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F0600
D

Failure to Protect Resident from Sexual Abuse by Another Resident

Auburn, California Survey Completed on 05-29-2025

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

A deficiency occurred when a resident with dementia and moderate memory impairment was subjected to inappropriate sexual contact by another resident, who also had moderate memory impairment. The incident took place in a hallway after an activity event, where a staff member witnessed one resident fondling the other's breasts without consent. The affected resident was unable to communicate well and appeared surprised and distressed during the incident, as observed by the staff member. The facility's records, including the admission record and Minimum Data Set, confirmed the cognitive impairments of both residents involved. The Interdisciplinary Team note documented the incident based on the staff witness report, but there was no evidence that the affected resident had given consent for any physical contact. When interviewed, the resident who committed the act declined to participate and asked to be left alone. The Director of Nursing confirmed the incident and acknowledged that it was witnessed by staff. The facility's abuse prevention policy states that all residents have the right to be free from abuse, including sexual abuse, by anyone. Despite this policy, the facility failed to protect the resident from abuse by another resident, resulting in a violation of the resident's rights.

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