Health inspection·December 11, 2025

F 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure Resident 2's grievance corrective action was followed through when the facility assigned certified nursing assistant (CNA) 4 to the resident after Resident 2 requested not to assign CNA 4 to provide care to her as indicated in her grievance on 7/21/24.As a result of this deficient practice, Resident 2's request to not be provided care by CNA 4 was not honored and the resident was at risk for further abuse by CNA 4. Cross reference F600 and F656.Findings: On 11/26/25 at 10:19 A.M., an onsite investigation was conducted to investigate three Facility Reported Incidents (FRIs) alleging CNA 4 inappropriately touched Residents 2 and two other residents. A review of Resident 2's admission Record indicated the resident was admitted to the facility on [DATE]. A review of Resident 2's Minimum Data Set assessment (MDS, a comprehensive assessment tool) dated 10/7/25, indicated the resident's brief interview of mental status was 15 out of 15, which indicated the resident was cognitively intact.A review of Resident 2's History and Physical dated 9/30/25, indicated the resident had capacity to understand and make decisions. A review of Resident 2's facility investigative summary dated 11/17/25, indicated, .On 11/13/25 at approximately 2100pm [9 P.M.], a report was received . [Resident 2] alleged that a male staff touched her inappropriately while.changing her brief. [Resident 2] heard the alleged situation of inappropriate behavior with another resident in the building. On 12/9/25 at 12 P.M., an interview was conducted with Resident 2. Resident 2 was asked about the incident with CNA 4 that she had reported to the facility on [DATE]. Resident 2 stated CNA 4 had changed her soiled brief. The resident stated CNA 4 told her that he was going to give her a massage which would make her feel better and help her go to sleep. Resident 2 stated CNA 4 then started massaging her vagina where he should not be rubbing. Resident 2 stated CNA 4 rubbed her vagina outside and inside, then she felt his hand starting to go into her vagina. Resident 2 stated she realized what was happening and told CNA 4, It better be the end of it. Never again do I want a massage, at which point CNA 4 stopped. Resident 2 stated CNA 4's actions made her feel very uncomfortable because no doubt in my mind that the brief change by CNA 4 was different from a normal one. Resident 2 stated the incident made her feel angry and she felt CNA 4 took advantage of her. A review of CNA 4's employee file indicated that there was a grievance filed against CNA 4 by Resident 2 on 7/21/25. The grievance indicated the CNA was a little too friendly and [Resident 2] just wa [sic] the CNA to do her brief change and so she can go to sleep and Resident 2 requested to not have CNA 4 be assigned to her. The grievance did not mention a sexual touch by CNA 4. On 12/11/25 at 10:04 A.M., another interview was conducted with Resident 2. Resident 2 was asked about the grievance she filed against CNA 4. Resident 2 was asked when the incident with CNA 4 had occurred. The resident stated it happened a few days before the grievance was filed (on 7/21/25). Resident 2 stated she did not include the sexual abuse encounter in the grievance. Resident 2 stated she regretted not including the sexual abuse Page 1 of 11 055890 055890 12/11/2025 Magnolia Post Acute Care 635 S Magnolia Ave El Cajon, CA 92020

F 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few committed by CNA 4 in the grievance because other residents could have been victimized by him, too. The resident stated she was especially worried about the non-verbal, vulnerable residents who could not speak up about abuse. Resident 2 stated when CNA 4 massaged her vagina, it was an unpleasant experience, and it felt sexual in nature. Resident 2 stated after the incident with CNA 4, I was on the edge as to who is going to be the CNA at night, worried that he was going to be my CNA again. Resident 2 stated CNA 4 changed her brief again one night in October. Resident 2 stated CNA 4 did not massage or insert his fingers into her vagina that time because she recognized him when he entered her room and told him, No massages, no nothing, just a change. A review of the CNA assignment for July through October 2025, indicated CNA 4 had provided care to Resident 2 on 7/14/25 and 10/21/25 during the NOC shift (11P.M. to 7A.M.). On 12/18/25 at 10:13 A.M., a phone interview and record review was conducted with the Director of Nursing (DON), the Administrator (ADM), and the facility's Clinical Consultant (CC). The DON stated CNA 4 being assigned to Resident 2 on 10/21/25 was an oversight on her part. The DON stated CNA 4 should not have been assigned to Resident 2 after the grievance indicated the resident refused to be cared by CNA 4. The facility's written form provided to their residents titled Resident Rights dated July 2017, indicated, .Safe Environment. You have a right to a safe.homelike environment. A review of the facility's policy titled Section: Resident Rights Subject: Grievance dated November 2025, indicated, .4. The grievance Official evaluates and investigates the concern and takes immediate action to resolve the concern and prevent further potential violations of any resident's right while the alleged violation is being investigated. 055890 Page 2 of 11 055890 12/11/2025 Magnolia Post Acute Care 635 S Magnolia Ave El Cajon, CA 92020

