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F0600
D

Failure to Protect Resident from Physical Abuse by Another Resident

San Rafael, California Survey Completed on 09-08-2025

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 with severe cognitive impairment from physical abuse by another resident, also with severe cognitive impairment. According to interviews and record reviews, one resident was struck on the left cheek by another resident as he wheeled past her in the dining room. The incident was witnessed by a staff member, who observed that the resident's cheek was slightly reddened but she did not cry out in pain. The event was reported to a licensed nurse, who assessed the resident and confirmed the redness but noted no complaints of pain. The facility's Social Services Director acknowledged awareness of the incident and agreed that the resident had suffered abuse, confirming the facility's responsibility to ensure resident safety. The facility's abuse prevention policy states that residents have the right to be free from abuse, including physical abuse. The report documents that the facility did not ensure this right for the resident involved in the incident.

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