Failure to Timely Report Alleged Verbal Abuse to Required Agencies
Penalty
Summary
The facility failed to ensure an allegation of verbal abuse involving one resident was reported to the California Department of Public Health (CDPH) within the required timeframe. The resident had been admitted with diagnoses including developmental delay, rheumatoid arthritis, major depressive disorder, and anxiety disorder, and had a BIMS score of 13, indicating cognitively intact status. During an interview, the resident reported that a CNA said to her that he wanted to clean her vagina. The resident stated that this disturbed her, that she did not feel comfortable having male CNAs clean her, and that she wanted to keep her dignity. The Administrator and DON stated that the resident reported the event to the Nurse Supervisor on the evening of 12/6/25, and that the Nurse Supervisor then notified them. The DON stated she called the incident in to CDPH that same evening; however, the Administrator and DON were unable to provide documented evidence that the event was reported to CDPH on that date. A review of the SOC 341 form showed that CDPH, the Ombudsman, and law enforcement were notified of the alleged abuse on 12/7/25. The facility’s Abuse Prevention and Management policy required the administrator or designee to notify law enforcement by telephone immediately or as soon as possible, but no longer than two hours after an initial report, and to send a written SOC 341 to the Ombudsman, law enforcement, and CDPH within two hours, for all allegations of abuse.
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