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 Page 1 of 2 555204 555204 03/17/2025 Childrens Hc Org No CA Saratoga Pediatric Subacute 13425 Sousa Lane Saratoga, CA 95070

F 0609 punching like motion to his stomach and grimaced. RN C stated she informed the ADM of the incident. Level of Harm - Minimal harm or potential for actual harm During an interview on 12/19/24 at 4:28 p.m., with the Director of Staff Development (DSD), the DSD stated the ADM informed the staff during the stand up meeting that the incident was not an abuse based on the investigation of the ADM. Residents Affected - Few During an interview on 3/5/25 at 4:15 p.m., with the ADM, the ADM stated he did not report the incident because it was not an abuse. The ADM stated that RN C informed him that Resident 1 had no marking on him. During a review of the facility's policy and procedure, titled Abuse prevention, intervention, reporting and investigation, revised 5/14, indicated In accordance with California penal code .requires that all mandated health care practitioners must report .any reasonable suspicion that a child has been abused or neglected .Staff is mandated reporters and must comply with state and federal regulations regarding reporting suspected abuse .For suspected child abuse cases of all types, a written report must be filed using Department of Justice form SS8572 .completed in detail and mailed within 36 hours of the telephone report .Will notify Department of Health Services. Licensing and Certification Program of an alleged abuse situation upon an adult and or child within 24 hours . 555204 Page 2 of 2