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F0607
D

Failure to Timely Suspend Staff Following Allegations of Resident Mistreatment

Saratoga, California Survey Completed on 08-12-2025

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

The facility failed to follow its abuse policy by not timely suspending two certified nurse assistants (CNAs) who were accused of resident mistreatment. In the first instance, a resident reported that a CNA verbally disrespected her on multiple occasions, including telling her to "shut up and mind your own business." Despite this allegation, the registered nurse who learned of the incident did not suspend the CNA as required by facility policy. In the second case, another resident reported to therapy staff that she was punched and poked on the sides of her abdomen by a CNA while being changed. When a licensed vocational nurse received this report, she changed the CNA's assignment but did not suspend the CNA. The facility's policy, revised in September 2024, states that any employee accused of resident abuse is to be placed on leave with no resident contact until the investigation is complete. However, interviews confirmed that the required suspensions did not occur in these cases.

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