F0609

E

Failure to Report Intruder-Related Abuse Allegations and Resident-to-Resident Physical Abuse to State Agency

Madera, California Survey Completed on 03-19-2026

Penalty

No penalty information released

Summary

The facility failed to report two separate episodes of alleged or suspected abuse to the state agency as required by regulation and facility policy. The first incident involved an unknown intruder who entered the building without staff knowledge and interacted with four residents in their rooms during evening hours. The intruder entered the room of two cognitively intact residents while they were in bed; one resident reported that the man, wearing a hoodie, spoke to her roommate and then asked her if she wanted to follow the word of God and follow him, and she stated that she and her roommate were scared and had experienced sleepless nights since the event. Another cognitively intact resident reported awakening to find the man inches from her face, leaning forward as if to kiss her, and described using her hands to stop him and feeling scared and needing to protect herself. A third cognitively intact resident reported seeing the intruder attempt to lift her moderately cognitively impaired roommate out of bed, describing him as acting as if he were on drugs and stating she was scared and did not know if he had a weapon. The fourth resident, with moderately impaired cognition, recalled the intruder entering her room and trying to lift her up, stating that he was rough with her and that she was scared and angry.

Licensed Vocational Nurse (LVN) 1 described returning from break in the evening and noticing a man at the nurses’ station, assuming he was a visitor. While passing medications, she saw him enter a resident room and initially did not intervene. She later heard a resident telling the man to get out, went to the doorway, and confronted him. The intruder stated he was spreading happiness and love and claimed to be visiting a resident whose name was posted near the door. LVN 1 told him to leave after being informed by a resident that he had tried to lift her roommate out of bed, and the intruder exited through a hallway door. LVN 1 later learned from residents that one had been scared by his attempt to lift her and another reported he had bent over and tried to kiss her, causing emotional distress. LVN 1 stated she did not think the incident needed to be reported to the Department because no one was physically injured, despite the residents’ reports of fear and distress.

The second unreported incident involved resident-to-resident physical abuse resulting in injury. One resident struck another across the face with a walker while being assisted out of bed for a therapy walk, causing approximately a one-inch laceration above the injured resident’s left eyebrow. Observation later showed a small bandage over the eyebrow, and the clinical record documented a physician’s order to monitor steri-strips on a skin tear to that area. Progress notes described the event as a resident-to-resident altercation in which the injured resident was the receiver and indicated that a suspected abuse report (SOC 341) was faxed to the Ombudsman and local police department, but did not list the state Department as a notified entity. The Director of Staff Development, who is responsible for educating staff on abuse reporting, stated that resident-to-resident abuse with injury should be reported to the Department and that she educates staff accordingly.

The Director of Nursing confirmed that both the intruder incident and the resident-to-resident altercation were reported to the local police department but not to the state Department. She stated that after reviewing policy and regulations, facility leadership believed the events were not reportable because they did not, in their view, result in physical harm, defining physical harm as skin tears, fractures, or hematomas. The Administrator, identified as the facility’s Abuse Prevention Coordinator, similarly stated that there was no point in reporting the intruder event because no residents were physically harmed and characterized the resident-to-resident event as back and forth, concluding it did not need to be reported. The Administrator also acknowledged that an intruder physically lifting a resident out of bed could be physical abuse and that a resident being awakened by the intruder’s face close to hers and having to use her hands to keep him away was abuse, and stated that the facility did not conduct a 5-day abuse investigation after either incident. Facility policies on abuse, neglect, exploitation, and reporting require that all allegations of abuse or mistreatment be reported immediately to the Administrator and appropriate agencies, including the state survey agency, within prescribed timeframes, and define abuse to include actions causing physical harm, pain, or mental anguish, including certain resident-to-resident altercations and mental abuse such as harassment or sexual coercion.