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F0600
D

Failure to Protect Resident from Physical Abuse by Another Resident

Sacramento, California Survey Completed on 12-22-2025

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 one resident with severe cognitive impairment was struck in the head by another resident with intact cognition. The incident was confirmed through clinical record review, interviews, and documentation. The resident who was hit reported pain and dizziness following the altercation and was sent to the hospital for evaluation. The altercation took place in a room without staff present, and both residents acknowledged their involvement in the incident during interviews. The facility's policy states that residents have the right to be free from abuse, including physical abuse. Despite this, the facility failed to protect this right, resulting in one resident experiencing pain and ongoing discomfort after being hit. The event was documented in the residents' clinical records and confirmed by the DON, who acknowledged the residents' rights as outlined in facility policy.

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