Health inspection·November 4, 2023

F 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure immediate protective measure was put into place to provide protections to one of three sampled resident (Resident 3) when a Certified Nurse Assistant (CNA) was not suspended immediately after an alleged abuse to Resident 3 was reported. Residents Affected - Few This failure had the potential for further abuse, neglect, exploitation, or mistreatment in a vulnerable population of 94 residents as the alleged perpetrator, CNA, continued to have access to the alleged victim, Resident 3, and to other residents while the investigation was still in process. Findings: During a review of Resident 3's admission Record (clinical record with demographic information), it indicated, Resident 3 was admitted to the facility on [DATE], with diagnoses of dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), hyperlipidemia (too many lipids (fats) in the blood), and hypertension (blood pressure that is higher than normal). During a review of Resident 3's history and physical examination, dated September 2, 2023, indicated Resident 3 does not have a capacity to understand and make decisions. A review of the facility's five (5) days summary, dated October 19, 2023, indicated, . On Tuesday October 17, 2023, at approximately 10:45 AM, two employees came to report that a housekeeper reported an incident . The DON [Director of Nurses] and Administrator interviewed the housekeeper, [named of the housekeeper] . The housekeeper stated she was cleaning room [ROOM NUMBER] when resident [named of Resident 3] slapped the CNA [Named of employee] and [Named of employee] told the resident, I am your CNA and slapped her leg . The administrator completed the SOC 341 [Suspected Dependent Adult/Elder Abuse form] and submitted to the Ombudsman [representatives assist residents in long-term care facilities], Sheriff, and the Department of Public Health. The CNA was suspended pending investigation . During an interview, on October 19, 2023, at 2:10 PM, with the Housekeeper (HKP), the HKP stated on October 17, 2023, in the morning around 10:45 AM, she reported to two (2) employees that she saw CNA slapped Resident 3's leg. During an interview, on October 20, 2023, at 11:20 AM, with CNA. CNA stated on October 17, 2023, around 11:25 AM, DON and Administrator called for a meeting and told her about the abuse allegation toward Resident 3. CNA then remembered and told the DON and the Administrator that she was not assigned to Resident 3. She further stated after that the Scheduler asked her to continue work and finish Page 1 of 2 055183 055183 11/04/2023 Heritage Gardens Health Care Center 25271 Barton Rd Loma Linda, CA 92354

F 0610 her shift. Level of Harm - Minimal harm or potential for actual harm A review of form titled [named of the facility] Nursing Staff Assignment and Sign-in Sheet dated October 17, 2023, indicated CNA was on duty .Shift 1- start time 07:00 AM . End time : 3:30 PM . Residents Affected - Few During a concurrent interview and record review, on October 25, 2023, at 12:05 PM, with the Administrator, the timecard of the CNA indicated, .[named of the CNA] 10/16/2023 - 10/31/2023 . range date . Date 10/17 . in 7:00 AM . out 10:39 AM . in 11:09 AM . out 3:08 PM . The Administrator stated she was not aware that CNA needed to be removed immediately during investigation. During an interview, on October 25, 2023, at 12:05 PM, with the Director of Staff Developer (DSD), the DSD stated once any employee has been accused of resident abuse, the Administrator will suspend the respective employee immediately while the investigation is in process to protect the resident (s). During a concurrent interview and record review, on October 25, 2023, at 12:15 PM, with the DON, the timecard of the CNA indicated, . Date/time 10/17/2023 .punch in 7:04:00 AM . Punch out 10:39:00 AM . Punch in 11:09:00 AM . Punch out 3:08:00 PM . The DON stated she was not aware the incident was reported around 10:40 AM. She stated she thought the incident was reported around 2:00 PM. The DON further stated she should have removed CNA immediately instead of her completing her shift. During a concurrent interview and record review, on October 30, 2023, at 12:40 PM, with the DON and the Administrator, the facility's policy and procedure (P&P) titled, Abuse Investigation and Reporting revised July 2017, was reviewed. The P&P indicated, Policy Statement All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source (abuse) shall be promptly reported to local, state, and federal agencies (as defined by current regulations) and thoroughly investigated by facility management. Findings of abuse investigations will also be reported. Policy Interpretation and Implementation. Role of the Administrator: . 4. The Administrator will suspend immediately any employee who has been accused of resident abuse, pending the outcome of the investigation. Both the DON and the Administrator stated the facility did not follow the policy. 055183 Page 2 of 2