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F0609
D

Failure to Report Resident Abuse Allegation

Santa Ana, California Survey Completed on 06-16-2025

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 who stated she felt harassed and threatened by another resident. According to the facility's own policies and procedures, all allegations of abuse, including those involving intimidation or fear, are to be reported immediately to the appropriate authorities, including the California Department of Public Health (CDPH), Licensing & Certification Program, Ombudsman, and law enforcement. Despite this, the administrator chose not to report the incident, stating it was not considered verbal or physical abuse, even though the resident reported feeling threatened and had called the police herself. Medical record reviews showed that the resident who made the allegation was cognitively intact, alert, and oriented, and had a documented history of reporting feeling threatened by another resident during a supervised activity. Progress notes indicated that both residents involved were placed on behavior monitoring following the incident. Staff interviews confirmed that the facility's abuse protocol required reporting such allegations, and both registered nurses interviewed stated that feeling threatened or harassed should be considered emotional abuse and reported accordingly. The administrator later acknowledged that the incident met the facility's definition of intimidation or fear and should have been reported as required by policy. However, the initial failure to report the allegation as abuse resulted in non-compliance with both facility policy and regulatory requirements. The deficiency was identified through interviews, medical record reviews, and policy review, with staff and administrative acknowledgment that the reporting protocol was not followed in this case.

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