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F0609
D

Failure to Report Resident-to-Resident Abuse Allegation

Yuba City, California Survey Completed on 08-27-2025

Penalty

Fine: $15,935
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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 one of five sampled residents. A resident, who was cognitively intact with a BIMS score of 15 and had diagnoses including Parkinson's Disease, COPD, hypertension, and muscle weakness, informed staff that another resident had slapped them on the face and chest, resulting in discoloration and scratches. The incident was documented in the resident's progress notes and a report of suspected dependent adult/elder abuse was completed, confirming the physical altercation between the two residents. Despite the facility's policy requiring all reports and findings of resident abuse to be reported to local, state, and federal agencies, the incident was not reported to the state licensing/certification agency. Both the Administrator and the DON confirmed the incident occurred but stated their belief, based on an All Facilities Letter, that abuse involving a perpetrator with a dementia diagnosis did not require reporting. As a result, the abuse allegation was not reported as required by facility policy.

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