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F0600
G

Failure to Protect Resident from Physical Abuse by Roommate

Artesia, California Survey Completed on 11-12-2025

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 resident with moderate cognitive impairment and a history of paranoid schizophrenia and generalized anxiety disorder physically assaulted his roommate, who had severe cognitive impairment and multiple psychiatric and medical diagnoses. The incident took place in a shared restroom, where the assaulted resident entered while the other was using the facility. The aggressor demanded the other resident leave, but when he did not comply and approached, the aggressor made physical contact, resulting in the victim being punched in the face and pushed to the floor. The assaulted resident sustained significant injuries, including a left periorbital discoloration, a nasal bridge discoloration, a skin tear on the left eyebrow, and a skin tear on the left dorsal fifth digit. Medical evaluation at a general acute care hospital confirmed a mildly depressed nasal bone fracture and a left periorbital hematoma. The incident was witnessed by a CNA who responded immediately, and emergency services were called to transfer the injured resident for further evaluation and treatment. Interviews with facility leadership confirmed that the altercation was considered physical abuse, and both the Assistant Director of Nursing and Director of Nursing acknowledged the residents' right to be free from abuse. The facility's policy also states a commitment to protect residents from abuse, including abuse from other residents. The report documents that the facility failed to protect the resident's right to be free from physical abuse, resulting in physical harm.

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