Health inspection·February 9, 2026

Code of Federal Regulations, 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. Section 483.12(a) The facility must- Section 483.12(a)(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion. On 1/7/26 at 12:33 p.m., an unannounced visit was conducted at the facility to investigate a facility reported incident/complaint regarding allegations of abuse that occurred on 12/13/25, 12/24/26, and 12/26/26. Based on observation, interview and record review, the facility failed to protect the right to be free from physical abuse for three of four sampled residents (Resident 2, Resident 3, and Resident 4), when: 1. On 12/13/25, Resident 1 spat at Resident 2 in the hallway; 2. On 12/24/25 in the dining room, Resident 1 slapped Resident 3 on the back of the head; and 3. On 12/26/25 in the dining room, Resident 1 slapped Resident 4 on the face. The facility failed to: Prevent the physical attack of one resident against another resident, when Resident 1 spat at Resident 2, and slapped Resident 3 and Resident 4. Follow its Policy and Procedure regarding abuse prevention, by failing to take adequate steps to prevent Resident 1 from spitting at Resident 2, and slapping Resident 3, and Resident 4, when facility staff was aware of Resident 1's violent and/or abusive tendencies. This failure compromised the ability of the residents' ability to maintain their highest practicable physical, emotional and psychological well-being. 1. A review of Resident 1's Admission Record (AR), dated 1/8/26 (print date), indicated Resident 1 was admitted to the facility in December of 2025 with diagnoses which included schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior) and age-related cognitive (process of acquiring knowledge and understanding through thought process) decline. A review of Resident 1's progress note (PN), dated 12/13/25, indicated, "At 1600 [4 p.m.] [Resident 1] was standing in the hallway using a walker. [Resident 2] was positioned in front of [Resident 1] and speaking loudly to himself...[Resident 1] became upset by the behavior and spat on [Resident 2]..." A review of Resident 2's AR, dated 1/8/26, indicated Resident 2 was admitted to the facility in May of 2025 with diagnoses that included schizoaffective disorder and depression (a mood disorder causing persistent sadness, loss of interest). During a concurrent observation and interview on 1/7/26 at 12:43 p.m. with Resident 2, Resident 2 was observed walking and talking in the hallway. When asked if he had been involved in any altercation with other residents, Resident 2 stated, "It was about a month ago when he spit on me..." When asked if he felt safe in the facility, Resident 2 stated, "I'm more worried about the staff here..." During a phone interview on 1/8/26 at 9:04 a.m. with Certified Nursing Assistant 1 (CNA 1), CNA 1 confirmed he witnessed the incident on 12/13/25 between Resident 1 and Resident 2 as they met in the hallway and Resident 1 spat at Resident 2. CNA 1 further stated that when staff intervened, Resident 2 was questioning why Resident 1 spat at him, and Resident 2 remained silent and looked stunned. 2. A review of Resident 3's AR, dated 1/9/26, indicated that Resident 3 was admitted to the facility in April of 2024 with diagnoses which included schizophrenia (a mental illness that is characterized by disturbances in thought) and dementia (a progressive state of decline in mental abilities due to reduced blood flow to the brain). A review of Resident 3's PN, dated 12/24/25, indicated, "[Resident 1 was observed standing from his wheelchair and approaching another resident table where [Resident 3] who was seated and drinking coffee. [Resident 1] subsequently stood up and then slapped [Resident 3] on the back of his head..." During a concurrent observation and interview on 1/7/26 at 12:56 p.m. with Resident 3, Resident 3 was not answering questions clearly, mumbled and difficult to understand. When asked if he was involved with any altercations with other residents, Resident 3 stated, "I was hit on the back of head by some guy. I don't remember exactly when." During an interview on 1/8/26 at 11:09 a.m. with the Social Services Assistant (SSA), the SSA stated that on 12/24/25 at around 9 a.m., he saw how Resident 1 hit Resident 3 on the back of the head with an audible sound when both residents were by the shared table in the dining room. The SSA further stated that Resident 3 looked shocked and confused, and Resident 1 stated that he slapped Resident 3 because he was looking at him in a weird way. 3. A review of Resident 4's AR, dated 1/8/26, the AR indicated that Resident 4 was re-admitted to the facility in March of 2024 with diagnoses that included schizoaffective disorder and posttraumatic stress disorder (PTSD - a disorder in which a person has difficulty recovering after experiencing or witnessing a traumatic event). A review of Resident 4's PN, dated 12/26/25, indicated, "...[Resident 4] was just sitting close to the nurse station attending the group, when [Resident 1] walked towards [Resident 4] sat down next to her and suddenly lay his hand on her and landed on her R [right] side face. Resident were separated right away..." During a concurrent observation and interview on 1/7/26 at 2:41 p.m. with Resident 4, Resident 4 walked from the dining room to her room. When asked what her name was, Resident 4 introduced himself with a different name. When asked if she was involved with altercations with other residents, Resident 4 was not able to elicit an appropriate response and recanted a story not related to the question. When asked if she was safe in the facility, Resident 4 stated, "I'm afraid that there will be fire...The man in the bathroom slapped me, he didn't do it, it's my word against everybody else." During an interview on 1/7/26 at 4:50 p.m. with Licensed Nurse 1 (LN 1), LN 1 stated that on 12/26/25, she saw how Resident 4 was sitting by the nurse's station, and Resident 1 approached Resident 4 and slapped her on the face with an audible slap sound. LN 1 further stated that Resident 4 cried and said that Resident 1 slapped her. During an interview on 1/8/26 at 3:04 p.m. with the Director of Nursing (DON), the DON confirmed that the incident on 12/13/25 between Resident 1 and Resident 2, the incident on 12/24/25 between Resident 1 and Resident 3, and the incident on12/26/25 between Resident 1 and Resident 4 were witnessed and constituted physical abuse. The DON further stated that she expected facility residents to be free from physical and verbal abuse. A review of the facility's policy and procedure (P&P) titled, "Abuse, Neglect, Exploitation and Misappropriation Prevention Program," revised 4/2021 indicated, "Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse..." Therefore, the department determined the facility failed to ensure Resident 2, Resident 3, and Resident 4 were free from physical abuse when Resident 1 spat on Resident 2, and slapped Resident 3 and Resident 4. These failures resulted in Resident 2, Resident 3 and Resident 4's compromised ability to maintain their highest physical, emotional and psychological wellbeing. manifested by worrying, shock, and crying. These violations had a direct or immediate relationship to the health, safety, or security of long-term care residents.