F0600

E

Failure to Prevent Repeated Resident-to-Resident Physical Abuse

Sacramento, California Survey Completed on 01-08-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to protect residents from physical abuse by another resident on three separate occasions. Resident 1, who had schizoaffective disorder and age-related cognitive decline, was admitted in December 2025. On 12/13/25 at approximately 4 p.m., Resident 1 was standing in the hallway using a walker when Resident 2, who had schizoaffective disorder and depression, was positioned in front of him and speaking loudly to himself. Resident 1 became upset by Resident 2’s behavior and spat on Resident 2. Resident 2 later confirmed that another resident had spit on him about a month prior and expressed more concern about staff than other residents when asked if he felt safe.

On 12/24/25, Resident 1 physically abused Resident 3 in the dining room. Resident 3, who had schizophrenia and dementia and had been admitted in April 2024, was seated at a table drinking coffee. Resident 1 was observed standing from his wheelchair, approaching the table where Resident 3 was seated, and then slapping Resident 3 on the back of the head, producing an audible sound. A social services assistant witnessed the incident and reported that Resident 3 looked shocked and confused, and that Resident 1 stated he slapped Resident 3 because Resident 3 was looking at him in a “weird way.” Resident 3 later stated he had been hit on the back of the head by “some guy,” though he did not recall exactly when.

On 12/26/25, Resident 1 physically abused Resident 4 near the nurse’s station. Resident 4, who had schizoaffective disorder and PTSD and had been re-admitted in March 2024, was sitting near the nurse’s station attending a group when Resident 1 walked toward her, sat down next to her, and suddenly struck the right side of her face with his hand. A licensed nurse witnessed the event, described hearing an audible slap, and reported that Resident 4 cried and said that Resident 1 had slapped her. During a later interview, Resident 4, who demonstrated confusion and difficulty providing appropriate responses, expressed fear about a fire and recounted being slapped by a man, stating it was her word against everybody else. The DON confirmed that the three witnessed incidents between Resident 1 and Residents 2, 3, and 4 constituted physical abuse, contrary to the facility’s abuse prevention policy, which states residents have the right to be free from physical abuse and other forms of mistreatment.