Failure to Submit 5-Day Abuse Investigation Report to State Agency
Penalty
Summary
The facility failed to report the results of an abuse investigation to the state survey agency (California Department of Public Health, CDPH) within 5 working days of an alleged abuse incident dated 2/1/26. Admission documents showed that Resident 1 and Resident 2 were admitted in February 2026. A mandated reporter document titled "Report of Suspected Dependent Adult/Elder Abuse" dated 2/1/26 indicated that an allegation of physical abuse involving Resident 1 as the alleged victim and Resident 2 as the alleged abuser was reported to CDPH. The report established that the initial allegation was reported, but the subsequent investigative findings were not forwarded as required. During interviews, the Nursing Manager stated that the 5-day investigative report for Resident 1 and Resident 2 was not sent to CDPH. The Executive Secretary confirmed that the 5-day report for both residents had been prepared and placed in a file to be sent, but it was never actually sent, despite facility policy requiring submission of the investigation report within 5 days of the incident. The DON also confirmed that the investigative report was not sent within 5 working days. Review of the facility’s policy "Alleged/Suspected Abuse, Resident Mistreatment and Misappropriation of Resident Property" dated 2025 showed that all alleged violations were to be promptly and thoroughly investigated, with results documented, retained, and forwarded to appropriate reporting agencies, which did not occur in this case.
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