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F0600
G

Failure to Protect Resident from Abuse by Another Resident

Kansas City, Missouri Survey Completed on 12-22-2025

Penalty

Fine: $22,315
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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 the facility failed to protect a resident from abuse by another resident. One resident, who had diagnoses including bipolar disorder, major depressive disorder, schizoaffective-bipolar disorder, and anxiety disorder, was assaulted while sleeping by another resident with a history of schizoaffective disorder, bipolar disorder, unspecified psychosis, and anxiety disorder. The assault involved the use of fingernails and a broken pen, resulting in multiple facial lacerations of varying depths and redness on the left side of the victim's face. The incident was witnessed by staff, and law enforcement was called to the scene. Prior to the assault, the resident who was attacked had entered the assailant's room, accused them of theft, and disrupted their belongings, including tearing up a picture and putting shampoo on the bed. The assailant, angered by these actions, entered the other resident's room while they were sleeping and initiated the physical altercation. Staff responded to the incident after hearing screams and found the assailant on top of the victim, clawing at their face with fingernails and holding a broken pen. The victim sustained multiple scratches and lacerations, some deep enough to draw blood, and was sent to the hospital for evaluation and treatment. Interviews with staff and residents confirmed the sequence of events, with multiple staff members observing the physical altercation and the injuries sustained. The facility's investigation documented the altercation, the residents' behavioral histories, and the physical evidence of abuse. The incident was classified as abuse in the facility's investigation, and law enforcement issued a citation for assault to the resident who initiated the attack.

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