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F0607
F

Failure to Protect Residents from Alleged Perpetrator During Abuse Investigation

Santa Rosa, California Survey Completed on 05-02-2025

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 protect all residents from sexual abuse by allowing a certified nursing assistant (CNA) who was the subject of an abuse allegation to continue working in the facility before a complete investigation was conducted, as required by facility policy. After a resident with cardiomegaly and dementia reported to a CNA that she experienced sexual abuse by a male staff member, the Director of Nursing (DON) identified the alleged perpetrator based on the resident's description. Despite this, the CNA was permitted to clock in and work a shift on the same day the allegation was reported, providing him access to the resident and others. The DON became aware of the allegation around midday and interviewed the CNA only after he had already started his shift. The CNA admitted to providing showers to the resident and documenting them under another CNA's name. Facility policy requires that residents be protected from abuse and from contact with alleged perpetrators during investigations, but this was not followed. The failure to immediately remove the CNA from the facility during the investigation placed the resident and others at risk.

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