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F0609
D

Failure to Timely Report Injury of Unknown Origin and Alleged Abuse

Sonoma, California Survey Completed on 12-24-2025

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 injury of unknown origin within the required timeframe for one resident. Emergency Medical Services (EMS) transported the resident to the hospital with bruising and pain to the hand, which was consistent with a grabbing injury. This incident was reported to Adult Protective Services (APS) by EMS, and the police visited the facility to investigate an allegation of abuse related to the injury. Despite being aware of the police investigation and the nature of the injury, the Assistant Director of Nursing (ADON) did not report the incident to the State agency, stating that she was conducting her own investigation first and believed that a report was unnecessary since another agency had already reported the allegation. A review of the facility's policy indicated that all alleged violations involving abuse, neglect, exploitation, or mistreatment—including injuries of unknown source—must be reported immediately, but not later than two hours if the alleged violation involves abuse or results in serious bodily injury, and not later than 24 hours for other violations. The facility did not follow this policy, as the incident was not reported to the Department by the facility within the required timeframe.

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