RANDOLPH — Walter D. Rice Jr. was growing increasingly aggressive and paranoid.
Throughout the summer, the burly, 58-year-old nursing home resident, who suffered from brain damage as well as dementia, complained that a friend was trying to kill him and rape his wife. He yanked pictures off walls, smashed glass, and wandered into other residents’ rooms, taking their food and belongings.
A nurse practitioner prescribed mood-stabilizing medication, which seemed to help for a while, state records show. But then the staff at CareOne at Randolph neglected to give him the drugs for an entire month, setting the stage for tragedy, according to inspection reports from the Massachusetts Department of Public Health.
Rice allegedly beat his 86-year-old roommate over the head with a heavy ceramic flower pot as the victim lay in bed on Sept. 5. James Schappell, an Army veteran who served in the Korean War, died the following day of severe head trauma.
Now, Rice is facing a murder charge, something his wife said is unfair. The nursing home is to blame, she said.
“They didn’t take care of him,” Regenia Rice said Friday before her husband’s arraignment. “He doesn’t deserve this.”
The case marks the second time in two years that CareOne has faced sharp criticism after a younger resident killed an older one at one of its Massachusetts nursing homes. The New Jersey-based company declined to comment on the specifics of the Randolph homicide or an earlier one in Lowell, but said in a prepared statement that the safety, security, and well-being of its residents are a priority.
The deaths highlight a troubling nationwide pattern of violent and sometimes deadly confrontations between nursing home residents, among them cases in which younger, stronger men attack and sometimes kill their older, more frail roommates. The attacks frequently involve people suffering from dementia or mental illness, separated by generations and living in close quarters with each other.
In North Carolina, an 89-year-old resident died after being attacked in August by a 50-year-old. In Baltimore, a 61-year-old fatally beat an 84-year-old last year. And in Houston, a 56-year-old with a mental illness bludgeoned his two roommates — 77 and 51 — with a wheelchair armrest three years ago, killing them both.
State and federal regulators say fatal encounters between residents at nursing homes are rare, but reports of violent encounters between nursing home residents in Massachusetts are on the rise at a time when the number of younger, stronger residents is also climbing. Researchers say the true number of violent incidents involving residents under the age of 65 is impossible to know, because government agencies don’t track them.
“This is a taboo topic, because the industry doesn’t want to talk about patients with serious mental disease, like Alzheimer’s, harming each other,” said Eilon Caspi, a Minnesota researcher who has spent more than a decade studying confrontations between nursing home residents in the United States and Canada. He said the lack of reporting is a major public health problem.
“I know of a lot of incidents where the family was told your father fell, and a closer look reveals one resident was pushed by another resident,” Caspi said.
In fact, the US Health and Human Services inspector general’s office recently warned that nursing homes are failing to report a significant number of assaults on residents that resulted in someone getting treatment at a hospital emergency room.
Caspi reviewed 100 fatal encounters between nursing home residents over the past three decades and found the attackers were, on average, about nine years younger than their victims. In all of the cases, at least one of the residents had dementia.
Nursing home leaders say they face a daunting task, expected to provide care for a growing number of patients with drug addictions and other complex needs while state funding has not kept pace. Tara Gregorio, president of the Massachusetts Senior Care Association, an industry trade group, said nursing home administrators “consistently engage in abuse prevention training,” including how to minimize resident-on-resident abuse.
“Nursing facilities are increasingly being asked by hospitals and physician organizations to care for a younger population with significant needs,” Gregorio said. “With fewer resources, this is an emerging and critical issue for our members.”
Elder advocates have increasingly raised concerns about much younger residents with mental health problems being admitted to nursing homes that do not have adequate staff and training to sufficiently care for them. In Massachusetts, 13 percent of nursing home residents are now under the age of 65, up from about 10 percent a decade ago. The increase is modest, but, in a challenged industry, many nursing home staffs feel overburdened already.
“Facilities are admitting residents that they simply don’t know how to meet their needs, especially younger residents who have mental health issues. That’s an underlying root cause” of many resident altercations, said Amity Overall-Laib, director of the National Long-Term Care Ombudsman Resource Center, which helps state ombudsman programs track complaints about nursing homes.
In Massachusetts, the number of resident-on-resident incidents reported to the state has declined — from 2,070 in 2012 to 1,836 last year — but the number of incidents involving more serious outcomes is growing. Confrontations ending with broken bones increased from 13 in 2012 to 20 last year. The number of sexual incidents rose from 64 in 2012 to 79 last year, while confrontations in which one resident inflicted pain on another jumped from zero reported incidents in 2012 to 32 last year.
Unfortunately, state officials do not track the ages of the attackers.
The state’s data show no deaths reported from resident confrontations during the past five years, except for 2015. In that year, state public health officials indicated there was at least one and perhaps as many as five deaths, but declined to disclose how many, saying it would violate patient confidentiality to do so.
