Failure to Protect Resident from Physical Abuse by Another Resident
Penalty
Summary
The facility failed to protect a resident's right to be free from abuse by another resident. On 11/10/2025, one resident (R3) entered a room to visit another resident (R9), where R8 (R9's roommate and R2's girlfriend) told R3 to leave. When R2 attempted to intervene, R3 became upset and physically assaulted R2 by grabbing and punching him in the neck. The incident was witnessed by staff, and the local police were called. The facility's investigation substantiated that abuse occurred, and it was acknowledged by the administrator that the environment was not kept safe for R2. R2 had a history of mental health diagnoses, including schizoaffective disorder, depressive type, personality disorder, schizophrenia, post-traumatic stress disorder, disorder of psychological development, and suicidal ideation, but was noted to have intact cognition at the time of the incident. R3, who also had mental health diagnoses, admitted to the physical altercation. The facility's abuse policy states that residents have the right to be free from all forms of abuse, but this policy was not upheld in this instance, resulting in a substantiated case of resident-to-resident physical abuse.