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F0600
D

Resident Physically Abused by Staff Following Aggressive Incident

Sacramento, California Survey Completed on 07-29-2025

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 facility staff member failed to protect a resident from physical abuse when a CNA pushed the resident in the face, causing the resident to fall to the ground. The resident, who had moderate cognitive impairment and lacked decision-making capacity, had become physically aggressive toward the CNA during care, striking the staff member in the face. In response, the CNA pushed the resident, resulting in a fall and subsequent unresponsiveness. The resident was transferred to the hospital for further evaluation after being found nonverbal and unable to move extremities, which was not at his baseline. Interviews with facility staff confirmed that the CNA's actions constituted physical abuse and were not in accordance with the facility's abuse prevention policy or the abuse training the CNA had received. The Director of Nursing acknowledged that the CNA should have known how to manage residents with dementia and that the staff member's actions placed the resident's safety at risk. Facility policy emphasized the right of residents to be free from abuse and the importance of compassionate care, particularly for those with behavioral and cognitive issues.

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