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F0600
G

Resident Subjected to Physical Abuse During Shower

Marshalltown, Iowa Survey Completed on 10-09-2025

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

A deficiency occurred when a Certified Nurse Aide (CNA) intentionally sprayed a resident with cold water at the end of a shower, despite the resident's cognitive impairment and care plan interventions. The resident, who had diagnoses of Alzheimer's disease, non-Alzheimer's dementia, and anxiety disorder, was assessed as having severely impaired cognition and required substantial assistance with showering. During the incident, the CNA told other staff to "watch this," turned the water to cold, and sprayed the resident for several seconds, causing the resident to become angry and strike the shower head against the wall. Two other CNAs were present during the incident. One CNA reported witnessing the event and described the resident as noncombative at the time, while the other CNA heard the resident yelling and saw the CNA continue to spray him with cold water despite being told to stop. Both witnesses stated that the CNA laughed during the incident, and the resident verbally expressed his discomfort and distress. The facility's policy clearly stated that all residents have the right to be free from abuse, including any act intended to cause pain, injury, or offensive physical contact. The incident was not reported immediately by the witnesses, as they did not initially recognize it as abuse. The Director of Nursing and Administrator both stated that staff are expected to treat residents with dignity and respect and to report suspected abuse immediately. The CNA involved denied intentionally spraying the resident, claiming it may have been accidental while turning off the water, but witness accounts contradicted this statement. The failure to protect the resident from physical abuse constituted a violation of the facility's abuse prevention policy.

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