Health inspection·July 1, 2025

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the comprehensive plan of care interventions were implemented for a suspected allegation of financial abuse for one of three sampled residents (Resident 1). This failure had the potential for not providing care and services to meet the residents' needs. Findings: Review of the facility's P&P titled Care Plan Revisions Upon Status Change revised 12/2022 showed the following: 1. The comprehensive care plan will be reviewed, and revised as necessary, when a resident experiences a status change. 2. Procedure for reviewing and revising the care plan when a resident experiences a status change: a. upon identification of a change in status, the nurse will notify the MDS coordinator, the physician, and the resident representative, if applicable. b. the MDS coordinator and the interdisciplinary team will discuss the resident condition and collaborate on intervention options. c. the team meeting discussion will be documented in the nursing progress notes. d. the care plan will be updated with the new or modified interventions. e. staff involved in the care of the resident will report resident response to new of modified interventions. f. the unit manager or other designated staff member will communicate care plan interventions to all staff involved in the resident's care. g. the unit manager or other designated staff member will conduct an audit on all residents experiencing a change in status, at the time the change in status is identified, to ensure care plans have been updated to reflect current resident needs. Review of the facility's P&P titled Abuse, Neglect and Exploitation revised 12/2022 showed the Page 1 of 3 055622 055622 07/01/2025 Bonita Hills Post Acute 1233 West LA Habra Boulevard LA Habra, CA 90631

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few facility will make efforts to ensure all the residents are protected from physical and psychosocial harm, as well as additional abuse, during and after the investigation. Examples include but are not limited to: a. responding immediately to protect the alleged victim and integrity of the investigation; b. examining the alleged victim for any sign of injury, including a physical examination or psychosocial assessment if needed; c. increased supervision of the alleged victim and residents; d. room or staffing changes, if necessary, to protect the resident(s) from the alleged perpetrator; e. protection from retaliation; f. providing emotional support and counseling to the resident during and after the investigation, as needed; and g. revision of the resident's care plan if the resident's medical, nursing, physical, mental, or psychosocial needs or preferences change as a result of the incident of abuse. Medical record review for Resident 1 was initiated on 7/1/25. Resident 1 was admitted to the facility on [DATE]. On 6/24/25 at 1435 hours, the CDPH, L&C Program received a complaint alleging Resident 1 had been financially abused by Family Member 1. Review of Resident 1's Care Plan Report dated 6/23/25, showed suspected financial abuse, assessment reveals suspected abuse and/or neglect or factors that may increase susceptibility to abuse/neglect included psychosocial distress and disturbed functioning. The Care Plan Report showed the following interventions included: - assure the resident he is in a safe and secure environment with caring professionals. Explain that psychosocial adjustment is often facilitated by developing a trusting relationship with another person (i.e., social worker, nurse, CNA, peer) and by verbalizing thoughts, needs and feelings; - assure the resident the staff members are available to help and department heads maintain an open door policy; - establish guidelines regarding visiting if the persons interested in visiting have a history of inappropriate and/or maladaptive behavior towards the resident. Provide supervision during visits, as necessary; - observe the resident for signs of fear and insecurity during delivery of care. Take steps to calm the resident and help the resident to feel safe; and - review the assessment information. Emphasize treatment of the causal factors and/or interventions designed to moderate/reduce symptoms (make treatment of compulsive behavior, substance abuse, anger 055622 Page 2 of 3 055622 07/01/2025 Bonita Hills Post Acute 1233 West LA Habra Boulevard LA Habra, CA 90631

F 0657 and mental health issues available to the resident, as indicated). Level of Harm - Minimal harm or potential for actual harm Review of the facility's document titled Visitors Log (undated) showed Family Member 1 visited the facility on three separate occasions between 6/24 to 6/30/25. Residents Affected - Few On 7/1/25 at 1325 hours, an interview was conducted with the SSD. The SSD stated Resident 1 wanted to continue to allow Family Member 1 to visit him in the facility. When asked how the facility protected Resident 1 from further financial abuse by Family Member 1, the SSD stated he was notified when Family Member 1 visited, and went in the room to visit Resident 1. When asked if the SSD assessed and monitored Resident 1 regarding the suspected financial abuse, the SSD stated, I didn't for this one. and I should have done it for this one. On 7/1/25 at 1352 hours, an interview was conducted with CNA 1. CNA 1 stated Family Member 1 visited Resident 1 over the weekend between 6/28 to 6/29/25. When asked if she was instructed to provide additional monitoring when Resident 1 had a visitor, CNA 1 stated no. CNA 1 stated she was not aware of the allegation until 7/1/25, and stated everyone should be made aware so Resident 1 could be monitored. On 7/1/25 at 1559 hours, an interview was conducted with LVN 1. LVN 1 stated her first day back was on 7/1/25, after being off for a medical leave. LVN 1 stated she was not informed of Resident 1's allegation until 7/1/25. LVN 1 stated Resident 1 should be monitored after an abuse allegation for a minimum of 72 hours and longer if necessary and monitored when Resident 1 had a visitor to ensure he was not receiving documents to sign. On 7/1/25 at 1432 an interview was conducted with the Administrator. The Administrator stated the process to prevent Resident 1 from further financial abuse by Family Member 1 when she visited, Resident 1 would be to have all eyes on her and ensure they were meeting in a public area within the facility. On 7/1/25 at 1534 hours, an interview and concurrent medical record review was conducted with the DON. The DON stated the assessments, change in condition documentation, post monitoring, and social services assessment and monitoring should have been implemented. The DON verified there were no assessments, physicians' notification, social services assessments, and the care plan interventions were not implemented. On 7/1/25 at 1622 hours, the Administrator and the DON acknowledged the above findings. 055622 Page 3 of 3