Failure to Timely Report Abuse Investigation Results and Assess Resident After Alleged Abuse
Penalty
Summary
The facility failed to ensure timely reporting of abuse investigation results to the California Department of Public Health (CDPH) and failed to complete a required nursing assessment following an abuse allegation. One resident, admitted in September 2025 with multiple diagnoses including surgical aftercare, and another resident, admitted in December 2024 with multiple diagnoses including respiratory failure, each reported physical abuse by a CNA. Incident reports for these allegations were submitted to CDPH on 1/26/26 and 1/28/26. However, the facility’s 5‑day investigation results for both incidents were not submitted to CDPH until 2/10/26, which exceeded the required five working days. The Administrator confirmed that the results of the investigations were not provided within the regulatory timeframe, despite facility policy stating that allegations of abuse will be reported to state or federal agencies within applicable regulatory timeframes. The facility also failed to perform and document a nursing assessment for the resident with respiratory failure after the abuse allegation on 1/28/26. Review of this resident’s medical record showed no documentation that a nurse assessed the resident following the reported abuse. In an interview, the DON confirmed that an assessment was not completed after the allegation and stated that the expectation was for an assessment to be done. The facility’s abuse prevention policy specified that a licensed nurse will immediately examine a resident upon receiving reports of alleged physical abuse and that the findings of the examination shall be recorded in the resident’s medical record, which did not occur in this case.
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