Health inspection·January 23, 2026

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and medical record review, the facility failed to ensure an environment free of accident hazards was provided for two of three sampled residents (Residents 1 and 2). * Resident 1 used a razor to self-inflict harm. * Resident 2 had two razors and two scissors in an unlocked bag inside Resident 2's closet, easily accessible to other residents. * The razors used to shave the male residents were unlocked and unsecured at Nurse Station A and inside a supply closet. These failures posed the risk of the residents accessing the sharp devices and resulting in injuries to the residents.Findings: 1. On 1/23/26, CDPH received a complaint about Resident 1 verbalizing thoughts of committing suicide. Closed medical record review for Resident 1 was initiated on 1/23/26. Resident 1 was admitted to the facility on [DATE], and was sent out to an acute hospital on 1/22/26, due to self-inflicted wounds. Review of Resident 1's Psychiatric Progress Note dated 12/4/25, showed the resident had a diagnosis of depressive disorder. Review of Resident 1's Progress Note dated 1/22/26, showed at 1508 hours, a report was received from the nursing staff, while making rounds regarding Resident 1 being seen with bleeding on the left wrist. The RN and charge nurse assessed the resident. Resident 1 was noted with multiple self-inflicted lacerations on the left wrist and was observed with one razor at hand. Resident 1 stated he wanted to harm himself. Resident 1 was transferred to an acute hospital via paramedics for further evaluation due to self-inflicted injuries to the left wrist with multiple lacerations. 2. On 1/23/26 at 1508 hours, during the initial tour of the facility, an observation and concurrent interview was conducted with Resident 2 and LVN 1 inside the resident's room. Resident 2 was observed with a beard. Resident 2 stated he was independent for his shaving needs. When asked how he addressed his shaving needs, Resident 2 was observed going to his closet, retrieving his personal bag, and retrieving shaving supplies including two pairs of scissors and two razors from his bag. Resident 2 stated the razors were supplied to him by the facility staff. LVN 1 verified the findings. LVN 1 stated the sharp items were not supposed to be stored inside the resident's room. Medical record review for Resident 2 was initiated on 1/23/26. Resident 2 was admitted to the facility on [DATE]. Review of Resident 2's H&P examination dated 12/19/25, showed Resident 2's diagnoses included schizoaffective disorder and anxiety. Resident 2 had the capacity to understand and make decisions. 3. On 1/23/26 at 1515 hours, an observation and concurrent interview was conducted with RN 1. RN 1 was observed at Nurse Station A which faced the facility's rehabilitation room. RN 1 stated residents could obtain shaving supplies from the nurse station, and there was a supply of razors inside the supply closet for the residents' use. When asked to show where the razors at the nurse station were stored, RN 1 showed an unlocked, five tier storage cart with transparent drawers located near an open path from a hallway into the nurse's station. RN 1 verified she was facing the rehabilitation room, with her back facing the unlocked storage cart. RN 1 showed one of the drawers contained a blue razor and another drawer contained two razors. RN 1 was asked to show the supplies Page 1 of 2 055742 055742 01/23/2026 Harbor Villa Care Center 861 S. Harbor Blvd Anaheim, CA 92805

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few closet containing the supply of razors for residents. RN 1 was observed going to a supplies closet located across from the facility's dining/activities room. The supply closet was unlocked. Inside the supply closet, an unlocked drawer was observed with multiple blue razors. RN 1 verified the findings and acknowledged the razors were not secured and easily accessible to the residents. On 1/23/26, an interview was conducted with the Administrator. The Administrator stated the facility did not know how Resident 1 got a hold of a razor. The Administrator also stated the staff in-services had been conducted on 1/22 and 1/23/26, including the staff going into residents' rooms to ensure razors were not being stored inside residents' rooms. The Administrator was informed of the above findings. 055742 Page 2 of 2