Failure to Provide Adequate Behavioral Health Services and Supervision for Residents With Dementia and Sexual Behaviors
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
Resources
Below are regulatory guidelines relevant to this citation:
A resident with dementia, psychosis, and a history of aggressive behaviors had a care plan calling for calm approaches, redirection, re-approach after de-escalation, non-judgmental support, and other non-pharmacological interventions. During a behavioral episode in which the resident entered another resident’s room and both began hitting each other, staff separated them and physically controlled the resident by "arm to arming" him to a chair near the nurses’ station, repeating this when he tried to get up and became argumentative. Documentation did not describe specific de-escalation or non-pharmacological measures used, and staff reported limited, mostly computer-based training on managing aggressive behaviors. The physician later indicated the resident’s behaviors were instigated by staff and that forceful handling could provoke retaliatory responses, while the facility’s behavior management policy required individualized, non-pharmacological strategies before or alongside psychotropic medication use. This resulted in a deficiency for not providing appropriate behavioral interventions consistent with the resident’s care plan.
A resident with Alzheimer's Dementia, chronic pain, and diabetes was rarely or never understood, had short-term memory problems, made poor decisions, and needed extensive ADL assistance. The EHR showed no care plan for the dementia diagnosis and no behavior monitoring on the MAR, and an RCM/LPN stated they could not locate a dementia care plan for the resident.
The facility failed to provide individualized dementia-focused treatment, activities, and supervision for several cognitively impaired residents on a memory unit. Care plans did not identify residents’ activity preferences or specify meaningful, personalized activities despite documented dementia, behaviors, and need for assistance. Observations showed residents sitting idle, wandering aimlessly, entering cupboards and rooms, yelling out, and one resident repeatedly exposing herself, while an activity aide only played music or passed donuts and drinks without engaging residents in structured activities. Nursing notes documented frequent falls related to self-transfers, physical altercations, feces smearing, and ongoing intimate contact between two residents despite a family member’s explicit request that they be kept apart. Staff interviews revealed that there had been no consistent activities on the unit, residents were largely unsupervised while staff performed care and med passes, and staffing levels were below required ratios, leaving only two aides for about 30 residents. The deficiency was cited under state regulations for resident care planning and nursing services.
Failure to provide person-centered dementia care and services: A resident with severe dementia, anxiety, and diabetes was repeatedly observed calling out for help while lying or sitting in a hospital gown with poor grooming and minimal stimulation in her room. Staff described her as easily overstimulated, needing one-on-one attention, and having worsening confusion and refusals of care, yet her activity plans were conflicting and did not include her known preferences such as classical music, the Beatles, quiet settings, or individualized sensory interventions. Records also showed no recent activity participation, and staff stated no dementia-specific interventions were in place beyond routine activities.
A resident with dementia, bipolar disorder, impaired cognition, and a documented history of exit-seeking behaviors was not accurately identified as an elopement risk on the facility’s Wander/Elopement Risk Evaluation, which failed to list dementia or other decision-making impairments and concluded there was no elopement risk. Despite care plan directives to assess elopement risk and facility policies requiring identification of residents at risk for unsafe wandering or elopement, staff, including an LVN, did not recognize or document the resident’s dementia diagnosis on the risk tool. Subsequently, the resident, who used a wheelchair independently and had been awake and moving in the hallway overnight, self-propelled past a nearby housekeeper and exited through an unlocked front door, and was later discovered missing during rounds, prompting a facility search and police notification.
A resident with dementia and a history of intrusive wandering and agitation was found lying in another resident’s bed despite care plans directing staff to redirect her to her own room or a quiet area. A laundry aide identified the room but did not redirect the resident or notify nursing staff, and an MCSS initially looked into the room and left before being informed the resident was still there. The other resident became visibly upset and stated the resident did not belong in the room.
Failure to Implement Care-Planned Behavioral Interventions for Dementia-Related Episode
Penalty
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.
