Health inspection·November 12, 2025

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure non consensual sexual contact (any sexual touching or contact that occurs without the explicit [clear] and voluntary agreement with individuals involved) did not recur for two of three sampled residents (Resident 1 and Resident 2), by failing to:1). Ensure Interdisciplinary Team ([IDT] group of healthcare professionals, including resident/ resident representative, working together to provide residents with needed care) meeting was conducted and plan of care with interventions created after the incident on 6/13/2025 when Resident 2 kissed Resident 1 in Resident 1's room and attempted to climb into Resident 1's bed.This failure resulted in the second nonconsensual sexual contact on 11/8/2025 when Certified Nursing Assistant 3 (CNA 3) witnessed Resident 1 placing his hand on Resident 2's upper thigh while in the family room (a room where residents gather), unsupervised by facility staff.Cross Refer to F609 and F610.Findings:During a review of Resident 1's admission Record, the admission Record indicated Resident 1, a male resident, was admitted to the facility on [DATE], with diagnoses including history of hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (weakness on one side of the body) following cerebral infarction (stroke, loss of blood flow to a part of the brain) and aphasia (a disorder that makes it difficult to speak). The admission Record indicated Resident 1 had a responsible party, Family Member 1 (FM 1). During a review of Resident 1's History and Physical (H&P), dated 4/27/2025, the H&P indicated Resident 1 did not have the capacity to understand and make decisions.During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool), dated 5/7/2025, the MDS indicated Resident 1 had unclear speech, impaired vision, and severe cognitive impairment. The MDS indicated Resident 1 did not exhibit physical behavioral symptoms toward others such as abusing others sexually or engaging in public sexual acts. The MDS indicated Resident 1 was dependent (helper does all of the effort, resident does none of the effort) on staff for personal hygiene (ability to maintain personal hygiene such as combing hair or shaving), rolling left and right (the ability to roll from lying on back to left and right side), and transferrin g from sitting to lying and from lying to sitting on the side of the bed. During a review of Resident 1's progress notes, dated 6/14/2025 at 1:32 a.m., the progress notes indicated on 6/13/2025 at 7:30 p.m., a CNA (unidentified) notified Licensed Vocational Nurse (LVN) 5 Resident 2 was observed kissing Resident 1 in Resident 1's room. The progress notes indicated upon LVN 5's arrival in Room A, LVN 5 observed Resident 2 kissing Resident 1 and was attempting to climb up the bed of Resident 1 from her wheelchair. The progress notes indicated both residents (Residents 1 and 2) were separated. The progress notes indicated Residents 1 and 2 were notified that male and female residents cannot be alone in each other's room, nor can be intimate in any way while under the facility's care. The progress notes indicated Resident 1 indicated that Resident 2 kissed him and accepted it. The progress notes indicated will continue with plan of care (POC). During a review of Resident 1's clinical Page 1 of 9 056458 056458 11/12/2025 Greenfield Care Center of South Gate 8455 State Street South Gate, CA 90280

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some records since admission [DATE]), Resident 1's clinical records did not indicate notes or consent provided for a consensual relationship with other residents in the facility. During a review of Resident 1's Care Plans, dated 6/2025, the care plans did not indicate a plan of care regarding the kissing incident on 6/13/2025 was created or interventions to address unconsented kissing incidents and prevention of potential sexual abuse. During a review of Resident 1's Weekly Nursing Summary, dated 6/16/2025, the weekly summary indicated Resident 1 was verbal, alert, and confused. During a review of Resident 1's Progress Notes, dated 11/8/2025 at 2:26 p.m., the progress notes indicated a Charge Nurse (CN- unidentified) reported to Registered Nurse (RN) 4 that a CNA (unidentified) saw Resident 1 put his hands in between Resident 2's thighs while the CNA (unidentified) was passing by the family room. The progress notes indicated the (unidentified) CNA told two (2) Restorative Nursing Assistants (RNA- unidentified) who were in the hallway at the time. The progress notes indicated one RNA removed Resident 2 from the family room. During a review of Resident 1's care plan titled At risk for emotional distress related to allegation of sexual abuse against resident, dated 11/8/2025, the interventions indicated to allow resident time to answer questions and to verbalize feelings, perceptions and fears, assessment of resident, place call light within reach at all times, identify resident's coping mechanisms, monitor every shift for any signs and symptoms (S/S) of emotional distress for 3 days, monitor/document Resident 1's feelings and notify the physician (MD) and resident representative for any S/S of change of condition (COC). 