F0600

D

Failure to Prevent Resident-to-Resident Physical Abuse Despite Known Aggressive History

Glendora, California Survey Completed on 01-29-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to protect a resident from physical abuse by another resident in accordance with its Abuse Prevention/Prohibition and Resident Rights policies. One resident (Resident 3) had a history of aggressive behavior, including an SBAR on 8/8/2025 documenting attempts to hit others in the hallway and a transfer to a general acute care hospital on 8/11/2025 for aggressive behavior, shouting, screaming, and attempting to hit others. Resident 3’s MDS dated 11/3/2025 showed severely impaired cognition and a need for partial/moderate assistance with ADLs and mobility. After a psychiatric hospitalization and readmission on 9/23/2025, the facility initiated a care plan for aggressive behavior, but the DON later acknowledged that the interventions in this care plan were vague, not individualized, and not behavior-specific, despite Resident 3’s known history of aggression.

Resident 4 was admitted on 12/5/2025 with diagnoses including pneumonia and anxiety disorder, with an MDS indicating moderately impaired cognition and a need for substantial/maximal assistance with ADLs and mobility. On 1/19/2026, an SBAR documented that Resident 4 was sitting by the time clock on the North Station when Resident 3 hit Resident 4 on the back of the head. Resident 4 reported head pain rated 7/10 and was transferred to a general acute care hospital for further evaluation and treatment. In an interview, Resident 4 stated they were seated in the lobby watching the clock when Resident 3 approached in a wheelchair; Resident 4 attempted to move out of the way but was struck in the back of the head before they could reposition, describing the contact as sudden and unexpected and reporting emotional distress and feeling shaken by the incident.

In interviews, Resident 3 demonstrated a fist motion as if punching Resident 4 and stated being angry because Resident 4 was blocking the way, though did not verbally admit to striking the other resident. RN 2 reported being at the North Nursing Station, hearing someone yell, “Ow, he hit me,” and immediately separating the two residents; RN 2 did not witness the actual strike but saw Resident 3 making a fist-like motion. RN 2 stated that when a resident has a known history of aggressive behavior, the care plan must be individualized and include specific, measurable interventions such as defined supervision levels, identification of triggers, early intervention strategies, de-escalation techniques, environmental modifications, redirection methods, staff approach guidelines, and escalation criteria, and that vague, generalized interventions without behavior-specific guidance leave staff without clear direction to prevent escalation. The DON similarly stated that without detailed individualized interventions for a resident with a known history of aggressive behavior, staff lack clear direction to proactively prevent escalation, increasing the risk for resident-to-resident altercations, even when aggressive behaviors have been dormant for months. The facility’s policies defined abuse as the willful infliction of injury resulting in physical harm, pain, or mental anguish and guaranteed residents the right to be free from abuse and neglect.