F0609

D

Failure to Timely Report Alleged Physical Abuse by Family Member

Bakersfield, California Survey Completed on 03-04-2026

Penalty

No penalty information released

Summary

The facility failed to timely report an allegation of abuse involving one resident within the required timeframe. The resident had diagnoses including unspecified dementia, anxiety, Alzheimer’s disease, depression, cognitive communication deficit, and a need for assistance with personal care. An MDS assessment indicated the resident was rarely or never understood, had memory problems, severely impaired decision-making, and required substantial/maximal assistance with eating. A Change in Condition Evaluation dated 2/26/26 documented that a CNA reported witnessing the resident’s sister slap the resident on the right side of the face, with green/yellow discoloration noted on the right cheek upon evaluation.

The facility’s 5-Day Investigation Summary indicated that on 2/26/26 the CNA reported having observed the family member strike the resident during a feeding interaction approximately three weeks earlier, on 2/1/26, and acknowledged not reporting the alleged incident to administration at the time it occurred. In an interview, the Administrator confirmed that the CNA did not report the alleged physical abuse until 2/26/26 and acknowledged there was a delay in reporting. In a separate interview, the CNA stated she had immediately informed an LVN on the date of the incident and that the LVN told her to “shut up,” not say anything, and to mind their own business. The LVN stated he did not recall the date and reported that the CNA only told him the resident was being aggressive, denying that the alleged abuse was reported to him. The facility’s abuse policy required immediate reporting of suspected abuse, with specific timeframes of no later than two hours for abuse involving serious bodily injury and no later than 24 hours for other reportable incidents, based on real time rather than business hours.