Health inspection·January 16, 2025

Stockton Nursing Center F609 Citation The following reflects the findings of the California Department of Public Health during a Federal Recertification survey with the investigation of Eight (8) facility reported incidents #CA00918130, #CA00920077, #CA00910949, #CA00933500, #CA00921286, #CA00930557, #CA00900328, #CA00911735. Survey Event ID: O4UG11 State Citation B was written. #CA00930557 (F609). Code of Federal Regulations, Title 42, Section §483.12 §483.12(c)(4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken. On 12/12/24, the California Department of Public Health (CDPH) conducted an unannounced visit at the facility to conduct a recertification survey and to investigate a Facility Reported Incident regarding abuse. The Department determined the facility failed to report the results of an investigation of an alleged resident-to-resident abuse incident to the Department, within 5 working days for 2 of 41 sampled residents (Resident 3 and Resident 79). On 11/15/24 at 9:24 AM, the Department received notification of an alleged resident-to-resident physical abuse situation between Resident 3 and Resident 79, when during an argument in the hallway, Resident 3 allegedly poured water on Resident 79's head and pushed Resident 79 to the ground. During a concurrent interview and record review on 12/12/24 at 11:10 AM with the facility's Administrator (ADM), the ADM was unable to locate documentation of the five-day follow-up report regarding the investigation results from the incident that occurred between Resident 3 and Resident 79. The ADM was also unable to find documentation or receipt the five-day follow-up was sent to the Department. The ADM further stated she was responsible for completing and sending the five-day follow-up investigations and it was possible it was not completed or sent. The ADM explained the importance of completing and sending the five-day follow-up was to ensure resident safety. The risk to the residents for not completing the five-day follow-up investigation was reoccurring abuse. During a concurrent interview and record review on 12/12/24 at 3:09 PM, it was confirmed with the Department that the five-day follow-up investigation was never received. Review of the facility policy "Abuse Prohibition Policy and Procedure," dated 2/21, indicated, " ...The CED [Center Executive Director] or designee will: Take all necessary corrective action depending on the results of the investigation; Report findings of all completed investigations within five (5) working days to the Licensing District Office [The Department] ..." Therefore, the Department determined the facility failed to report the results of an investigation of an alleged resident-to-resident abuse incident (between Resident 3 and Resident 79) to the Department within 5 working days. This failure had the potential for the alleged abuse to reoccur and prevented the Department from initiating possible necessary action to protect Resident 3, Resident 79, and other residents in the facility. This violation had a direct or immediate relationship to the health, safety, or security of patients or residents.