F 0600 Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Level of Harm - Actual harm Residents Affected - Some **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure three out of three residents (Resident 1, 2, and 3) were free from sexual abuse when:1. Resident 1 stated certified nursing assistant (CNA) 4 fondled her clitoris and inserted his fingers in her vagina during care.2. Resident 2 stated CNA 4 massaged her vagina during a brief change. 3. Resident 3 stated CNA 4 inserted his fingers into her vagina during a brief change.4. The facility hired CNA 4 with reference checks that reflected negative past employment performance. As a result of this deficient practice, Resident 1, 2, and 3 experienced psychosocial harm (damage to a person's mental, emotional, and social well-being that was caused by their environment or experiences), stating the incidents with CNA 4 made them feel angry, humiliated, embarrassed, ashamed, and worried. Findings: On 11/26/25 at 10:19 A.M., an onsite investigation was conducted to investigate three Facility Reported Incidents (FRIs) alleging CNA 4 inappropriately touched Residents 1, 2, and 3. 1. A review of Resident 1's admission Record indicated the resident was admitted to the facility on [DATE] with diagnosis that included constipation, difficulty walking, and need for assistance with personal care. A review of Resident 1's Minimum Data Set Assessment (MDS, a comprehensive assessment tool) dated 11/28/25, indicated the resident's BIMS (Brief Interview for Mental Status) was 15 out of 15, indicating the resident was cognitively intact (no memory, focus, or judgment issues).A review of Resident 1's History and Physical dated 11/10/25 indicated the resident had capacity to understand and make decisions. A review of Resident 1's facility investigative summary dated 11/16/25, indicated, .According to [Resident 1], during the NOC [night] shift on 11/11/25. [Resident 1] had a large soft stool that needed to be cleaned. The CNA came in, introduced himself as [CNA 4] . and explained that he would change the brief.felt as if something brushed against her vaginal area. On 12/9/25 at 11:13 A.M., an interview was conducted with Resident 1. Resident 1 was asked about the allegation which the resident reported to the facility on [DATE]. The resident stated she told a nurse about her abdominal pain caused by her constipation in the early morning of 11/12/25. Resident 1 stated CNA 4 came into her room and told her he could help with her constipation around 3 A.M. The resident stated CNA 4 then removed the front part of her brief and she felt his fingers rubbing against her clitoris. The resident then stated she felt CNA 4's fingers going into her vagina. Resident 1 stated when CNA 4 rubbed her clitoris and inserted his fingers into her vagina, it felt sexual in nature and was uncomfortable. Resident 1 stated she felt humiliated and ashamed, and she was glad CNA 4 no longer worked at the facility. The resident stated she reported this incident to her husband and the facility later that day. Resident 1 stated she reported the incident because it felt wrong that CNA 4 was taking advantage of people like her sexually. The resident remembered and verbalized CNA 4's name and stated she was worried if there were other residents who had been abused by CNA 4. A review of Resident 1's Care Plan initiated on 11/12/25, indicated, the resident requested to have only female CNA or a female CNA to be present if a male CNA was to give her care. 2. A review of Resident 2's admission Record indicated the resident was admitted to the facility on [DATE]. A review of Resident 2's MDS assessment dated [DATE], indicated the resident's BIMS was 15 out of 15.A review of Resident 2's History and Physical dated 9/30/25, indicated the resident had capacity to understand and make decisions. A review of Resident 2's facility investigative summary dated 11/17/25, indicated, .On 11/13/25 at approximately 2100pm [9 P.M.], a report was received . [Resident 2] alleged that a male staff touched her inappropriately while.changing her brief. [Resident 2] heard the alleged situation of inappropriate behavior with another resident in the building. On 12/9/25 at 12 P.M., an interview was conducted with Resident 2. Resident 2 was 055890 Page 3 of 11 055890 12/11/2025 Magnolia Post Acute Care 635 S Magnolia Ave El Cajon, CA 92020

