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F0600
D

Failure to Protect Residents from Abuse and Neglect by CNA

Murrieta, California Survey Completed on 07-03-2025

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 two residents from abuse by a Certified Nursing Assistant (CNA). For one resident, the CNA refused to provide care and made a derogatory statement, saying, "I am not your slave." This refusal and verbal abuse were witnessed by staff and reported by the resident, who expressed being taken aback by the CNA's attitude and comments. The resident required significant assistance due to multiple medical conditions, including multiple sclerosis, COPD, and congestive heart failure, and was dependent on staff for care. For another resident, the CNA provided care in a rough and aggressive manner. Multiple staff members, including two LVNs, observed the CNA forcefully moving the resident, pulling a sheet out from under him, and not addressing the resident while he was screaming in pain. The resident, who had diagnoses of Parkinson's disease and dementia, was described as frail, confused, and requiring moderate to maximum assistance for bed mobility. The incident was witnessed by staff who reported that the resident was not being combative at the time, contrary to the CNA's claims. The resident's roommate was also visibly upset by the incident. Interviews and record reviews confirmed that the CNA's actions and statements constituted both physical and verbal abuse, as well as neglect by refusing care. The facility's policies prohibit such conduct and require staff to provide compassionate care, report abuse, and use appropriate techniques when caring for residents with behavioral challenges. The events described led to the residents experiencing or being at risk for physical and emotional distress.

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