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F0600
D

Failure to Prevent Resident-to-Resident Physical Abuse

Sacramento, California Survey Completed on 04-24-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to protect a resident from physical abuse when one resident, who had severe cognitive impairment due to Alzheimer’s disease, slapped another resident on the left cheek and head. The incident occurred in a common area, where the cognitively impaired resident was observed swinging and making contact with the other resident, who was attempting to defend himself by blocking the hits. Staff, including the activities director and a certified nursing assistant, witnessed the altercation and intervened to separate the residents. The resident who was struck had multiple sclerosis and was cognitively intact at the time of the incident. Documentation and interviews confirmed that the altercation involved physical contact, including slapping and attempted punches. The facility’s policy defines such actions as physical abuse, including slapping and punching, and staff acknowledged that resident-to-resident altercations are not tolerated.

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