2). During a review of the Resident 2's admission Record, the admission Record indicated Resident 2 was admitted to the facility on [DATE] with diagnoses including history of hydrocephalus (increased pressure in the brain, can cause cognitive problems), bacterial diseases (illnesses caused by bacteria that can multiply and cause harm within the human body), amnestic disorder (a condition with partial or total memory loss), and mild cognitive impairment (decline in thinking, remembering, or reasoning). The admission Record indicated Resident 2 had a power-of-attorney for care (an agent who makes decisions on behalf of the resident). During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 2 had severe cognitive impairment and could independently wheel 150 feet in a manual wheelchair. The MDS indicated Resident 2 required setup assistance (helper assists only prior to or following the activity, resident completes the activity) to transfer between a wheelchair and bed and walk ten feet. During a review of Resident 2's progress notes, dated 6/14/2025 at 1:32 a.m. (late entry), the progress notes indicated at 7:30 p.m., date not indicated, a CNA (unidentified) notified LVN 5 regarding a resident (unspecified) from Room A (Resident 1). The progress notes indicated upon LVN 5's arrival in Room A, Resident 2 was observed kissing Resident 1. The progress notes indicated Resident 2, who was in her wheelchair, was attempting to climb to the top of Resident 1's bed. The progress notes indicated both residents (Residents 1 and 2) were separated and were notified that male and female residents cannot be alone in each other's room, nor can be intimate in any way while under the facility's care. The progress notes indicated Resident 2 stated she went to Resident 1's room to greet him with a happy father's day and offered him a kiss. During a review of Resident 2's clinical records since admission [DATE]), Resident 2's clinical records did not indicate notes or consent provided for a consensual relationship with other residents in the facility. During a review of Resident 2's Care Plans, dated 6/2025, the care plans did not indicate a plan of care regarding the kissing incident on 6/14/2025 was created or interventions to address unconsented kissing incidents and prevention of potential sexual abuse. During a review of Resident 2's H&P dated 10/28/2025, the H&P indicated Resident 2 had the capacity to understand and make decisions. During a review of Resident 2's progress notes, dated 11/8/2025 at 2 p.m., the progress notes indicated a CN (unidentified) reported to RN 4 that a CNA (unidentified) saw 056458 Page 2 of 9 056458 11/12/2025 Greenfield Care Center of South Gate 8455 State Street South Gate, CA 90280

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Resident 1 put his hands in between Resident 2's thighs while the CNA (unidentified) was passing by the family room. The progress notes indicated the (unidentified) CNA told 2 RNAs (unidentified) who were in the hallway at the time. The progress notes indicated the 2 RNAs went to Residents 1 and 2right away and observed Resident 1 was in the patio. The progress notes indicated one RNA removed Resident 2 from the family room. During a review of Resident 2's care plan titled At risk for emotional distress related to allegation of sexual abuse,, dated 11/8/2025 the interventions indicated to allow the resident time to answer questions and to verbalize feelings, perceptions and fears, assessment of resident, place call light within reach at all times, identify resident's coping mechanisms, monitor every shift for any S/S of emotional distress for 3 days, monitor/document resident's feelings and notify MD and resident representative for any S/S of COC. During an interview on 11/10/2025 at 1:25 p.m. with RN 4, RN 4 stated on 11/8/2025 she investigated the alleged sexual abuse (any act of sexual contact including