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F0600
D

Resident Physically Abused and Restrained by CNA During Care

Sacramento, California Survey Completed on 12-12-2025

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 Certified Nursing Assistant (CNA) physically abused a resident by striking them on the head and directing two student witnesses to physically restrain the resident during care. The incident was observed by two students who were assisting with the resident's care and later reported the abuse to their instructor and facility staff. The CNA instructed the students to hold the resident's arms and legs, claiming the resident was aggressive, and then proceeded to hit the resident on the forehead with an open hand. The resident involved had a history of traumatic hemorrhage of the cerebrum, dementia, and muscle weakness, and was assessed as having moderate cognitive impairment, requiring additional support for daily living tasks. During the incident, the resident was being changed and was unable to provide an account of the event when later interviewed. Both student witnesses confirmed that they were told by the CNA to restrain the resident, and both expressed discomfort with the situation, stating that they had received abuse prevention training and recognized the actions as inappropriate. Interviews with facility leadership, including the Director of Staff Development (DSD) and Director of Nursing (DON), confirmed that the CNA's actions were reported and that the facility does not have a policy permitting the restraint of residents. The facility's abuse prevention policy explicitly prohibits all forms of abuse, including physical abuse and the use of restraints. Documentation in the CNA's personnel file indicated an admission to restraining the resident during care.

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