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F0610
E

Failure to Timely Report Abuse Investigation Results to State Agency

San Francisco, California Survey Completed on 07-24-2025

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 report the results of investigations into abuse allegations to the State Survey Agency (SSA) within five working days of the incidents for four residents. Specific incidents included allegations of rough handling by two CNAs during a bed change, verbal aggression and rudeness by a CNA, a nurse being harsh and hitting a resident, and a resident-to-resident altercation involving physical contact. In each case, while initial reports of the allegations were made to the appropriate authorities, the required follow-up documentation detailing the results of the investigations was not submitted to the SSA within the mandated five-day period. Record reviews showed that the follow-up reports were faxed to the California Department of Public Health (CDPH) several days after the five-day window had passed. The facility's policy requires that the results of abuse investigations be reported to government agencies within five working days, but this procedure was not followed in these instances. The administrator confirmed during an interview that the five-day reporting requirement was not met for these cases.

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