unwanted sexual touching, forced sexual acts and rape that occur without consent) between Resident 1 and Resident 2, when CNA 3 passed by the family room on 11/8/2025, witnessed Resident 1's hands were placed between Resident 2's thighs and suspected sexual abuse. RN 4 stated neither Residents 1 nor 2 had the capacity to consent for any form of sexual contact due to both residents' severe cognitive impairment. RN 4 stated Resident 1 placing his hands between Resident 2's thighs could have been sexually motivated (refers to the impulse to gratify sexual needs and encompasses the human desire and interest in participating in sexual activities, activated by both internal and external signals). RN 4 stated CNA 3 should have immediately intervened, separated the Residents 1 and 2, and remained with the residents instead of walking away and telling RNA 1. RN 4 stated the inappropriate, nonconsensual contact (any sexual touching or contact that occurs without the explicit [clear] and voluntary agreement with individuals involved) between Residents 1 and 2 was allowed to continue due to CNA 3's lack of intervention. During an interview on 11/12/2025 at 9:07 a.m. with CNA 3, CNA 3 stated on 11/8/2025 at 11:30 a.m., while passing by the family room, CNA 3 stated she observed Resident 1 and Resident 2 sitting in the family room and Resident 1's hand was on Resident 2's upper thigh. CNA 3 stated the family room had no staff present or any supervision. CNA 3 stated the contact may have been sexually motivated. CNA 3 stated she walked down the hallway (approximately 20 feet down the hallway) and informed RNA 1 about Resident 1's hand was on Resident 2's thigh. During an interview on 11/12/2025 at 11:30 a.m. with RNA 1, RNA 1 stated on 11/8/2025, CNA 3 notified her (RNA 1) that Resident 1 was touching Resident 2's inner upper thigh, while in the family room, unsupervised, but did not stop to intervene because she was at lunch. RNA 1 stated she ran 20 feet down the hallway to intervene and separated Residents 1 and 2 who were in the family room. RNA 1 stated she physically removed Resident 2 from the family room to prevent continued abuse. RNA 1 stated CNA 3 should have immediately intervened and removed Resident 2 and should not have left the family room after witnessing a potential sexual abuse between Residents 1 and 2. RNA 1 stated CNA 3 delayed staff response and allowed the witnessed sexual abuse to continue. During a concurrent interview and record review on 11/12/2025 at 12:02 p.m. with LVN 3, Residents 1 and 2's progress notes and care plans for 6/2025, were reviewed. LVN 3 stated both residents' progress notes dated 6/13/2025 indicated Resident 1 and Resident 2 had a previous incident of nonconsensual sexual contact when Resident 2 kissed Resident 1 and when Resident 2 attempted to climb into Resident 1's bed. LVN 3 stated neither Resident 1 nor Resident 2 had the capacity to provide consent for any sexual activity, thus the incident was sexual abuse. LVN 3 stated the facility did not create a care plan for Resident 1 and Resident 2 to address the sexual abuse on 6/13/2025, including emotional, physical and location monitoring. LVN 3 stated not creating care plan interventions on the history of sexual abuse on 056458 Page 3 of 9 056458 11/12/2025 Greenfield Care Center of South Gate 8455 State Street South Gate, CA 90280

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 6/13/2025 put Resident 1 and Resident 2 at high risk of repeated sexual abuse. LVN 3 stated Resident 1's hand on Resident 2's inner thigh was sexual in nature and could have been prevented if interventions were implemented to prevent repeated sexual abuse. LVN 3 stated Residents 1 and 2's locations should have been monitored, and interactions should have been supervised. During an interview on 11/12/2025 at 12:21 p.m. with RN 1, RN 1 stated Resident 1 and Resident 2 care plans were not updated after the sexual abuse on 6/13/2025. RN 1 stated Resident 1's and Resident 2's locations were not monitored to maintain separation. RN 1 stated an IDT meeting should have been conducted after the sexual abuse incident on 6/13/2025, including both residents' representatives, the Social Services department, Nursing department, and Activities department, to ensure adequate care and services were provided. During a concurrent interview and record review on 11/12/2025 at 2:48 p.m. with the DON, the facility's P&P titled Abuse and Neglect Prevention Management, dated 1/2018, Resident 1's progress notes, dated 6/2025, Resident 1's MDS, dated [DATE], Resident 