Failure to Prevent Resident-on-Resident Physical Abuse
Penalty
Summary
The facility failed to protect multiple residents from physical abuse by other residents. In one incident, an abuse investigation dated 3/15/2026 at 8:45 PM documented that one resident (R3) became agitated with another resident (R10), accusing R10 of being in R3's house, and then began hitting R10 on the head with a shoe. A Licensed Practical Nurse (V10) witnessed R3 hitting R10 on the head with the shoe. During an interview on 3/24/2026 at 12:46 PM, R10 recalled being hit a few times with a house slipper by R3, stated that R3 was accusing R10 of being in R3's home, and reported that this interaction was frightening. The Administrator (V1) later confirmed that, based on interviews with R10 and V10, it was determined that R3 did hit R10 multiple times in the head with a shoe and that the allegation of abuse was substantiated. In another incident, the facility’s abuse investigation dated 2/9/2026 at 8:45 PM documented that resident R7 had aggressive behaviors toward resident R6, with R6 reporting that R7 hit R6 with a closed fist. R6’s care plan shows an admission date of 10/25/2024 and diagnoses including poisoning by hydantoin derivatives, essential hypertension, and cerebral infarction, with a Minimum Data Set (MDS) indicating moderate cognitive impairment. R7’s MDS documents severe cognitive impairment, and R7’s care plan lists diagnoses including schizophrenia, dysphagia (oropharyngeal phase), constipation, hyperlipidemia, and benign prostatic hyperplasia. On 3/23/2026 at 10:55 AM, R6 stated having been hit by a roommate in the past but could not recall the specific date, while R7 was deemed non-interviewable due to severe cognitive decline and dysphasia. On 3/23/2026 at 3:15 PM, an LPN (V7) reported that R7 admitted to hitting R6 on the arm when questioned on 2/9/2026. The facility’s abuse policy dated 10-2022 defines abuse as any physical or mental injury or sexual assault inflicted upon a resident other than by accidental means.
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