Health inspection·June 4, 2025

F 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to complete and submit an investigation summary regarding an alleged abuse incident that occurred between two of three sampled residents (Residents 1 and 2). Residents Affected - Few This failure had the potential to compromise the facility's ability to determine the circumstances surrounding the incident and could have compromised the residents' safety. Findings: Review of Resident 1's medical record indicated she was admitted on [DATE] and had the diagnosis of cellulitis (a skin infection that causes swelling and redness) of left and right limb, peripheral vascular disease (PVD, a slow progressive narrowing of the blood flow to the arms and legs), abnormal posture and history of falling. Resident 1's Minimum Data Set (MDS, a federally mandated resident assessment tool) dated 3/18/25, indicated she had a (Brief Interview for Mental Status, an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) BIMS of 12 meaning her cognition was moderately impaired. Review of Resident 2's medical record indicated she was admitted on [DATE] and had the diagnosis of alcohol dependence with withdrawal, depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), abnormal posture and history of falling. Resident 2's MDS dated [DATE], indicated she had a BIMS of 7 meaning her cognition was severely impaired. Review of Resident 1's Change in Condition Evaluation, dated 4/1/25, indicated an incident had occurred between Resident 1 and Resident 2. The documentation indicated, nurse heard yelling and argument with roommate Resident 2. During a concurrent interview and record review on 6/4/25 at 9:40 a.m., with the Director of Nursing (DON), she reviewed interdisciplinary team (IDT, facility staff members from different departments who coordinate care provided to residents) IDT note dated 4/5/25 and stated that on 4/1/25 around 11:50 p.m., staff heard Resident 1 and Resident 2 yelling to each other and charge nurse transferred Resident 2 to another room. In the morning of 4/2/25, Resident 1 told the DON and the Social Services Director (SSD) that her roommate Resident 2 tapped her on the back of the head, and she was not comfortable. The DON and charge nurse assessed Resident 1 and no visual injury noted and denies pain or discomfort and the primary doctor (MD) was notified. Page 1 of 2 055800 055800 06/04/2025 Stonebrook Health and Rehabilitation 350 DE Soto Drive Los Gatos, CA 95032

F 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview with the administrator (ADM) on 6/3/25 at 12 p.m., he stated the above incident between Residents 1 and 2 was reported to the police, the Ombudsman (resident advocate), and the California Department of Public Health (CDPH, state survey agency). During a concurrent interview and record review with the ADM on 6/3/25 at 1:15 p.m., he confirmed that when an alleged abuse incident occurs, the facility must submit an investigation summary to CDPH within five days. The ADM stated he was not able to find a fax transmittal confirmation that the five-day summary or an investigation summary for the incident that occurred between Residents 1 and 2 on 4/2/25 was faxed to CDPH except for the fax transmittal confirmation dated 6/3/25 at 1 p.m. Review of the facility's policy and procedure, revised 7/2017, titled Abuse Investigation and Reporting, indicated, All reports of resident's abuse, neglect, exploitation of resident property, mistreatment and/or injuries of unknown source (abuse) shall be promptly reported to local, state and federal agencies (as defined by current regulation) and thoroughly investigated by facility management. Findings of abuse investigation will also be reported The Administrator, or his/her designee, will provide the appropriate agencies or individuals listed above with a written report of the findings of the investigation within five (5) working days of the occurrence of the incident. 055800 Page 2 of 2