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F0600
D

Failure to Prevent Resident-to-Resident Physical Abuse

Oroville, California Survey Completed on 08-01-2025

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 another resident struck him in the right eye with a closed fist. The incident occurred after the first resident, who has multiple medical conditions including multiple sclerosis, dementia, and depression, asked the second resident to stop talking loudly and to leave the room. The first resident admitted to possibly yelling due to being hard of hearing, after which the second resident, who also has several medical and psychiatric diagnoses including bipolar disorder and depression, reacted by hitting him. The altercation resulted in the first resident sustaining a bruised right eye and experiencing discomfort for several days. Staff interviews confirmed that yelling was heard from the room, and by the time staff arrived, the physical altercation had already taken place. The resident who was struck was sent to the hospital for evaluation of his injury. Both the DON and the facility administrator confirmed that the incident constituted physical abuse. The facility's policy on abuse, neglect, and exploitation requires the prevention of such incidents, but in this case, the policy was not effectively implemented to protect the resident from harm.

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