F 0600 Level of Harm - Actual harm Residents Affected - Some asked about the incident with CNA 4 that she had reported to a CNA on 11/13/25. Resident 2 stated CNA 4 had changed her soiled brief. The resident stated CNA 4 told her that he was going to give her a massage which would make her feel better and help her go to sleep. Resident 2 stated CNA 4 then started massaging her vagina where he should not be rubbing. Resident 2 stated CNA 4 rubbed her vagina outside and inside, then she felt his hand starting to go into her vagina. Resident 2 stated she realized what was happening and told CNA 4, It better be the end of it. Never again do I want a massage, at which point CNA 4 stopped. Resident 2 stated CNA 4's actions made her feel very uncomfortable because no doubt in my mind that the brief change by CNA 4 was different from a normal one. Resident 2 stated the incident made her feel angry and she felt CNA 4 took advantage of her. A review of CNA 4's employee file indicated that there was a grievance filed against CNA 4 by Resident 2 on 7/21/25. The grievance indicated the CNA was a little too friendly and [Resident 2] just wa [sic] the CNA to do her brief change and so she can go to sleep and Resident 2 requested to not have CNA 4 be assigned to her. The grievance did not mention a sexual touch by CNA 4. On 12/11/25 at 10:04 A.M., a follow up interview was conducted with Resident 2. Resident 2 was asked about the grievance she filed against CNA 4 on 7/21/25. Resident 2 was asked when the incident with CNA 4 had occurred. The resident stated it happened a few days before the grievance was filed (on 7/21/25). Resident 2 stated she did not include the sexual abuse encounter in the grievance. Resident 2 stated she regretted not including the sexual abuse committed by CNA 4 in the grievance because other residents could have been victimized by him, too. The resident stated she was especially worried about the non-verbal, vulnerable residents who could not speak up about abuse. Resident 2 stated when CNA 4 massaged her vagina, it was an unpleasant experience, and it felt sexual in nature. Resident 2 stated after this incident with CNA 4 on 7/21/25, I was on the edge as to who is going to be the CNA at night, worried that he was going to be my CNA again. Resident 2 stated CNA 4 changed her brief again one night in October. Resident 2 stated CNA 4 did not massage or insert his fingers into her vagina that time because she recognized him when he entered her room and told him, No massages, no nothing, just a change. A review of the CNA assignment for July through October 2025, indicated CNA 4 had provided care to Resident 2 on 7/14/25 and 10/21/25 during the NOC shift (11P.M. to 7A.M.). A review of Resident 2's therapy note dated 11/14/25, indicated, the therapist and Resident 2 discussed the recent Stressful incident with male staff and Resident 2 expressed feeling Worry during the therapy. A review of Resident 2's Care Plan Intervention initiated on 10/24/25, indicated Resident 3 refused certain CNAs without providing specific reasons. 3. A review of Resident 3's admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses which included a need for assistance with personal care. A review of Resident 3's MDS assessment dated [DATE], indicated the resident's BIMS was 15 out of 15.A review of Resident 3's History and Physical dated 12/7/24, indicated the resident had capacity to understand and make decisions. A review of Resident 3's facility investigative summary dated 11/17/25, indicated, .On 11/13/25 at approximately 18:45pm [6:45 P.M.], a report was received. [Resident 3] told the psychologist (a mental health professional who helps people understand their thoughts, feelings, and behaviors to manage life's challenges) that she heard the alleged situation of inappropriate behavior with another resident in the building.prompted her to share her own allegation.some months ago.After cleaning her.the CNA applied barrier cream.around the private area.that made her feel it was inappropriate. On 12/9/25 at 11:34 A.M., an interview was conducted with Resident 3. Resident 3 stated that CNA 4 touched her inappropriately on multiple days but could not remember the exact dates or times of the incidents. Resident 3 stated she remembered one incident when CNA 4 inserted a finger into her vagina after a brief change. Resident 3 stated this was a few months ago. 055890 Page 4 of 11 055890 12/11/2025 Magnolia Post Acute Care 635 S Magnolia Ave El Cajon, CA 92020