2's Progress Notes, dated 6/13/2025, Resident 2's MDS, dated [DATE], and Resident 1's Progress Notes, dated 11/8/2025 were reviewed. The DON stated on 6/13/2025 during the evening (time not specified), LVN 5 notified her (DON) that in the evening 6/13/2025 (time not specified), Resident 2 kissed Resident 1 and Resident 2 climbed on top of Resident 1's bed. The DON stated she should have informed the nursing staff to immediately assess, monitor, and update the care plans for Resident 1 and Resident 2 but did not. The DON stated the P&P titled Abuse and Neglect Prevention Management indicated nonconsensual sexual contact of any type is sexual abuse. The DON stated that both residents' progress notes indicated Resident 2 kissed Resident 1 and kissing was considered sexual contact. The DON stated Resident 1's MDS indicated Resident 1 had severe cognitive impairment. The DON stated Resident 2's MDS indicated Resident 2 had severe cognitive impairment. The DON stated neither resident had the capacity to consent to sexual contact, therefore the nonconsensual kissing was sexual abuse. The DON stated the P&P should have been followed to respond to the sexual abuse on 6/13/2025 but was not. The DON stated Resident 1's and Resident 2's IDT team meetings should have occurred, care plans should have been updated, and the residents should have been assessed, monitored for emotional and physical changes, and residents' locations monitored to ensure they maintain separation. The DON stated those steps could have prevented sexual abuse in the future. The DON stated Resident 1 and Resident 2 were not evaluated by a psychologist to rule out negative effects of sexual abuse and plan the residents' care. The DON stated Resident 1 and Resident 2 may not receive appropriate services because Resident 1 and Resident 2 were not assessed after the sexual abuse on 6/13/2025The DON stated CNA 3 should not have walked away after witnessing potential sexual abuse on 11/8/2025. The DON stated this delay allowed potential sexual abuse to continue and risk Resident 2's safety. The DON stated CNA 3 should have immediately intervened and removed Resident 2 from the family room.During an interview on 11/13/2025 at 3:05 p.m. with Family Member (FM) 2, FM 2 stated FM 2 stated she was notified about the sexual abuse on 6/13/2025 and 11/8/2025. FM 2 stated as Resident 2's primary decision maker, she did not consent to Resident 2 to have any sexual contact with other residents and did not want Resident 1 and Resident 2 unsupervised together. FM 2 stated the facility did not provide a plan of care or outline interventions to prevent sexual abuse from recurring. FM 2 stated she would have felt violated if another resident touched her upper thigh, consensually. FM 2 stated the facility has not informed her about any changes in Resident 2's plan of care and how the facility plans to prevent recurrence. During an interview on 11/13/2025 at 4:13 p.m. with FM 1, FM 1 stated she was notified about the sexual abuse on 6/13/2025 and 11/8/2025. FM 1 stated she was Resident 1's primary decision maker and did not consent to Resident 1 having any sexual contact with other residents and did not want unsupervised visits between 056458 Page 4 of 9 056458 11/12/2025 Greenfield Care Center of South Gate 8455 State Street South Gate, CA 90280

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Resident 1 and Resident 2, especially after Resident 2 climbed into Resident 1's bed and kissed him on 6/13/2025. FM 1 stated she would have felt scared if another resident kissed her and climbed into her bed. During a concurrent interview and record review on 11/14/2025 at 3:15 p.m. with the Director of Staff Development (DSD), the facility's In-Service Binder, for 2025, was reviewed. The DSD stated following the sexual abuse in June 2025, in-services and trainings were not provided to the facility staff because she was not notified of the incident. The DSD stated staff should have been in-serviced and trained to prevent repeated sexual abuse, especially between two residents. During a review of the facility's P&P titled Abuse and Neglect Prevention Management, dated 2/2018, the P&P indicated sexual abuse is a non-consensual sexual contact of any type with a resident. The P&P indicated staff should manage the allegations by removing and protecting the residents and assessing the residents for injury and notifying the Admin. The P&P indicated after the resident has been cared for, the licensed nurse should document the resident's condition each shift for 72 hours, update the care plan with identified actions that took place, updates the 24-hour report to alert following shifts to the allegations as well as the care plan updates and communicated specific care plan updates to direct care staff. 056458 Page 5 of 9 056458 11/12/2025 Greenfield Care Center of South Gate 8455 State Street South Gate, CA 90280

