Health inspection·November 30, 2023

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 and record review, the facility failed to report for one of three sampled residents (Resident 1) per there policy and procedure to the state agency and the local ombudsman for an alleged physical abuse by staff member towards (Resident 1). This failure has the potential to put (Resident 1) health, safety, and well-being at risk. Findings: During review of Residents 1's admission Record (general demographics), the document indicated Resident 1 was admitted to the facility on [DATE], with diagnoses to include: kidney transplant, drug, or chemical induced diabetes mellitus (condition affecting how body processes sugar), hypertension (high blood pressure), osteoporosis (bones are brittle and fragile). During an interview with the License Vocational Nurse (LVN1) on November 30, 2023, at 12:06 PM, the (LVN1) stated, Around noon time on Sunday November 26, 2023, Resident 1, said I want to call 911, there was a woman who walked in, and she held me upside down. Which I thought that was odd, he was alert. He wanted to file a report, we got the RN supervisor and resident told resident him the same thing. So, we called our Director of Nursing (DON), we spoke with him about the situation. We told the CNA not to enter the room or come near the resident. We follow protocol. The resident states he was fine, but it was out of character for him. I did not document, I was supposed to document on the incident. With allegations we must fill out document SOC341 (report of suspected dependent adult/elder abuse), however I just reported to the supervisor. During an interview with the Director of Nursing (DON) on November 30, 2023, at 11:26 AM, the (DON) stated, Resident 1 on Sunday November 26, 2023, there was an allegation of abuse, I was told by our LVN 1 that he is saying things didn't make sense, that the CNA1 took him upside down and took him to a dark corner, it was stories that just were not making any sense, he said the CAN1 carried him in her arms, picked him up from the floor and threw him 6 feet away. I went to talk with him, he didn't say anything to me. Then Monday following day, he got to his chemo appointment and comes back, and he gives them the same story, the Police came to investigate on the allegation, the doctor's office reported it. We did not document in progress notes regarding the allegation from Sunday November 26, 2023, we started investigation Monday November 27, 2023, when the police were here. I thought because the Police officer stated it was reported and I got a case number I didn't have to report to CDPH, since it would be multiple submissions on this allegation. Based on our policies we reviewed, we should have reported. (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: 056024 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 056024 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highland Palms Healthcare Center 7534 Palm Ave Highland, CA 92346 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)