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F0600
D

Failure to Prevent Resident-to-Resident Physical Abuse in Hallway

Garden Grove, California Survey Completed on 02-18-2026

Penalty

Fine: $12,735
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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

The facility failed to protect a resident’s right to be free from physical abuse by another resident, in violation of its Abuse Prohibition Policy and Procedure. The policy, dated 2/23/21, prohibits abuse, mistreatment, neglect, misappropriation of resident property, and exploitation, and defines abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, injury, or mental anguish. On the date of the incident, a cognitively intact resident (Resident 105), who used a wheelchair, was in the Station 2 hallway when another resident (Resident 3), who had severe cognitive impairment, attempted to pass. Resident 3 yelled for Resident 105 to get out of the way and, when Resident 105 did not move quickly enough, Resident 3 swung his hand and struck Resident 105 in the face. The altercation was witnessed by staff and corroborated by interviews and documentation. An RN reported hearing Resident 3 yell "get out of my way" and observed both residents in the hallway, with Resident 3 unable to pass because Resident 105 was blocking his way; the RN stated that Resident 3 then swung his hand and slapped Resident 105’s head. The Social Services Assistant, who heard yelling from his office, also reported seeing Resident 3 slap Resident 105’s face. Resident 105 reported that he was sitting in his wheelchair in the hallway, that the other resident was going in the opposite direction, and that he could not move out of the way fast enough before being hit in the face, which he described as a closed-fist strike. An eINTERACT Change in Condition Evaluation documented that Resident 105 had redness on the face and forehead following the slap. The Administrator later confirmed that the facility substantiated the physical abuse based on the witnessed incident and the observed redness on Resident 105’s face.

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