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 an allegation of sexual abuse (non-consensual sexual contact of any type with a resident) to the California Department of Public Health (CDPH), for one of three sampled residents (Resident 1), when Resident 2 kissed Resident 1, who did not have the capacity to understand and make decisions (consent) and was found lying in Resident 1's bed. This failure resulted in a delay in the investigation by the CDPH and placed Resident 1 at risk for further abuse by Resident 2. Findings:During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (weakness on one side of the body) following cerebral infarction (stroke, loss of blood flow to a part of the brain) and aphasia (a disorder that makes it difficult to speak).During a review of Resident 1's History and Physical (H&P), dated 4/27/2025, the H&P indicated Resident 1 did not have the capacity to understand and make decisions.During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool), dated 5/7/2025, the MDS indicated Resident 1 had severe cognitive (ability to think and reason) impairment and did not exhibit physical behavioral symptoms toward others such as abusing others sexually or engaging in public sexual acts. The MDS indicated Resident 1 was dependent (helper does all of the effort, resident does none of the effort) on staff for personal hygiene (ability to maintain personal hygiene such as combing hair or shaving), rolling left and right (the ability to roll from lying on back to left and right side), and transferring from sitting to lying and from lying to sitting on the side of the bed.During a review of Resident 1's Weekly Nursing Summary, dated 6/9/2025, the summary indicated Resident 1 was verbal, alert, and confused. During a review of Resident 1's Progress Notes, dated 6/14/2025, the progress notes indicated another resident (Resident 2) kissed Resident 1 and attempted to climb into Resident 1's bed. The progress notes did not indicate the incident was reported to the Administrator (Admin) or the CDPH.During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was admitted to the facility on [DATE] with diagnoses including hydrocephalus (increased pressure in the brain which could cause problems with cognition [ability to think and reason] problems) and amnestic disorder (a condition with partial or total memory loss).During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 2 had severe cognitive impairment and could independently (resident completes the activity by themselves with no assistance) wheel 150 feet in a manual wheelchair. The MDS indicated Resident 2 required setup assistance (helper assists only prior to or following the activity, resident completes the activity) to transfer between a wheelchair and bed.During a review of Resident 2's Progress Notes, dated 6/13/2025, the Progress Notes indicated Certified Nurse Assistant (unnamed) reported Resident 2 kissed Resident 1 and attempted to climb into Resident 1's bed. The Progress Notes did not indicate the incident was reported to the Administrator (Admin) or the CDPH. During an interview on 11/12/2025 at 12:21 p.m. with Registered Nurse (RN) 1, RN 1 stated she was assigned to Resident 1 and Resident 2 on 6/14/2025, the day after the alleged sexual abuse between the residents and had not reported the incident to the Administrator (ADM) nor the CDPH. RN 1 stated Residents 1 and Resident 2 had cognitive impairment, and neither could consent. RN 1 also stated, Resident 2 kissing Resident 1 and the incident (on 6/14/2025) licensed nurses should have followed the abuse policy to report the allegation of sexual abuse. During a concurrent interview and record review on 11/12/2025 at 2:48 p.m. with the Director of Nursing (DON), the facility's P&P titled, Abuse and Neglect Prevention Management dated 2/2018, Resident 1's Progress Notes dated 6/2025, Resident 1's MDS, dated [DATE], 056458 Page 6 of 9 056458 11/12/2025 Greenfield Care Center of South Gate 8455 State Street South Gate, CA 90280

