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F0600
G

Resident Physically Abused by CNA During Care

Bakersfield, California Survey Completed on 12-08-2025

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 during care. While two CNAs were changing the resident's adult brief, the resident, who has Alzheimer's disease, major depressive disorder, and legal blindness, became agitated and began hitting and grabbing the CNAs. One CNA, after having her hand grabbed and scratched by the resident, responded by hitting the resident on the right side of his face with an open hand. This act was witnessed by the other CNA, who described the action as a slap delivered out of anger, and observed that the resident became upset, cried, and had visible redness on his cheek. The resident involved was severely cognitively impaired, wheelchair-bound, and required substantial assistance with activities of daily living, including toileting and hygiene. The care plan for the resident noted a history of physical behaviors related to Alzheimer's disease, with interventions to provide cues and positive feedback to alleviate anxiety. On the night of the incident, documentation indicated no behavioral symptoms prior to the event. The physical abuse was not reported by the CNA who committed it, but was instead reported by the witnessing CNA to the facility administrator. Interviews and documentation confirmed that the CNA admitted to hitting the resident and did not initially report the incident. The administrator and other staff corroborated the sequence of events, including the demonstration of the slapping motion during interviews. The facility's policy states that residents have the right to be free from abuse, neglect, and mistreatment, but this policy was not followed in this instance, resulting in the resident experiencing physical and emotional distress.

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