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F0600
D

Failure to Prevent Resident-to-Resident Physical Abuse

Roseville, California Survey Completed on 06-18-2025

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

The facility failed to protect a resident from physical abuse when another resident punched him in the leg in the activity room. According to progress notes and staff interviews, one resident, who had no memory impairment and was admitted with anxiety, was sitting in the activity room when another resident, diagnosed with dementia and depression and exhibiting significant memory impairment, rammed his wheelchair into the first resident's wheelchair and proceeded to punch him in the leg multiple times. The incident was witnessed by the activities assistant, who also reported that the aggressive resident attempted to hit her as well. Following the altercation, the assaulted resident expressed feeling unsafe and scared to return to the activity room when the other resident was present. Documentation from the social services director confirmed the resident's fear and reluctance to participate in activities due to the incident. The facility's abuse prevention policy defines physical abuse as including hitting and punching and requires the administrator or designee to provide a safe environment for residents. The failure to prevent this incident decreased the potential for the resident to maintain his highest practicable physical, mental, and psychosocial well-being.

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