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few and Resident 2's Progress Notes, dated 6/13/2025, were reviewed. The DON stated on 6/13/2025, Licensed Vocational Nurse (LVN) 5 notified her that Resident 2 was found kissing Resident 1 and had climbed on top of him (Resident 1) in his bed. The DON stated she did not instruct LVN 5 to report the incident to the CDPH. The DON stated nonconsensual sexual contact of any type was considered sexual abuse. The DON stated Resident 2 kissing Resident 1 was considered sexual contact and sexual abuse because Resident 1 and Resident 2 had severe cognitive impairment and neither resident could consent to sexual contact. The DON stated the incident between Resident 1 and Resident 2 should have been reported to the CDPH. The DON also stated the incident on 6/13/2025 was not reported to the CDPH in part because Resident 2 had forgotten the incident and there were no complaints from the residents or the resident representatives. The DON stated it was important to ensure allegations of sexual abuse were reported to the CDPH for resident safety. During a concurrent interview and record review on 11/12/2025 at 3:43 p.m. with the Admin, Resident 2's Progress Note, dated 6/13/2025, was reviewed. The Admin stated he was the facility's Abuse Coordinator and licensed nurses should have informed him and the CDPH of the incident (alleged sexual abuse) between Resident 1 and Resident 2 on 6/13/2025, however was not done. During an interview on 11/13/2025 at 9:20 a.m. with Certified Nursing Assistant 2 (CNA 2), CNA 2 stated she saw Resident 2 kissing Resident 1's lips and laying in Resident 1's bed, on top of Resident 1, on 6/13/2025. CNA 2 stated she was a mandated reporter and should have reported the sexual abuse to the Admin and CDPH.During a review of the facility's P&P titled, Abuse and Neglect Prevention Management, dated 2/2018, the P&P indicated sexual abuse is non-consensual sexual contact of any type with a resident. The P&P indicated all facility employees are required to report any known or suspected abuse immediately upon identifying a concern. The P&P indicated all allegations of abuse will be reported to the Admin and the state survey and certification agency no later than two hours after the allegation is made. 056458 Page 7 of 9 056458 11/12/2025 Greenfield Care Center of South Gate 8455 State Street South Gate, CA 90280

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 investigate an allegation of sexual abuse (non-consensual sexual contact of any type with a resident) for one of three sampled residents (Resident 1), when Resident 2 kissed Resident 1, who did not have the capacity to understand and make decisions (consent), and was found lying in Resident 1's bed.This failure resulted in a sexual abuse not being addressed, resulting in the potential for repeated sexual abuse.Findings:1. During a review of Resident 1's admission Record, the admission Record indicated Resident 1, a male resident, was admitted to the facility on [DATE], with diagnoses including history of hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (weakness on one side of the body) following cerebral infarction (stroke, loss of blood flow to a part of the brain) and aphasia (a disorder that makes it difficult to speak). The admission Record indicated Resident 1 had a responsible party, Family Member 1 (FM 1). During a review of Resident 1's History and Physical (H&P), dated 4/27/2025, the H&P indicated Resident 1 did not have the capacity to understand and make decisions.During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool), dated 5/7/2025, the MDS indicated Resident 1 had severe cognitive impairment and did not exhibit physical behavioral symptoms toward others such as abusing others sexually or engaging in public sexual acts. The MDS indicated Resident 1 was dependent (helper does all of the effort, resident does none of the effort) on staff for personal hygiene (ability to maintain personal hygiene such as combing hair or shaving), rolling left and right (the ability to roll from lying on back to left and right side), and transferring from sitting to lying and from lying to sitting on the side of the bed.During a review of Resident 1's Weekly Nursing Summary, dated 6/9/2025, the summary indicated Resident 1 was verbal, alert, and confused. During a review of Resident 1's Progress Notes, dated 6/14/2025, the progress notes indicated another resident, Resident 2, kissed Resident 1 and attempted to climb into Resident 1's bed. The progress notes did not indicate whether Resident 1, Resident 2, or any potential witnesses were interviewed.2. During a review of the Resident 2's admission Record, the admission Record indicated Resident 2 was admitted to the facility on [DATE] with