F 0600 Level of Harm - Actual harm Residents Affected - Some Resident 3 stated she did not want her brief changed by CNA 4 anymore after the incident and would feel relieved when someone else was assigned as her CNA. Resident 3 stated when CNA 4 was alone with her, he touched her inappropriately. Resident 3 stated when he had another staff member with him, he would not touch her in the wrong way. Resident 3 stated she felt having CNA 4's fingers around or inside her vagina was sexual and wrong. Resident 3 stated she did not report the incident right away because she thought she was going crazy and questioned if the incident really happened. Resident 3 then stated she felt she was old enough to differentiate what was sexual and what was not. The resident stated she told herself that reporting was the right thing to do because CNA 4 should not be touching her the way he did. Resident 3 stated she was concerned there were other victims.A review of Resident 3's Psychiatry (medical doctors treating mental health) Progress Note dated 9/10/25, indicated, Resident 3 denied sleep disturbance, depressive symptoms, and anxiety symptoms.A review of Resident 3's therapy Progress Note dated 11/13/25, indicated, Resident 3 discussed about a recent negative encounter and Resident 3 expressed having anxiety, depressed mood/grief, fatigue, and sleep disturbance. The Progress Note indicated Resident 3 reported a safety concern. A review of Resident 3's therapy Progress Note dated 11/14/25, indicated, Resident 3 discussed thoughts and feelings surrounding stressful incident and expressed having anxiety, depressed mood/grief, helplessness, and worry. A review of Resident 3's therapy Progress Note dated 11/17/25, indicated, Resident 3 discussed about anxiety regarding recent decision and expressed having anxiety, fatigue, negative self-talk, and sleep disturbance. 4. A review of CNA 4's employee file indicated CNA 4 was hired on 1/28/25. There were two printed reference checks titled [Facility name] Confidential Reference Check both dated 1/24/25 in CNA 4's employee file. The reference checks reflected CNA 4's past employment. The reference checks indicated the CNA .became lazy in PT [patient] care, unreliable.over confident [sic].became inconsistent and .caught sleeping on the job. Both previous employers indicated they would not rehire CNA 4. A review of Resident 1, 2, and 3's facility investigative summaries dated 11/16/25 and 11/17/25 indicated that the facility's review of CNA 4's three pre-employment references revealed only positives [sic] things to say about the employee. On 12/11/25 at 3:25 P.M., an interview was conducted with the director of nursing (DON) and administrator (ADM). The DON stated the facility did not have a policy regarding reference checks. The DON stated recruiters at HR (Human Resources) were responsible for the initial reference checks. The ADM further stated the facility did not have a paper written statement by CNA 4 regarding the three sexual abuse allegations. On 12/11/25 at 4:47 P.M., an interview and record review was conducted with the Director of Staff Development (DSD). The DSD reviewed the facility's undated policy titled Administration and stated it was the material she used to educate the staff regarding abuse and abuse related topics. The DSD stated it was considered sexual abuse for a staff to rub and insert their fingers in a resident's vagina. The DSD stated CNA 4 received in-service regarding proper communication after Resident 2 filed the grievance on 7/21/25. The DSD stated she had no other grievance filed against CNA 4. The DSD reviewed CNA 4's pre-employment references dated 1/24/25 and stated she would hesitate to hire someone with such negative references. The DSD stated CNA 4 was not given any abuse in-services after the first sexual abuse report made by Resident 1 on 11/12/25 because he was sent home and suspended during the facility investigations for the three allegations and then he resigned effective 11/25/25. A review of CNA 4's Employee Resignation Form dated 11/25/25, indicated CNA 4 resigned from his CNA position at the facility effective 11/25/25. On 12/11/25 at 4:52 P.M., a concurrent interview and record review was conducted with the ADM. The ADM stated that he reached out to CNA 4 via text on his phone as he was previously asked for CNA 4's phone number. The ADM presented the text for review and stated CNA 4 had declined a 055890 Page 5 of 11 055890 12/11/2025 Magnolia Post Acute Care 635 S Magnolia Ave El Cajon, CA 92020

F 0600 Level of Harm - Actual harm Residents Affected - Some phone interview with the surveyor. On 12/11/25 at 5:41 P.M., an interview and record review was conducted with the ADM and the DON. The DON stated she recognized there was a red flag when she received the report from Resident 1 on 11/12/25. The DON stated she would have had CNA 4 terminated when the third sexual allegation was reported to her, because of the magnitude of the allegations. The DON also stated if CNA 4 had not quit, he would have been terminated for the safety of the other residents. The DON and ADM reviewed CNA 4's two printed reference checks dated 1/24/25. The ADM was asked about the discrepancies between the three favorable reference checks mentioned in the facility's investigative summary report for Resident 1, 2, and 3 and the two unfavorable references contained in the CNA's personnel file. The ADM and DON reviewed the two unfavorable references dated 1/24/25 and stated they had never seen them. The DON stated that reviewing references was a part of onboarding