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F0609
D

Failure to Timely Report Alleged Staff-to-Resident Abuse

Bell Gardens, California Survey Completed on 11-14-2025

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 report an allegation of staff-to-resident physical abuse to the California Department of Public Health (CDPH) within the required timeframe. A resident with severe cognitive impairment, quadriplegia, and total dependence on staff for activities of daily living was re-admitted to the facility and later alleged to his responsible party that he had been hit by an unidentified male CNA. This allegation was communicated to the facility's Interdisciplinary Team during a meeting, and both the Director of Nursing (DON) and the Administrator acknowledged awareness of the allegation. Despite facility policy and federal requirements mandating that all allegations of abuse be reported within two hours, the DON and Administrator confirmed that the incident was not reported to the State Agency. The facility's own policies, reviewed during the investigation, also specified the need for timely reporting of abuse allegations. The failure to report the incident as required constituted a deficiency in the facility's abuse reporting procedures.

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