The February 26 incident was one of at least five documented attacks by Resident #2 against other residents and staff since November. In each case, facility staff failed to implement basic supervision measures required by the resident's own care plan.
"When Resident #2 passed by Resident #1, she slapped him on his left cheek with her open hand," the incident report stated. A dietary aide witnessed the attack.
The 71-year-old woman's care plan specifically required staff to encourage her "to travel on one side of the hallway to mitigate disruptive interactions with others." Yet inspectors observed her wheeling freely through facility corridors on March 25 and 26, passing close to other residents without any staff intervention.
At 1:15 p.m. on March 25, Resident #2 left her room and propelled her wheelchair down the hallway toward the candy store. Staff members at the nursing station did not follow her. She passed close to two residents before returning to her room.
The pattern repeated at 3:10 p.m. when she wheeled to the dining room, again passing other residents without supervision.
Resident #2's attacks escalated over months. On January 2, she hit Resident #13 in the chest while he waited for her to pass in a hallway. "Get out my way," she told him after striking him.
Three weeks earlier, she grabbed another resident's hair after their wheelchairs made contact in a hallway.
The facility's nursing home administrator told inspectors that Resident #2 was "willful" in her physical abuse toward other residents, dismissing the connection between her dementia diagnosis and her aggressive behaviors.
Her care plan documented that she "hit people in the past due to being short tempered and impulsive responses" related to her Alzheimer's disease and schizoaffective disorder. The plan called for assigning a one-to-one caregiver for emotional support and keeping her away from residents she didn't get along with.
None of these interventions were observed during two days of continuous monitoring by inspectors.
On February 3, Resident #2 tried to hit and scratch a nurse who simply asked how he could help her. The nursing progress note documented her "continued irritability towards other residents at times in the hallways" and verbal aggression "when provoked."
The facility's dementia care policy required staff to "identify and document the resident's condition and level of support needed" and communicate those needs through care plan conferences and shift reports. Progressive worsening of symptoms should trigger immediate team response.
Instead, staff treated each incident as isolated, placing residents on "frequent safety checks" after attacks but failing to prevent future confrontations through proper supervision.
Meanwhile, another resident with dementia and schizophrenia walked out of the facility at 5:30 a.m. on March 2 and remained missing for six hours.
Resident #4 left through the back door of the smoking area and climbed through a wooden fence while staff failed to respond promptly to security alarms. The resident, who had a wander guard device on his wrist, was found by police after walking to a bank that was closed.
"Staff noticed the alarm was going off," the director of nursing told inspectors, but she "could not speak to what occurred that day" or whether staff responded appropriately.
The facility's elopement policy required staff to respond to alarms within five minutes, but the director of nursing admitted she didn't know if staff met that standard. The nursing home administrator said staff needed a key from the nurses' station to turn off the back gate alarm, suggesting a delayed response.
Resident #4's care plan identified him as an elopement risk who was "unsafe to be in the community independently" due to an unsteady gait and history of falls. His picture was supposed to be kept in the facility's elopement binder for quick identification.
The resident had previously attempted to leave the facility multiple times, fixated on getting to a bank and buying cigarettes. Staff were supposed to reassure him that he had enough cigarettes and didn't need to buy more, but the director of nursing said the facility had stopped providing cigarettes because "it got expensive."
Activities staff discussed putting him in a work program to keep him occupied, but never followed through.
When inspectors requested the facility's investigation report for the March 2 elopement, the nursing home administrator admitted no investigation had been conducted and the incident was never reported to state authorities as required.
A certified nursing assistant working the day shift said she didn't know Resident #4 had ever eloped from the facility, despite his documented history of exit-seeking behaviors.
The registered nurse on duty said Resident #4 "had had a couple of attempts of leaving the facility" and wore a wander guard "for his safety and elopement reasons." She said alarms were installed on outside gates, but acknowledged they failed to prevent his departure.
Resident #4 told police he wanted to open a bank account and get a bank card, explaining why he left for the bank that morning. A nurse promised staff would help him open an account, but no follow-up was documented.
Both residents remained at the facility during the March inspection, with their underlying conditions unchanged. Resident #2 continued wheeling through hallways without the supervision her care plan required, while Resident #4 maintained his early morning routine and fixation on banking and cigarettes.
The inspection found University Heights Care Center failed to provide appropriate dementia care and adequate supervision to prevent accidents, putting vulnerable residents at continued risk of harm.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for University Heights Care Center from 2025-03-26 including all violations, facility responses, and corrective action plans.
Additional Resources
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