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F0609
D

Failure to Timely Report Alleged Abuse and Mistreatment

Oakland, California Survey Completed on 04-24-2025

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 ensure that allegations of abuse or mistreatment involving two residents were reported to the appropriate authorities within the required timeframe. One resident, admitted with anxiety disorder and requiring assistance with personal care, reported during a resident council meeting that a CNA was rough and aggressive during perineal care. The Director of Staff Development (DSD) did not interview the CNA until four days after the allegation was made, waiting until the CNA was next scheduled to work. The incident was not reported to the State Survey Agency, Long-Term Care Ombudsman, or law enforcement until nine days after the initial report. A second resident, admitted with dependence on renal dialysis and muscle weakness, filed a grievance alleging that the same CNA pointed a finger and made a dismissive comment after the resident expressed frustration over a delayed response to a call light. The DSD received this grievance the day after the alleged incident but delayed interviewing the CNA for two days, again waiting until the CNA was scheduled to work. Both incidents were reported to the required authorities only after the DSD had spoken with the CNA, contrary to the facility's policy, which requires immediate reporting, but not later than two hours after an allegation is made.

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