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F0600
D

Failure to Protect Resident from Physical Abuse by Another Resident

San Rafael, California Survey Completed on 08-12-2025

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 resident with severe obesity, bed confinement, and severe cognitive impairment was physically abused by another resident who entered his room and struck him in the face with a hanger. The incident was confirmed through interviews and record reviews, including a nursing note documenting two new superficial scratches on the resident's left cheek. The resident who committed the abuse had moderate cognitive impairment and Parkinson's disease, and admitted to entering the other resident's room and hitting him with a hanger due to being upset by his yelling. Staff interviews confirmed awareness of the incident, with the Social Services Director and Director of Nursing both acknowledging the facility's responsibility to protect residents from abuse. The facility's policy on abuse prevention was reviewed and stipulated that residents have the right to be free from abuse, including physical abuse. The failure to prevent this incident resulted in physical harm to the resident and demonstrated a lapse in protecting residents from abuse by others within the facility.

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