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F0609
D

Failure to Timely Report Alleged Physical Abuse Incident

Glendora, California Survey Completed on 09-17-2025

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 report an incident of alleged physical abuse involving a resident with schizoaffective disorder and legal blindness. The resident, who had severely impaired cognition and required assistance with activities of daily living, reported being pushed to the floor by another resident. This allegation was corroborated by a Licensed Vocational Nurse (LVN), who witnessed the accused resident admitting to the act and observed the victim on the floor requesting help. The LVN notified the Administrator and Director of Nursing (DON) of the incident, and was instructed not to complete the abuse reporting form, as the Administrator and DON would handle the reporting. Despite facility policy requiring the reporting of abuse allegations within specified time frames, the incident was not reported to the California Department of Public Health (CDPH) within the required two-hour window. The DON confirmed that the facility failed to meet the mandated reporting timeline for this incident, as outlined in their Abuse, Neglect, Exploitation and Misappropriation Prevention Program policy.

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