F0609

D

Failure to Timely Report Alleged Abuse to State Authorities

Glendale, California Survey Completed on 01-08-2026

Penalty

No penalty information released

Summary

The facility failed to timely report an allegation of abuse involving a cognitively intact resident with decision-making capacity who had diagnoses including a right patella fracture and acute respiratory failure with hypoxia. The resident’s Change in Condition Evaluation noted behavioral changes with false allegations toward staff. On 1/7/2026, the Social Services Director (SSD) documented that the resident’s representative reported receiving a call from the dialysis center stating the resident claimed that “the walking ladies” at the facility hit her and forced her to walk. The representative told the SSD she believed the allegation was not true and that family had not observed any signs of abuse. The SSD reported the allegation to the Director of Nursing (DON), and the interdisciplinary team was made aware, but the allegation was not reported to the California Department of Public Health (CDPH) within two hours as required by the facility’s abuse reporting policy.

Later that evening, a registered nurse documented that the police arrived and stated they had received a report from Adult Protective Services that the resident had reported to the dialysis center that three female physical therapy staff were forcing her to walk. The facility’s policy titled “Abuse Neglect, Exploitation or Misappropriation-reporting and Investigating” required that all suspected abuse be reported immediately to the administrator and appropriate officials, defining “immediately” as within two hours for allegations involving abuse or resulting in serious bodily injury. During interview and policy review, the DON acknowledged that the policy was not followed because the incident was not reported to CDPH within two hours, explaining that the resident was not in the facility at the time the allegation was received.