F0609

D

Failure to Timely Report Resident’s Allegation of Rough Handling During Toileting

Visalia, California Survey Completed on 03-02-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure an allegation of abuse was promptly reported to the abuse coordinator as required by policy. Resident 1 was admitted with metabolic encephalopathy, difficulty in walking, cognitive communication deficit, bilateral lower extremity range-of-motion impairment, and was wheelchair-bound and dependent for transfers. An MDS dated 1/30/26 documented that the resident was cognitively intact with a BIMS score of 13. On 1/28/26 during the p.m. shift, the resident reported that an unknown CNA who assisted her to and from the restroom while her regular CNA was on lunch had been rough and hurt her back while providing care, which the facility categorized as an allegation of physical abuse.

A SOC 341 form dated 1/29/26 documented the resident’s report that an unknown staff member was rough while assisting her to the restroom on the 1/28/26 p.m. shift. Progress notes dated 1/30/26 at 1:57 p.m. indicated that the IDT met to discuss the staff-to-resident alleged abuse that occurred on 1/28/26, and that the resident’s granddaughter had found the resident crying and was told by the resident that a female staff member had been rough and hurt her back while helping her to the bathroom. The resident stated the staff member was not her usual CNA but was helping out during the CNA’s lunch break and was unable to identify the CNA involved.

Multiple staff interviews confirmed that the allegation was reported by the resident and her family to CNA 3 during the 1/28/26 p.m. shift, and that CNA 3 relayed the allegation to LVN 1 that same evening. LVN 1 acknowledged that she did not report the allegation to the administrator (abuse coordinator) or the DON, stating she was overwhelmed and it slipped her mind, and further acknowledged it should have been reported right away. The SSD and administrator both stated they did not become aware of the allegation until the following day when the family reported it, and both indicated that staff should have reported the allegation to the abuse coordinator immediately. The facility’s abuse, neglect, and exploitation policy required reporting all alleged violations to the administrator and appropriate agencies immediately, but not later than two hours after the allegation is made when the events involve abuse or result in serious bodily injury, which did not occur in this case.