Health inspection·June 12, 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, medical record review, and facility P&P review, the facility failed to implement their P&P on Abuse Investigation and Reporting by failing to report an allegation involving the resident to resident physical altercation between two sampled residents (Residents 1 and 2) when Resident 1 alleged Resident 2 had hit him on the right cheek and Resident 1 had allegedly hit back Resident 2. This failure had the potential to put Residents 1 and 2 and other residents at risk of not being protected against the alleged abuse. Findings: Review of the facility's P&P titled Abuse Investigation and Reporting (undated) showed all the reports of the 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. 1. Medical record review forResident 1 was initiated on 6/12/25. Resident 1 was admitted to the facility on [DATE], and was readmitted to the facility on [DATE]. Review of Resident 1's H&P examination dated 8/24/24, showed Resident 1 was competent and able to make decisions. Review of Resident 1's MDS assessment dated [DATE], showed a BIMS Summary score of 15, which meant Resident 1 was cognitively intact. Review of Resident 1's Change In Condition notes dated 5/28/25 at 1825 hours,showed the following nursing observations, evaluation, and recommendations: Resident 1 was on his way to the kitchen when the hand of one of the residents that was confused and being moved by the staff accidentally grazed to his right cheek, the charge nurse was notified, the MD was made aware, the responsible party was made aware, no redness or swelling wasnoted on the right cheek, and the ice pack PRN and monitoring were ordered by the MD. 2. Medical record review for Resident 2 was initiated on 6/12/25. Resident 2 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 2's H&P examination dated 5/17/25, showed Resident 2 was competent and able to make decisions. (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 6 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 06/12/2025 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)