process and if she had seen those reviews she would not have hired him. The ADM stated he called the HR recruiter and received positive comments on CNA 4's references during his investigation. The ADM stated the facility should not have hired CNA 4 because red flag references were indicators of someone whom the facility would not hire. On 12/18/25 at 10:13 A.M., an interview and record review was conducted with the DON, the ADM, and the facility's Clinical Consultant (CC). The ADM was asked what sexual abuse was. The ADM stated sexual abuse could be an act or word that was sexual in nature from one person to another. The ADM stated when a resident reported inappropriate touch or uncomfortable touch, the resident could mean that those touches felt sexual in nature, especially if the encounter happened during a peri care (care around genitals and anal area). A review of the facility's undated policy titled Administration, indicated, .it is the policy of this Facility that each resident has the right to be free from abuse., and exploitation. The facility will provide oversight and monitoring to ensure that its staff, who are agents of the Facility, deliver care and services in a way that promotes and respects the right of the residents to be from abuse., and exploitation.A. SCREENING (Prospective Employees) .6. All employees.will be properly screened prior to working at the Facility.C. TRAINING.1. e. Reporting reasonable suspicion of a crime against a resident in accordance with Section 1150B of the Social Security Act; . Sexually aggressive behavior such as., inappropriate touching.Residents that require extensive nursing care.E. IDENTIFICATION 1. The Facility will assist staff in identifying abuse.and exploitation of residents.This includes identifying.sexual abuse.2. Because some cases of abuse are not directly observed, understanding resident outcomes of abuse can assist in identifying whether abuse is occurring or has occurred. Possible indicator of abuse include, but are not limited to: . Occurrences, patterns, and trends that may constitute abuse.I. DEFINITIONS.Abuse is willful infliction.includes .sexual abuse.Willful.means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm.Exploitation means taking advantage of a resident for personal gain.Sexual abuse is non-consensual sexual contact of any type with a resident. 055890 Page 6 of 11 055890 12/11/2025 Magnolia Post Acute Care 635 S Magnolia Ave El Cajon, CA 92020

F 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to thoroughly investigate and identify sexual abuse in the facility after conducting three investigations when:1. The facility unsubstantiated Resident 1's sexual abuse allegation against certified nursing assistant (CNA) 4.2. The facility unsubstantiated Resident 2's sexual abuse allegation against CNA 4.3. The facility unsubstantiated Resident 3's sexual abuse allegation against CNA 4.4. The facility's investigation into the allegations against CNA 4 indicated the CNA had only favorable pre-employment references when this was not correct. In addition, the facility failed to ask clarifying questions during the course of their investigations to fully understand the residents' allegations. As a result of the facility's failure to identify and substantiate sexual abuse through its own investigative process, residents were placed at risk for abuse. Findings: On 11/26/25 at 10:19 A.M., an onsite investigation was conducted to investigate three Facility Reported Incidents (FRIs) alleging CNA 4 inappropriately touched Residents 1, 2, and 3. 1. A review of Resident 1's admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses to include constipation, difficulty walking, and need for assistance with personal care. A review of Resident 1's Minimum Data Set Assessment (MDS, a comprehensive assessment tool) dated 11/28/25, indicated the resident's BIMS (Brief Interview for Mental Status) was 15 out of 15, indicating the resident was cognitively intact.A review of Resident 1's History and Physical dated 11/10/25, indicated the resident had capacity to understand and make decisions. A review of Resident 1's facility investigative summary dated 11/16/25, indicated, .According to [Resident 1], during the NOC [night] shift on 11/11/25.she [Resident 1] had a large soft stool that needed to be cleaned. The CNA came in, introduced himself as [CNA 4] . and explained that he would change the brief.felt as if something brushed against her vaginal area. On 12/9/25 at 11:13 A.M., an interview was conducted with Resident 1. Resident 1 was asked about the allegation which the resident reported to the facility on [DATE]. The resident stated she told a nurse about her abdominal pain caused by her constipation in the early morning of 11/12/25. Resident 1 stated CNA 4 came into her room and told her he could help with her constipation around 3 A.M. The resident stated CNA 4 then removed the front part of her brief and she felt his fingers rubbing against her clitoris. The resident then stated she felt CNA 4's fingers going into her vagina. Resident 1 stated when CNA 4 rubbed her clitoris and inserted his fingers into her vagina, it felt sexual in nature and was uncomfortable. Resident 1 stated she felt humiliated and ashamed, and she was glad CNA 4 no longer worked at the facility. The resident stated she reported this incident to her husband and the facility later that day. Resident 1 stated she reported the incident because it felt wrong that CNA 4 was taking advantage of people like her sexually. The resident remembered and verbalized CNA 4's name and stated she was worried if there were other residents who had been abused by CNA 4. 