Health inspection·March 14, 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 interview and record review, the facility failed to report one of four sampled residents (Resident 1) to a state agency when Resident 1 was noticed to have a blanchable redness to left side of face near left eye.This failure has the potential to affect (Resident 1) ' s health, safety and well-being. Findings: During review of Residents 1 ' s admission Record (general demographics), the document indicated Resident 1 was admitted to the facility on [DATE], with diagnoses that included encephalopathy (a condition where the brain does not function properly). A review of SBAR (document containing information about change of condition) dated 03/12/2025 indicated, . skin evaluation: abrasion . Observation summary: Resident noted to have blanchable redness to left side of face near left eye . During an interview on March 14, 2025, at 11:32 PM, with Licensed Vocational Nurse (LVN 1) the LVN 1 stated she received a report from Resident 1 ' wife that Resident 1 was complaining about water being too hot when Certified Nurse Assistant (CNA 1) gave him a shower. Resident 1 ' s wife also stated that resident 1 ' s face was scrubbed to hard with the hot water. Stated she reported resident 1 wife ' s complaint to Front Desk LVN (LVN 2) and the Registered Nurse (RN 1). During an interview on March 14, 2025, at 12:21 PM with the LVN 2, the LVN 2 stated LVN 1 reported to her that Resident 1 ' wife was complaining about the CNA1. LVN 1 stated there was red mark on resident face from the water being too hot, and when CNA 1 was rubbing resident face, Resident 1 said the water was too hot. LVN 1 further stated that she reported the complaint to the Director of Nursing (DON). During an interview on March 14, 2025, at 12:35 PM, with the RN 1, the RN 1 stated, Resident 1 ' s wife stated her husband reported that CNA 1 was washing Resident 1 ' s face with a brush of some sort the wife can ' t say if it is a washcloth, and her husband was complaining of the water too hot. Stated she did assessment and noted redness on resident 1 cheek but blanchable. During an interview on March 14, 2025, at 12:50 PM, with the Director of Nursing (DON), the DON stated prior to the shower per the CNA 1 resident doesn ' t have redness on the face, and the redness was not there after the shower, what causes the redness to appear cannot be determined. When asked if the facility reported the unknown injury to California Department of Public Health (CDPH), the DON stated, We did not report it, because they don ' t think it was an abuse although the resident and Page 1 of 2 055619 055619 03/14/2025 Las Colinas Post Acute 800 East 5th Street Ontario, CA 91764

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few wife reported of water too hot and the scrubbing was hard but the Interdisciplinary Team (IDT) don ' t see it as an abuse because based on their investigation it doesn ' t seem there is an intent to abuse. During a telephone interview on March 14, 2025, at 4:02 PM, with the Administrator (Admin 1), when asked if the facility reported the unknown injury to CDPH, the Admin stated, because family did not say abuse or alleged abuse and he did not see it as alleged abuse he did not report it to CDPH. During concurrent telephone interview and record review on March 21, 2025, at 11:31 with Admin 1, the facility policy and procedure (P&P) titled, Abuse, Neglect, Exploitation or Misappropriation – Reporting and Investigating dated April 2021, was reviewed. The P&P indicated, .All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported . Admin 1confirmed the policy and stead the believe the abuse did not occur and that is why it was not reported. During concurrent telephone interview and record view on March 21, 2025, at 12:40 PM, with Admin 1, document titled IDT (Interdisciplinary Team) Review dated March 12, 2025, was reviewed. The IDT Review indicated, IDT reviewed the plan of care for resident [NAME]. Resident expressed to his wife that he felt the water temperature was hot during his shower earlier. The resident ' s wife spoke with the CNA who spoke with her charge nurse to inform of the resident's wife's concern. The charge nurse and RN supervisor were made aware with interviews conducted with all the staff participating in the care. During the interviews with the staff, staff reviewed process for bathing the resident and determined the resident had specific preferences for care during showers. Upon assessment by the RN supervisor, blanchable redness was noted to the left side of his face. It was determined after review with the interdisciplinary team there was no malicious intent or intent to harm the resident. Staff continued to encourage the resident and his wife to express his preferences in care such as preferred water temperatures during his shower. Staff was also reminded to observe the resident's preferences. After review, there is no incident of abuse determined by IDT. When asked were Resident 1 and Resident 1 ' s wife, included in the meeting, Admin 1 responded no they were not included in meeting. 055619 Page 2 of 2