Health inspection·March 17, 2025

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to report an allegation of abuse involving one of two sampled residents (Resident 1) to the State Survey Agency. This failure had the potential to delay investigations and compromise Resident 1's safety. Findings: Review of Resident 1's clinical record indicated he was admitted to the facility on [DATE] with diagnoses including congenital central alveolar hypoventilation syndrome ( a rare, life-threatening genetic disorder that affects normal breathing), short bowel syndrome with colon in continuity (a rare malabsorption disorder that occurs when the small intestine is damaged or shortened preventing it from absorbing enough nutrients from food), chronic respiratory failure with hypercapnia (a condition where the body cannot adequately remove carbon dioxide from the blood), dependence on respirator status (unable to breathe independently after being on a ventilator). During an interview on 12/19/24 at 10:09 a.m., with the Respiratory Therapist (RT), the RT stated Resident 1 suddenly lunged at him when the RT disconnected the television and started scratching, hitting and biting. The RT stated he held the forearms of Resident 1 and placed him on the bed. The RT stated Resident 1 started to kick his groin area, so he turned sideways and raised one of his leg to protect his groin area. During an interview on 12/19/24 at 10:36 a.m., with Registered Nurse (RN) B, RN B stated she saw the RT holding Resident 1's wrists and pinned on the bed. RN B stated she told the RT to get off of Resident 1 two to three times before the RT let go of Resident 1. RN B stated she reported the incident to the Administrator (ADM). RN B stated she reported the incident to the police. During a review of RN B's Incident Note, dated 11/30/24, the Incident Note indicated Local authorities were notified for suspected child abuse.Two policemen arrived at the facility and spoke to primary nurse, charge nurse, and patient. During an interview on 12/19/24 at 12:45 p.m., with RN C, she stated she heard the RT yelling at Resident 1 in the hallway to turn the television volume down. RN C stated she saw the RT going into Resident 1's room and heard more yelling. RN C stated she went in to Resident 1's room and saw the RT and Resident 1 standing at the back of the room facing at each other then the RT grabbed Resident 1's head and neck with one hand and the shoulder with the other hand and pushed Resident 1 on the bed. RN C stated the RT held Resident 1's wrist while lying flat in bed and one knee on the chest or stomach. RN C stated she assessed Resident 1 and saw red markings on both wrists and Resident 1 made a (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 555204 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555204 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/17/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Childrens Hc Org No CA Saratoga Pediatric Subacute 13425 Sousa Lane Saratoga, CA 95070 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)