety, sundowning, combative behavior at night, and a history of throwing a chair, walking naked, and visual hallucinations. Orders included multiple psychotropic medications such as Haldol, Ativan, Vistaril, Depakote, Trazodone, and later Klonopin, with several dose changes over time. Nursing notes repeatedly documented this resident wandering the halls, entering other residents’ rooms, pacing, yelling, slamming chairs and doors, being verbally and physically aggressive, and having explosive episodes. The care plan identified mood and behavior problems, including disruptive behavior, resisting care, socially inappropriate behavior, wandering into other rooms, exit seeking, and combativeness, but listed only general interventions such as consulting social services, administering medications, monitoring behaviors, and gentle redirection. There was no documented evidence of specific non‑pharmacological interventions being planned or implemented to address these behaviors. The second resident had diagnoses including behavioral disturbance and agitation, intermittent explosive disorder, major depressive disorder, psychotic disorder, delirium, and later severely impaired cognition, with documented behaviors such as wandering daily, rejecting care, and physical and verbal behaviors toward others. This resident frequently wandered into other residents’ rooms and was found in their recliners or beds, yet the record showed no non‑pharmacological interventions to address wandering or to prevent altercations. Multiple incidents occurred between the two residents: one resident hit the other on the jaw while the victim sat near the nurse’s station; on another occasion, one resident repeatedly rammed a walker into the other’s legs, leading to mutual hitting and facial scratches; and later, the wandering resident entered the other’s room, resulting in a serious altercation where the victim was found on the floor with significant facial trauma, periorbital swelling, scalp laceration, and a large bruise from hip to knee. Despite these escalating events and the known mutual dislike between the two residents, interviews and record review confirmed that no new, individualized non‑pharmacological interventions were added beyond temporary increased or one‑on‑one supervision, and the facility did not effectively implement behavioral health services to prevent further resident‑to‑resident altercations. Title: Failure to Implement Effective Dementia Behavioral Care Leading to Resident Altercations ShortSummary: Two residents with dementia and significant behavioral histories repeatedly wandered, entered other rooms, and displayed agitation and aggression without individualized non‑pharmacological interventions or effective behavioral health care plans. Staff documented frequent wandering, pacing, yelling, slamming furniture, and explosive episodes, and the care plans relied largely on psychotropic medications and general redirection rather than specific, person‑centered strategies. Multiple altercations occurred, including one resident striking another near the nurse’s station, an incident involving a walker being rammed into another resident’s legs with mutual hitting and facial scratches, and a later episode in which a wandering resident entered another’s room and sustained significant facial trauma, scalp laceration, and extensive bruising. Records and interviews confirmed that, despite these events and awareness that the two residents did not get along, the facility did not develop or implement comprehensive, individualized non‑pharmacological interventions to manage behaviors or prevent further resident‑to‑resident altercations.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

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

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A deficiency occurred when staff failed to provide appropriate and dignified dementia care to a resident with severe cognitive impairment and a diagnosis of Alzheimer's disease. The resident required one-person assistance with activities of daily living (ADLs) and had care plans in place that emphasized respecting her right to refuse care, maintaining a calm environment, and not forcing her to complete tasks. Despite these documented approaches, three CNAs attempted to provide incontinence care while the resident was combative, resulting in the staff holding her wrists and arms. This led to significant bruising on both wrists and lower forearms, as confirmed by skin assessments and X-rays ordered due to complaints of pain. The incident was precipitated by the resident's refusal of care and escalating combative behaviors, including hitting, kicking, biting, and pinching. Staff attempted multiple comfort and redirection measures, but these were ineffective. Instead of discontinuing care and re-approaching later, as outlined in the care plan and facility training, the staff proceeded with care by physically restraining the resident's wrists. There was no documentation indicating that the nurse was notified of the resident's escalating behavior or that the situation required immediate intervention for safety. The medical record and investigation did not provide evidence that care could not have been delayed or that the resident was unsafe if care was postponed. Interviews with staff and review of facility policies confirmed that staff were trained to step away and re-approach residents who refused care, and that physical restraint or force was not an acceptable practice. The facility's abuse prevention policy and dementia care training both emphasized the importance of respecting resident rights and using non-physical interventions. Despite this, the staff involved did not follow these protocols, resulting in actual harm to the resident in the form of bruising and pain.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide specialized memory care services as advertised for all residents residing on the memory care unit. Record review showed that multiple residents with diagnoses such as dementia, Alzheimer's disease, depression, and other cognitive impairments were admitted to the unit. Despite facility brochures and fliers promoting a specialized memory care program, interviews with staff and observations revealed that no specific memory care program or specialized activities were implemented. The activities provided to memory care residents were the same as those offered to the rest of the facility, and there was no separate activity calendar or tailored programming for the memory care unit. Observations on the memory care unit showed a lack of engagement and stimulation for residents, with minimal activities occurring and residents often left sitting in common areas or in their rooms without interaction. Staff interviews confirmed that the activity director was unable to provide activities for the memory care unit due to other responsibilities, and activity assessments for these residents were not completed until after they were requested by surveyors. The only activities listed, such as beverage cart and sit and chat, were not consistently provided, and staff did not consider them meaningful activities. Residents were not routinely invited to participate in facility-wide activities, and the activity room was locked when the activity director was not present. Staffing on the memory care unit was consistently reported as inadequate, with only one aide assigned per shift, leading to periods when residents were left unsupervised while staff attended to individual care needs. Staff and family interviews expressed concerns about resident safety and the lack of engagement, stimulation, and supervision. Families reported not being informed about the benefits of memory care and expressed expectations for more specialized activities and higher staffing levels. The facility's own policies and job descriptions outlined requirements for individualized activity programming and assessments, which were not met for the memory care residents.