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F0600
D

Failure to Prevent Resident-to-Resident Physical Abuse Resulting in Injury

Woodland, California Survey Completed on 09-02-2025

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's right to be free from physical and mental abuse when one resident shoved a walker into another resident's legs, resulting in a skin tear. The incident occurred after an argument between the two residents, one of whom had a diagnosis of dementia and was seated in a wheelchair, while the other was cognitively intact and standing. A certified nursing assistant witnessed the event, confirming that the walker was pushed into the standing resident, causing a skin tear to the left knee with bleeding that required dressing changes. Documentation and interviews confirmed the injury, with the affected resident displaying a circular scab and bruising on the left knee during observation. The facility's abuse prevention policy states that residents must not be subjected to abuse by anyone, including other residents. The incident was recognized by staff as physical abuse, and the injury was directly linked to the altercation between the two residents.

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