2. A review of Resident 2's admission Record indicated the resident was admitted to the facility on [DATE]. A review of Resident 2's MDS assessment dated [DATE], indicated the resident's BIMS was 15 out of 15.A review of Resident 2's History and Physical dated 9/30/25, indicated the resident had capacity to understand and make decisions. A review of Resident 2's facility investigative summary dated 11/17/25, indicated, .On 11/13/25 at approximately 2100pm [9 P.M.], a report was received . [Resident 2] alleged that a male staff touched her inappropriately while.changing her brief.[Resident 2] heard the alleged situation of inappropriate behavior with another resident in the building. On 12/9/25 at 12 P.M., an interview was conducted with Resident 2. Resident 2 was asked about the incident with CNA 4 that she had reported to the facility on [DATE]. Resident 2 stated CNA 4 had changed her soiled brief. The resident stated CNA 4 told her that he was going to give her a massage which would make her feel Residents Affected - Few 055890 Page 7 of 11 055890 12/11/2025 Magnolia Post Acute Care 635 S Magnolia Ave El Cajon, CA 92020

F 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few better and help her go to sleep. Resident 2 stated CNA 4 then started massaging her vagina where he should not be rubbing. Resident 2 stated CNA 4 rubbed her vagina outside and inside, then she felt his hand starting to go into her vagina. Resident 2 stated she realized what was happening and told CNA 4, It better be the end of it. Never again do I want a massage, at which point CNA 4 stopped. Resident 2 stated CNA 4's actions made her feel very uncomfortable because no doubt in my mind that the brief change by CNA 4 was different from a normal one. Resident 2 stated the incident made her feel angry and she felt CNA 4 took advantage of her. 3. A review of Resident 3's admission Record indicated the resident was admitted to the facility on [DATE] with diagnosis including need for assistance with personal care. A review of Resident 3's MDS assessment dated [DATE], indicated the resident's BIMS was 15 out of 15.A review of Resident 3's History and Physical dated 12/7/24, indicated the resident had capacity to understand and make decisions. A review of Resident 3's facility investigative summary dated 11/17/25, indicated, .On 11/13/25 at approximately 18:45pm [6:45 P.M.], a report was received. [Resident 3] told the psychologist that she heard the alleged situation of inappropriate behavior with another resident in the building.prompted her to share her own allegation.some months ago.After cleaning her.the CNA applied barrier cream.around the private area.that made her feel it was inappropriate. On 12/9/25 at 11:34 A.M., an interview was conducted with Resident 3. Resident 3 stated that CNA 4 touched her inappropriately on multiple days but could not remember the exact dates or times of the incidents. Resident 3 stated she remembered one incident when CNA 4 inserted a finger into her vagina after a brief change. Resident 3 stated this was a few months ago. Resident 3 stated she did not want her brief changed by CNA 4 anymore after the incident and would feel relieved when someone else was assigned as her CNA. Resident 3 stated when CNA 4 was alone with her, he touched her inappropriately. Resident 3 stated when he had another staff member with him, he would not touch her in the wrong way. Resident 3 stated she felt having CNA 4's fingers around or inside her vagina was sexual and wrong. Resident 3 stated she did not report the incident right away because she thought she was going crazy and questioned if the incident really happened. Resident 3 then stated she felt she was old enough to differentiate what was sexual and what was not. The resident stated she told herself that reporting was the right thing to do because CNA 4 should not be touching her the way he did. Resident 3 stated she was concerned there were other victims. 