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F0600
D

Resident-to-Resident Physical Abuse Following Roommate Dispute

Portland, Oregon Survey Completed on 05-15-2025

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 Alzheimer's disease and moderate cognitive impairment was physically abused by a roommate with dementia, also exhibiting moderate cognitive impairment. The incident took place in a shared room when one resident turned on the overhead light, waking the other, who became angry, used profanity, and pushed the first resident back onto the bed. The resident who was pushed reported feeling scared and later complained of shoulder pain. Staff interviews confirmed that the incident involved a physical altercation following a dispute over the room light, and both residents had a history of issues related to sharing the room. The event was witnessed and reported by staff, with both residents interviewed after the incident. The resident who was pushed described feeling abused and afraid at the time, while the other resident admitted to pushing due to frustration over the light being turned on. Staff and administrative personnel acknowledged the incident as meeting the definition of abuse, and documentation indicated that the affected resident felt unsafe immediately following the event.

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