Health inspection·April 25, 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, medical record review, and facility P&P review, the facility failed to implement their P&P to ensure the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act when the facility staff failed to immediately report an abuse allegation involving a CNA to the facility's Administrator or DON for one of two residents reviewed for abuse (Resident 1). This failure had the potential for not protecting the resident from abuse. Findings: Review of the facility's P&P titled Patient Protection Abuse, Neglect, Mistreatment and Misappropriation Prevention dated October 2021 showed the following: - Employees are educated upon hired and annually on the abuse prevention program, including the immediate reporting of any suspicious of abuse, neglect, exploitation, mistreatment, misappropriation or crime involving a resident. - Resident protection actions include immediately remove the resident from contact with the alleged abuser during the investigation. If the incident involves an employee, the employee is suspended immediately after obtaining their statement. Review of the Report of Suspected Dependent Adult/Elder Abuse dated 4/19/24, showed Resident 1 made an abuse allegation against a CNA, which occurred on 4/17/24. Medical record review for Resident 1 was initiated on 4/25/24. Resident 1 was admitted to the facility on [DATE]. On 4/25/24 at 0912 hours, an interview was conducted with CNA 1. CNA 1 stated he was assigned to Resident 1 on 4/17/24, duringthe 1500-2300 hours shift. CNA 1 stated while he assisted Resident 1 with the shower around 1600 to 1630 hours, the resident became aggressive, yelling, using crude language, and attempted to hit CNA 1. CNA 1 stated after the shower, he brought Resident 1 back to the resident's room wherethe resident told him to go away and alleged CNA 1 had hit him. CNA 1 stated he notified RN 1. CNA 1 stated CNA 2 assisted with Resident 1 after the allegation was made. CNA 1 stated later in the shift, he went to answer Resident 1's call light twice. The first time, the resident seemed fine and the second time, Resident 1 yelled at CNA 1 to go away and stated to call the law enforcement because CNA 1 had hit him earlier. CNA 1 stated he went and told the RN Supervisor. On 4/25/24 at 1112 hours, an interview was conducted with CNA 2. CNA 2 stated on 4/17/24, in the (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 2 Event ID: 555328 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 555328 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/25/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fountain Valley Post Acute 11680 Warner Avenue Fountain Valley, CA 92708 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)