F0609

D

Failure to Timely Report Resident’s Allegation of Physical Abuse

Davis, California Survey Completed on 02-02-2026

Penalty

No penalty information released

Summary

The facility failed to ensure an allegation of abuse was reported within the required timeframe after a cognitively intact resident reported being injured by staff during care. The resident, admitted with chronic kidney disease, schizophrenia, and bipolar disorder, was observed by a charge nurse late in the evening with purple and yellow discoloration on the right cheek. When questioned, the resident stated that a CNA assigned to her had hit her in the face and pulled her hair after she touched the CNA without notice, though she could not recall the exact date, time, or identity of the staff member involved. The resident later described that the CNA thought she was acting out in aggression, grabbed her hands, hit her in the face, and pulled her hair, which made her feel scared and hurt.

Investigation documents showed that another CNA (CNA 2) became aware of the resident’s allegation the day before the charge nurse noted the bruising, when the resident asked if she saw the bruise and reported that a CNA had hit her and pulled her hair in the middle of the night. CNA 2 did not report this allegation at that time, stating she did not know what to do with the information and did not believe the resident because of things the resident says, and instead waited until the next day to ask the resident again, who repeated the same story. The facility’s abuse policy required staff with knowledge of an actual or potential violation to report it to a supervisor or the administrator immediately, and stated that all allegations of abuse, neglect, misappropriation, or exploitation should be reported immediately to the administrator. The Executive Director confirmed this was a reportable incident and that his expectation was that staff report such allegations to the charge nurse within the required timeframe.