Health inspection·July 23, 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 and record review, the facility failed to the California Department of Public Health (CDPH) in two hours of an allegation for one of five sampled residents (Resident 1). This deficient practice placed Resident 1 at risk for further abuse in the facility and had the potential for abuse for all residents in the facility. Findings:During a review of Resident 1's admission Record (Face Sheet), the admission Record indicated Resident 1 was initially admitted on [DATE] and was readmitted on [DATE] with diagnoses including muscle wasting and atrophy (gradual decline), lack of coordination, and Type 2 (II) Diabetes Mellitus (DM: a chronic disease that affects how the body processes sugar). During a review of Resident 1's history and physical (H&P) dated 6/18/2025, the H&P indicated Resident 1 has fluctuating capacity to understand and make decisions.During a review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool) dated 6/20/2025, the MDS indicated Resident 1 was cognitively intact. The MDS indicated Resident 1 was dependent on toileting hygiene, lower body (below waist) dressing, chair/bed-to-chair transfer, roll left and right, toilet transfer, required maximal assistance (provides more than half the effort) for bathing and upper body (above waist) dressing, and required moderate assistance (provides less than half the effort) for eating, oral hygiene, and personal hygiene. During a review of Resident 1's Change of Condition form (COC: a worsening or change in an individual's health) dated 7/13/2025 at 2:47a.m., the COC indicated around 2:00a.m. Resident 1 had alleged a Certified Nursing Assistant (CNA) 1 finger touched his anal area. The COC indicated Resident 1 complained of pain in his butt and was given Hydrocodone-Acetaminophen (medication used to treat pain) oral tablet 10-325 milligram (mg: unit of measurement)During a review of the fax dated 7/13/2025 at 8:45p.m. to the California Department of Public Health (CDPH), the fax indicated it was sent on 7/13/2025 at 8:45p.m. regarding an allegation of abuse that occurred on 7/13/2025 around 2:00a.m. involving Resident 1 and CNA 1.During an interview on 7/22/2025 at 9:58a.m with Registered Nurse Supervisor 1 (RNS) 1, RNS 1 stated he was informed Resident 1 complained about pain in his buttocks and went to assess Resident 1. RNS 1 stated Resident 1 indicated he felt pain around his rectum almost right after CNA 1 cleaned him and stated CNA 1 touched his anal part while cleaning him. RNS 1 stated when there is a COC, he assesses the resident and notifies the Director of Nursing (DON) and Administrator (ADM). RNS 1 stated he informed the DON about the incident but did not try calling the ADM as it was 1:00a.m or 2:00a.m. in the morning. RNS 1 stated an alleged allegation of abuse is reported to the CDPH as soon as possible within 24 hours. During a concurrent interview and record review on 7/22/2025 at 11:09a.m. with Registered Nurse Supervisor 2 (RNS 2), RNS 2 stated if she was informed of an incident that sounds like an abuse, she will inform the ADM, do her own investigation, do an assessment, and inform the doctor. RNS 2 stated if an injury was noted, she will have to report as soon as possible (within 2 hours). RNS 2 stated based on her assessment, if there are no major injuries noted, residents are stable and can communicate with them, this incident will be Page 1 of 3 056308 056308 07/23/2025 Heritage Rehabilitation Center 21414 S. Vermont Avenue Torrance, CA 90502

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few reported within 24 hours. RNS 2 stated the ADM will report to the CDPH within 24 hours RNS 2 stated if allegations are not reported, it can result in physical harm, decline in mental state, feeling of being unsafe, result in more serious injury, or death due to being neglected in their care.During a concurrent interview and record review on 7/22/2025 at 2:09p.m. with RNS 2, RNS 2 stated the COC dated 7/13/2025 indicated the allegation of CNA 1's finger touching Resident 1's anal area. RNS 2 stated since Resident 1 verbalized that he was touched in his anal area it is considered a verbal allegation of abuse. RNS 2 stated abuse is intentional, and unless it is intentionally done, this was how Resident 1 felt and was not considered abuse. RNS 2 stated based on the abuse policy, if this is an abuse allegation, it says to report to the CDPH within 2 hours. RNS 2 stated despite reviewing the abuse policy, she believes the incident should still be reported within 24 hours because there are no bodily injuries and it is not really abuse because it was not intentional.During a concurrent interview and record review on 7/22/2025 at 2:58p.m. with the DON, the DON stated on 7/13/2025, RNS 1 called him to inform him of the incident. The DON stated this incident was an allegation of abuse. The DON stated the ADM was the one that determined this was not an abuse. The DON stated when this incident was first reported, it was an allegation of abuse, however due to a witness, no bodily injury, the allegation of abuse was not substantiated by the facility, so it was reported within 24 hours to the CDPH, not two hours as stated in the policy.During an interview on 7/22/2025 at 3:53p.m. with the DON, the DON stated CDPH is the one that determines the outcome of any abuse allegation. During a concurrent interview and record review on 7/22/2025 at 4:26p.m. with ADM, the ADM stated an allegation of abuse is when there is a resident that said someone slapped another resident or hit a resident. The ADM stated that when she is informed of an alleged abuse allegation, she will follow