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F0600
D

Failure to Protect Resident from Physical Abuse by Another Resident

Sacramento, California Survey Completed on 07-18-2025

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

A deficiency occurred when a resident with multiple sclerosis and intact cognition was physically abused by another resident diagnosed with vascular dementia and moderate cognitive impairment. The incident took place when the resident with dementia punched the other resident on the left arm after a verbal altercation, which was witnessed by staff. The assaulted resident reported being punched, and the aggressor admitted to the action, stating it was in response to perceived disrespect toward his deceased wife. Record review revealed that there was no documented evidence of a person-centered care plan addressing the potential risk of aggressive behavior for the resident with vascular dementia prior to the incident. The facility's policy states that residents have the right to be free from all forms of abuse, including physical abuse, but this right was not upheld in this case.

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