Health inspection·May 16, 2024

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 physical abuse in accordance with the facility's policy and procedure titled Abuse Prevention Program, for one of four sampled residents (Resident 1), when a Licensed Vocational Nurse (LVN) 1 reported a physical abuse allegation to the Administrator (ADM) on 5/14/24, and the facility did not notify the appropriate agencies of Resident 1 ' s allegations of abuse within the required timeframe. This failure resulted in a delay of reporting Resident 1 ' s allegation of physical abuse investigation and had the potential to place Resident 1 and other resident ' s health and safety at risk of harm or injury. Findings: During an interview on 5/16/24 at 5:31 p.m. with LVN 1, LVN 1 stated during medication pass she overheard Resident 1 on the phone staff were hitting her. LVN 1 stated she reported the abuse allegation to the ADM on 5/14/24. During a review of Resident 1's Progress Notes (PN), dated 5/14/24, the PN indicated, .Resident was heard on phone by CNA [Certified Nursing Assistant] and nurse talking to her son. She had made a statement to her son that the nursing staff abuses her and hits her. Nurse immediately made a phone call to administrator to make him aware of the situation . During a concurrent observation and interview on 5/16/24 at 5:56 p.m. with Resident 1, in Resident 1 ' s room, Resident 1 was lying in bed. Resident 1 stated, they hit me. During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool used to identify cognitive (mental processes) and physical functional level assessment dated [DATE], the MDS indicated Resident 1's Brief Interview for Mental Status (BIMS - screening tool used to assess resident cognitive level) assessment score was 12 out of 15 (0-7 indicated severe cognitive impairment - [memory loss, poor decision making-skills] 8-12 moderate cognitive impairment, 13-15 cognitively intact). During an interview on 5/16/24 at 6:31 p.m. with the Social Service Director (SSD), the SSD stated she was aware of the abuse allegation on 5/14/24 and told the ADM of Resident 1 ' s allegations of abuse on 5/14/24. During a concurrent interview and record review on 5/16/24 at 7:30 p.m., with the ADM, the facility policy titled Abuse Prevention Program dated 8/2006 was reviewed. The policy indicated, . Our abuse (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: 555352 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 555352 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/16/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grace Healthcare Center 2939 S. Peach Avenue Fresno, CA 93725 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)