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F0610
D

Failure to Interview Witness During Abuse Investigation

Fall River Mills, California Survey Completed on 05-27-2025

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 conduct a thorough investigation into an allegation of staff-to-resident abuse involving a resident with severely impaired cognition, as indicated by a Brief Interview for Mental Status (BIMS) score of 3 out of 15. According to facility policy, all suspected incidents of abuse require obtaining written statements from all persons involved and conducting staff and resident interviews. However, despite a roommate witnessing the alleged abuse and confirming she was not interviewed, the facility's investigation records did not include an interview with this witness. The Director of Nursing confirmed that no interview was conducted with the roommate, despite her being a witness to the incident.

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