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F0609
D

Failure to Timely Report Alleged Abuse to Authorities

Santa Rosa, California Survey Completed on 07-22-2025

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 an allegation of physical abuse made by a resident against a licensed nurse was reported to the appropriate authorities within the required two-hour timeframe. According to documentation, the resident reported the abuse on 7/7/25 at 3:10 p.m., but the allegation was not reported to the local police department until the following day, 7/8/25. Interviews with facility staff, including the Director of Nursing, Licensed Nurse, and Director of Staff Development, confirmed that all abuse allegations should be reported to the police, ombudsman, and state licensing agency within two hours to ensure resident safety. Record reviews further verified that the reporting to law enforcement was delayed beyond the required period. A review of the facility's policy and relevant regulatory guidance indicated that abuse allegations must be reported immediately, defined as within two hours, to state licensing, the ombudsman, and law enforcement. The facility's own documentation and fax confirmation sheet confirmed the delay in reporting. This deficiency was identified for one of three sampled residents and was substantiated through interviews, record reviews, and examination of facility policies and state requirements.

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