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F0600
D

Failure to Protect Resident from Physical Abuse by Another Resident

Sacramento, California Survey Completed on 08-06-2025

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 by another resident. One resident, who had a history of mental health disorders including hallucinations, delusions, anxiety, impulse disorder, and mood disorder, was found with injuries including a bleeding lip, scratches on the forearm, and redness to the hand knuckles after being punched in the face by another resident. Both residents involved were documented as incapable of understanding their rights, responsibilities, and informed consent. Prior to the physical altercation, the aggressor was observed yelling profanities and exhibiting racially preoccupied, delusional behavior toward the victim. Progress notes and interviews confirmed that the aggressor admitted to repeatedly hitting the other resident until he fell to the floor. The incident was acknowledged by the DON, who confirmed that all residents have the right to be free from abuse. The facility's policy also states that residents must be protected from abuse by anyone, including other residents. The failure to prevent this altercation resulted in physical harm to the resident.

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