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F0609
D

Failure to Timely Report Alleged Physical Abuse

Cedarville, 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 physical abuse in a timely manner as required by its Abuse Policy and state law. A resident with severe cognitive impairment, including Alzheimer's disease and dementia, verbally reported being treated roughly during a shower. This allegation was discussed among staff and residents for several weeks before it was formally reported. The Activities Director (AD) heard the allegation during a Resident Council meeting but did not immediately report it to the Abuse Coordinator or Director of Nursing (DON). Additionally, a Certified Nursing Assistant (CNA) informed a Licensed Vocational Nurse (LVN) about the allegation, but the LVN did not report it at the time and could not recall when the incident occurred. The facility's policy requires that all abuse allegations be reported to the administrator and appropriate authorities within two hours if abuse or serious bodily injury is involved. However, the Report of Suspected Dependent/Elder Abuse (SOC-341) was not submitted to the California Department of Public Health (CDPH) until the day after the DON was informed, and weeks after the initial allegation was made. Interviews with staff confirmed that the abuse allegation was not reported in accordance with facility policy, resulting in a delayed notification to CDPH.

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