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F0609
D

Failure to Timely Report Alleged Abuse with Injury

Castro Valley, California Survey Completed on 04-16-2025

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 timely reporting of an alleged abuse incident involving a resident with dementia and major depressive disorder. On the morning of the incident, the resident complained to an LVN of left arm pain and alleged that a night shift CNA had been mean, rough, and had hit her arm. The LVN observed swelling in the resident's left arm several hours later, obtained a physician's order for an X-ray, and the results revealed a fracture. The resident was subsequently transferred to the hospital for further evaluation. Despite being aware that allegations of abuse with injury should be reported immediately or within two hours, the LVN did not notify the Administrator or DON at the time of the initial complaint, stating she forgot to report the incident. The Administrator was not informed of the alleged abuse until later that evening, and the mandated SOC 341 report was faxed to the state department approximately eight hours after the injury was first observed. Review of facility policy indicated a lack of clear direction regarding immediate reporting of abuse allegations with injury to the Administrator and state officials. Both the DON and Administrator acknowledged that the incident should have been reported within the required timeframe, as outlined in federal regulations.

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