F0600

D

Failure to Prevent Resident-to-Resident Physical and Verbal Abuse

Battle Creek, Michigan Survey Completed on 01-22-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to protect residents from resident-to-resident physical and verbal abuse, resulting in one resident sustaining a facial injury and being subjected to threats by another resident. One male resident with traumatic brain injury, intermittent explosive disorder, psychological disorder, anxiety, and depression, and who was cognitively intact per a BIM score of 13, was self-propelling in his wheelchair in the main dining room during a resident activity. Another male resident with vascular dementia, irritability and anger, anxiety, and depression, also cognitively intact per a BIM score of 15, was in his wheelchair in the same area. According to the then–NHA’s witness statement, the first resident’s wheelchair bumped into the second resident’s wheelchair, after which the second resident swung back with his right arm and closed fist, striking the first resident on the right side of the face near the mouth. The first resident yelled out and was later observed to have a small open area on his bottom lip and blood in his mouth.

The NHA reported that when he questioned the second resident about the incident, the resident stated that the other resident had run into his chair and that this was a good reason to hit him. The second resident also used explicit language and laughed about the situation. The facility’s 5-day investigation substantiated that abuse had occurred and that the first resident sustained an injury. At the time of the surveyor’s later observations and interviews, both residents appeared calm, reported feeling safe at the facility, and denied fear of others, but the cited deficiency centers on the earlier failure to prevent the resident-to-resident altercation that resulted in physical contact, a facial laceration, and verbal threats.