F0609

D

Failure to Timely Report Allegation of Potential Sexual Abuse

Stockton, California Survey Completed on 03-10-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure timely reporting of an allegation of potential sexual abuse to the state survey agency within the required two-hour timeframe. A housekeeper observed an interaction between two residents in the dining room in which one resident placed his right hand inside the left sleeve of another resident’s shirt and put his hand on her chest/near her shoulder and underarm. The resident who was touched had a history of sequelae of cerebral infarction and dementia and, per a recent MDS, had severe cognitive impairment with a Brief Interview for Mental Status score of 7 out of 15. Despite having received prior abuse training and knowing that any kind of abuse must be reported, the housekeeper did not report the incident to anyone on the day it occurred or during the following workdays.

The housekeeper only reported the incident to the administrator seven days later, after attending another scheduled abuse training. The administrator then reported the allegation to the state agency, law enforcement, and the ombudsman that same afternoon. The DON and administrator both confirmed that the incident had occurred on the earlier date and that it was not reported to facility administration until a week later, contrary to facility policy. Facility policies titled “Abuse Prohibition” and “Abuse Investigation and Reporting” require that anyone who witnesses suspected abuse immediately report the incident to a supervisor and that alleged violations involving abuse or serious bodily injury be reported immediately, but no later than two hours. The delay in reporting by the housekeeper constituted a failure to follow these policies and to meet the regulatory requirement for timely reporting of alleged abuse.