The October 13 incident occurred at 2:30 a.m. when staff found one resident holding another by the right arm and biting her left forearm. The victim, identified as Resident D, suffered bruising and swelling to her right forearm and a skin tear to her left forearm from the bite.
Resident D complained of pain in her wrist and fingers after the attack. Her physician ordered X-rays of her right wrist and forearm, and prescribed triple antibiotic ointment for the bite wound on her left arm.
The Assistant Director of Nursing measured the wound the morning after the incident and documented it as approximately one inch in diameter on a facility shower sheet. When inspectors observed the healing wound two days later, it appeared as a dark red, one-inch-long skin tear that was closed but still required daily dressing changes.
The bite wound wasn't Resident D's only recent problem. She had been wandering more frequently and becoming increasingly agitated in the days before the attack, with incidents involving other residents on October 6 and 7.
Despite these escalating behavioral issues, facility staff never updated Resident D's care plan to address her increased wandering or difficulty with redirection.
"It would have been appropriate to update Resident D's plan of care following an increase in Resident D's behavior of wandering following incidents on 10/6/25 and 10/7/25 that involved other residents and an increase in Resident D's agitation and difficulty with redirection," the Social Service Director told inspectors.
The facility's response to wandering residents appears to lack structure entirely. The Assistant Director of Nursing admitted the facility had no policy regarding resident behavior and wandering prevention.
Resident D has severe cognitive impairment according to her most recent quarterly assessment. Her diagnoses include Alzheimer's disease and vascular dementia, conditions that commonly lead to wandering behavior in nursing home residents.
The wound required ongoing medical attention. Her physician's orders specified applying triple antibiotic ointment to the left forearm wound topically each morning, along with daily cleansing with wound cleanser and covering with a dry dressing. The treatment was scheduled to continue until October 28.
A Physical Aggression Received report filed after the incident described how a certified nursing assistant observed the attacking resident in Resident D's room, holding her by the right forearm and wrist before biting her on the left forearm and wrist.
The facility does have a policy for assessing skin alterations, dating from November 2017, which requires immediate assessment and physician-ordered treatment for any skin problems. Staff followed this protocol after the bite, with the Assistant Director of Nursing noting that the wound was bleeding when she arrived for her shift the morning after the incident.
However, the more fundamental issue of preventing such incidents through proper care planning went unaddressed. Federal nursing home regulations require facilities to develop comprehensive care plans that address residents' behavioral symptoms and risks.
The failure to update Resident D's care plan despite clear warning signs represents a missed opportunity to prevent the October 13 attack. The documented incidents on October 6 and 7, combined with staff observations of increased wandering and agitation, should have triggered an immediate review of her care approach.
Without policies specifically addressing wandering prevention, the facility appears unprepared to manage residents with dementia who exhibit this common but potentially dangerous behavior.
The wound from the bite has been healing under medical treatment, but Resident D continues to live in an environment where her behavioral needs remain inadequately planned for and addressed.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Premier Healthcare of New Harmony from 2025-10-16 including all violations, facility responses, and corrective action plans.
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