Health inspection·January 16, 2026

Title 42, Section 483.12 Freedom from Abuse, Neglect, and Exploitation The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. (a) The facility must- (1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion. INTENT Section 483.12(a)(1) Each resident has the right to be free from abuse, neglect and corporal punishment of any type by anyone. DEFINITIONS Section 483.12(a)(1) "Abuse," is defined at Section 483.5 as "the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled using technology. "Neglect," as defined at Section 483.5, means "the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress." "Sexual abuse," is defined at Section 483.5 as "non-consensual sexual contact of any type with a resident." "Willful," as defined at Section 483.5 in the definition of "abuse," and "means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm." GUIDANCE Section 483.12(a)(1) NOTE: For purposes of this guidance, "staff" includes employees, the medical director, consultants, contractors, and volunteers. Staff would also include caregivers who provide care and services to residents on behalf of the facility, students in the facility's nurse aide training program, and students from affiliated academic institutions, including therapy, social, and activity programs. ABUSE Sections Section 1819(c)(1)(A)(ii) and Section 1919(c)(1)(A)(ii) of the Social Security Act provide that each resident has the right to be free from, among other things, physical or mental abuse and corporal punishment. The facility must provide a safe resident environment and protect residents from abuse. Resident to Resident Abuse of Any Type A resident-to-resident altercation should be reviewed as a potential situation of abuse. The surveyor should not assume that every resident-to-resident altercation results in abuse. For example, infrequent arguments or disagreements that occur during normal social interactions (e.g., dinner table discussions) would not constitute abuse. The surveyor must determine whether the incident would meet the definition of abuse. Also, when investigating an allegation of abuse between residents, the surveyor should not automatically assume that abuse did not occur, especially in cases where either or both residents have a cognitive impairment or mental disorder. Having a mental disorder or cognitive impairment does not automatically preclude a resident from engaging in deliberate or non-accidental actions. In determining whether F600-Free from Abuse and Neglect should be cited in these situations, it is important to remember that abuse includes the term "willful". The word "willful" means that the individual's action was deliberate (not inadvertent or accidental), regardless of whether the individual intended to inflict injury or harm. An example of a deliberate ("willful") action would be a cognitively impaired resident who strikes out at a resident within his/her reach, as opposed to a resident with a neurological disease who has involuntary movements (e.g., muscle spasms, twitching, jerking, writhing movements) and his/her body movements impact a resident who is nearby. If it is determined that the action was not willful (a deliberate action), the surveyor must investigate whether the facility is in compliance with the requirement to maintain an environment as free of accident hazards as possible and that each resident receives adequate supervision. The facility may provide evidence that it completed a resident assessment and provided care planning interventions to address a resident's distressed behaviors such as physical, sexual or verbal aggression. However, based on the presence of resident-to-resident altercations, if the facility did not evaluate the effectiveness of the interventions and staff did not provide immediate interventions to assure the safety of residents, then the facility did not provide sufficient protection to prevent resident- to-resident abuse. For example, redirection alone is not a sufficiently protective response to a resident who will not be deterred from targeting other residents for abuse once he/she has been redirected. Staff should monitor any behaviors that may provoke a reaction by residents or others, which include, but are not limited to: Verbally aggressive behavior, such as screaming, cursing, bossing around/demanding, insulting to race or ethnic group, intimidating; Physically aggressive behavior, such as hitting, kicking, grabbing, scratching, pushing/shoving, biting, spitting, threatening gestures, throwing objects; Sexually aggressive behavior such as saying sexual things, inappropriate touching/grabbing; Taking, touching, or rummaging through other's property; and Also, resident- to-resident abuse could involve a resident who has had no prior history of aggressive behaviors, since a resident's behavior could quickly escalate into an instance of abuse. For example, a resident pushes away or strikes another resident who is rummaging through his/her possessions. On 12/4/25 at 9:31 a.m., an unannounced visit was conducted at the facility to investigate a facility reported incident/complaint regarding an allegation of abuse that occurred on 11/24/25. Based on observation, interview, and record review, the facility failed to ensure one of four sampled residents (Resident 1) was free from physical abuse, when Resident 2 struck Resident 1 with her fist, hitting her on the left side of her forehead. The facility failed to: Prevent the physical attack of one resident against another, when Resident 2 struck Resident 1; Follow its Policy and Procedure regarding abuse prevention, by failing to take adequate steps to prevent Resident 2 from striking Resident 1, when facility staff was aware of Resident 2's violent and/or abusive tendencies. This failure resulted in Resident 1's bruised left forehead and fear manifested by crying. A review of Resident 1's Admission Record (AR), dated 10/1/24, indicated Resident 1 was admitted to the facility in late 2024 with diagnoses which included aphasia (a disorder that makes it