Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect multiple residents from abuse, resulting in several resident‑to‑resident physical altercations. One incident report dated 11/05/25 documents that a resident (R4), who has major depressive disorder, bipolar disorder, essential hypertension, and hyperlipidemia and is care planned as being at risk for abuse due to psychiatric diagnosis and verbal aggression, reported that another resident (R3) pushed him. Another incident report dated 11/20/25 documents an alleged altercation between R6 and R5 after R5 allegedly invaded R6’s personal space, which allegedly escalated into a physical altercation. R6’s care plan identifies him as at risk for health, safety, and behavioral concerns, and during an interview in his bedroom he stated that he was hit by another resident before they began to fight. Additional incident reports show further failures to prevent abuse. A report dated 1/12/26 documents that R7 showed aggression toward R8, who has a cognitive communication deficit, unspecified dementia, essential hypertension, and muscle wasting and atrophy; a therapist’s written witness statement from the same date states that R7 entered the room, greeted R8, and then instantly punched him. Another incident report dated 1/12/26 documents that R9 allegedly became agitated with R10 and allegedly hit R10; R10’s care plan notes that he is at risk for abuse due to poor cognition related to severe dementia with mood disturbance, and he also has diagnoses including an unspecified fracture of the right ilium, adult failure to thrive, unspecified atrial fibrillation, and hypertensive heart disease with heart failure. An LPN stated that R9 was sent to the hospital for hitting R10. The administrator acknowledged that no resident deserves to be hit and that there have been some recent physical altercations between residents, despite a facility policy stating that residents have the right to be free from verbal, sexual, physical, and mental abuse, involuntary seclusion, exploitation, and misappropriation of property by anyone.
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