Missing Dementia Care Plan and Behavior Monitoring
Penalty
Summary
Failure to provide appropriate treatment and services for a resident with dementia was identified for Resident 9, who was admitted with diagnoses of Alzheimer's Dementia, chronic pain, and diabetes. The resident was rarely or never understood, had short-term memory problems, made poor decisions, and required extensive assistance with activities of daily living. Review of the electronic health record showed there was no care plan specifically addressing Alzheimer's Dementia, and the April 2026 MAR showed no behavior monitoring in place related to the dementia diagnosis. During interview, the RCM/LPN stated they were unable to locate a care plan for Resident 9 related to dementia care and stated the expectation was that residents have an individualized care plan addressing all areas of care.
Failure to Provide Individualized Dementia Care, Activities, and Supervision on Memory Unit
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to provide appropriate treatment and services for multiple residents with dementia residing on the Memory Impaired Unit (MIU). The facility’s own assessment dated April 6, 2026 stated that the MIU offers specialized cognitive activities provided by staff trained in dementia care and that Life Enrichment staffing should include one full-time director and three full-time aides. However, review of care plans and observations showed that residents with dementia did not have individualized activity preferences identified or implemented. For example, quarterly MDS assessments for four cognitively impaired residents with dementia (Residents 9, 10, 11, and 12) showed needs for staff assistance and, in some cases, independent ambulation and behaviors, yet their care plans either failed to identify activity preferences or contained only vague, non-individualized directions such as providing activities resembling a prior lifestyle without specifying what those activities were. Observations on the MIU over two days showed that residents were not being engaged in meaningful or structured activities despite the unit’s stated purpose. On one day, 14 residents were observed sitting around tables in the common room while an activity aide played music but did not engage them in any activity. One resident repeatedly pulled her shirt over her head, exposing her breasts, and staff were not consistently present in the common room to address this behavior. No further activities were observed that day. On the following day, an activity aide brought a coffee cart with donuts and drinks, but service to residents was delayed, two residents were not offered any items, and no group activity or engagement occurred. During these observations, residents were seen wandering aimlessly, getting into cupboards and drawers, yelling out, or sitting and sleeping in the common area without stimulation. Clinical record review and nursing notes documented frequent falls and behavioral incidents among the cognitively impaired residents. One resident (Resident 9) was involved in a physical altercation in which he punched his roommate in the face. Another resident (Resident 10) experienced numerous falls over a span of weeks and months, often while attempting to self-transfer from bed, chairs, or to the bathroom, and was also noted to remove her ostomy bag and smear feces in various places. Residents 11 and 12, both with dementia and independent ambulation, were repeatedly documented as engaging in close physical contact, including holding hands, attempting to leave the unit together, and being found in bed together with exposure noted, despite a family member’s clear request that they be separated and that contact not be permitted or encouraged. Staff interviews revealed that there had not been activities in the MIU for some time, that residents wandered the locked unit without redirection while staff were occupied with care and medication administration, and that staffing levels were below the facility’s own requirements, leaving only two nurse aides for 30 residents at times. The Nursing Home Administrator acknowledged that staffing was out of compliance and that the facility was unable to meet necessary nurse aide ratios or daily PPD, contributing to the failure to provide appropriate dementia-specific treatment and services. The deficiency was cited under 28 Pa. Code 211.11(d) Resident care plan and 28 Pa. Code 211.12(d)(5) Nursing services, based on the lack of individualized activity care planning for residents with dementia, the absence of consistent, specialized cognitive activities and engagement on the MIU, the unmanaged wandering and behavioral issues, and the inadequate staffing that left residents largely unsupervised and without appropriate redirection or structured activities.
