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F0600
D

Failure to Prevent Physical and Verbal Abuse of Residents

Fall River Mills, California Survey Completed on 05-27-2025

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 prevent physical and verbal abuse for two residents with severe cognitive impairment. One resident, diagnosed with dementia, chronic pain, and weakness, was reported by her roommate to have been pushed and handled roughly by a CNA. A nursing note documented that this resident was emotional and distraught following the incident. Another resident, also with dementia and a severely impaired BIMS score, experienced an incident where a CNA cursed, pushed the resident, and threw personal care items onto the resident's chest. A witness CNA reported that the resident expressed fear of the CNA due to her aggressive behavior. The facility's policy prohibits all forms of abuse and mistreatment, but interviews and record reviews confirmed that staff members engaged in rough and aggressive conduct toward these residents. The incidents were directly observed or reported by other staff and residents, and the affected residents were noted to be emotionally distressed and fearful as a result of the staff's actions.

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