Health inspection·August 28, 2025

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 observation, interview, and record review, the facility failed to ensure one resident (Resident 1) was protected from abuse when Resident 1's wife was allowed to visit Resident 1 without close monitoring. This failure had the potential to affect Resident 1's safety and well-being. Findings:Resident 1 was admitted to the facility on [DATE] with diagnoses including severe protein-calorie malnutrition (inadequate intake of nutrients to meet the body's needs) and dementia (an impairment of brain function, such as memory loss and judgment) according to the facility's admission Record. A review of Resident 1's progress notes (PN) in the electronic medical record (EMR) was conducted. The PN dated 8/17/25 at 12:08 P.M. indicated Resident 1 reported to staff that his wife smacked him on his thighs.during assessment, resident told writer [Licensed Nurse 5] the spouse slapped him on the cheek. During an interview on 8/28/25 at 9:33 A.M. with the Administrator, the Administrator stated Resident 1's wife has been limited to visiting Resident 1 in the common areas for close monitoring of the resident. The Administrator stated Resident 1's wife was not allowed to visit Resident 1 in the room alone. An observation and interview with Resident 1 was conducted on 8/28/25 at 10:21 A.M. Resident 1 was lying in bed with oxygen on via nasal cannula (tubing through the nose). Resident 1 stated he just returned from therapy and his wife visited earlier. Resident 1 stated his wife has done unusual things in the past such as throwing a book at him while he and his wife were sitting around the dining table. Resident 1 stated there was some kind of altercation between him and his wife recently. Resident 1 stated he did not remember what happened, but something happened. Resident 1 stated he was unsure if it was safe to be with his wife but it was fine for her to visit. During an interview on 8/28/25 at 10:38 A.M. with Resident 1's assigned certified nurse assistant (CNA) 1, CNA 1 stated she was not aware of the abuse allegation involving Resident 1 and the wife. CNA 1 stated Resident 1's wife arrived around 9 A.M. and assisted Resident 1 with breakfast in Resident 1's room. CNA 1 stated Resident 1's wife was allowed to visit in the room without being closely monitored. An interview on 8/28/25 at 10:46 A.M. was conducted with licensed nurse (LN) 2. LN 2 stated she was aware of the allegation that Resident 1's wife smacked Resident 1. LN 2 stated the plan of care was to ensure Resident 1's safety and visitations should be in the common area only. LN 2 stated staff assigned to Resident 1 should be monitoring and should be aware of the incident. During an interview on 8/28/25 at 10:54 A.M. with CNA 2, CNA 2 stated Resident 1's wife used the microwave the day before on 8/27/25 then proceeded to go into Resident 1's room without being monitored. CNA 2 stated she was not aware that Resident 1's wife was not supposed to be in Resident 1's room alone. During an interview on 8/28/25 at 11:04 A.M. with LN 4 (Resident 1's assigned LN), LN 4 stated she did not receive report regarding Resident 1's abuse allegation and was not aware of the plan of care that Resident 1's visits with his wife should be monitored/ or that the visits should only be in the common area. An interview on 8/29/25 at 10:59 A.M. was conducted with the Director of Nursing (DON). The DON stated Resident 1's wife was allowed to visit Resident 1 in public areas such as the Residents Affected - Few Page 1 of 2 555136 555136 08/28/2025 Poway Healthcare Center 15632 Pomerado Road Poway, CA 92064

F 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few TV room or activity room, where the visits may be monitored, and not in Resident 1's room. The DON acknowledged that staff should monitor Resident 1 whenever his wife visits, to protect the resident from abuse. A review of the facility's policy and procedure (P&P) titled, Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating, dated September 2022 was conducted. The P&P did not provide guidance for corrective actions when a family member was the alleged perpetrator. A review of the facility's policy and procedure (P&P) titled. Visitation, dated September 2022 was conducted. The P&P indicated, Some visitation may be subject to reasonable clinical and safety restrictions that protect the health, safety, security and/or rights of the facility's residents such as.denying access or providing limited and supervised access to an individual if that individual is suspected of abusing.a resident. 555136 Page 2 of 2