Health inspection·July 17, 2024

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to protect the resident's rights to be free from physical abuse by a staff for one of two sampled residents (Resident 1). * CNA 2 was observed by her colleague slapping Resident 1 on the face,resulting in redness to Resident 1's face. Resident 1 stated the incident made him feel embarrassed. This failure had the potential to cause serious injury and physical and/or psychological harm to the resident. Findings: Review of the facility's P&P titled Resident Rights revised 2/2021 showed employees shall treat all residents with kindness, respect, and dignity. Federal and State laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to be treated with respect, kindness, dignity and be free from abuse. Medical record review for Resident 1 was initiated on 7/17/24. Resident 1 was admitted to the facility on [DATE]. Review of Resident 1's MDS dated [DATE], showed Resident 1 had the ability to make himself understood when expressing ideas and wants. Further review of Resident 1's MDS showed Resident 1 had the ability to understand others verbal content with clear comprehension. Review of Resident 1's Change of Condition dated 7/4/24 at 1910 hours, showed Resident 1 was allegedly witnessed being hit by his assigned CNA (CNA 2) during care. Resident 1 was assessed and observed with skin discoloration. Review of Resident 1's Resident Health Status Note dated 7/4/24 at 2205 hours, showed at 1910 hours, CNA 1 witnessed Resident 1 being hit by CNA 2. Resident 1 was assessed and noted with light pink (discoloration) on the left side of his face. On 7/17/24 at 1035 hours, an interview was conducted with Resident 1. Resident 1 stated on 7/4/24, CNA 2 slapped him on the left side of his face. Resident 1 was asked to describe the incident. Resident 1 stated CNA 2 probably slapped him because he was yelling at CNA 2. Resident 1 was asked how the incident made him feel. Resident 1 stated he felt embarrassed. Resident 1 was asked if anyone else witnessed the incident. Resident 1 stated CNA 1 was present and witnessed the incident. On 7/17/24 at 1218 hours, an interview was conducted with CNA 1. CNA 1 stated on 7/4/24, she (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 055742 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055742 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/17/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harbor Villa Care Center 861 S. Harbor Blvd Anaheim, CA 92805 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)