Caspi, the Minnesota researcher, said regulators need a system for tracking such cases, because “if you really want to tackle this phenomenon, you need to capture it.”
The experience at CareOne facilities in Massachusetts in recent years, which includes two homicides and a rape, suggests that resident-on-resident violence is a serious challenge, and that staffs struggle to manage the outbursts.
An inspection report by Massachusetts regulators detailed a July 2015 episode in which a 41-year-old resident of the CareOne facility in Lowell knocked 66-year-old Anthony Mazzurco to the ground, striking his head on the floor. Mazzurco died hours later. The report indicates that, after Mazzurco struck his head on the floor, staff waited 85 minutes to notify a doctor. Regulators found that CareOne at Lowell repeatedly failed to properly supervise residents, including Mazzurco and the resident who pushed him. Both residents were “known to have behavior issues and had previously engaged in physical altercations,” according to investigators’ findings.
After Mazzurco’s death, the Centers for Medicare & Medicaid Services imposed a fine of $109,396 on the Lowell facility for a list of failures, including providing substandard care and a critical delay in notifying a doctor.
Separately, CareOne paid a $92,077 fine for failing to investigate allegations of sexual abuse and to prevent the rape of one resident by another at the same Lowell nursing home this past February.
In that case, a resident diagnosed with HIV, schizophrenia, dementia, and bipolar disorder was accused by his roommate of forcing oral and anal sex on him, according to state documents. The documents noted that the alleged attacker had also been accused of sexually assaulting two other residents last year and had frequently been observed masturbating in his room while watching pornography.
In a statement to the Globe, CareOne said accusations in the state’s report that staff waited 85 minutes to notify a doctor about Mazzurco’s head injuries were “inaccurate and false.” It also contested the accuracy of the state findings after the investigation into the alleged rape, but did not elaborate.
State health inspectors cited CareOne at Randolph for numerous failings after Schappell’s death last month. He leaves three daughters, nine grandchildren, and 11 great-grandchildren. He raised his family in Lawrence Township, N.J., where he owned a service station and was an avid bowler, according to his obituary.
State inspectors indicated that Rice had been aggressive and agitated for months prior to the attack. He underwent a psychiatric evaluation at a hospital in December 2016 because he was suffering from hallucinations and paranoia and tried to jump out a window, according to records. The following month, he was readmitted to the Randolph nursing home, where he failed to get adequate care as he became increasingly aggressive and agitated, state inspectors found.
On Aug. 6, mood-stabilizing medication that Rice had been taking for a month, resulting in an improvement in his behavior, was “stopped in error,” according to documents. Rice did not get his prescribed a medication again until Sept. 5, just 20 minutes before he attacked his roommate, state inspectors found.
State officials faulted CareOne for failing to give Rice medications and for not providing adequate services or monitoring his escalating behaviors in the month before the attack. Federal regulators have yet to determine financial penalties for CareOne as a result of Schappell’s death.
Timothy Hodges, chief strategy officer for CareOne, which runs more than a dozen nursing homes in Massachusetts, declined to comment on allegations that staff neglected to give Rice his medication, citing patient privacy. But he said the company follows industry best practices and state and federal guidelines.
“We are deeply saddened by this recent incident, and our thoughts are with the families of those affected as well as our residents, our dedicated staff, the entire CareOne at Randolph community and all those coping with the realities of dementia,” Hodges said in a statement.
Nursing home companies are rarely criminally prosecuted for failing to protect residents from violence, said David Hoey, a Reading attorney who has represented families in civil lawsuits against nursing homes for more than two decades. He said prosecutors often are reluctant to pursue abuse, neglect, and related charges against nursing homes, given the complexity and cost of such cases.
“A lot of these nursing home companies are out-of-state companies, so now you are in federal court and it’s a major production,” said Hoey.
In most fatal resident altercations, prosecutors don’t pursue charges against the attackers either, usually because the attacker suffers from dementia or mental illness and is not competent to stand trial.
But the Norfolk district attorney’s office is pursuing murder and assault charges against Rice, who was arraigned Friday in his bed in the intensive care unit at Morton Hospital in Taunton because he was deemed too ill to appear in court He kept his eyes closed and never spoke as a court clerk read the charges and entered not-guilty pleas on his behalf.
Attorney James Murphy stood beside his client and told a judge that Bridgewater State Hospital had declared Rice competent to stand trial after a mental health evaluation, even though paperwork provided by staff appeared to contradict that finding. He said a doctor’s report indicated that Rice does not have and never will have “rational or sufficient understanding of court proceedings in this case.”
Rice, who has no prior criminal record, has not been the same since he was diagnosed with a brain tumor at age 50, according to his wife. The man charged with killing his roommate, she said, “This isn’t him.”
Shelley Murphy can be reached at firstname.lastname@example.org. Follow her on Twitter @shelleymurph. Kay Lazar can be reached at email@example.com. Follow her on Twitter @GlobeKayLazar.