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F0600
D

Resident Subjected to Verbal Abuse and Neglect After Fall

Roseville, California Survey Completed on 06-11-2025

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 significant cognitive and physical impairments, including aphasia, memory problems, and dependence on staff for daily activities, was found on the floor after a fall. The resident was unable to explain why he was on the floor and called out for help. A Certified Nursing Assistant (CNA) who was not assigned to the resident entered the room, used profane and demeaning language, and told the resident he would remain on the floor until the end of the shift. The CNA placed a pillow and blanket under the resident and then left, rather than assisting him off the floor or ensuring his immediate safety and comfort. The incident was witnessed and corroborated by the resident's roommate, who reported hearing the CNA use inappropriate language and dismiss the resident's needs. The CNA herself admitted to using profanity in the presence of residents and staff, citing frustration as the reason for her behavior. Facility records and interviews confirmed that the CNA's actions were verbally abusive and neglectful, as she failed to provide appropriate care and respect for the resident's dignity following his fall. The facility's investigation substantiated the allegations of verbal abuse and neglect, with both the resident and his roommate providing consistent accounts of the CNA's conduct. The facility's policy requires staff to treat residents with dignity and respect at all times, and prohibits demeaning practices. The CNA's actions directly violated these standards, resulting in a failure to protect the resident from abuse and neglect.

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