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F0609
D

Failure to Timely Report Alleged Abuse to Authorities

Pomona, California Survey Completed on 04-09-2025

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 abuse involving a resident with diagnoses including type 2 diabetes mellitus, dementia, and unsteadiness of feet. The resident was assessed as moderately impaired in cognitive skills and required supervision for lower body dressing and bathing. On the evening of the incident, a CNA witnessed another CNA mistreat and physically abuse the resident and reported the incident to an LVN, an RN, and the DON. The CNA also provided a written statement about the abuse. Despite these reports, the facility did not notify the California Department of Public Health, the Ombudsman, or local law enforcement within the required two-hour timeframe as outlined in the facility's policy and procedure for reporting abuse. Interviews with staff confirmed that the incident was discussed among the CNA, LVN, RN, and DON, and that a written statement detailing the abuse was received by the DON and DSD the following day. Both the DON and DSD acknowledged that the written statement contained allegations of abuse and that the facility should have reported the incident within two hours, as required by their policy. A review of the facility's policy confirmed the requirement to report all allegations of abuse to the appropriate authorities within the specified timeframe.

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