Failure to Timely Report Resident-to-Resident Altercation
Penalty
Summary
The facility failed to report a resident-to-resident altercation to the California Department of Public Health (CDPH) within the required timeframe for two of three sampled residents. Resident 118, who had a history of bipolar disorder, anxiety, polyosteoarthritis, and myalgia, was found on the floor in his room and stated that his roommate had tripped him. Resident 59, who had diagnoses including abnormalities of gait and mobility, psychosis, muscle wasting, and lack of coordination, denied the allegation. Both residents were assessed as having moderately impaired cognitive skills and required partial assistance with activities of daily living. The incident occurred on 6/8/2025, but the facility did not report the allegation to CDPH until 6/10/2025. Interviews with the Director of Nursing (DON) and Assistant Administrator revealed that they were not informed of the incident on the day it occurred. The DON and Assistant Administrator both acknowledged that the facility's policy required reporting allegations of abuse within two hours, especially if the incident involved abuse or resulted in serious bodily injury. The delay in reporting resulted in a delay in CDPH's investigation and placed other residents at risk for further abuse.