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F0609
D

Failure to Timely Report Alleged Abuse

Sunnyvale, California Survey Completed on 09-11-2025

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 follow its abuse reporting policy and procedure for one of three sampled residents. An allegation was made by a resident that a male CNA was rough when changing his roommate's incontinent brief during the night shift. The resident reported this incident to the charge nurse, who asked for more details. The resident's clinical records indicated he had a diagnosis of post-traumatic stress disorder and an intact cognitive status, as evidenced by a BIMS score of 15. Interviews with the CNA and LVN assigned to the resident on the night in question revealed that both denied any knowledge or report of the alleged rough handling. The DON confirmed that the allegation was not brought to her attention by staff and stated that, had they been notified, they would have reported it to the appropriate authorities. Review of the facility's policy indicated that any suspicion of abuse must be reported immediately to the administrator and other officials as required by law. The failure to report the allegation as per policy had the potential to compromise the resident's safety.

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