Health inspection·June 3, 2024

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 ensure one of four allegations of abuse was reported within 24 hours per Federal and State law when one resident (Resident 1) left the facility AMA (against medical advice) for his safety after he telephoned the police to report an allegation of being touched inappropriately. This failure had the potential to compromise resident's safety and result in further abuse. Findings: During a review of Resident 1's Face Sheet (document that contains a summary of personal and demographic information), the Face Sheet indicated, Resident 1 was admitted to the facility on [DATE] with a primary diagnosis of fusion of the spine (major surgery designed to stop motion to alleviate pain) in the lumbar region (series of small bones enclosing the spinal cord in the low back). Face Sheet further indicated Resident 1 was self-responsible. During a review of Resident 1's Release from Responsibility for Discharge, dated 10/14/23, the Release from Responsibility for Discharge indicated, Resident 1 was leaving against the advice of the attending physician. During a review of Resident 1's Notice of Transfer or Discharge, dated 10/17/23, the Notice of Transfer or Discharge indicated, a discharge date of 10/14/23 and Resident 1 left AMA. There was nothing documented why Resident 1 left AMA. During a telephone interview, on 5/2/24 at 1:25 p.m., with Resident 1, Resident 1 stated two certified nursing assistants (CNAs) ripped off my covers and pulled my sweatpants down and grabbed my genitals. Resident 1 stated he called 911 (three-digit emergency number for police, fire, or safety) and the police came out. Resident 1 stated he felt like he was the victim of sexual assault, and he left the facility for his safety. During an interview, on 5/3/24 at 11:47 a.m., with the Assistant Director of Staff Development (ADSD), the ADSD stated Resident 1 called the police and told them someone touched him inappropriately. ADON stated the Administrator is the Abuse Coordinator. During an interview, on 5/3/24 at 11:56 a.m., with the Administrator (ADM), the ADM stated he does not recall if it was reported to him. ADM stated it was his first few weeks of being on the job. During a subsequent interview, on 5/3/24 at 1:07 p.m., with the ADSD, the ADSD stated she 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 4 Event ID: 056116 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 056116 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/03/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Los Altos Post-Acute 809 Fremont Avenue Los Altos, CA 94024 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)