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F0600
D

Failure to Protect Resident from Physical Abuse and Mistreatment by CNA

Claremont, California Survey Completed on 12-17-2025

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 nursing assistant (CNA) failed to provide a safe environment and protect a resident with severe cognitive impairment from physical abuse and mistreatment. The resident, who had diagnoses of Alzheimer's disease and dementia and required moderate assistance with activities of daily living, was subjected to rough handling and verbal aggression by the CNA. Multiple witnesses, including the resident's roommate and another CNA, observed the CNA speaking loudly and firmly to the resident, grabbing the resident tightly by the arms, and placing the resident into a wheelchair in a fast and rough manner. The CNA was also seen brushing the resident's hair roughly, causing concern for the resident's comfort. The roommate, who was cognitively intact, reported that the CNA's actions were forceful enough to cause discomfort and that the CNA yelled at the resident not to get up. Another CNA corroborated these observations, stating that the resident appeared uncomfortable and that the CNA's tone of voice was inappropriate. The incident was reported to facility leadership, and interviews with staff and residents confirmed the rough treatment and verbal mistreatment by the CNA. The resident, when interviewed, did not recall the incident, but later described the CNA as rude and stated that the CNA had yelled and handled them harshly. The roommate refused further care from the CNA due to these actions. Facility records and interviews with the Director of Staff Development and Director of Nursing confirmed that concerns about the CNA's behavior were reported by both residents and staff, and that the facility's abuse prevention policy prohibits any form of resident abuse or mistreatment.

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