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F0600
D

Failure to Protect Resident from Staff-Perpetrated Abuse

Fremont, California Survey Completed on 04-18-2025

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 staff member failed to protect a resident from abuse during a confrontation in the dining room. The resident, who had a history of schizoaffective disorder, type 2 diabetes, and assaultive behavior, became agitated after a CNA removed a cup of juice from their meal tray. In response, the resident threw the juice at the CNA. Multiple staff statements and documentation confirm that the CNA then threw juice back at the resident and subsequently approached the resident with a disinfectant spray bottle, aiming it at the resident and making a threatening statement. The incident was witnessed by several staff members, including a registered nurse and a special treatment program counselor, who observed the CNA's actions and heard the threatening language directed at the resident. The resident was described as having intact cognition and did not sustain any injuries or changes in behavior following the incident. There was no evidence of a prior history of conflict between the CNA and the resident. Facility records, including progress notes, abuse report forms, and staff interviews, consistently documented that the CNA did not deny the actions and admitted to losing their temper. The facility's policy clearly prohibits any form of abuse, including physical or mental harm, and the actions of the CNA were in direct violation of this policy, resulting in a failure to protect the resident's right to be free from abuse.

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