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F0609
D

Failure to Timely Report Allegation of Sexual Abuse

El Cajon, California Survey Completed on 12-19-2025

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 sexual abuse involving a resident with impaired cognition and multiple diagnoses, including alcoholic cirrhosis, major depressive disorder, anxiety disorder, and unspecified dementia. The incident began when the resident called 911 to report that a staff member had engaged in flirtatious and inappropriate physical contact, which the resident described as sexual harassment. The Assistant Director of Nursing (ADON) and a Licensed Nurse (LN) were present during the police interview, during which the resident identified a staff member as the alleged perpetrator. Both the ADON and LN recognized the resident's statements as an allegation of abuse. Despite the clear identification of the incident as abuse, the Director of Nursing (DON) did not report the allegation to the State Licensing Agency or the Ombudsman, nor did she initiate an investigation, citing a desire to train the ADON in handling such incidents. The Director of Operations, who was the designated abuse coordinator, also acknowledged that the allegation was not reported as required. A review of the facility's policy confirmed that all allegations of abuse must be reported to the appropriate authorities within specified timeframes, which was not followed in this case.

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