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F0609
D

Failure to Report Alleged Abuse to State Authorities

Stockton, California Survey Completed on 11-18-2025

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 allegation of abuse involving a resident who had hemiplegia of her right dominant side. The resident communicated to a family member that she had been hit on the head by an unknown person while receiving care. The family member reported this allegation to facility staff, who acknowledged the report and stated they would investigate. However, the facility did not report the allegation to the state licensing and certification agency as required by policy and regulation. Interviews with facility staff, including the Social Services Director, Director of Nursing, and Director of Staff Development, confirmed that the allegation was not reported to the Department. Staff acknowledged that all allegations of abuse, regardless of whether they are believed to be factual, should be reported to the appropriate authorities, including the Department, ombudsman, and law enforcement. The facility's own policy required immediate reporting of suspected abuse, but this was not followed in this case. A review of the resident's clinical records and grievance documentation showed that the allegation was documented internally, but there were no progress notes, care plans, or social services notes addressing the abuse allegation. The facility's failure to report the incident as required by law and policy was confirmed by multiple staff members and documented in the facility's records.

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