Failure to Provide Person-Centered Dementia Care and Services
Penalty
Summary
The facility failed to provide person-centered dementia-specific care and services for a resident with diagnoses including type II diabetes mellitus with diabetic neuropathy, unspecified dementia with agitation, and anxiety disorder. The resident was repeatedly observed lying in bed or sitting in a wheelchair in a hospital gown, with unkempt grooming at times, including tangled or greasy hair, a soiled bandage on the upper right forehead with dried dark substance around it, and long fingernails with dark debris under them. Her room often contained only a television on a news station, with no other sensory stimulation observed, while she was heard repeatedly calling out, "help, help, help me please." Facility staff described the resident as having severe dementia that had worsened after returning from the hospital. The wound NP stated she was confused, often refused turning/repositioning and insulin, and no longer could have mildly coherent conversation, instead repeatedly saying "help help, please help me" even when her needs had been met. An LPN stated the resident used to answer some yes/no questions but now mostly said "help help help," and staff did not know what activities would help beyond visiting with her. Another LPN stated the resident was easily overstimulated, preferred one-on-one time, and most enjoyed someone sitting with her or holding her hand at all times. The resident’s record showed prior documentation that her guardian and the facility agreed she would be better suited for an all-female dementia care unit, and later notes stated she would benefit from a dementia unit and might transition there once Medicaid was approved. Her activity care plans were conflicting, with one indicating she was self-directed and another indicating she was dependent on staff for activities, cognitive stimulation, or social interaction. Neither plan included her documented preferences such as the Beatles, classical music, one-on-one discussion approaches, or other sensory interventions. Activity records showed no coded activities for the prior 30 days, and she was not observed in activities on multiple days. The social service director stated no dementia-specific interventions were in place besides routine activities, and the guardian stated staff needed to be more proactive and dementia-aware, noting the resident did better in small quiet environments and liked music and books.
Failure to Accurately Assess Dementia-Related Elopement Risk Leading to Resident Elopement
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident with a diagnosis of dementia received necessary care and services related to dementia, specifically in the assessment and management of elopement risk. The resident’s admission record documented dementia, bipolar disorder, and insomnia, and the history and physical indicated the resident lacked capacity to understand or make decisions. The MDS assessment showed impaired cognition for daily decision-making and a need for supervision with ADLs. The resident’s care plan identified cognitive status that could increase the risk of wandering or exit seeking and called for assessment of elopement/wandering risk on admission, quarterly, and as needed. Despite these documented conditions and risk factors, the Wander/Elopement Risk Evaluation completed for the resident on 4/6/2026 did not indicate a diagnosis of dementia or any other diagnosis impacting decision-making and concluded the resident was not an elopement or wander risk. During interviews, LVN3 confirmed that the evaluation omitted dementia and other cognition-impacting diagnoses and still indicated no elopement risk, and also stated not knowing whether the resident had a dementia diagnosis. The DON later verified that the evaluation showed no dementia or decision-making diagnosis and that, based on the resident’s assessments and risk factors, the resident had multiple risks for elopement that should have triggered an elopement risk designation under the facility’s own evaluation instructions. On 4/11/2026, nursing progress notes documented that during morning rounds the resident was found missing from the room after having been awake all night and seen self-propelling in a wheelchair in the hallway. A facility search and Code Green were initiated, and local police were notified when the resident could not be located. Review of surveillance video from the front lobby showed the resident in a wheelchair near the front door while a housekeeper worked nearby. After the housekeeper briefly left the camera’s view, the resident rapidly self-propelled around a retractable barrier and exited through an unlocked front door. The housekeeper re-entered the lobby seconds later and continued working while the resident was no longer present. This sequence of events demonstrated that the inaccurate elopement risk assessment contributed to the resident eloping from the facility.
Failure to Redirect Resident with Dementia from Another Resident’s Bed
Penalty
Summary
The facility failed to provide appropriate treatment and services for a resident with dementia who displayed intrusive wandering and agitation. Resident 4’s clinical record showed diagnoses including dementia and multiple behavior care plans directing staff to redirect her to her own room or a quiet area, offer calm reassurance, and have her lay down when she became verbally or physically aggressive or wandered into other residents’ rooms. Despite these care plan interventions, Resident 4 was observed lying in another resident’s bed in a shared room on the memory care unit, with her eyes closed, while the door remained open and the other resident entered and then shut the door with Resident 4 still in the bed. During the observation, a laundry aide who was in the adjacent room came to the doorway, identified whose room it was, and left without redirecting Resident 4 or notifying nursing staff that she was in another resident’s bed. The Memory Care Support Specialist later came to the room, looked inside, and left before being informed that Resident 4 was still there; after being told, the MCSS entered to address the situation while the other resident repeatedly stated, in a raised and irritated voice, that Resident 4 did not belong in the room. The Memory Care Unit Manager stated that when Resident 4 was found in another resident’s bed, staff would normally redirect her to her own room and indicated the laundry aide should have redirected her or informed nursing staff.
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