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F0609
D

Failure to Timely Report Alleged Abuse Incident

Vallejo, California Survey Completed on 08-15-2025

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 alleged abuse incident within the required two-hour timeframe after a resident reported inappropriate touching by another resident and a staff member. The resident, who had diagnoses including left and right hemiplegia and dysarthria but no memory impairment, informed the charge nurse that a male resident kissed her forehead while she was asleep and that an X-ray technician touched her inappropriately on her shoulder, forehead, and breast, and made inappropriate comments. Documentation showed that the report of suspected abuse was not received by the state agency until two days after the initial allegation was made to the charge nurse. Interviews with facility staff, including the administrator, CNA, and RN, confirmed that the resident reported the incident promptly and that facility policy required immediate reporting of abuse allegations, but this protocol was not followed. The resident expressed feeling uncomfortable, ignored, and disappointed by the lack of urgency in the facility's response. The delay in reporting resulted in a delayed investigation of the allegations.

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