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F0610
D

Failure to Investigate and Protect Resident After Abuse Allegation

Bakersfield, California Survey Completed on 12-04-2025

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, Neglect & Exploitation Policy when an allegation of physical abuse was made by a resident against a Certified Nursing Assistant (CNA). On the day of the incident, the resident expressed to a visitor and the Director of Clinical Services (DCS) that she had been physically abused by the CNA during assistance in the restroom. Despite this allegation, the CNA was not immediately removed from providing care to the resident and continued to work with her for approximately six more hours. There was no immediate physical assessment of the resident, and no investigation into the abuse allegation was initiated at that time. The facility's policy requires that upon learning of an alleged abuse, the accused staff member should be suspended until the matter is investigated, and the resident should be provided with medical attention as appropriate. Additionally, the policy mandates that an internal investigation be initiated as soon as practicable and that a licensed nurse or physician should immediately examine the resident, with findings documented in the medical record. These steps were not followed, as confirmed by interviews with staff and review of records, resulting in a failure to protect the resident and to investigate the allegation in a timely manner.

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