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F0607
D

Failure to Separate Accused Staff Following Abuse Allegation

Delano, California Survey Completed on 08-20-2025

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 implement its abuse policy and procedure for one resident who alleged abuse by a Certified Nursing Assistant (CNA). The resident, who had a tracheostomy and cerebral infarction and was assessed as cognitively intact, communicated an allegation of bullying by a CNA using a letter board. The allegation was reported to the facility's Nursing Facility Supervisor (NFS) and Quality Assurance Nurse (QAN), who confirmed that the accused CNA was neither removed from the facility nor placed under supervision after the allegation was made. The CNA continued to work her shift and was only instructed not to enter the resident's room, but no further action was taken to separate her from other residents or to monitor her interactions. Review of the facility's policy indicated that in cases of alleged abuse, the involved staff member should be assigned to non-patient care activities or, if not possible, should be supervised at all times during the investigation. The policy emphasizes the need to protect residents from potential abuse during investigations. However, the facility did not follow these procedures, as the CNA remained in her regular duties without supervision or reassignment, potentially exposing other residents to risk.

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