4. A review of CNA 4's employee file indicated CNA 4 was hired on 1/28/25. There were two printed reference checks titled [Facility Name] Confidential Reference Check both dated 1/24/25 in CNA 4's employee file. The reference checks reflected CNA 4's past employment. The reference checks indicated the CNA .became lazy in PT [patient] care, unreliable.over confident [sic].became inconsistent and .caught sleeping on the job. Both previous employers indicated they would not rehire CNA 4. On 12/11/25 at 3:25 P.M., an interview was conducted with the director of nursing (DON) and the administrator (ADM). The DON stated the facility did not have a policy regarding reference checks. The DON stated recruiters at HR (Human Resources) were responsible for the initial reference checks. The ADM further stated the facility did not have a paper written statement by CNA 4 regarding the three sexual abuse allegations. On 12/11/25 at 4:47 P.M., an interview and record review was conducted with the Director of Staff Development (DSD). The DSD reviewed CNA 4's pre-employment references dated 1/24/25 and stated she would hesitate to hire someone with such negative references. A review of Resident 1, 2, and 3's facility investigative summary indicated that the facility's review of CNA 4's three pre-employment references revealed only positives [sic] things to say about the employee. On 12/11/25 at 5:41 P.M., an interview and record review was conducted with the ADM and the DON. The DON stated she recognized there was a red flag when she received the report from Resident 1 on 11/12/25. The DON and ADM reviewed CNA 055890 Page 8 of 11 055890 12/11/2025 Magnolia Post Acute Care 635 S Magnolia Ave El Cajon, CA 92020

F 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 4's two printed reference checks dated 1/24/25. The ADM was asked about the discrepancies between the three favorable reference checks mentioned in the facility's investigative summary report for Resident 1, 2, and 3, and the two unfavorable references contained in the CNA's personnel file. The ADM and DON reviewed the two unfavorable references dated 1/24/25 and stated they had never seen them. The DON stated that reviewing references was a part of onboarding process and if she had seen those reviews she would not have hired him. The ADM stated he called the HR recruiter and received the three positive reviews on CNA 4's references during his investigation. The ADM stated the facility should not have hired CNA 4 because red flag references were indicators of someone whom the facility would not hire. On 12/18/25 at 10:13 A.M., a phone interview and record review was conducted with the DON, the ADM, and the facility's Clinical Consultant (CC). Regarding conflicting pre-employment reference reviews of CNA 4, the ADM stated he should have verified CNA 4's actual references as a part of his investigation, not verifying through a phone call with the facility's recruiters. The DON stated the three positive professional reference reviews indicated in the facility's investigational summary were not accurate. Then ADM was asked what sexual abuse was. The ADM stated sexual abuse could be an act or word that was sexual in nature from one person to another. The ADM stated when a resident reported inappropriate touch or uncomfortable touch, the resident could mean that those touches felt sexual in nature, especially if the encounter happened during a peri care (care around genitals and anal area). The DON reviewed Resident 1's facility investigative summary dated 11/16/25. The DON stated she did not clarify what Resident 1 meant by uncomfortable experience caused by CNA 4 during her investigative interview with the resident on 11/12/25.The DON reviewed Resident 2's facility investigative summary dated 11/17/25. The DON stated she did not clarify what Resident 2 meant when the resident expressed uncomfortable experience and touched her inappropriately by CNA 4 during her investigative interview with Resident 2 on 11/13/25.The DON reviewed Resident 3's facility investigative summary dated 11/17/25. The DON stated she did not clarify what Resident 3 meant by inappropriate touching by CNA 4 during her investigative interview with Resident 3 on 11/13/25. The DON stated because the facility did not clarify the vague expressions used in the resident's sexual abuse allegations such as inappropriate touch, the facility's investigations were not thorough. The DON stated that because of this reason, she could not affirm that the allegations were truly unsubstantiated. A review of the facility's undated policy titled Administration, indicated, .A. SCREENING (Prospective Employees) .6. All employees.will be properly screened prior to working at the Facility.C. TRAINING.1. e. Reporting reasonable suspicion of a crime against a resident in accordance with Section 1150B of the Social Security Act; . Sexually aggressive behavior such as., inappropriate touching.Residents that require extensive nursing care.E. IDENTIFICATION 1. The Facility will assist staff in identifying abuse.and exploitation of residents.This includes identifying.sexual abuse.2. Because some cases of abuse are not directly observed, understanding resident outcomes of abuse can assist in identifying whether abuse is occurring or has occurred. Possible indicator of abuse include, but are not limited to: . Occurrences, patterns, and trends that may constitute abuse.F. INVESTIGATION.2. All allegations of abuse.and exploitation will be.thoroughly investigated by the Administrator or his/her designee. I. DEFINITIONS.Abuse is willful infliction.includes.sexual abuse.Willful.means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm.Exploitation means taking advantage of a resident for personal gain.Sexual abuse is non-consensual sexual contact of any type with a resident. 055890 Page 9 of 11 055890 12/11/2025 Magnolia Post Acute Care 635 S Magnolia Ave El Cajon, CA 92020