her 24 hours reporting for alleged abuse when there is no bodily injury. The ADM stated the facility is the one that determines the outcome of any abuse allegations. The ADM stated this incident was not an allegation of abuse.During an interview on 7/23/2025 at 2:17p.m. with DON, DON stated everyone is a mandated reporter, and if he sees or witnesses any type of allegation of abuse, he has to report it. The DON stated anyone can call CDPH and does not have to wait for the ADM to report abuse. the reporting time, is within 2 hours. During a review of the facility's policy and procedure (P&P) titled, Abuse, Neglect, Exploitation or Misappreciation-Reporting and Investigation undated, the P&P indicated all reports or resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. If resident abuse, neglect, exploitation, misappropriation or resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law. Immediately is defined as: within 2 (two) hours of an allegation involving abuse or result in serious bodily injury; or within 24 (twenty-four) hours of an allegation that does not involve abuse or result in serious bodily injury.During a review of the facility's P&P titled, Quality of Life-Dignity undated, the P&P indicated each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality. Treated with dignity means the resident will be assisted in maintaining and enhancing his or self-esteem and self-worth. 056308 Page 2 of 3 056308 07/23/2025 Heritage Rehabilitation Center 21414 S. Vermont Avenue Torrance, CA 90502

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 implement its abuse policy and procedure by failing to do a complete investigation and remove a Certified Nurse Assistant (CNA) 1 during the investigation for an allegation of abuse for one of five sampled residents (Resident 1). This deficient practice had the potential to place Resident 1 and all residents in the facility at risk of abuse. Findings: During a review of Resident 1's admission Record (Face Sheet), the admission Record indicated Resident 1 was initially admitted on [DATE] and was readmitted on [DATE] with diagnoses including muscle wasting and atrophy (gradual decline), lack of coordination, and Type 2 (II) Diabetes Mellitus (DM: a chronic disease that affects how the body processes sugar)During a review of Resident 1's history and physical (H&P) dated 6/18/2025, the H&P indicated Resident 1 has fluctuating capacity to understand and make decisions.During a review of Resident 1's Minimum Data Set (MDS: a resident assessment tool) dated 6/20/2025, the MDS indicated Resident 1 was cognitively intact. The MDS indicated Resident 1 was dependent on toileting hygiene, lower body (below waist) dressing, chair/bed-to-chair transfer, roll left and right, toilet transfer, required maximal assistance (provides more than half the effort) for bathing and upper body (above waist) dressing, and required moderate assistance (provides less than half the effort) for eating, oral hygiene, and personal hygiene. The MDS indicated Resident 1 utilized a wheelchair.During a review of Resident 1's Change of Condition form (COC: deviating from what is normal) dated 7/13/2025 at 2:47a.m., the COC indicated around 2:00a.m., Resident 1 alleged a CNA 1 finger touched his anal area while cleaning the resident. CNA 1was assigned was removed from Resident 1's care but not removed from the facility. During a review of the Employee Timesheet from 7/16/2025 -7/31/2025 The employee timesheet dated 7/23/2025, indicated CNA 1 worked on the night during 7/16/2025 from 12:00a.m. to 7:01a.m., 7/17/2025 from 12:00a.m. to 7:00a.m., and on 7/18/2025 from 2:35p.m. to 11:01p.m.During an interview on 7/22/2025 at 9:30a.m. with CNA 1, CNA 1 stated around 2:30a.m. on 7/13/2025, the Registered Nurse Supervisor 1 (RNS 1) called her and informed her Resident 1 complained about her and alleged she put her finger in his buttocks. CNA 1 stated after that complaint, she was removed from her assignment and Resident 1 was assigned to a different Certified Nursing Assistant (CNA). CNA 1 stated she finished her shift at 7:00a.m. and went home. CNA 1 stated she came back to work on 7/15/2025, her next scheduled shift.During an interview on 7/22/2025 at 12:57p.m. with the Director of Staff Development (DSD), the DSD stated staff with allegations of abuse are usually sent home to protect the residents.During a concurrent interview and record review on 7/22/2025 at 3:57p.m. with the Director of Nursing (DON), the DON stated the abuse policy indicated to place an employee who has been accused of resident abuse is placed on leave and CNA 1 should have been removed from the facility right away. The DON stated CNA 1 was transferred to another unit and finished her shift with other residents. During a concurrent interview and record review on 7/22/2025 at 4:54p.m. with the Administrator (ADM), the ADM stated they did not remove the staff from the facility when they were accused of an allegation and should have been removed to protect the residents. During a review of the facility's policy and procedure (P&P) titled, Abuse, Neglect, Exploitation or Misappreciation-Reporting and Investigation undated, the P&P indicated all allegations are thoroughly investigated. The administrator initiates investigations. Any employee who has been accused of resident abuse is placed on leave with no resident contact until the investigation is complete.During a review of the facility's P&P titled, Job Descriptions-Administration dated 2003, the P&P indicated ensure that all employees, residents, visitors, and the general public follow the facility's established policies and procedures. Residents Affected - Few 056308 Page 3 of 3