F0610

D

Failure to Submit 5‑Day Investigation Summary for Resident‑to‑Resident Altercation

Lodi, California Survey Completed on 01-09-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to submit a required 5‑day written investigation summary to the Department following a reportable resident‑to‑resident altercation. Resident 1, admitted with diagnoses including unspecified dementia, chronic kidney disease, and cognitive function and awareness symptoms, was involved in an incident on 11/8/25 at 6 AM in which a former roommate, Resident 5, blocked the bathroom door while Resident 1 was inside, preventing Resident 1 from exiting. Resident 5 had diagnoses including orthopedic aftercare, a displaced intertrochanteric fracture of the right femur, history of falling, gait and mobility abnormalities, type 2 DM, and depression. Care plans for both residents were initiated on 11/8/25, documenting each resident as being at risk for psychosocial and mood changes related to the bathroom‑locking incident.

The Social Services Director completed and submitted the initial Report of Suspected Dependent Adult/Elder Abuse to the Department on 11/8/25 but did not submit the 5‑day investigation summary. In interview, the Social Services Director stated that he completed the 5‑day investigation for the resident‑to‑resident altercation but did not send the 5‑day investigation report to the Department. In a separate interview, the DON confirmed that the 5‑day investigation summary for the altercation involving these two residents was not submitted and that there was no documentation or confirmation of submission, despite her awareness that the summary was required within five working days. The facility’s undated Abuse Investigation and Reporting policy states that the Administrator or designee will provide a written report of investigation findings to the appropriate agencies within five working days of the incident, which was not followed in this case.