The incident happened at 6:29 PM on September 14, 2024, when the resident with Alzheimer's disease walked to his roommate's side of their shared room, took a book, and struck the other resident on the left cheek when he tried to get it back. Staff found redness on the victim's face.
Federal inspectors who investigated the complaint found Marion Regional Nursing Home violated multiple care standards, including failing to protect residents from abuse and providing inadequate behavioral health services.
The aggressor had severe cognitive impairment with a mental status score of four out of 15, indicating advanced dementia. His diagnoses included Alzheimer's disease and mood disorder.
One day before the assault, a licensed practical nurse documented alarming behavioral changes. "Resident has been exhibiting some hostile behavior, resisting care, taking others belongings and becoming very agitated when request are made," the nurse wrote on September 13 at 3:15 PM. The hospice physician had ordered Depakote to address the behaviors.
The facility's own policy required "ongoing assessment, care planning and monitoring of residents with needs or behaviors that may lead to inadequate care, including abuse/neglect." The policy also mandated "assessing residents with signs and symptoms of behavioral issues with the development of targeted care plans."
Staff provided none of this.
Licensed practical nurse LPN #13 was charting at the nurses' desk around 6:30 PM when she heard the victim calling "help, help." She found the aggressor had hit his roommate and observed redness on the victim's cheek.
During interviews five months later, LPN #13 told inspectors the aggressor "was confused, had Dementia, and would pick up items." She said the resident "would go and pick up the personal items" belonging to his roommate, who "had a lot of items around."
When inspectors asked what level of supervision the aggressive resident required, LPN #13 said he "was monitored visually and redirected as needed and did not require one-on-one."
The Director of Nursing painted a different picture. She told inspectors the resident "was confused and had advanced Dementia" and "would plunder through RI #25's personal items and required redirection." But when asked about monitoring, she admitted "the staff were visually monitoring RI #313 for behaviors but there was no documentation of monitoring."
The facility provided no evidence of any behavioral monitoring.
Administrator told inspectors she learned of the incident around 7:00 PM from the social worker and director of nursing. She described how the confused resident "walked to RI #25's side of the room pilfering, picked up a book of RI #25's, and when RI #25 tried to get the book back, RI #313 hit RI #25 in the left side of the cheek."
The administrator said the roommates were separated after the incident, notifications were made, and an investigation began. Based on the victim's account and the visible redness on his cheek, the facility substantiated the incident as "resident on resident physical abuse."
The facility reported the abuse to the state at 8:11 PM through an online incident report.
Inspectors found additional violations involving respiratory care that put residents at infection risk. Four of five residents sampled had improperly maintained breathing equipment.
One resident's oxygen tubing lacked required dating labels. Three residents had nebulizer masks lying face-down on bedside tables and dressers without protective bags, violating the facility's own infection control policy.
The facility's nebulizer policy, last updated February 12, 2025, required masks to be "dried and stored when not in use" with "the residents name and the date written on the bag, tubing and mask."
Instead, inspectors found masks contaminated by direct contact with furniture surfaces. One resident's mask was observed lying face-down on a dresser on consecutive days. Another resident's mask sat directly on the nebulizer machine without any covering.
Licensed practical nurse LPN #12 acknowledged the violations when inspectors showed her the uncovered masks. She said masks "should be labeled with the resident's name and date and stored in a bag" and that "germs could get on the mask when not covered." She called the uncovered masks "an infection control issue."
The facility's infection preventionist, a registered nurse, explained that bacteria builds up on oxygen tubing, requiring 30-day replacement cycles and proper dating. She said nebulizer masks should be stored in labeled bags because "if there was no name on it, someone else could use it and that would be cross-contamination."
The Director of Nursing confirmed that undated oxygen tubing meant "staff would not know when it was last changed" and that uncovered nebulizer masks "could get contaminated."
Inspectors also found inaccurate resident assessments. Two residents had state-mandated mental health screenings indicating they required specialized services, but staff incorrectly marked their assessment forms as not needing such care.
Both residents had documented PASRR Level II determinations — one dated October 12, 2023, and another dated March 4, 2024. These screenings identify residents with serious mental illness or developmental disabilities who need enhanced services.
The facility's MDS coordinator admitted the coding errors when inspectors showed her the screening documents. She said the mistakes would be "corrected right away" and acknowledged the importance of accurate coding "to ensure accuracy of the MDS data."
One of the residents with the incorrect assessment was the victim of the September abuse incident, who had a documented mood disorder diagnosis.
The inspection violations affected multiple residents across different units. The abuse prevention failure affected one resident directly but potentially others given the lack of behavioral monitoring systems. The respiratory care violations affected four residents, and the assessment errors affected two residents.
Federal inspectors classified all violations as causing "minimal harm or potential for actual harm" but noted the facility's systematic failures to follow its own policies designed to protect resident safety and health.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Marion Regional Nursing Home from 2025-02-20 including all violations, facility responses, and corrective action plans.