Health inspection·December 6, 2024

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, medical record review, and facility P&P review, the facility failed to follow the abuse protocol during the facility investigation period for one of two sampled residents (Resident 1). Residents Affected - Few * The facility failed to suspend CNAs 2 and 3 from work when Resident 1 reported an allegation of physical abuse against these two CNAs on 11/10/24. This failure had the potential to place Resident 1 and other residents at risk of not being protected against the alleged abusers. Findings: Review of the facility's P&P titled Abuse Policy and Procedure revised 3/1/24, showed during and after the investigation, the residents will be protected from the alleged harm through the following methods: - staff will closely and frequently supervise the resident, and - if a staff member is accused or suspected of abuse, that staff member will be suspended pending the completion of the investigation. On 11/12/24, the CDPH, Licensing and Certification Program received a report from the facility regarding Resident 1's allegation of physical abuse by CNAs 2 and 3 on 11/10/24. Medical record review for Resident 1 was initiated on 11/26/24. Resident 1 was admitted to the facility on [DATE]. Review of Resident 1's H&P examination dated 11/5/24, showed Resident 1 could make her own medical decisions. On 11/26/24 at 0920 hours, a review of the facility's investigation file was conducted. The document showed the interviews and statements of the facility's staff members and residents. However, further review of the documents failed to show the two alleged CNAs were suspended during the investigation period from 11/10/24 to 11/13/24. On 11/26/24 at 1042 hours, a telephone interview was conducted with CNA 2. CNA 2 stated she was aware Resident 1 just had a hip surgery and being gentle when providing the care to Resident 1. When asked if she had worked from 11/10/24 to 11/13/24, CNA 2 stated the Administrator consented her to return to work the following day after the reported abuse allegation, but she was given a different assignment and not working directly with Resident 1. (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 3 Event ID: 555391 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 555391 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/06/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Freedom Village Healthcare Center 23442 El Toro Road Lake Forest, CA 92630 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)