Failure to Submit Required Five-Day Abuse Investigation Reports
Penalty
Summary
The facility failed to provide the State Survey Agency (CDPH) with written five-day investigation reports for two separate, facility-reported allegations of suspected dependent adult/elder abuse involving resident-to-resident altercations. One allegation involved an altercation between Resident 1 and Resident 2, and another involved an altercation between Resident 3 and Resident 4. Facility documents showed that both allegations were reported to CDPH on the same dates they were made, but there was no evidence that the required follow-up investigation reports were completed and submitted within five calendar days as required by facility policy and regulatory expectations. During interviews, the Administrator, whose first day in the role was 1/01/2026, stated she could not locate the facility files that would normally contain the five-day investigation reports for either abuse allegation and confirmed she could not provide evidence that the reports were sent to CDPH. The DON stated she did not know if the investigation reports for both abuse allegations were completed and acknowledged that the purpose of these reports was to ensure the facility investigated what happened and what interventions were implemented to provide resident safety, and that it was a regulatory requirement to provide the five-day investigation report to CDPH. The facility’s written policy on abuse, neglect, exploitation, or misappropriation specified that all allegations are thoroughly investigated, that the administrator initiates investigations, and that a follow-up investigation report is to be provided within five business days of the incident, which did not occur in these cases.
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