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F0600
G

Failure to Prevent Resident-to-Resident Physical Abuse

Petaluma, California Survey Completed on 10-22-2025

Penalty

Fine: $45,920
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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 when another resident punched him in the eye, resulting in a bruise. Resident 2, who had a history of angry outbursts and physical aggression and was prescribed multiple psychotropic medications, engaged in a verbal argument with Resident 1 after being asked to turn off the light. The argument escalated, and Resident 2 physically struck Resident 1. Documentation and interviews confirmed that Resident 1 sustained a bruise under the left eye as a result of the altercation. Resident 1, who had a history of alcoholic cirrhosis and type 2 diabetes with mild cognitive impairment, reported tolerable pain and emotional distress following the incident. Staff observed the injury and offered medical assistance, which was declined by the resident. The incident was witnessed by staff, and the police were involved, resulting in Resident 2 being removed from the facility. The facility's policy states that each resident has the right to be free from abuse, but this right was not upheld in this instance.

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