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and implement a person-centered care plan in a timely manner after Resident 2 filed a grievance and requested certified nursing assistant (CNA) 4 to not be assigned to her. As a result of this deficient practice, Resident 2's request to not be provided care by CNA 4 was not honored and the resident was at risk for further abuse by CNA 4.Findings: On 11/26/25 at 10:19 A.M., an onsite investigation was conducted to investigate three Facility Reported Incidents (FRIs) alleging CNA 4 inappropriately touched Residents 2 and two other residents. A review of Resident 2's admission Record indicated the resident was admitted to the facility on [DATE]. A review of Resident 2's Minimum Data Set assessment (MDS, a comprehensive assessment tool) dated 10/7/25, indicated the resident's brief interview of mental status was 15 out of 15, which indicated the resident was cognitively intact.A review of Resident 2's History and Physical dated 9/30/25, indicated the resident had capacity to understand and make decisions. A review of CNA 4's employee file indicated that there was a grievance filed against CNA 4 by Resident 2 on 7/21/25. The grievance indicated the CNA was a little too friendly and [Resident 2] just wa [sic] the CNA to do her brief change and so she can go to sleep and Resident 2 requested to not have CNA 4 be assigned to her. The grievance did not mention a sexual touch by CNA 4. On 12/11/25 at 10:04 A.M., an interview was conducted with Resident 2. Resident 2 was asked about the grievance she filed against CNA 4. Resident 2 was asked when the incident with CNA 4 had occurred. The resident stated it happened a few days before the grievance was filed (on 7/21/25). Resident 2 stated she did not include the sexual abuse encounter in the grievance. Resident 2 stated she regretted not including the sexual abuse committed by CNA 4 in the grievance because other residents could have been victimized by him, too. The resident stated she was especially worried about the non-verbal, vulnerable residents who could not speak up about abuse. Resident 2 stated the incident involved CNA 4, and that he had massaged her vagina during care and it was an unpleasant experience. Resident 2 stated the incident felt sexual in nature. Resident 2 stated after the incident with CNA 4, I was on the edge as to who is going to be the CNA at night, worried that he was going to be my CNA again. Resident 2 stated CNA 4 changed her brief again one night in October. Resident 2 stated CNA 4 did not massage or insert his fingers into her vagina that time because she recognized him when he entered her room and told him, No massages, no nothing, just a change. A review of the CNA assignment for July through October 2025, indicated CNA 4 had provided care to Resident 2 on 7/14/25 and 10/21/25 during the NOC shift (11P.M. to 7A.M.). A review of Resident 2's care plan ADL Self Care Performance Deficit related to UTI, Chest pain, pain to left shoulder, weakness, impaired mobility indicated Resident have preference on some CNAs over others without being specific on reasons why she refuse certain CNAs as an intervention. The care plan was initiated on 10/24/25. On 12/17/25 at 3:31 P.M., a record review was conducted with the Medical Record Director (MDR) through emails. The MDR reviewed Resident 2's care plan and stated the facility did not have a care plan developed in response to Resident 2's request to not have CNA 4 assigned to her when the grievance was filed on 7/21/25. On 12/18/25 at 10:13 A.M., a phone interview and record review was conducted with the Director of Nursing (DON), the Administrator (ADM), and the facility's Clinical Consultant (CC). The DON stated the facility did not develop a care plan promptly to honor Resident 2's request to not assign CNA 4 to her as indicated in the grievance filed on 7/21/25. A review of the facility's policy titled Care Planning/Care Conference dated January 2025, indicated, .4. Revision and update of care plan should transpire to accommodate resident needs.where IDT [Interdisciplinary Team, a group of health care professionals that coordinate 055890 Page 10 of 11 055890 12/11/2025 Magnolia Post Acute Care 635 S Magnolia Ave El Cajon, CA 92020

F 0656 resident care] will respect resident's decision. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 055890 Page 11 of 11