F0600

D

Failure to Protect Resident From Physical Abuse by Another Resident

Elk Grove, California Survey Completed on 01-13-2026

Penalty

No penalty information released

Summary

The facility failed to protect a resident’s right to be free from physical and mental abuse when one cognitively impaired resident forcefully grabbed another resident by the throat during an altercation. Resident 1, admitted in January 2023 with generalized weakness and Alzheimer’s disease, had a BIMS score of 3 indicating severe mental and cognitive impairment. Resident 2, admitted in December 2024 with dementia and a BIMS score of 4, also had severe cognitive impairment. On 12/26/25 at approximately 3 a.m., a CNA responded to Resident 1 yelling and asked if he needed to be changed; Resident 1 declined, and the CNA left to another room. After approximately 5–6 minutes, the CNA again heard Resident 1 yelling and, upon re-entering the room, observed Resident 2’s hand forcefully gripping Resident 1’s throat and immediately separated the residents.

Nursing documentation for 12/26/25 reflected the CNA’s report that Resident 2’s hands were on Resident 1’s neck and that Resident 1 stated Resident 2 had been squeezing his hand and neck. During a later interview, Resident 1 reported that someone had grabbed his neck and hands, rubbed his wrists, and stated his hands had been hurting since the incident, and further indicated he felt safe only when not near his old room. The DON acknowledged that the facility was considered Resident 1’s home and that he should not be subjected to physical abuse. The facility’s Abuse Prohibition Policy and Procedure, revised 2/21, stated that the center prohibits abuse, mistreatment, neglect, misappropriation of resident property, and exploitation for all residents and that it will implement an abuse prohibition program through prevention of occurrences; however, the incident demonstrated that the resident was not protected from physical abuse by another resident.