diagnoses including history of hydrocephalus (increased pressure in the brain, can cause cognitive problems), bacterial diseases (illnesses caused by bacteria that can multiply and cause harm within the human body), amnestic disorder (a condition with partial or total memory loss), and mild cognitive impairment (decline in thinking, remembering, or reasoning). The admission Record indicated Resident 2 had a power-of-attorney for care (an agent who makes decisions on behalf of the resident). During a review of Resident 2's History and Physical (H&P), dated 10/28/2025, the H&P indicated Resident 2 had the capacity to understand and make decisions.During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 2 had severe cognitive impairment and could independently (resident completes the activity by themselves with no assistance) wheel 150 feet in a manual wheelchair. The MDS indicated Resident 2 required setup assistance (helper assists only prior to or following the activity, resident completes the activity) to transfer between a wheelchair and bed.During a review of Resident 2's Progress Notes, dated 6/13/2025, the progress notes indicated another resident, Resident 2, kissed Resident 1 and attempted to climb into Resident 1's bed. The progress notes did not indicate whether Resident 1, Resident 2, or any potential witnesses were interviewed.During an interview on 11/12/2025 at 12:21 p.m. with Registered Nurse 2 (RN 2), RN 2 stated she was the RN assigned to Resident 1 and Resident 2 on 6/14/2025, the day after the sexual abuse. RN 2 stated there was no investigation into the incident.During a concurrent interview and record review on 11/12/2025 at 2:48 p.m. with the Director of Nursing (DON), the facility's P&P titled Abuse and Neglect Prevention Management, Residents Affected - Few 056458 Page 8 of 9 056458 11/12/2025 Greenfield Care Center of South Gate 8455 State Street South Gate, CA 90280

F 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few dated 2/2018, Resident 1's Progress Notes, dated 6/2025, Resident 1's MDS, dated [DATE], and Resident 2's Progress Notes, dated 6/13/2025, were reviewed. The DON stated the P&P indicated nonconsensual sexual contact of any type was sexual abuse. The DON stated that both residents' progress notes indicated Resident 2 kissed Resident 1 and kissing was considered sexual contact. The DON stated Resident 1's MDS indicated Resident 1 had severe cognitive impairment. The DON stated Resident 2's MDS indicated Resident 2 had severe cognitive impairment. The DON stated neither resident could consent to sexual contact and thus the nonconsensual kissing was sexual abuse and should have been investigated according to the P&P. The DON stated Licensed Vocational Nurse 5 (LVN 5) notified her that Resident 2 kissed Resident 1 and climbed on top of him in his bed in the evening 6/13/2025. The DON stated she did not instruct LVN 5 to investigate the incident. The DON stated the incident on 6/13/2025 was not investigated because Resident 2 had forgotten the incident and there were no complaints from the residents or the resident representatives. The DON stated the incident should have been investigated to prevent future sexual abuse.During a concurrent interview and record review on 11/12/2025 at 3:43 p.m. with the Administrator (Admin), Resident 2's Progress Note, dated 6/13/2025, was reviewed. The Admin stated he was the facility's abuse coordinator and investigator. The Admin stated he should have been notified about the incident described in the progress note but was not notified. The Admin stated the incident was not investigated but should have been investigated to prevent future abuse.During an interview on 11/13/2025 at 9:20 a.m. with Certified Nursing Assistant 2 (CNA 2), CNA 2 stated she saw Resident 2 kissing Resident 1's lips and laying in Resident 1's bed, on top of Resident 1, on 6/13/2025. CNA 2 stated she never investigated the incident, never provided a written statement, and was never interviewed about the incident by any facility staff.During a review of the facility's P&P titled Abuse and Neglect Prevention Management, dated 2/2018, the P&P indicated sexual abuse is non-consensual sexual contact of any type with a resident. The P&P indicated resident-to-resident altercations are investigated in an objective, timely, and complete manner. The P&P indicated all allegations of abuse will be investigated and the written findings of the investigation will be reported to the department of public health within five days of the alleged occurrence. 056458 Page 9 of 9