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F0609
D

Failure to Timely Report Alleged Abuse

Modesto, California Survey Completed on 09-03-2025

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 that an allegation of abuse involving a resident was reported to the Department in a timely manner. A resident with a diagnosis of bipolar disorder and intact cognitive function alleged that a certified nursing assistant (CNA) forcefully grabbed her legs, causing pain and bruising. The incident was initially reported by the resident to licensed nurses, who assessed her but did not observe visible marks and failed to document or report the allegation as required. Both nurses later acknowledged that they should have documented and reported the incident for the safety of the resident and others. The incident occurred on a Saturday evening, but the administrator did not become aware of the allegation until five days later, resulting in a delayed report to the Department. Interviews confirmed that two licensed nurses and the CNA involved were aware of the resident's allegations on the day of the incident, but no immediate action was taken to notify the administration or authorities. Facility policy required immediate reporting of suspected abuse within two hours, but this protocol was not followed, leading to a delay in the investigation process and a failure to protect the resident and others from potential harm.

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