Health inspection·May 2, 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 report immediately not later than two hours an allegation of abuse to the State Survey Agency (SSA) for one of three sampled residents (Resident 1) when on 4/30/2025 at 2 p.m. Resident 1 reported to the Social Worker (SW) an unnamed certified nursing assistant (CNA) touched him (Resident 1) inappropriately. This abuse allegation was reported to the SSA on 5/1/2025 at 4:02 p.m. This deficient practice placed Resident 1 at risk for further abuse. Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted on [DATE] with diagnoses including traumatic hemorrhage of cerebrum (a collection of blood forms within the brain following a traumatic brain injury), chronic respiratory failure (a long-term condition where the lungs are unable to adequately exchange oxygen), anemia (a deficiency of red blood cells), diabetes (a group of diseases that result in too much sugar in the blood), and hydrocephalus (a build-up of fluid in the cavities deep within the brain). During a review of Resident 1's Minimum Data Set (MDS - resident assessment tool), dated 2/10/2025, indicated Resident 1 was cognitively intact (thinking, learning, and memory skills are functioning within the expected range for their age and other relevant factors). The MDS indicated Resident 1 required maximal assistance with eating, oral hygiene, dressing, and personal hygiene. During a concurrent interview and record review on 5/2/2025 at 10:29 a.m. with the Infection Preventionist Registered Nurse (IPRN), the Fax Call Report regarding the date and time the facility faxed the SOC 341 (form used to report suspected elder and dependent adult abuse) report regarding Resident 1's abuse allegation to the SSA was reviewed. The IPRN stated the Fax Call Report indicated the SOC 341 regarding Resident 1's allegation of abuse was sent to the SSA on 5/1/2025 at 4:02 p.m. The IPRN stated Resident 1 reported to the SW on 4/30/2025 at 2 p.m. that about a year ago a CNA (name not indicated) took Resident 1 to the shower and placed a finger in Resident 1's anus. During an interview with Resident 1 on 5/2/2025 at 1 p.m., Resident 1 stated that about one year ago, a staff member touched him (Resident 1) inappropriately while in the shower. Resident 1 stated, he does not know the name of the staff member and cannot give a description of the staff member. During a concurrent interview and record review on 5/2/2025 at 2 p.m. with SW, Resident 1's Social Services Director Progress Notes, dated 4/30/2025 at 2:49 p.m., was reviewed. The Progress Note Page 1 of 2 056407 056407 05/02/2025 All Saints Healthcare Subacute 11810 Saticoy Street North Hollywood, CA 91605

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few indicated SW was made aware by Resident 1 that he 9Resident 1) was inappropriately touched by a staff member approximately one year ago when he (Resident 1) was first regaining consciousness (state of wakefulness, awareness, or alertness). The SW stated she notified the [NAME] President of Operations regarding Resident 1's allegation of abuse. The SW stated Resident 1 made the allegation of abuse on 4/30/2025 and they reported to the SSA the following day. The SW stated allegations of abuse must be reported within two hours. The SW stated she does not know why it was not reported immediately to the SSA. During an interview with [NAME] President of Operations (VPO) on 5/2/2025 at 2:30 p.m., the VPO stated the SW reported to her on 4/30/2025 that Resident 1 reported an allegation of being touched inappropriately by a staff member. The VPO stated she interviewed Resident 1 and he stated the incident happened a year ago while in the shower. The VPO stated Resident 1 could not provide a detailed description of the incident and who the staff member was. The VPO stated the allegation was not reported within two hours because Resident 1 did not have any injuries. The VPO stated since there was no injury, the report was made the following day. A review of the facility's Policy and Procedure titled, Alleged Abuse, Neglect, and Involuntary Seclusion, reporting of, revised on 4/2025, indicated allegations of abuse are reported as soon as possible in the absence of a shorter state time frame requirement, but no later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. 056407 Page 2 of 2