F0609

D

Failure to Timely Report Resident-on-Resident Physical Abuse Allegation to SSA

Temecula, California Survey Completed on 03-05-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to report an alleged incident of physical abuse between two residents to the state survey agency (SSA) within the required two-hour timeframe. On January 4, 2026, at approximately 6:30 p.m., a physical altercation occurred in the hallway of Station 3 between Resident 1 and Resident 2. Resident 2 reported that Resident 1 choked him, stating, "He choked me, but I managed to get out," while Resident 1 stated that Resident 2 came very close to his face, prompting him to push Resident 2 away. Staff, including an LVN, intervened to separate the residents and assessed Resident 2 for skin issues or injuries, and the physician was notified.

Resident 1’s medical record showed admission with multiple diagnoses including peripheral vascular disease, anxiety disorder, right below-knee amputation, type 2 diabetes mellitus, orthopedic aftercare following amputation, osteomyelitis, cellulitis of the left lower limb, and MRSA infection. A history and physical dated January 1, 2026, indicated no neuro focal deficits. Resident 2’s record indicated admission with diagnoses including opioid use, anxiety disorder, a displaced bicondylar fracture of the left tibia status post ORIF, and injuries from a pedestrian–vehicle collision, with a history and physical dated January 5, 2026, documenting that Resident 2 was oriented to person, place, and time. Progress notes and eINTERACT SBAR summaries documented that Resident 2 admitted to using profanity toward an LVN related to a prior incident, that Resident 1 witnessed this verbal altercation, intervened, and that Resident 2 alleged choking while Resident 1 denied choking and reported only pushing Resident 2 away.

Interviews with staff confirmed both the occurrence of the altercation and the delay in reporting it to the SSA. LVN 1 stated that when two residents have a physical altercation, the RN should be notified immediately and that such altercations should be reported within two hours. The Social Services Director and the Director of Nursing both confirmed that the altercation occurred at 6:30 p.m. on January 4, 2026, and that the SSA was not notified until 9:15 a.m. on January 5, 2026. The DON acknowledged that the altercation was considered abuse and should have been reported immediately. Review of the facility’s abuse, neglect, exploitation, and misappropriation reporting policy, revised September 2022, showed that suspected abuse must be reported immediately to the administrator and appropriate agencies, with “immediately” defined as within two hours for allegations involving abuse or resulting in serious bodily injury. The facility did not adhere to this policy or the regulatory requirement for timely reporting.