Timber Springs: Resident Attack Causes Face Injuries - ID

The March 13 attack left Resident #87 with visible injuries while the attacker, Resident #113, was arrested by police after staff placed him under one-on-one observation.

Federal inspectors found the facility failed to protect residents from abuse, documenting actual harm to one resident and placing all others at risk for ongoing abuse and potential physical and psychological harm.

Resident #113 had exhibited escalating threatening behavior in the days before the assault. On March 7, he approached a nurse demanding Norco, an opioid pain medication, hours before his scheduled dose. When the nurse explained his medication wasn't due until 2 AM and offered Tylenol instead, he declined.

"He needed to get out of the building so he can self-medicate," the nurse documented. Resident #113 told the nurse "she better have his pain pill at 2:00 AM, and she better not be late." He then warned the nurse "better not write any notes on him or else."

The threats escalated the following day.

On March 8, Resident #113 again approached nursing staff about medications. "I am going to leave this place I am tired of waiting for you to give me my meds," he told the nurse. He then made a specific suicide threat: he was going to go to the overpass, jump in front of the first diesel truck he could find and kill himself.

When the nurse asked him to clarify his intentions, he repeated the threat. "If he did not get his goddamn pills, that he was going to kill himself."

Staff immediately requested he remain at the first-floor nurses' station while certified nursing assistants monitored him from a safe distance. The nurse contacted the second-floor nurse about his changed cognition and threatening statements.

Five days later, Resident #113 struck Resident #87.

The 4:30 PM incident report documented that Resident #113 was observed hitting Resident #87 in the face. The blow caused bruising and a facial laceration to the left orbital area, with redness visible in the sclera and nose.

Staff separated the residents immediately after the attack. Both residents were assessed for injuries and treated as needed. Police were notified and arrested Resident #113, who was then placed on continuous one-on-one observation.

The facility completed a psychosocial evaluation on Resident #87 with no additional findings. Staff interviewed other residents, who reported no concerns about the incident.

Both Resident #87's and Resident #113's family representatives were notified of the attack.

Resident #87 had been admitted to the facility with multiple diagnoses including Parkinson's disease and dementia. A quarterly assessment indicated he had no cognitive impairment, scoring 15 on the Brief Interview for Mental Status.

Resident #113 had been admitted with multiple diagnoses including cerebral infarction and anxiety. Like Resident #87, his discharge assessment showed no cognitive impairment with a BIMS score of 15.

But Resident #113 had a documented history of mental health struggles. A January 17 nurse practitioner note revealed he had experienced significant anxiety and restlessness with suicidal thoughts while outside the facility. He reported having "suicidal ideations with a plan for self-harm and means to carry this out."

The note documented that while Resident #113 felt safe inside the facility, "he continues to have fluctuating moods and behaviors with anxiety." He had declined to restart citalopram, an antidepressant medication.

His behavior around pain medication had become increasingly problematic. The March 7 incident showed his growing agitation when told to wait for his scheduled Norco dose. He reminded staff he was on a pain contract that needed to be followed, yet threatened consequences if they documented his behavior.

The March 8 escalation revealed the depth of his mental health crisis. His specific suicide plan involving a diesel truck and overpass demonstrated both intent and means. Staff recognized the severity, implementing immediate monitoring protocols and alerting other nursing staff about his changed mental state.

Despite these documented warning signs and escalating threats, the facility failed to prevent Resident #113 from physically attacking another resident five days later.

The Executive Director confirmed to inspectors on September 10 that "the resident-to-resident abuse did happen and the staff immediately separated the residents."

Federal inspectors cited the facility for failing to ensure residents' rights to be free from abuse under the facility's own April 2025 policy, which documented it was facility policy "to protect its residents from abuse, neglect, exploitation, and misappropriate of resident property."

The violation resulted in actual harm to Resident #87, who suffered facial injuries and trauma from the unprovoked attack. Inspectors determined the failure placed all facility residents at risk for ongoing abuse and potential physical and psychological harm.

Resident #113's arrest following the assault marked the culmination of a week-long pattern of escalating threats against staff and suicidal statements that should have triggered more intensive intervention before he physically harmed another resident.

Full Inspection Report

The details above represent a summary of key findings. View the complete inspection report for Timber Springs Transitional Care from 2025-09-12 including all violations, facility responses, and corrective action plans.

Additional Resources

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