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F0609
D

Failure to Timely Report Alleged Abuse to Authorities

Clearlake, California Survey Completed on 10-07-2025

Penalty

Fine: $61,705
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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 within the required two-hour timeframe to the Department for one sampled resident. The resident, who had a history of post laminectomy syndrome and constipation, reported feeling violated after a registered nurse administered a rectal suppository, stating that the procedure took too long and caused discomfort. The incident was documented in the nursing notes, and the resident expressed his concerns during an interview, specifying the time and nature of the event. Despite the facility's policy requiring immediate reporting of abuse allegations within two hours, there was no evidence that the initial report was sent to the Department as required. The administrator was notified of the allegation by a charge nurse, who claimed to have faxed the report, but a review of the fax log showed no such transmission. The Department did not receive notification until the following morning, when the administrator sent the required form after confirming the initial report had not been received.

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