difficult to speak), cognitive communication deficit and right-side body weakness. A review of Resident 1's Physician's Orders (PO), dated 10/1/24, indicated Resident 1 was incapable of making her own healthcare decisions. A review of Resident 1's Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 11/5/25, indicated Resident 1 had no mood or behavioral symptoms of crying or verbalization of fear. A review of Resident 1's hospital emergency department notes, dated 11/23/25, indicated the chief complaint was assault with fist, hematoma (a collection of blood outside of a blood vessel caused by a broken blood vessel) on forehead, had a bruise to the left forehead. A review of the SBAR (Situation, Background, Assessment, Recommendations; a form used for urgent resident updates to communicate between healthcare professionals), and initial change of condition (COC) alert charting, dated 11/23/25, indicated Resident 1 was punched by Resident 2 in the left side of her head with a closed fist. The SBAR also indicated Resident 1 manifested fear by crying after being struck by Resident 2. A review of Resident 2's AR, dated 2/21/25, indicated Resident 2 was admitted to the facility in early 2025 with diagnoses which included bipolar (mental health condition causing extreme mood swings) disorder and aggression. A review of Resident 2's PO dated 2/21/25, indicated Resident 2 was capable of making her own healthcare decisions and was her own responsible party. A review of Resident 2's Nursing Care Plan (NCP), dated 3/21/25, indicated, "[Resident 2] has demonstrated physical behavior r/t [related to] uncontrolled anger, poor impulse control...aggressive verbal and physical behaviors...assess and anticipate resident's needs, immediately separate any party members involved in confrontation." A review of Resident 2's MDS, dated 11/23/25, indicated Resident 2 had physical behavioral symptoms directed towards others that occurred daily. A review of the SBAR and COC alert charting dated 11/23/25, indicated Resident 2 punched Resident 1, made verbal threats, and displayed physical aggression. The SBAR and COC also indicated Resident 2 punched Resident 1 in the left side of her head with a closed fist. During an interview on 12/4/25 at 12:30 with the Director of Nursing (DON), the DON stated her expectation was that no resident should be hit and no one deserved to be hit. During a concurrent observation and interview on 12/4/25 at 12:52 p.m. inside Resident 1's room, Resident 1 was seated in her wheelchair with no distress. When asked if Resident 1 recalled someone who hit her forehead, she lowered her head to her left shoulder and cried but could not verbalize why she was crying. Resident 1 shook her head and flailed her hands when Resident 2's name was mentioned. During an interview on 12/4/25 at 1:13 p.m. with Certified Nurse Assistant 2 (CNA 2), CNA 2 confirmed Resident 2 hit Resident 1 with her fist. CNA 2 stated Resident 1 feared Resident 2 because Resident 2 cursed, yelled, shouted and said bad words. CNA 2 indicated Resident 1 did not want to stay in her room when Resident 2 was also inside the room and Resident 1 would cry when Resident 2 was present in the room. During an interview on 12/4/25 at 2:03 p.m. with the Social Services Director (SSD), the SSD indicated as reported, Resident 2 hit Resident 1 with her fist. The SSD confirmed Resident 2 was verbally abusive and could hit someone with her temper. The SSD stated Resident 2 had this outburst of anger even with little things. The SSD stated Resident 1 could not verbally express herself. The SSD validated "No one deserved to be hit, everybody should be equal here." The SSD indicated, because she was hit, Resident 1 could be traumatized, could be more scared and be more aloof. During an interview on 12/4/25 at 3:01 p.m. with the Administrator (ADM), the ADM indicated Resident 2 was a very difficult and complicated resident and as reported and witnessed by the nurse, Resident 2 hit Resident 1. The ADM stated, "No one deserved to be hit, everybody had the right to be safe." During an interview on 12/9/25 at 1:49 p.m. with the Licensed Nurse (LN), the LN confirmed she witnessed Resident 2, with her fist, hit Resident 1 in her left temple. The LN confirmed that when the police came and spoke with Resident 1, Resident 1, because she could not fully verbalize, she demonstrated to the police and said "hit, hit" with her fist to indicate she was hit by Resident 2. The LN confirmed Resident 1 was very scared of Resident 2. LN stated Resident 1 and the other roommate did not want to stay in the room because of Resident 2. The LN confirmed Resident 2 screamed and yelled and when roommate or Resident 1 watched her television, Resident 2 screamed and said, "Shut that television off." The LN confirmed this was the regular behavior of Resident 2, yelling, cursing, screaming at her roommates and striking staff who would come inside her room. The LN confirmed Resident 2 had become very abusive and even threatened the police officer when she was questioned about her hitting Resident 1. The LN indicated she was glad that Resident 1 and her roommate were safe now that Resident 2 was sent out for evaluation because of her very aggressive and abusive behavior, and stated, "No one deserved to be abused or hit." A review of the facility's Policy and Procedure titled, "Abuse Prevention Program," revised 2018, indicated, "...Resident have the right to be free from abuse... this includes but is not limited to...physical abuse...as part of the abuse prevention program, the administration will protect our residents from abuse by anyone including other residents..." Therefore, the department determined the facility failed to ensure Resident 1 was free from physical abuse when Resident 2 struck Resident 1 with her fist, hitting her on the left side of her forehead. This failure resulted in Resident 1's bruised left forehead and fear manifested by crying. This violation had a direct or immediate relationship to the health, safety, or security of long-term care residents.